Every finding on record at Crestview Health & Rehabilitation

Based on observations and staff interviews, the facility failed to remove expired milk from 1 of 1 walk-in refrigerator and 1 of 1 reach-in refrigerator. This failure had the potential to affect all resident who eat food items prepared with milk and all residents who may ingest milk as fluid.The findings included:An observation of the facility's kitchen on 09/08/25 at 10:23 AM revealed one gallon of whole milk with a use by date of 09/02/25 was found in the reach-in refrigerator. The gallon of milk was opened, with approximately 1/5 of it remained and was available for use. Additionally, one unopened gallon of whole milk and one opened gallon of whole milk with expiration dates of 09/02/25 were located in the facility's walk-in refrigerator along with one individual carton of 2% milk with an expiration date of 09/03/25 observed in the same walk-in refrigerator.An interview with the Dietary Manager on 09/11/25 at 10:34 AM revealed the dietary aides were typically responsible for checking the kitchen areas daily for foods that were expired or were approaching their expiration date. The Dietary Manager reported he also goes behind the dietary aides to ensure that they did not overlook any food items that had expired. He stated the failure to remove the expired milk from the reach-in and walk-in refrigerators ultimately fell to him and that he must have overlooked the expired milk when he had checked the kitchen for expired food items last on 09/05/25.An interview with the Administrator on 09/11/25 at 11:51 AM revealed he expected the kitchen should be checked daily for expired food. He reported to prevent excessive food waste he expected the dietary staff to use food on a first arrival, first used approach. The Administrator reported the gallons of milk with expiration dates of 09/02/25 and the individual carton of milk with an expiration date of 09/03/25 should have been removed on their expiration date.

Based on record review, and resident and staff interviews, the facility failed to maintain accurate advance directive information throughout the medical record (Resident #50) and failed to have a signed Medical Orders for Scope of Treatment (MOST) form (Resident #13, Resident #74, Resident #84). This deficient practice affected 4 of 8 residents reviewed for advance directives (Resident #50, Resident #13, Resident #74, Resident #84).The findings included: Resident #50 was admitted to the facility on [DATE]. Review of Resident #50’s quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact. Review of the Code Book (a binder that contained paper copies of residents’ advanced directives and code status) revealed Resident #50’s paper medical record contained a signed MOST form that indicated Resident #50’s preference for a DNR (Do Not Resuscitate) status in the event she had no pulse and was not breathing. The form was signed by Resident #50’s Resident Representative and dated 8/25/2025, there was also a Goldenrod Form signed by the provider and dated 8/21/2025. Review of Resident #50’s active Physician’s orders revealed an active order for Full Code. Review of the profile page of Resident #50’s electronic health record on 9/8/2025 at 3:22 PM revealed both Do Not Resuscitate (DNR), and Full Code listed as Resident #50’s code status. During an interview on 9/9/2025 at 12:15 PM Resident #50 stated she wanted her code status to be a DNR. Resident #50 stated she and her family had discussed advanced directives, and Resident #50 made the decision to be a DNR. During an interview on 9/9/2025 at 10:39 AM Nurse #2 stated the code status for a resident was found in the Code Book and the profile page of the resident’s electronic medical record and the resident’s care plan. Nurse #2 verified Resident #50’s profile page contained both DNR and Full Code listed as the current Code status and had an active order for Full Code listed in physician’s orders. Nurse #2 Stated there should not be two code statuses listed on the profile page. Nurse #2 stated that having two on the profile page could have caused an issue and she would make sure the profile page was corrected after the orders were verified. Nurse #2 stated the nurses or unit managers are responsible for entering the updated code status into the electronic health record when the status is changed. Nurse #2 stated when Resident #50’s code status changed the old order should have been discontinued and the old code status removed from the profile page, but it appeared the new status was added to the profile page without the old status being removed. During an interview on 9/9/2025 at 10:50 AM the Unit Manager #2 stated a resident’s code status was found in the Code Book or on the resident’s profile page in the electronic health record and care plan. During an interview on 9/9/2025 at 11:20 AM the Unit Manager #1 stated a resident’s code status was found on the profile page of the resident’s electronic health record and each nurse’s station had a Code Book that contained MOST forms and DNR forms. The Unit Manager #1 stated Resident #50 changed her code status to DNR when she had the procedure in August, prior to the procedure Resident #50 had been a Full Code. The Unit Manager stated normally the old code status was removed from the resident’s profile page when the new code status was entered. Unit Manager #1 stated it was normally her responsibility to update the code status; it could also be updated by the nurses that work on the hall. During an interview on 9/11/2025 at 11:15 AM the Director of Nursing (DON) stated the Unit Managers or hall nurses were responsible to update the electronic health record when a resident’s code status was updated. The DON stated she expected a resident’s code status to be accurate and consistent throughout the resident medical record and that the profile page should not contain two different code statuses. During an interview on 9/11/2025 at 10:35 AM the Administrator stated his expected a resident’s code status to be correct, up to date and consistent through the entire medical record. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses which included paraplegia (paralysis which affects the lower body) and chronic pain. Physician orders for Resident #13 dated 06/02/25 revealed an order for full code. A review of the active care plan revised on 06/02/25 revealed that Resident #13 had goals and interventions for advance directives and was a full code. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact. The Medical Orders for Scope of Treatment (MOST) form completed on 07/12/24 for Resident #13 was found in the advance directive's binder at the nurse's station but had not been signed by Resident #13 or her representative. Resident #13 was a full code per MOST form. An interview with the Social Worker was conducted on 09/11/25 at 9:11 AM revealed the Social Worker was responsible for the completion of the advance directives. The Social Worker indicated she reviewed the residents’ wishes as part of the admission and then reviewed with the resident or their representative quarterly. The Social Worker stated that she thought the signature was optional since it said at the bottom of the MOST form “you are not required to sign this form to receive treatment”. The Social Worker stated that Resident #13 was alert and oriented and would be able to sign the form. An interview on 09/11/25 at 9:52 AM with the Director of Nursing (DON) indicated it was the responsibility of the Social Worker to obtain the resident's or representative's signature which was required on the MOST form. The DON stated that advance directive forms should be completed fully and accurately, and the signature indicated informed consent. An interview conducted on 09/11/25 at 11:07 AM with the Administrator revealed advance directive forms should be completed accurately. 3. Resident #74 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included Parkinson’s disease and chronic kidney disease. Physician orders for Resident #74 dated 05/28/25 revealed an order for full code. The MOST form completed on 06/05/25 for Resident #74 was found in the advance directive's binder at the nurse's station but had not been signed by Resident #74 or her representative. The Resident Representative name was written in, and it stated “via phone” but did not indicate a date or time that verbal consent was obtained or who obtained the verbal consent. Resident #74 was a full code per MOST form. A review of the active care plan revised 08/19/25 revealed that Resident #74 had goals and interventions for advance directives and was a full code. A review of the quarterly MDS dated [DATE] revealed Resident #74 was severely cognitively impaired. An interview with the Social Worker was conducted on 09/11/25 at 9:11 AM. The Social worker stated she was responsible for the completion of advance directives. The Social Worker indicated she reviewed the residents’ wishes as part of their admission and then reviewed with the resident or their representative quarterly. The Social Worker stated that she thought the signature was optional since it said at the bottom of the MOST form “you are not required to sign this form to receive treatment”. The Social Worker stated that when a verbal consent was obtained, she just writes “verbal” on the MOST form and had not included time, date or who witnessed verbal consent. The Social Worker stated that Resident #74 was severely cognitively impaired and would not be able to sign the MOST form. An interview on 09/11/25 at 9:52 AM with the DON indicated it was the responsibility of the Social Worker to obtain the resident or representative's signature as required on the MOST form. The DON stated that advance directive forms should be completed fully and accurately. The DON stated verbal consent should contain the name of who the consent was obtained from, the date, time, and who witnessed the verbal consent. An interview conducted on 09/11/25 at 11:07 AM with the Administrator revealed advance directive forms should be completed accurately. 4. Resident #84 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included end-stage renal disease and diabetes mellitus. A review of the admission MDS dated [DATE] revealed Resident #84 was cognitively intact. A review of the active care plan revised 08/04/25 revealed that Resident #84 had goals and interventions for advance directives and was a full code. The MOST form completed on 08/29/25 for Resident #84 was found in the advance directive's binder at the nurse's station but had not been signed by Resident #84 or her representative. Resident #84 was a full code per MOST form. An interview with the Social Worker was conducted on 09/11/25 at 9:11 AM and revealed the Social Worker was responsible for the completion of the advance directives. The Social Worker indicated she reviewed the residents’ wishes as part of the admission and then reviewed with the resident or their representative quarterly. The Social Worker stated that she thought the signature was optional since it said at the bottom of the MOST form “you are not required to sign this form to receive treatment”. She stated that Resident #84 was alert and oriented and would be able to sign the MOST form. An interview on 09/11/25 at 9:52 AM with the Director of Nursing (DON) indicated it was the responsibility of Social Worker to obtain the resident or representative's signature as required on the MOST form. Advance directive forms should be completed fully and accurately. An interview conducted on 09/11/25 at 11:07 AM with the Administrator revealed advance directive forms should be completed accurately.

Based on observations, record reviews, and staff interviews, the facility failed to post cautionary signage outside of resident rooms that indicated the use of oxygen for 4 of 5 residents reviewed for respiratory care (Resident #2, Resident #55, Resident #87, and Resident #88).Findings included: 1. Resident #2 was admitted on [DATE] with diagnoses that included heart failure, asthma, and dependence on supplemental oxygen. Resident #2’s physician orders revealed an order dated 09/11/24 for oxygen via nasal cannula as needed for shortness of breath at 3 liters per minute. A review of Resident #2’s care plan updated on 05/28/25 revealed a plan for oxygen therapy for respiratory disease. The stated goal was that Resident #2 would be free from respiratory complications. Interventions included oxygen via nasal cannula as ordered, monitor for signs of respiratory distress and notify provider if indicated, and administer medications as ordered. Resident #2’s admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 was severely cognitively impaired, dependent on staff for all activities of daily living, and coded for asthma, heart failure, and oxygen use. An observation of Resident #2 in her room on 09/08/25 at 9:50 AM revealed oxygen concentrator in use via nasal cannula at 3 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #2's room indicating oxygen was in use. A second observation of Resident #2 in her room on 09/08/2025 3:17 PM revealed oxygen concentrator in use via nasal cannula at 3 liters per minute. No cautionary oxygen in use signage outside of Resident #2's room indicating oxygen was in use. A third observation of Resident #2 in her room on 09/09/2025 11:08 AM revealed the oxygen concentrator in use via nasal cannula at 3 liters per minute. No cautionary oxygen in use signage outside of Resident #2's room indicating oxygen was in use. An interview with Nurse #1’s (agency staff) was conducted on 09/09/25 at 9:18 AM. Nurse #1 stated Resident #2 received oxygen continuously. Nurse #1 indicated she did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms. Nurse #1 verbalized she had not noticed that Resident #2 did not have an oxygen in use sign on door. An interview was conducted with the Director of Nursing (DON) on 09/11/2025 9:52 AM. The DON stated that oxygen in use cautionary signage should be posted outside the doors of all residents’ rooms that used continuous or as needed oxygen. The DON verbalized that the facility had to order more oxygen signs because they were out of them. 2. Resident #55 was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease. Resident #55’s physician orders revealed an order dated 2/19/2025 for oxygen continuous at 2 to 3 Liters Per Minute (LPM) via nasal canula every 24 hours as needed. A review of Resident #55’s care plan updated 5/22/2025 revealed a plan for respiratory complications with interventions that included administer medications as ordered, administer oxygen as ordered, head of bed elevated to prevent shortness of breath as tolerated. Resident #55’s quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 had moderately impaired cognition, was independent with most activities of daily living, required set up assistance with lower body dressing and personal hygiene and supervisory/touching assistance with toileting hygiene, and coded for chronic obstructive pulmonary disease. An observation of Resident #55 in her room on 9/8/2025 at 1:51 PM revealed oxygen concentrator in use via nasal cannula at 3 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #55's room indicating oxygen was in use. A second observation 9/9/2025 at 10:05 AM revealed oxygen concentrator in use via nasal cannula at 3 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #55's room indicating oxygen was in use. A third observation 9/10/2025 at 9:49 AM revealed oxygen concentrator in use via nasal cannula at 3 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #55's room indicating oxygen was in use. During an interview on 9/10/2025 at 9:59 AM Nurse #2 stated that when a resident is admitted with an order for oxygen, the Unit Manager received the paperwork, entered the order into the electronic health record, the nurse was responsible to have the concentrator and nasal cannula ready, to administer when the resident arrived and to place the oxygen in use sign on the door. Nurse #2 stated that the Unit Managers also help make sure the equipment and signs were on the door. During an interview on 9/10/2025 at 11:27 AM the Unit Manager #1 stated when a resident was admitted with an order for oxygen the nurse on the hall was supposed to put the oxygen in use sign on the resident’s door. The Unit Manager #1 stated she normally tried to double check that the oxygen use signs were in place. The Unit Manager #1 stated they had recently ordered and received more oxygen use signs to make sure they had enough. The Unit Manager placed an oxygen use sign on Resident #55’s door after the interview. During an interview on 09/11/2025 at 9:52 AM the Director of Nursing (DON) stated that oxygen in use cautionary signage should be posted outside the doors of all residents’ rooms that used continuous or as needed oxygen. The DON verbalized that the facility had to order more oxygen signs because they were out of them. During an interview on 9/11/2025 at 10:35 AM the Administrator stated residents that used oxygen should have a sign posted at the door. 3. Resident #87 was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), pneumonia, and other nonspecific abnormal findings of lung field. Resident #87’s physician orders revealed an order dated 9/4/2025 for oxygen 2 liters per minute via nasal canula continuous. A review of Resident #87’s care plan initiated 9/3/2025 revealed Resident #87 was care planned at risk for respiratory complications secondary to chronic obstructive pulmonary disease, pneumonia and respiratory failure with interventions that include administer medication as orders, administer oxygen as ordered, head of bed elevated to prevent shortness of breath as tolerated, observe for signs symptoms of respiratory complications An observation of Resident #87 on 9/8/2025 at 11:50 AM in her room revealed oxygen concentrator in use via nasal cannula at 2 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #87's room indicating oxygen was in use. A second observation on 9/9/2025 at 10:05 AM revealed Resident #87 in her room, oxygen concentrator in use via nasal cannula at 2 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #87's room indicating oxygen was in use. A third observation on 9/10/2025 at 9:50 AM revealed Resident #87 in her room, oxygen concentrator in use via nasal cannula at 2 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #87's room indicating oxygen was in use. During an interview on 9/10/2025 at 9:59 AM Nurse #2 stated that when a resident was admitted with an order for oxygen, the Unit Manager received the paperwork, entered the order into the electronic health record, the nurse was responsible to have the concentrator and nasal cannula ready, to administer when the resident arrived and to place the oxygen in use sign on the door. Nurse #2 stated that the Unit Managers also help make sure the equipment and signs were on the door. During an interview on 9/10/2025 at 11:27 AM the Unit Manager #1 stated when a resident was admitted with an order for oxygen the nurse on the hall is supposed to put the oxygen in use sign on the resident’s door. The Unit Manager #1 stated she normally tried to double-check that the oxygen use signs were in place. The Unit Manager #1 stated they had recently ordered and received more oxygen use signs to make sure they had enough. The Unit Manager placed an oxygen use sign on Resident #87’s door after the interview. During an interview on 09/11/2025 at 9:52 AM the Director of Nursing (DON) stated that oxygen in use cautionary signage should be posted outside the doors of all residents’ rooms that used continuous or as needed oxygen. The DON verbalized that the facility had to order more oxygen signs because they were out of them. During an interview on 9/11/2025 at 10:35 AM the Administrator stated residents that used oxygen should have a sign posted at the door. 4. Resident #88 was admitted on [DATE] with diagnoses that included pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). Resident #88’s physician orders revealed an order dated 9/5/2025 for oxygen 10 liters via nasal canula continuous one time a day for COPD. A review of Resident #88’s care plan updated on 9/8/2025 revealed a care plan for risk of respiratory complications secondary to COPD, respiratory failure, supplementary oxygen requirement with interventions that included administer medications as ordered, administer oxygen as ordered, head of bed elevated to prevent shortness of breath as tolerated, observe for signs and symptoms of respiratory complications. An observation of Resident #88 on 9/08/2025 at 11:36 AM in his room revealed oxygen concentrator in use via nasal cannula at 10 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #88's room indicating oxygen was in use. A second observation on 9/8/2025 at 3:16 PM revealed oxygen concentrator in use via nasal cannula at 10 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #88's room indicating oxygen was in use. A third observation 9/9/2025 at 10:27 AM revealed oxygen concentrator in use via nasal cannula at 10 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #88's room indicating oxygen was in use. During an interview on 9/10/2025 at 9:59 AM Nurse #2 stated that when a resident was admitted with an order for oxygen, the Unit Manager received the paperwork, entered the order into the electronic health record, the nurse was responsible to have the concentrator and nasal cannula ready, to administer when the resident arrived and to place the oxygen in use sign on the door. Nurse #2 stated that the Unit Managers also help make sure the equipment and signs were on the door. During an interview on 9/10/2025 at 11:27 AM the Unit Manager #1 stated when a resident was admitted with an order for oxygen the nurse on the hall was supposed to put the oxygen in use sign on the resident’s door. The Unit Manager #1 stated she normally tried to double-check that the oxygen use signs were in place. The Unit Manager #1 stated they had recently ordered and received more oxygen use signs to make sure they had enough. The Unit manager stated a sign had been placed on Resident #88’s door. During an interview on 09/11/2025 at 9:52 AM the Director of Nursing (DON) stated that oxygen in use cautionary signage should be posted outside the doors of all residents’ rooms that used continuous or as needed oxygen. The DON verbalized that the facility had to order more oxygen signs because they were out of them. During an interview on 9/11/2025 at 10:35 AM the Administrator stated residents that used oxygen should have a sign posted at the door.

Based on observation, record review, and staff interviews, the facility failed to implement their infection control policy for Enhanced Barrier Precautions (EPB) when the Wound Nurse did not don (put on) a gown when performing wound care for Resident #44. The Wound Nurse also failed to perform change gloves and perform hand hygiene between wound sites. This occurred for 1 of 3 staff members observed for infection control practices (Wound Nurse).Findings included:Review of the facility's Enhanced Barrier Precautions (EBP) dated 03/28/24 revealed it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident activities such as wound care.A review of the facility's Infection Prevention and Control Policy revised 06/01/23 revealed hand hygiene should be completed after contact with non-intact resident's skin, wound dressings, or contaminated items.A continuous observation of wound care for Resident #44 was completed on 09/10/25 from 9:36 AM through 10:04 AM. Resident #44 had a sign for EBP over the bed which instructed staff to don gloves and a gown for high contact resident care activities which included wound care. Personal protective equipment (PPE) was observed on Resident #44's door. The Wound Nurse performed hand hygiene and donned gloves. The Wound Nurse did not don a gown per the EBP policy. Resident #44 was positioned for wound care and the Wound Nurse cleaned Resident #44's wound to left ischium (lower buttock area above thigh) with gauze. The gauze was noted to have large amount of brown colored drainage on the gauze after cleaning. The Wound Nurse removed the glove from her right hand and discarded it along with gauze but did not remove the glove from her left hand. The Wound Nurse entered the bathroom and performed hand hygiene on right hand only. The Wound Nurse then applied a new glove to her right hand but failed to change the left-hand glove. The Wound Nurse then cleaned Resident #44's sacral wound with gauze. The Wound Nurse cleaned the left ischium wound for a second time with a cotton tipped swab without changing gloves and performing hand hygiene directly after cleaning the sacral wound. The Wound Nurse removed her gloves, then reapplied new gloves without performing hand hygiene. The Wound Nurse then cleaned right ischium wound with gauze and removed her gloves and performed hand hygiene. The Wound Nurse donned new gloves and placed gauze to right ischium wound and applied new bordered dressing. The Wound Nurse removed gloves and performed hand hygiene. The Wound Nurse applied new gloves, placed gauze on sacral wound, applied a new bordered dressing to wound, removed her gloves and performed hand hygiene. The Wound Nurse donned clean gloves, applied gauze and a bordered dressing to Resident #44's left ischium wound. The Wound Nurse removed gloves, discarded trash, and performed hand hygiene to complete wound care. An interview with Wound Nurse was conducted on 09/10/25 at 11:42 AM. The Wound Nurse verbalized understanding that a gown should have been applied as required by the facility EBP policy for wound care. The Wound Nurse stated that she had been educated on EBP when hired and she would normally apply a gown and follow EBP policy for wound care. The Wound Nurse reported that due to nervousness, she had forgotten to apply a gown prior to wound care on Resident #44. The Wound Nurse further stated she was nervous and didn't notice she had not performed hand hygiene between wounds. An interview with the Director of Nursing (DON) (the facility's Infection Preventionist) was conducted on 09/11/25 at 9:52 AM. The DON stated that Resident #44 required EBP due to chronic wounds. The DON verbalized that staff were expected to follow EBP when performing care that required EBP per facility's EBP policy. The DON stated that staff should perform hand hygiene between wounds and changing gloves during wound care per the hand hygiene policy.

Based on observations, record review, and staff interviews, the facility failed to assess a resident for the use of side rails prior to installation of bed rails on the resident's bed for 1 of 1 resident reviewed for side rails (Resident #4).The findings included:Resident #4 was most recently readmitted to the facility on [DATE] with diagnoses that included dementia with behaviors, bipolar disorder, polyneuropathy, and anxiety disorder.Review of Resident #4's annual Minimum Data Set assessment dated [DATE] revealed he was cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. He was coded as requiring limited assistance with bed mobility and was not using any restraints or alarms.Review of Resident #4's physician orders revealed an order dated 04/07/25 for 1/4 side rails to be up while in bed to promote independence.Review of Resident #4's treatment administration record indicated Resident #4 had side rails installed on his bed on 07/12/25. The treatment administration record for Resident #4's use of side rails was signed off by Nurse #5.Multiple attempts to reach Nurse #5 were unsuccessful.Review of Resident #4's care plans last updated on 07/28/25 revealed a care plan for an activity of daily living, self-care performance deficit related to decreased mobility. The interventions within the care plan included 1/4 side rails while in bed to promote independence.Review of Resident #4's electronic medical health record revealed an assessment titled Side Rail & Entrapment Risk Assessment dated 08/19/25 that showed in progress. Additional review of the assessment revealed that it was a quarterly assessment and side rails would be used for the assistance of turning and positioning.Additional review of Resident #4's electronic medical health record revealed no additional documented side rail assessments, including no initial assessment prior to the installation of Resident #4's side rails on 07/12/25.An observation of Resident #4 completed on 09/09/25 at 9:05 AM revealed he had 1/4 side rails installed and in operation on his bed.Attempts to interview Resident #4 on 09/09/25 at 9:06 AM and 09/11/25 at 10:27 AM were unsuccessful.An interview with the Maintenance Director on 09/10/25 at 4:25 PM revealed he was responsible for the installation and removal of all side rails in the facility. He stated he was typically notified through the electronic maintenance request program utilized by the facility to place maintenance requests. He continued, reporting that he had nothing to do with the completion of side rail assessments prior to the installation of the side rails and that he does not verify the completion of an initial side rail assessment prior to installation of side rails. The Maintenance Director reported he believed Unit Manager #1 would be the staff member responsible for ensuring that an initial side rail assessment was completed prior to the installation of side rails.An interview with Unit Manger #1 on 09/11/25 at 10:36 AM revealed there were multiple staff members who could be responsible for completing an initial side rail assessment including the nurse assigned to the resident upon their admission, herself, or the Director of Nursing. She stated once they receive a physician's order for the placement of side rails, an initial side rail assessment was completed before the Maintenance Director installed side rails onto a resident's bed. The Unit Manager indicated that she did not complete the initial side rail assessment for Resident #4 and that she did not know if anyone had completed his initial side rail assessment prior to the side rails being installed on his bed.An interview with the Director of Nursing on 09/11/25 at 11:39 AM revealed that the facility's unit managers were typically assigned to ensure that initial side rail assessments were completed prior to the installation of side rails. She stated if the unit managers were unavailable or busy, the responsibility would be hers to ensure the side rail assessment was completed. She reported it appeared as though Resident #4 did not have an initial side rail assessment prior to the installation of side rails to his bed. She reported if she had to surmise the reason it was not completed, she would assume it had to do with the amount of agency staff in the building and they probably just did not do the work.An interview with the Administrator on 09/11/25 at 11:51 AM revealed he was very new to the facility and was not familiar with the facility's side rail policy and procedures but stated he expected that an initial side rail assessment be completed prior to the installation of side rails on a resident's bed.

Based on record review, resident, family, staff interviews and physician interviews, the facility failed to provide care in a safe manner when Resident #1 fell out of her bed during incontinent care. Resident #1 fell from an elevated bed position hitting her head and reported immediate pain in her right lower extremity upon falling. Resident #1 was subsequently transported to the Emergency Department via ambulance and was diagnosed with a right leg bone fracture. The facility also failed to provide a transfer in a safe manner when Resident #3's left eyebrow area was grazed with the mechanical lift during a transfer causing a skin tear. The deficient practice occurred for 2 of 3 residents reviewed for supervision to prevent accidents (Resident #1 and Resident #3). Findings included: 1.Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral vascular accident (a stroke) with left sided hemiparesis and hemiplegia (weakness and paralysis), left above the knee amputation, type II diabetes, hypertension, depression and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact and was dependent requiring assistance with 2 or more staff for bed mobility and dependent for toileting/incontinent care. Resident #1’s revised Care Plan dated 4/1/25 noted focus areas for falls. Additionally, there was a care plan focus related to activities of daily living performance deficit with interventions revised on 5/7/25 that read; Bed mobility, toileting, hygiene, dressing, bathing: resident requires substantial to total dependance on 1-2 staff. Physician orders showed an active order dated 8/1/24 for Eliquis 5 mg (Eliquis is a blood thinning medication that helps prevent blood clots and mg is short for milligram and is a unit of measurement for certain medications) one tablet by mouth daily for blood clot prevention related to her history of stroke. Review of Resident #1’s Medication Administration Record (MAR) of May 2025 revealed that she had received all of her ordered doses of Eliquis up to and including her dose at 9:00 AM on 5/29/25. A Nursing Progress note dated 5/29/25 by Nurse #1 at 9:41AM read Resident #1 fell out of bed during a bed bath and hit her head on the floor and Nurse Aide (NA) #1 had called for help. Resident #1 was noted to be awake and complaining of pain to her right leg and she was being sent to the hospital by EMS (Emergency Medical Services) for evaluation. Resident #1’s responsible party was notified of event. A review of incident reports showed an incident report for falls was completed by Nurse #1 for 5/29/25 at 9:48 AM for Resident #1’s fall. The incident report indicated that NA #1 was giving Resident #1 a bed bath, the Resident was holding on to the privacy curtain and her right leg slipped off the bed. Resident #1 had a left leg amputation to her knee and was not able to balance herself which caused her to fall off the bed and hit her head on the floor. Resident #1 stated that she “told the aide that she was about to fall but the aid couldn’t catch her”. The incident report also indicated that neurological checks commenced, vital signs and limbs were assessed and that the Resident was stabilized in her position while they awaited EMS because she reported pain in her right leg. A phone interview was conducted on 6/25/25 at 11:09 AM with NA #1. NA #1 informed that she was Resident #1’s nurse assistant on 5/29/25 when the fall occurred. NA #1 stated she had worked at the facility for approximately 7 months and had the same assignment for the duration so she knew Resident #1 very well. NA #1 indicated that because she took care of Resident #1 so frequently they “had a very regular routine”. NA #1 informed that Resident #1 did not like to be in the lift for transfer and usually refused the lift. NA #1 stated that Resident #1 would ask for bed baths rather than be transferred by the lift to the shower/spa room for her bath. NA #1 said that she would roll Resident #1 over to her left side and Resident #1 would usually be able to assist by holding onto the bed or privacy curtain. NA #1 reported that the bed was elevated to waist height during the bed bath. While she was cleaning Resident #1’s back, the Resident had a bowel movement. NA #1 reported that she immediately proceeded to re-clean the Resident but that instead of Resident #1 holding on to the privacy curtain like she always did, the Resident was startled and “let go of everything including the curtain and rolled off the right side of the bed”. NA #1 reported that Resident hit her head when she fell. NA #1 stated that she asked the Resident if she was ok and “made sure she was alert and awake and breathing”, then she went to get help. NA #1 stated she got assistance from staff that were working at that time which included several nurses and another nursing assistant. Resident #1 was assessed by the nurses and the supervisor and provider were notified. In an interview on 6/25/25 at 12:05 PM with the Director of Nursing (DON), the DON informed that she was present at the facility when the fall occurred and was notified. The DON informed that the standard of care was for Resident #1 to have two-person assistance for bed baths. The DON informed that education was reinforced with NA #1 and other staff. The DON informed that Resident #1 was transferred to the hospital that same day and informed that she thought the Resident sustained a fracture but she was not sure about that. On 6/25/25 at 2:30 PM an interview with the Wound Care Nurse was obtained. The Wound Care Nurse informed that on 5/29/25 she responded to a request for assistance immediately following Resident #1’s fall. The wound care nurse said that Nurse #1 and the previous Nurse Manager (who no longer works for the organization) and several other nurses responded as well. The Wound Care Nurse stated that she did not remember the names of the other nurses as they were agency staff. Resident #1 was assessed and was awake throughout, but she reported pain in her leg. The Wound Care Nurse stated that staff deliberated on whether to get Resident back into the bed because Resident #1 was calling out to put her back in bed but the decision was made to await EMS and so that is what they did. In a phone interview with NA #2 on 6/25/25 at 3:05 PM NA #2 confirmed that he responded to NA #1’s call for assistance following Resident #1’s fall out of bed on 05/29/25. NA #2 informed that the Resident was awake and alert but did report pain in her leg. NA #2 reported that Resident #1 was repeatedly asking to be put back in her bed but that he told her he had to wait until she was assessed by the nurse or by EMS. NA #2 reported that EMS arrived approximately 20 minutes later and the Resident was transported to the hospital. NA #2 reported he had taken care of Resident #1 before and that she was total care for getting up and for activities but that she could roll herself in bed with one person assisting and when he took care of her, he was usually able to perform her care by himself. A 6/25/25 phone interview at 3:30 PM with former Unit Manager revealed that on the morning of 5/29/25 the Wound Care nurse told her that a Resident had fallen, and the NA was asking for help. The former Unit Manager reported that upon entering the room, she saw Resident #1 lying on the floor, her bed was elevated. She asked NA #1 what happened. NA #1 told her Resident #1 “turned and rolled and she couldn’t catch her”. The former Unit Manager confirmed that Nurse #1 immediately began assessing her. The former Unit Manager reported that she observed the bed was in the highest position. She reported that Resident #1’s vital signs were stable and that her right leg hurt. The former Unit Manager informed that the providers were notified of the fall and that she requested to have the Resident evaluated at the hospital which the provider agreed to. The former Unit Manager informed that Resident #1 was usually a one person assist, sometimes two and the Resident was able to roll herself with help. The former Unit Manager stated that at the morning meeting the next day, the new Administrator (Admin) informed her that the Resident had a fracture. On 6/26/25 at 1:30 PM an interview with Nurse #1 was conducted. Nurse #1 confirmed she was Resident #1’s primary nurse on 5/29/25 when Resident #1 fell out of bed. Nurse #1 reported that she was called into the Resident’s room on the day of the incident by staff saying NA #1 needed help because the Resident had fallen out of bed. Nurse #1 reported that upon entry into the room, Resident #1 was on the floor. Nurse #1 reported that she began assessing the Resident “with neuro checks, the Resident was awake and alert throughout and vitals were stable”. Nurse #1 confirmed that Resident #1 said she hit her head when she fell. Nurse #1 stated that she assessed Resident #1 and she reported pain in her leg. Nurse #1 reported that they did not move her, they put a new brief on her and covered her and put blankets underneath her so she could be as comfortable as could be while they waited for EMS. Nurse #1 reported that EMS arrived about 20-25 minutes later and took Resident #1 to the hospital. Review of the EMS report from 5/29/25 revealed that on they received a call at 10:33 AM, dispatched at 10:37 AM and arrived at the patient at 10:43 AM. Resident #1 was found lying on the floor upon arrival, with pillows under head and that she was covered with blankets. Resident #1 was alert and oriented and she reported severe pain to her right lower extremity. EMS noted shortening and rotation of right leg upon arrival. EMS notes indicated that EMS staff lifted Resident #1 to the transfer stretcher with a draw sheet once spinal precautions and hip immobilization was achieved. Transfer to hospital then followed. A history and physical obtained in the emergency room on 5/29/25 indicated Resident #1’s report of rolling and falling out of a raised bed at her nursing home and that she complained of right knee pain. The physical exam showed right upper knee tenderness and swelling. Further review of the 5/29/25 hospital records revealed an x-ray of the right knee showed distal femoral diaphyseal fracture and that bone demineralization present (the femur bone had a fracture in it and the bone itself was weak and brittle). A Computed Tomography scan, or CT scan (a type of x-ray scan) of the head on 5/29/25 showed no head trauma or bleeding, no intraparenchymal hemorrhage, no extra-axial fluid collection, no mass, mass effect or midline shift (no bleeding had occurred). A chest x-ray on 5/29/25 showed cardiomegaly and pulmonary vascular congestion (enlargement of the heart muscle and lung congestion). There was notation of Resident #1’s past history of hypoxic respiratory failure related to a diagnosis of pneumonia in 2024. Resident #1 was admitted to the hospital to ensure stable cardiopulmonary condition, pain control and to obtain an orthopedic consult. Review of an Orthopedic progress note on 6/3/25 indicated that Resident #1 had just finished eating, was wearing a right knee immobilizer, her pain was controlled with medication. The Orthopedic physical exam showed that Resident #1 had easily palpable pulses in her right foot, she was able to flex and extend her right foot fully, which indicated her right leg and foot were neurologically intact and she had intact sensation. The noted plan was non-operative and for Resident #1 to continue to be non-weight bearing to her right lower extremity, to continue wearing the knee immobilizer at all times, to ice the knee and to continue medical management and treatment per the hospitalist service. The progress note indicated that the orthopedic team had signed off. A repeat head CT on 6/11/25 was negative for bleeding. A repeat right knee x-ray on 6/15/25 showed the distal femur fracture, same as prior. A follow up Orthopedic progress note dated 6/16/25 was reviewed and indicated that a follow up visit was per Resident #1’s request. Orthopedic physician reiterated the plan for non-operative treatment secondary to Resident #1 being notably high risk for surgery and that surgery would not benefit her at this time. The plan was for Resident #1 to follow up with orthopedic team as an outpatient, to continue treatment per the hospitalist service and to continue to be non-weight bearing to the right lower extremity and to wear the right knee immobilizer as able. A hospital progress noted dated 6/26/25 noted that Resident #1 was being planned for discharge but the discharge was cancelled per the Resident #1 and her family’s request that they did not want to return to the same facility. A hospital progress note 7/2/25 noted that Resident #1 was stable for discharge due to non-operative treatment for fracture, stable and chronic cardiopulmonary condition and that case management was working on placement. In a phone interview with Resident #1 on 7/2/25 at 2:00 PM, she recalled the events that occurred on 05/29/25. Resident #1 stated she had a bowel movement and NA #1 was changing her “diaper.” She stated that she has always had 2 people assist her with care even when changing her “diaper” but NA #1 did it by herself on that day. Resident #1 stated NA #1 was on the left side of the bed and she was holding on to the side rail and fell out of the bed on the right side. She stated when she hit the floor she screamed in pain in her right leg. Resident #1 also stated she hit her head when she rolled out of bed and the nurse came in but she was unable to recall the nurse’s name. Resident #1 stated that generally they use the lift to transfer her but this day they did not and they did not use a draw sheet, they just picked her up and put her back to bed. She stated it took EMS about 20 minutes to get to the facility, and she went to the hospital where she had a broken hip bone but the doctor and her family told her she was too weak to have surgery. Resident #1 stated her pain was better, but she had a lot of healing to do. Resident #1 stated she had been waiting on a facility and she hoped to be out of the hospital this weekend. On 6/26/25 at 1:40 PM a joint interview with the DON and Administrator as conducted. The Administrator and DON both confirmed that Resident #1 should have had assistance from two staff members for her bed bath care. The DON stated that NA #1 was educated that she should have had another staff member assisting her based on Resident #1’s care plan and care guide. On 7/7/25 at 1:07 PM a phone interview was conducted with the facility Medical Director. The Medical Director informed that the clinical picture for Resident #1 from what he could remember was that Resident #1 was pleasantly confused at times, but no significant altered mental status, she was overweight, she had impaired mobility. The Medical Director reported that he was not in the facility at the time of the fall but that the DON did call him to inform him that Resident had fallen. The Medical Director informed that when DON called him with the update, the Resident’s family had already decided not to return Resident #1 to the facility, thus he did not receive any report or update from any of the hospital physicians as to her condition after she left the facility. At 11:30 AM on 7/10/25, a phone interview was conducted with the hospital Physician overseeing Resident #1’s hospital care. The Physician informed that Resident #1 was still in the hospital. He reported her femur fracture was consistent with her report of falling from an elevated bed position. The Physician confirmed Resident #1 sustained one fracture to her right distal femur on 5/29/25 and that repeat x-rays were performed on 5/16/25 and 7/8/25 and showed the same right femur fracture. He said she had no other fractures. The Physician confirmed Resident #1’s head CTs on 5/29/25 and 6/11/25 were negative for bleeding. The Physician informed that Resident #1’s chest x-rays which showed pulmonary congestion were chronic and stable. Her pain has been controlled throughout her hospital course, that she was clinically improved and was stable for discharge and awaiting placement at this time. The facility provided the following corrective action plan with a completion date of 5/31/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 5/29/2025 at 9:48 am, Resident #1 sustained a fall from the bed while turning and repositioning during a bed bath by Certified Nursing Assistant (CNA #1). According to CNA # 1 the resident lifted her right leg and crossed it over to assist in turning to her side. Additionally, it was noted Resident #1 removed her hand from the bed enabler and grabbed the privacy curtain while in motion. CNA #1 did not instruct resident to continue to use the enabler bar and allowed the resident to continue to hold the privacy curtain. Resident #1 was care planned to be a 1-2 assist with care. CNA #1 was unable to stabilize Resident #1 in time and as a result Resident #1 rolled out of bed and onto the floor. Resident #1 assessed by Unit Manager and Nurse Practitioner. Resident #1 complained of pain; an order was issued to send to the hospital for evaluation. Resident #1 was diagnosed at the hospital with a fracture of the right femur. On 5/29/2025 Certified Nursing Assistant #1 was re-educated by Director of Nursing (DON) to review all residents’ Kardex (Resident Care Guide) for level of assist required prior to providing care. If Kardex does not reflect the level of care status, alert the nurse before providing care to ensure appropriate assistance is provided for all residents. On 5/29/2025 the DON educated CNA #1 to direct residents to utilize bed rails during care. On 05/30/25 Resident #1’s bed mobility status was updated to populate to resident care guide (Kardex) by the Minimum Data Set (MDS) nurse to reflect 2-person assist with ADL care. · Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Root Cause Analysis identified that Resident #1 required extensive assistance of 1-2 staff with bed mobility per care plan, however, this was not populating to the Kardex for staff to see. On 05/30/2025, the MDS Coordinator and DON audited and corrected all resident care plans to ensure the level of activities of daily living (ADL) assistance was accurate and appropriately populated to the Kardex. The MDS Coordinator/designee will ensure that all residents’ Activities of Daily Living (ADL) status and level of assistance are appropriately reflected on the Kardex. This duty began 5/30/25. The facility Administrator instructed the MDS Coordinator on 5/30/25 to update ADL status as needed following each quarterly, annual, and significant changes. · Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 05/30/2025, Education began with all nurses and CNAs, including agency staff on the requirement to review resident's Kardex for level of assist required prior to providing care. If Kardex does not reflect the level of care status, alert the nurse before providing care to ensure appropriate assistance is provided. Any staff not educated in person on 05/30/2025 were educated via phone by the Assistant Director of Nursing. Education for all nurses and CNAs was completed on 5/30/25. · Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Ongoing audits will be conducted once a week for 8 weeks of all new admissions and 5 random residents Kardex’s to ensure that the level of ADL assistance is accurately reflected. DON/designee will conduct 3 random observations of ADL care. Random ADL observation audits are performed to ensure care plans and Kardex are being followed. Observation of appropriate ADL level during care to be done by DON/designee 3 times a week for 8 weeks. On 5/29/25 a plan of correction was completed. On 5/29/25 the facility Administrator made the decision to complete a corrective action plan and present the monitoring tools and review of incidents during QAPI (Quality Assurance Performance Improvement). An Ad Hoc QAPI meeting was held on 05/30/25 with the Interdisciplinary team. The Director of Nursing will review the ADL observations of care audits and any further incidents to ensure continued compliance. Results will be reported in QAPI monthly until substantial compliance is met. The Kardex and the observation of care audits will be included in QAPI and reviewed by the Director of Nursing to ensure compliance. Alleged date of compliance: 5/31/2025 The facility's corrective action plan with a completion date of 5/31/25 was validated on 7/11/25. Review of in-service sign in sheets and interviews revealed staff had received training as specified in the corrective action plan. Observations of the provision of care during the survey yielded no concerns for resident safety. Audits of the care plans, kardex and observations/audits of the provisions of care were reviewed and were completed as specified in the corrective action plan. The corrective action plan completion date of 5/31/25 was validated. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type II diabetes mellitus, atherosclerotic heart disease, and hypertension. Review of Resident #3’s quarterly Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. He was coded with an impairment to one side of his upper extremity and impairments to both sides of his lower extremities. Resident #3 was dependent on others for transfers. Review of Resident #3’s care plan, last updated on 01/23/25 revealed a care plan area for “[Resident #3] has an [activities of daily living] self-care performance deficit related to weakness”. Interventions included “extensive assistance with dressing, hygiene, bathing, toileting with one staff assist, and [mechanical lift] with 2 staff assist for transfers”. Review of facility incident accident logs revealed an incident with Resident #3 on 04/20/25. Per the facility’s handwritten incident/accident report, Resident #3 suffered a skin tear to his left eye area after the top handle of the mechanical lift hit him. The report indicated that the hall nurse was alerted to the incident and when she entered the room, Resident #3 was still in the mechanical lift with a noted skin tear with scant bleeding to his left upper eyelid. Per the report, 2 nurse aides (NA #5 and NA #6) stated that Resident #3 was hit with the mechanical lift handle during a transfer. The incident report indicated that the physician was notified and Resident #3’s skin tear was treated by cleaning the area with sterile water, was pat dry, and a steri-strip bandage was applied. The incident report was completed by Nurse #5. An observation and interview with Resident #3 on 06/25/25 at 11:01 AM revealed he was being transferred via mechanical lift from his bed into his chair on 04/20/25 when he was hit above his left eye. He stated there were 2 staff members in the room at the time, though he could not recall their names. He indicated he had a cut above his left eye from the incident. Resident #3’s left eye area was noted to be healed with no lasting issues. An interview with NA #5 on 06/25/25 at 2:49PM via telephone call revealed she was present when Resident #3 suffered a skin tear during a mechanical lift transfer. She stated she was operating the mechanical lift with NA #6, and they had lifted Resident #3 out of his bed and were lowering him into his chair. She reported as they got Resident #3 almost completely lowered, NA #6 reportedly tried to adjust Resident#3 into a better seated position and when she pulled on one of the mechanical lift pad straps, the mechanical lift tipped to the side and one of the handles grazed Resident #3 above his left eye causing a skin tear. She reported the mechanical lift tipped and then immediately settled back into an upright position. She reported she did not know what caused the mechanical lift to tip to the side as she reported all parts of the mechanical lift were in the correct operating positions with the legs opened. She reported after the incident, the hall nurse, whom she could not recall, was immediately notified and the wound was treated. An interview with NA #6 on 06/25/25 at 3:03 PM via telephone call revealed she was working with NA #5 on 04/20/25 to transfer Resident #3 from his bed to his chair via mechanical lift. She stated as they were lowering Resident #3 into the chair she noticed that he needed to be adjusted further back into the chair and when she went to adjust him, the mechanical lift tipped to the side, and he was grazed above his left eye causing a small skin tear. She reported the mechanical lift leaned to one side and then almost immediately settled back into an upright position. She stated they immediately notified the nurse who came and assessed Resident #3, cleaned the wound and placed a bandage over the area. NA #5 stated she kept an eye on Resident #3 the rest of her shift and did not notice any other injuries or swelling to the area. Multiple attempts to locate and interview Nurse #5 were unsuccessful. A telephone interview with the Former Director of Nursing was conducted on 06/26/25 at 11:21 AM, who was present at the time of the incident on 04/20/25 revealed she vaguely recalled the incident. She reported, if she remembered correctly, she was at home when the incident occurred and came into the building to complete an investigation. She stated she reviewed the mechanical lift for mechanical failure with no issues found and reviewed the straps of the lift pad Resident #3 used with no concerns noted. She reported she believed the nurse involved was an agency nurse and did not have her contact information. She reported after the incident; the facility held in-service training on mechanical lifts and reviewed the competencies of the nurse aides involved. She reported she ultimately could not determine the root cause of the failure which resulted in Resident #3 being hit with the mechanical lift. She did indicate that a resident should not be injured during transfers. Multiple attempts to reach the Former Administrator via telephone were unsuccessful. The facility provided the following corrective action plan with a completion date of 4/23/25. How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 4/20/25 Resident #3 was being transferred to his chair with a mechanical lift by a 2-person assist. While Resident #3 was being transferred with the mechanical lift, Resident #3 obtained a skin tear above his left eye. Nurse Aide (NA) 6 attempted to adjust the sling straps in an attempt to better position Resident #3 when the skin tear occurred. Resident #3 was assessed immediately by Nurse #5 post incident. Nurse #5 observed a skin tear to the left eye of Resident #3 and treatment and monitoring were initiated by protocol by Nurse #5. The facility Wound Nurse monitored area above left eye until resolved. A safety and incident report were completed by the Unit Manager on 5/7/25. Resident #3’s representative was notified by the Unit Manager on 4/21/2025. On 04/20/2025 NA #5 and NA #6 were removed from transfer duties and immediately reeducated on transfer duties on the total mechanical lift use and transfer safety by the Director of Nursing (DON). How will the facility identify other residents having the potential to be affected by the same deficient practice? Root cause analysis determined (NA) # 6 did not remove the sling from the lift prior to repositioning Resident #3 in the wheelchair resulting in the lift bar striking the resident above the left eye. A cross-check of all resident care plans and physician orders and assistive device needs was completed by the MDS coordinator on 4/21/25. No concerns were noted. On 4/21/25 through 4/23/25 observations of transfers were completed on all shifts to identify additional risks the by Director on Nursing. All residents requiring a total mechanical lift were assessed. No other residents were identified to have received unsafe transfers. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? On 4/21/2025 through 4/23/2025 All staff received mandatory in-person retraining on total mechanical lift procedures, 2-person transfers protocol and education not to pull on lift straps per manufacturer’s instructions. Education was completed by the Director of Nursing and Unit Manager. All new staff, agency staff, or staff not educated on 4/21/25 were educated prior to starting the shift by the DON/designee. All facility total lift equipment was inspected by the Maintenance Director to ensure the equipment was functioning correctly. The facility Environmental Services Director inspected all slings to ensure the facility slings were free from damage. All lifts were functioning properly, and all slings were free from damage. Audits were completed 4/21/25. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? The DON/designee will conduct 3 random total lift audits 3 times a week for one month and then one audit once a week for one month. The observation audit tools include 2-person transfer, communication between staff and residents, and equipment safety check. Audit findings will be reviewed during monthly QAPI (Quality Assurance and Performance Improvement). Noncompliance will result in immediate reeducation and disciplinary review if necessary. On 4/21/25 QAPI meeting was held with the interdisciplinary team to discuss the incident, education and audit tools implemented. Completion date: 4/23/25 The facility's corrective action plan with a completion date of 4/23/25 was validated on 7/11/25. Review of in-service sign in sheets and interviews revealed staff had received training as specified in the corrective action plan. Observations of the provision of care during the survey yielded no concerns for resident safety. Audits of lift transfers were reviewed and were completed as specified in the corrective action plan. The corrective action plan completion date of 4/23/25 was validated.

Based on observations, record review, and staff and resident interviews, the facility failed to provide notification of an accident that resulted in Resident #3 being hit in the eye area with the mechanical lift handle causing a skin tear with a small amount of bleeding that required a wound covering to the resident's family member or resident representative for 1 of 4 residents reviewed for notification of change (Resident #3).Resident #3 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type II diabetes mellitus, atherosclerotic heart disease, and hypertension.Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact.Review of Resident #3's electronic health record revealed Family Member #1 as his resident representative.Review of facility incident accident logs revealed an incident with Resident #3 on 04/20/25. Per the facility's handwritten incident/accident report, Resident #3 suffered a skin tear to his left eye area after the top handle of the mechanical lift hit him. The report indicated that the hall nurse was alerted to the incident and when she entered the room, Resident #3 was still in the mechanical lift with a noted skin tear with scant bleeding to his left upper eyelid. Per the report, 2 nurse aides (NA #5 and NA #6) stated that Resident #3 was hit with the mechanical lift handle during a transfer. The incident report indicated that the physician was notified and Resident #3's skin tear was treated by cleaning the area with sterile water, was patted dry, and a steri-strip bandage was applied. The incident report indicated that the family or resident representative was not notified at the time of the incident. There was a place on the incident report for the nurse completing the report to write in which family member or resident representative was contacted, time and date of the contact, and the name of the staff member that contacted the family member or resident representative. These areas on the incident report were the only areas not completed and left blank. The report was completed by Nurse #5.An interview with Resident #3 on 06/25/25 at 11:01 AM revealed he was being transferred via mechanical lift from his bed into his chair on 04/20/25 when he was hit above his left eye. He stated there were 2 staff members in the room at the time, though he could not recall their names. He indicated he had a cut above his left eye from the incident. Resident #3 reported he did not know if his family was notified of the incident.An interview with Nurse Aide (NA) #5 on 06/25/25 at 2:49PM via telephone call revealed she was present when Resident #3 suffered a skin tear during a mechanical lift transfer. She stated she was operating the mechanical lift with NA #6 and they had lifted Resident #3 out of his bed and were lowering him into his chair. She reported as they got Resident #3 almost completely lowered, NA #6 reportedly tried to adjust Resident#3 into a better seated position and when she pulled on one of the mechanical lift pad straps, the mechanical lift tipped to the side and one of the handles grazed Resident #3 above his left eye causing a skin tear. She reported after the incident that the hall nurse, whom she could not recall, was immediately notified and the wound was treated. NA #5 stated as a nurse aide, she was only responsible for notifying the nurse of any injuries and did not know if Resident #3's family or resident representative was notified.An interview with NA #6 on 06/25/25 at 3:03 PM via telephone call revealed she was working with NA #5 on 04/20/25 to transfer Resident #3 from his bed to his chair via mechanical lift. She stated as they were lowering Resident #3 into the chair, she noticed that he needed to be adjusted further back into the chair and when she went to adjust him, the mechanical lift tipped to the side, and he was grazed above his left eye causing a small skin tear. She stated they immediately notified the nurse who came and assessed Resident #3, cleaned the wound and placed a bandage over the area. NA #6 reported she did not notify Resident #3's family or resident representative as she believed that it was the responsibility of the nurse to notify the physician and family know of incidents after the occurred.Multiple attempts to locate and interview Nurse #5 were unsuccessful.Multiple attempts to speak to Family Member #1 were made but unsuccessful.An interview with the Former Director of Nursing was conducted 06/26/25 at 11:21 AM via telephone call revealed she vaguely recalled the incident. She reported, if she remembered correctly, she was at home when the incident occurred and came into the building to complete an investigation. She reported that her staff were expected to complete the incident/accident report in its entirety and reported that although she could not state for certain whether or not Resident #3's family was notified, she stated she would have to assume they were not since the incident report did not have the required information on who was notified along with the date, time, and who notified the family or resident representative.Multiple attempts to reach the Former Administrator via telephone were unsuccessful.

Based on record review, observations and staff interviews, the facility failed to implement care planned interventions by not placing a fall mat at the bedside of a resident with a history of falls. This occurred for 1 of 3 residents reviewed for care plan implementation (Resident #2). Findings Included: Resident #2 was admitted to the facility on [DATE] with Parkinson’s disease, epilepsy and dementia. A care plan revised on 5/7/25 indicated Resident #2 was at risk of falls related to cognitive impairment and impulsively attempting to get up without assistance at times. An intervention noted was to have a fall mat at the right side of the Resident’s bed. Review of the Quarterly MDS assessment dated [DATE] revealed Resident was cognitively intact. On observation of Resident #2 on 6/26/25 at 10:45 AM, Resident was asleep in the center of her bed, the bed was in the lowest position and the left side of bed was against the wall. The head of the bed was elevated approximately 30 degrees. There was no fall mat on the floor at right side of the bed. On observation of Resident #2 on 6/26/25 at 11:45 AM, Resident was asleep in center of her bed, the bed was in the lowest position and the left side of the bed was against the wall. The head of the bed was elevated approximately 30 degrees. There was no fall mat on the floor at right side of the bed. In an interview with Nurse Aide (NA) #3 on 6/26/25 at 12:00 PM, NA #3 informed that he did not know Resident #2 yet as it was his first day working at the facility. NA #3 stated that the nurse assistants look at the care guide to obtain needed information regarding Resident care and they also got needed information from their shift change report at the beginning of their shift. NA #3 informed that fall precaution information was obtained from the care guide. NA #3 stated that he had not seen the directive regarding the fall mat to be at the Resident’s right side of the bed but that he would inform the nurse and would place the fall mat down. On 6/26/25 at 12:10 PM an interview with Nurse #1was conducted. Nurse #1 informed that Resident #2 was usually cooperative but that she was impulsive and tried to get up sometimes without help. Nurse #1 stated that Resident #2 was confused sometimes and at other times was more alert, usually got up out of bed every day. Nurse #1 stated this morning Resident #2 was sleeping more because she had a seizure last night but her vitals have been stable and she was able to take her morning medications. Nurse #1 informed that NAs and Nurses obtained information regarding fall precautions from the care plan and the care guide. Nurse #1 could not remember if Resident #2’s fall mat was present this morning. Nurse #1 added that Resident#2 had a seizure last night it may have been moved but it should have been present. During a joint interview with the Director of Nursing (DON) and the Administrator on 6/26/25 at 2:00 PM, they both stated that NAs and Nurses obtained Resident care information from shift report as well as from care plans and the care guides. The Administrator and DON informed that a fall mat should have been present for Resident #2 with her history of falls and that it was the responsibility of all nursing staff to ensure that fall mats were on the floor beside the bed.

Based on record reviews, staff and Resident interviews the facility failed to protect a resident's (Resident #1) right to be free from abuse for 1 of 2 residents reviewed for abuse. Resident #2 was observed to cover Resident #1's mouth with his hand and pinch her nose using his thumb and index finger preventing her from breathing and causing her face to turn bright red and causing her to cry. Resident #1 stated she was afraid of Resident #2. The finding included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included traumatic spinal cord dysfunction, anoxic brain injury and paraplegia (paralysis which can result from a spinal cord injury which can affect all or part of the trunk, legs and pelvic organs). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and required set up to dependent level of assistance from staff with most of her activities of daily (ADL). The care plan revised on 09/28/23 revealed Resident #1 had an ADL self-care deficit performance related to anoxic brain injury, paraplegia and physical limitations. Resident #2 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes mellitus. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2's was cognitively intact, and no behaviors indicated on the MDS. The MDS also indicated the Resident required independent to dependent assistance from staff for his activities of daily living. The care plan revised 05/21/24 revealed Resident #2 had an ADL self-care deficit performance related to weakness, respiratory failure. The goal that Resident #2 would improve in his ADL function would be attained by utilizing interventions that included providing limited to extensive assistance from staff to perform ADLs. Review of a nurse progress note written by Nurse #1 dated 06/28/24 at 7:41 PM revealed during report with Nurse #2, writer watched Resident #1 and Resident #2 sitting by the nurses' cart face to face. Resident #2 began to cover Resident #1's mouth with his left hand and pinch her nose closed with his thumb and index finger. Nurse #1 alerted Nurse #2 to turn around and observe what Resident #2 was doing to Resident #1. Both Nurses witnessed Resident #1's color begin to change, and Resident #1 looked up at both Nurse #1 and Nurse #2 for help. Resident #2 let go and began to force his thumb vigorously and deep into Resident #1's mouth. Nurse #2 interfered and asked Resident #1 if she was okay. A few minutes later Resident #1 began to cry, and Resident #2 wiped her tears away. Resident #1 was removed from the situation and placed into bed. An interview was conducted with Nurse #1 on 07/22/24 at 9:20 AM who explained that she was on duty during the day of 06/28/24 and noticed that Resident #1 and Resident #2 were together all during the shift sitting in the hallway together holding hands and thought that was their normal routine. The Nurse explained that the night of 06/28/24 during shift change, she and Nurse #2 were standing at the medication cart giving shift report when she observed Resident #2 reach up with hand and cover her mouth. Resident #1's eyes began to roll back while she was looking at the two nurses standing close by. Nurse #1 stated Resident #2 then released his grip then pinched Resident #1's nose closed using his thumb and index finger after which Resident #1's face started to turn red, and her head fell backwards. Nurse #1 continued to explain that she alerted Nurse #2 who was closer to the two residents to see what was happening and when she alerted Nurse #2, Resident #2 removed his hand from Resident #1's mouth and started to force his thumb in her mouth and by that time Nurse #2 had reached the two residents. She stated the whole encounter happened in a matter of about 20 seconds. Nurse #1 continued to explain that Nurse #2 immediately removed Resident #1 from Resident #2 and asked her if she was okay when Resident #2 answered her that Resident #1 was okay. Nurse #1 described the look on Resident #1's face during the incident as fright. Review of a nurse progress note written by Nurse #2 dated 06/28/24 at 10:50 PM revealed a late entry note that revealed Nurse #2 observed Resident #2 pressing his hand against Resident #1's face, covering up her nose and mouth which appeared to cause Resident #1's face to become red and flushed. Nurse #2 asked Resident #2 what he was doing, and he removed his hand off Resident #1's face. Asked Resident #1 if she was, okay? As staff began moving Resident #1's wheelchair away, Resident #2 stated to Resident #1 tell them you're okay two times quickly. Resident #1 gave Resident #2 a blank stare then stated I'm okay as a few tears rolled down her face. The Residents were separated. Resident #1's vital signs and skin check was completed (in the Resident's room). Resident #1 was placed in her bed and as she was transferred to bed Resident #1 stated I am scared of him, but I love him. Informed Resident #1 that management was involved and has worked out a plan to keep her safe. Resident #1 smiled and appeared to be relieved and calm stating thank you for caring about me. Interviews were conducted with Nurse #2 on 07/18/24 at 4:45 PM and 07/18/24 at 8:40 PM. Nurse #2 explained that during shift change report on the evening of 06/28/24 she was receiving report from Nurse #1 while standing by the medication cart in the hallway. The Nurse stated that Nurse #1 told her to turn around and look at what Resident #2 was doing to Resident #1 who were sitting in their wheelchairs in the hallway directly behind her. Nurse #2 reported that she observed Resident #2's hand over Resident #1's mouth with his thumb and index finger pinching Resident #1's nose and appeared to be pushing Resident #1's head back. Resident #1's head was leaning to the left and there was a pillow behind her head for support. Nurse #2 continued to explain that Resident #1's face was bright red, and her eyes were rolled to the top of her eyelids. The Nurse rushed to the two residents and stated to Resident #2 what are you doing and Resident #2 slowly moved his hand off her face as if he was in a trance. Nurse #2 reported she then moved Resident #1 away from Resident #2 and asked Resident #1 if she was okay and as she moved the Resident, she gave Nurse #2 a look like Resident #1 was in shock. The Nurse stated as she was moving Resident #1 away from Resident #2, Resident #2 stated to Resident #1 to tell them that you are okay twice while being wheeled to her room. The Nurse continued to explain that after Resident #1 was taken to her room and put to bed Nurse #2 assured the Resident that she was safe, and she would not have to have any contact with Resident #2 that night. The Nurse reported Resident #1 never stated Resident #2 was trying to hurt her, but Resident #1 did say that she was afraid of him and did not want to make him mad. Nurse #2 explained that as she was assessing Resident #1's vital signs and performed a skin check she assured Resident #1 again that she was safe, and tears began to roll down the Resident's face. The Nurse stated Resident #1 was okay but that she appeared to be in shock because the Resident seemed just as surprised at what happened as the staff were. Nurse #2 reported she called the Director of Nursing (DON), the Administrator, the on-call provider and Resident #1's representative and informed them of what happened. She stated the Administrator had her repeat the incident twice and instructed her to put Resident #2 on a one-on-one observation until Monday 07/01/24 and for Resident #2 not to have any contact with Resident #1. Nurse #2 revealed Resident #1 and Resident #2 were a couple and in a relationship in that they were with each other all the time like sitting in the hallway and in rooms together. She stated they were in each other's faces all the time but that she had never seen anything abnormal between the two before the incident on 06/28/24. An interview was conducted with Resident #1 on 07/18/24 at 1:25 PM. The Resident was sitting in her wheelchair in her room with her head leaning to her left almost resting on her left shoulder. The Resident was asked about the incident on the evening of 06/28/24 and Resident #1 acknowledged she was aware of the incident in question. Resident #1 explained that she and Resident #2 were sitting in the hallway and Resident #2 put his hand over her mouth and put his finger in her mouth for her to hold and suck on, which she did often. Resident #1 continued to explain that she did not know that Resident #2 was going to put his finger in her mouth at that time but that in doing so, he did not hurt her. She indicated that she did not mind Resident #2 putting his finger in her mouth and that she liked it. The Resident stated she often let Resident #2 put his finger in her mouth and she held it there because she wanted him to. When asked directly if Resident #2 pinched her nose during the incident on the evening of 06/28/24 the Resident stated that she did not remember that part nor did she remember it making her cry. She stated she loved Resident #2 and had plans to marry him. On 07/18/24 at 3:50 PM during an interview with Resident #2 about the incident documented on the evening of 06/28/24 the Resident explained that he and Resident #1 were sitting in the hallway, and he blacked out and when he came to his hand was up on Resident #1's mouth. The Resident stated the staff asked him if Resident #1 was okay and he told them yes. Resident #2 continued to explain that the staff told him that he put his hand up over Resident #1's nose, but he did not know it. He insisted his hand was not on her nose before he blacked out. Resident #2 stated the staff took Resident #1 to her room and did not allow him to see or speak to Resident #1 for several days. During an interview with the Director of Nursing (DON) on 07/18/24 at 2:30 PM the DON explained that she was informed about the incident between Resident #1 and Resident #2 the night of 06/28/24 after it happened and instructed Nurse #2 to remove Resident #1 away from Resident #2 and provide safety for the Resident which the Nurse did. She also instructed the Nurse to obtain Resident #1's vital signs and conduct a complete head to toe assessment (which she had already completed) and to notify the on-call provider and Resident #1's representative. The DON stated she instructed Nurse #2 to notify the Administrator of the incident and follow his directions. The DON reported that Resident #1 and Resident #2 was a couple and in a relationship since about January 2024 shortly after Resident #2 was admitted to the facility and spent a lot of time together but nothing like the incident on 06/28/24 had been reported. An interview was conducted with the Administrator on 07/19/24 at 12:25 PM. The Administrator explained that Nurse #2 called him the night of 06/28/24 and reported that Nurse #1 reported that she observed Resident #2's hand over Resident #1's mouth and they had separated them and took Resident #1 to her room. The Nurse reported that Resident #2 was not happy about Resident #1 being separated from him and wanted to see Resident #1, but the Administrator told the Nurse to put Resident #2 on one-to-one observation until he had a chance to evaluate the situation. The Administrator stated that the way the incident was described to him by Nurse #2 that he felt the situation was questionable and did not think of it as abuse.

Based on record review and staff interviews, the facility failed to implement their abuse policy in the areas of reporting and investigating. When there was an allegation of abuse, an initial report was not submitted to the State Agency, a 5 day investigation was not submitted to the State Agency, law enforcement and Adult Protective Services (APS) were not notified for 1 of 2 residents reviewed for abuse (Resident # 1). The finding included: The facility's policy titled, Abuse, Neglect and Exploitation, revised 10/22/23 read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for investigation; identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; providing complete and thorough documentation of the investigation. The facility will have written procedures that include: reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable within specified timeframes: a) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse and result in serious bodily injury or b) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; and assuring that reporters are free from retaliation or reprisal. An interview was conducted with Nurse #1 on 07/22/24 at 9:20 AM who explained that she was on duty during the day of 06/28/24 and noticed that Resident #1 and Resident #2 were together all during the shift sitting in the hallway together holding hands and thought that was their normal routine. The Nurse explained that the night of 06/28/24 during shift change, she and Nurse #2 were standing at the medication cart giving shift report when she observed Resident #2 reach up with his hand and cover her mouth. Resident #1's eyes began to roll back while she was looking at the two nurses standing close by. Nurse #1 stated Resident #2 then released his grip then pinched Resident #1's nose closed using his thumb and index finger after which Resident #1's face started to turn red, and her head fell backwards. Nurse #1 continued to explain that she alerted Nurse #2 who was closer to the two residents to see what was happening and when she alerted Nurse #2, Resident #2 removed his hand from Resident #1's mouth and started to force his thumb in her mouth and by that time Nurse #2 had reached the two residents. She stated the whole encounter happened in a matter of about 20 seconds. Nurse #1 continued to explain that Nurse #2 immediately removed Resident #1 from Resident #2 and asked her if she was okay when Resident #2 answered her that Resident #1 was okay. Nurse #1 described the look on Resident #1's face during the incident as fright. Interviews were conducted with Nurse #2 on 07/18/24 at 4:45 PM and 07/18/24 at 8:40 PM. Nurse #2 explained that during shift change report on the evening of 06/28/24 she was receiving report from Nurse #1 while standing by the medication cart in the hallway. The Nurse stated that Nurse #1 told her to turn around and look at what Resident #2 was doing to Resident #1 who were sitting in their wheelchairs in the hallway directly behind her. Nurse #2 reported that she observed Resident #2's hand over Resident #1's mouth with his thumb and index finger pinching Resident #1's nose and appeared to be pushing Resident #1's head back. Resident #1's head was leaning to the left and there was a pillow behind her head for support. Nurse #2 continued to explain that Resident #1's face was bright red, and her eyes were rolled to the top of her eyelids. The Nurse rushed to the two residents and stated to Resident #2 what are you doing and Resident #2 slowly moved his hand off her face as if he was in a trance. Nurse #2 reported she then moved Resident #1 away from Resident #2 and asked Resident #1 if she was okay and as she moved the Resident, she gave Nurse #2 a look like Resident #1 was in shock. The Nurse stated as she was moving Resident #1 away from Resident #2, Resident #2 stated to Resident #1 to tell them that you are okay twice while being wheeled to her room. The Nurse continued to explain that after Resident #1 was taken to her room and put to bed Nurse #2 assured the Resident that she was safe, and she would not have to have any contact with Resident #2 that night. The Nurse reported Resident #1 never stated Resident #2 was trying to hurt her, but Resident #1 did say that she was afraid of him and did not want to make him mad. Nurse #2 explained that as she was assessing Resident #1's vital signs and performed a skin check she assured Resident #1 again that she was safe, and tears began to roll down the Resident's face. The Nurse stated Resident #1 was okay but that she appeared to be in shock because the Resident seemed just as surprised at what happened as the staff were. Nurse #2 reported she called the Director of Nursing (DON), the Administrator, the on-call provider and Resident #1's representative and informed them of what happened. She stated the Administrator had her repeat the incident twice and instructed her to put Resident #2 on a one-on-one observation until Monday 07/01/24 and for Resident #2 not to have any contact with Resident #1. Nurse #2 revealed Resident #1 and Resident #2 were a couple and in a relationship in that they were with each other all the time like sitting in the hallway and in rooms together. She stated they were in each other's faces all the time but that she had never seen anything abnormal between the two before the incident on 06/28/24. An interview was conducted with the Administrator on 07/19/24 at 12:25 PM. The Administrator explained that Nurse #2 called him the night of 06/28/24 and reported that Nurse #1 reported that she observed Resident #2's hand over Resident #1's mouth and they had separated them and took Resident #1 to her room. The Nurse reported that Resident #2 was not happy about Resident #1 being separated from him and wanted to see Resident #1, but the Administrator told the Nurse to put Resident #2 on one-to-one observation until he had a chance to evaluate the situation. The Administrator stated that the way the incident was described to him by Nurse #2 that he felt the situation was questionable and did not think of it as abuse. The Administrator indicated that in retrospect he should have perceived the incident as abuse and followed the facility's abuse policy and procedures by submitting an initial and 5-day investigation report to the state agency and he should have notified adult protective services and local law enforcement.

Based on record review, staff, and Medical Director interviews the facility failed to ensure that Nurse Aides (NA) #3 and NA #4 knew how to respond to a medical emergency, and what role to assume during a medical emergency, and were certified in cardiopulmonary resuscitation (CPR) before participating in an emergency situation that resulted in performing CPR on Resident #70. On [DATE] Resident #70 went into sudden cardiac arrest and NA #3, NA #4, and NA #5 began CPR without the use of backboard which creates a hard surface for effective chest compressions that allows for adequate recoil (allow the chest to fully expand after compressions which pushes blood to vital organs). NA #3 and NA #4 were not certified in CPR for Healthcare Providers. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compressions were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching out with the Staff Development Coordinator who could assist. EMS arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired. In addition, Nurse #4 and the Staff Development Coordinator did not receive orientation on response to medical emergencies. The deficient practice affected 5 of 5 staff reviewed for emergency procedure competencies. Immediate jeopardy began on [DATE] when NA #3 and NA #4 performed CPR on Resident #70 without being trained in CPR for Healthcare Providers. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete education and ensuring monitoring system put into place are effective. The findings included: This tag is cross referred to: F678: Based on observations, record review, staff, and Medical Director interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by Nurse Aide (NA) #3, NA #4, and NA #5 and continued for 7 minutes without a backboard. The backboard creates a hard surface for effective compressions that allow for adequate recoil (allowing the chest to fully expand after compression which pushes the blood to vital organs) and ensure perfusion for vital organs. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. NA #3 and NA #4 were not certified in CPR for Healthcare Providers. Emergency Medical Services (EMS) arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired. A review of a document provided by the facility titled, Orientation Overview with no date noted, indicated that on day 1 and day 2 of orientation new staff would watch a video on emergency preparedness. The required paperwork was listed as CPR card (required for Nurses only, but good to have for other staff), facility codes and security access, and included a facility tour. A review of NA #3's training file revealed his date of hire was [DATE] and there was no Orientation and/or Skills Competencies on emergency situations, how to respond or what their role during an emergency was, and no CPR certification. There was no job description in the file. A review of NA #4's training file revealed his date of hire was [DATE] and there was no Orientation and/or Skills Competencies on emergency situations, how to respond or what their role during an emergency was, and no CPR certification. There was no job description in the file. A review of NA #5's training file revealed his date of hire was [DATE] and there was no Orientation and/or Skill Competencies on emergency situation, how to respond or what their role during an emergency was noted. There was an active CPR certification from the American Heart Association with an expiration of ,d+[DATE]. There was no job description in the file. The NA job description dated [DATE] indicated that job requirements included a preference for current/active CPR certification. A review of Nurse #4's training file revealed her date of hire was [DATE] and there was no Orientation and/or Skill competencies on medical emergency situations, how to respond or what her role during an emergency was. There was no CPR certification or job description noted in the file. Nurse #4 was able to produce a copy of her CPR certification from the American Heart Association with an expiration on ,d+[DATE]. A review of the Staff Development Coordinator's training file revealed her date of hire was [DATE] and no Orientation and/or Skills Competencies on medical emergency situations, how to respond or what her role during an emergency was. There was no CPR certification or job description noted in the file. The Staff Development Coordinator was able to produce a copy of her CPR certification from the American Heart Association with an expiration on ,d+[DATE]. The Nurse job description dated [DATE] indicated that job requirements included: current/active CPR certification. The essential duties and responsibilities included: confirm that all nursing personnel assigned to you comply with the written policies and procedures established by this facility and verify that all nursing service personnel are in compliance with their respective job descriptions. NA #3 was interviewed via phone on [DATE] at 8:57 AM. NA #3 stated he had only been employed at the facility for a short time and his CPR certification had expired and was no longer valid. NA #3 stated that when he came to work at the facility, he was given no training in medical emergencies, how to respond, where emergency equipment was located, and no training in CPR. He also stated he had not completed any competencies or skills check since coming to the facility. The Staff Development Coordinator was interviewed on [DATE] at 10:27 AM. The Staff Development Coordinator stated that she had only been at the facility for less than a week and had not had the time to get the training program started but would be working on that in the future. She explained when she started, she was not given any information on location of emergency supplies or equipment, was told nothing about code situations, how to run one or what was supposed to be on the crash cart or where the crash carts were located. She stated she had to ask the DON where the crash cart was located during the emergency situation on [DATE]. She added that her CPR certification was active and was also trained in advance life support as well. The DON was interviewed on [DATE] at 11:14 AM. She explained she had been at the facility since [DATE], and she had not had consistent staff and no one to oversee the training program. The Staff Development Coordinator was only recently hired and had not had the time to develop and implement all the things that needed to be done at the facility. She stated that at the bare minimum staff should be given a tour of the facility and shown where the crash carts and emergency equipment were located. The DON was asked for the training records for NA #3, NA #4, Nurse #4, and the Staff Development Coordinator and she stated that there were none because she had not had a staff member in that role consistently since she started in [DATE]. She stated that she had plans with the Staff Development Coordinator from a sister facility to come over and train their current Staff Development Coordinator and set up the orientation manual like she wanted, to ensure that all staff received the required training. She further stated that a part of that training was going to include skills and competencies for each staff member. The DON stated that currently new staff were brought into the facility given a quick tour of the facility and then sent out with a staff member to be trained. The Administrator was interviewed on [DATE] at 4:10 PM. He explained the previous Staff Development Coordinator had started the training program but when they began requesting the training she was unable to produce it, so they had to part ways with the employee which created a long-term vacancy in that position. The Administrator was notified of the immediate jeopardy on [DATE] at 5:13 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure that the staff were trained in Emergency Response, how to respond, when to respond, and their role during medical or clinical emergency situations in the facility. The facility also failed to complete staff competency checklists to include medical and clinical emergency responses, medical and clinical facility codes, and location of medical and clinical emergency equipment. Starting [DATE], the Staff Development Coordinator, Director of Nursing and Unit Manager will ensure that all staff to include nursing staff, administrative staff, dietary staff, laundry/ housekeeping staff, and maintenance staff complete competency checklists based on their job descriptions for medical and clinical emergencies, medical and clinical codes and location of medical and clinical emergency equipment to ensure staff is aware of how to respond in clinical and medical emergencies. Staff will not be allowed to participate in medical and clinical emergencies without completing the competency. All the current residents are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system complete.to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting [DATE], the Staff Development Coordinator will ensure all staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapists, housekeeping/ laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff complete competency checklists to include medical and clinical emergencies, medical and clinical facility codes and the location of medical and clinical emergency equipment. Starting [DATE], the Director of Nursing and Staff Development Coordinator (SDC) will educate the facility staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapists, housekeeping/ laundry staff, dietary staff, social services staff, administrative staff, weekend staff, agency and prn staff on emergency responses to include how to respond, when to respond, and their role during medical and clinical emergency situations in the facility and where to find the medical and clinical emergency equipment located at the nursing stations. The night shift licensed nurses will complete the medical and clinical emergency equipment check list daily. The DON will check the medical and clinical emergency equipment and the completed medical and clinical check list weekly to ensure compliance. Starting [DATE], the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring licensed nurses, weekend staff, CNAs, therapists, housekeeping/laundry staff, dietary staff, social services staff, administrative staff and CMAs including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] A validation of immediate jeopardy removal was conducted on [DATE]. Staff across all departments were able to verbalize that they had received education on responding to emergenices, thier individual role in emergencies, how to respond, location of emergency equipment, and who was able to render care during an emergency. The non lisenced staff were able to report that they could contact EMS services, direct them to the appropriate place, and gather supplies as instructed by the licensed Nurse. The licensed nurse were able to report their role in an emergency, how to direct the non licensed staff, initating and rendering emergency care. Review of the emergency checklist revealed that the staff had been ensuring the emergency equipment was stocked and ready for use each night since [DATE]. The immediate jeopardy removal date of [DATE] was validated.

Based on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of the resident's chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directed that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. Nurse #3 notified the provider on-call and obtained an order for a one-time dose of Ibuprofen (pain medication, decreases inflammation) to be given for pain and a left hip/pelvis x-ray. Nurse #3 administered that medication as well as oxycodone-acetaminophen 5-325 mg (pain medication) that was scheduled (for every 6 hours) at 12:00 am and Resident #40 continued to grimace in pain throughout the remainder of her shift. Nurse #3 administered the 6:00 am oxycodone-acetaminophen. Nurse #10 administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, and documented a pain assessment of 8 out of 10 for Resident #40. An x-ray was performed in the facility on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone) and Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice occurred for 1 of 3 residents (Resident #40) reviewed for pain management. Immediate jeopardy began on 5/27/2024 when Resident #40 had fallen and was noted to have an obvious deformity and was not immediately transferred to the acute care hospital to ensure effective pain management. Immediate jeopardy was removed on 6/10/2024 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #40 was admitted to the facility on [DATE]. His recent diagnosis as of January 2024 included a dislocation of the internal left hip. Resident #40 was documented as deaf and mute. Review of a Medical Order for Scope of Treatment dated 7/13/2023 completed by PA #1 revealed Resident #40 did not want to be resuscitated if he had no pulse and was not breathing. The MOST form stated Resident #40 wanted comfort measures to include keep clean, warm dry. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Resident #40 was not to be transferred to the hospital unless comfort needs could not be met in the facility. A review of physician's orders dated 1/17/2024 revealed Resident #40 was ordered oxycodone-acetaminophen 5-325 milligrams (mg) scheduled every 6 hours. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was severely cognitively impaired. Resident #40 was documented as receiving opioids (pain medication). The pain management section of the MDS revealed Resident #40 had a scheduled pain medication regimen, he had not received any as needed pain medications, had not received any non-medication intervention for pain, and had not had any pain in the last 5 days. The care plan dated 5/8/2024 revealed Resident #40 required partial to moderate assistance with transfers. Resident #40 was care planned for chronic pain and risk for pain with interventions which included to evaluate the effectiveness of pain interventions. The pain documentation, on the MAR, from 5/1/2024 through 5/26/2024 revealed Resident #40 had a pain scale of 0 out of 10, when checked during the day and night shift), every day. Review of the MAR from 5/1/2024 through 5/26/2024 revealed documentation for administration of oxycodone-acetaminophen 5-325 mg every 6 hours (12:00 am, 6:00 am, 12:00 pm, and 6:00 pm) as scheduled for Resident #40. An incident report dated 5/27/2024 completed by Nurse #3 revealed Resident #40 was found at 10:40 pm lying face down on the floor beside the bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, a small head laceration to the top of the scalp, and a small laceration to the left outer ankle. Nurse #3 documented Resident #40 to be unconsolable, rigid with clenched fists, moaning, groaning, and had facial grimacing. A nursing note dated 5/27/2024 at 10:40 pm written by Nurse #3 revealed Resident #40 was found lying face down on the floor beside his bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, pain when moving/repositioning his leg, small head laceration on the left side of his forehead, and a small laceration on his left ankle. Resident #40 was assessed, and vital signs taken. Resident #40 complained of pain in his left hip. Resident #40's physician's orders dated 5/27/2024 written by the MD revealed an order for Ibuprofen (pain medication, decreases inflammation) 600 mg to be administered by mouth one time only for pain. The May 2024 Medication Administration Record (MAR) revealed the following: Nurse #3 documented that she administered Ibuprofen 600 mg to Resident #40 on 5/27/2024 at 11:15 pm and oxycodone-acetaminophen 5-325 mg tablet (which lasts 6 hours) on 5/28/2024 at 12:00 am, as scheduled, and had not documented a pain assessment for Resident #40 or re-evaluated the pain medication's effectiveness. Nurse #3 documented that she administered oxycodone-acetaminophen 5-325 mg tablet again at 6:00 am, as scheduled, and had not documented a pain assessment for Resident #40 or re-evaluated the pain medication's effectiveness. A nursing note dated 5/28/2024 at 5:24 am written by Nurse #3 revealed PA #2 had been contacted to inform PA #2 that Resident #40 had a low blood pressure. An interview was conducted on 6/4/2024 at 12:38 pm written by Nurse #3. Nurse #3 reported she was passing medications on 300 hall on 5/27/2024, and was assigned Resident #40, when Nurse Aide (NA) #1 and NA #2 came to tell her that Resident #40 was laying in the floor by the bed. Nurse #3 reported she observed Resident #40's left leg to be internally rotated and shorter than his right leg. Nurse #3 stated she contacted the on-call provider, PA #2, and informed her Resident #40 had fallen, that she had observed internal rotation and shortening of his left leg, and that he was experiencing a lot of pain, at which time PA #2 ordered Ibuprofen 600 milligrams (mg) one time for pain. Nurse #3 verified Resident #40 was crying, rigid with clenched fists, moaning/groaning, and had facial grimacing. Nurse #3 stated she administered Ibuprofen 600 mg in addition to his scheduled pain medication (oxycodone-acetaminophen) that he already had ordered. Nurse #3 reported the NAs had told her Resident #40 experienced excessive pain, continued to moan anytime his leg was touched, guarded, and was unable to consoled throughout the night. Nurse #3 stated she had contacted PA #2 again on 5/28/2024 at 5:30 am to inform her of a low blood pressure but failed to notify her that Resident #40 was still in pain. Nurse #3 stated she had forgotten to mention it because she was more worried about Resident #40's blood pressure being too low. Nurse #3 reported she had not administered any additional pain medication, except another scheduled dose of oxycodone-acetaminophen 5-325 mg at 6:00 am. PA #2 was unavailable for an interview. An interview was conducted on 6/4/2024 at 7:26 pm with NA #2. NA #2 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 400 hall. NA #2 stated Resident #40 moaned, grimaced, and guarded his left leg anytime he was moved or repositioned throughout the night when she assisted with him, and that Nurse #3 was notified about his pain. NA #2 reported staff checked on Resident #40 at least every 2 hours. An interview was conducted on 6/4/2024 at 7:57 pm with NA #1. NA #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 200 and 400 halls. NA #1 reported during the transfer Resident #40 was crying during transfer and when NA #2 would help her turn and reposition Resident #40 throughout the remainder of the shift. NA #1 stated she was hesitant to reposition Resident #40 throughout the night because he was exhibiting nonverbal grimacing, moaning, and guarding of his left leg. The pain documentation, on the MAR, from 5/27/2024 through 5/28/2024 revealed Resident #40 experienced pain 6 out of 10 during day shift on 5/28/2024, with no time noted, and 8 out of 10 on 5/28/2024 at 12:19 pm prior to being transferred to the hospital. An interview was conducted on 6/4/2024 at 4:51 pm with Nurse #1. Nurse #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 on 400 hall and was passing medications when she heard Resident #44 yell that Resident #40 was in the floor. Nurse #1 reported she worked the remainder of the shift and came back every couple of hours to check on him throughout the night and thought he was in pain because he would moan. Nurse #1 reported she had not administered any additional medication to Resident #40 because he was not assigned to her. A physician's order dated 5/27/2024, at 10:54 pm, for Resident #40 revealed an order for an x-ray of the left hip and pelvis written by the MD. The order was entered by Nurse #3 after she called to report Resident #40's left leg was internally rotated and shorter than his right leg. A radiology report dated 5/28/2024 at 9:37 am revealed Resident #40 had a dislocation of a left hip arthroplasty (a surgery to restore the hip joint) and an acute fracture of the proximal (close to the hip) left femur noted as new since 1/12/2024. A progress note completed by PA #1, dated 5/28/2024, with no time noted, revealed Resident #40 was seen for evaluation after a fall on 5/27/2024. Resident #40 had complained of pain. The x-ray was reviewed and noted to have a fracture of the proximal left femur with lateral displacement. Resident #40 was recommended for hospital transfer for evaluation. The physician's orders dated 5/28/2024 at 12:15 pm written by PA #1 revealed Resident #40 was to give an additional oxycodone-acetaminophen 5-325 mg tablet one time only for increased pain. An interview was conducted on 6/4/2023 at 3:19 pm with PA #1. PA #1 reported she had been made aware the morning of 5/28/2024 of Resident #40's fall on 5/27/2024. PA #1 stated she was very familiar with Resident #40 and could tell on 5/28/2024 he was in a lot of pain and was grimacing. PA #1 reported she reviewed the x-ray of the left hip/pelvis and noticed an acute fracture. PA #1 reported she ordered an additional pain pill to be administered, and ultimately sent him to the hospital for further evaluation. PA #1 reported she had not been made aware Resident #40 had experienced increased pain throughout the night and would have expected nursing staff to report increased pain to the on-call provider. PA #1 reported Resident #40 was ordered oxycodone-acetaminophen 5-325 mg, 2 tablets, every 6 hours for pain on his arrival back to the facility. Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, as scheduled, and documented a pain assessment of 8 out of 10 for Resident #40. On 5/28/2024 at 1:15 pm, PA #1 ordered Resident #40 to be transferred to the hospital. The Emergency Medical Services (EMS) report dated 5/28/2024 at 1:43 pm revealed Resident #40 had pointed to his left leg, and made a grimacing face as if to say that it hurt and there was obvious deformity noted in the left hip with inward rotation with no other obvious injuries were noted. The Acute Care Hospital documentation dated 5/28/2024 through 5/29/2024 revealed Resident #40 presented to the Emergency department after he fell to the ground while transferring from his bed on 5/27/2024. Documentation revealed Resident #40 was complaining of pain and appeared to be less ambulatory. Resident #40 had an x-ray of his left hip and pelvis that demonstrated left hip arthroplasty with an associated fracture dislocation. Resident #40 was admitted to hospital further evaluation and pain management and medications were adjusted (he was administered hydrocodone-acetaminophen 5-325 mg every 6 hours) and his oxycodone was continued. Resident #40 was recommended nonsurgical interventions and was to follow up in two weeks with outpatient orthopedics. Resident #40 was discharged back to the facility on [DATE]. The physician's orders dated 5/28/2024 at 6:00 pm revealed Resident #40 was ordered oxycodone-acetaminophen 5-325 mg, 2 tablets, every 6 hours for pain, and was discontinued on 5/31/2024. The physician's orders dated 5/31/2024 at 12:00 pm revealed Resident #40 was ordered oxycodone-acetaminophen 5-325 mg every 4 hours for pain. An observation and interview were conducted on 6/4/2024 at 1:16 pm. Resident #40 was lying in bed turned on his right size and pointed to his left upper outer thigh area, made a grimacing face and a squeezing motion with his hands. Resident #40 nodded yes that he had pain and mouthed the pain medication only helped a little. An interview was conducted on 6/5/2024 at 8:41 am with the Director of Nursing (DON). The DON stated Nurse #3 had contacted her about Resident #40's fall the night of 5/27/2024. The DON stated Nurse #3 told her Resident #40's leg was internally rotated and shorter, and she advised Nurse #3 to contact the on-call provider and the family to see if Resident #40 should be transferred to the hospital for further evaluation. The DON stated she was not aware Resident #40 had experienced increased pain and the provider had not been notified. The DON stated staff were to report increased or uncontrolled pain to the provider. An interview was conducted on 6/5/2024 at 3:09 pm with the MD. The MD reported she had been made aware on 5/28/2024 of Resident #40's fall on 5/27/2024 by PA #1. The MD stated PA #1 had Resident #40 sent to the hospital for evaluation because she was concerned how his leg looked. The MD reported PA #1 had adjusted Resident #40's pain medications after he returned to the facility and that she had seen him earlier on 6/5/2024 and he was smiling and had not appeared to be in pain. The MD was not aware of Resident #40's pain the night of his fall and reported staff should have reported increased or uncontrolled pain. An interview was conducted on 6/7/2024 at 3:23 pm with the Administrator. The Administrator reported he knew Resident #40 fell on [DATE] but had not been made aware Resident #40 had increased or uncontrolled pain that was not reported to the on-call provider. The Administrator agreed the on-call provider should have been made aware of Resident #40's pain, The Administrator was notified of Immediate Jeopardy on 6/5/2024 at 11:35 am. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to address Resident #40's pain to his left hip after sustaining a fall from his wheelchair which resulted in an acute fracture of the proximal femur. Starting 6/6/24, the Director of Nursing and the licensed nurses will complete new pain assessments of the current residents to include review of progress notes, care plans and resident pain regiments to ensure resident pain is being managed and/or prevented. Interviewable residents will also be interviewed by the licensed nurse to ensure that their current pain regime is adequate. All the current residents are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 6/5/24, the Chief Nursing Officer reviewed the Maple Health Pain Management Prevention Plan with the Director of Nursing. Starting 6/5/24, Director of Nursing and the Staff Development Coordinator will educate the licensed nurses, certified nursing assistants (CNA), and the certified medication aides (CMA) on identifying signs and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective. Pain will be assessed every shift, after a fall, with changes in condition and before and after pain medication administration and documented in the medication administration record or the progress notes. Starting 6/5/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring licensed nurses, weekend nursing staff, CNAs, and CMAs receive the education to include identifying sign and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective. Staff including new hires and prn staff and agency staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Effective 6/5/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 6/10/24 A validation of immediate jeopardy removal was conducted on 06/13/24. The initial pain assessments and interviews were reviewed with no issues noted. Licensed nurses were able to verbalize that they had the education reguarding pain and that pain was assessed after a fall, with change in condition, before and after pain medication administration and would documented in the medical record. Non licensed staff were able to vervalize that if a resident complained of pain or indicated thier pain medication was not effective who to report that information too. The licensed nurses were able to verbalize the need to communicate to the medical provider and involve the responsibel party if the residents pain could not be managed in the facility and needed a higher level of care. The immediate jeopardy removal date of 06/10/24 was validated.

Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The facility also failed to follow up with a provider about an abnormal radiology report, failed to obtain ordered laboratory testing, failed to ensure the necessary diagnostics were completed for a resident (Resident #196) that had confusion reported by the RP on 12/24/2023, and failed to immediately initiate Emergency Medical Services (EMS) when Resident #196 was only responsive to painful stimuli. Resident #196 was transferred to the hospital on 12/26/2023 at 2:04 pm and was admitted for respiratory failure and placed on Bilevel Positive Airway Pressure (BiPAP, non-invasive ventilator). The deficient practice occurred for 2 of 3 residents reviewed for change of condition (Resident #40 and Resident #196). Immediate jeopardy began on 5/27/2024 when nursing staff failed to assess or obtain vital signs prior to moving Resident #40 after finding him face down on the floor and failed to follow through with emergency medical services for a resident with obvious signs of injury. Immediate jeopardy was removed on 6/12/2024 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of G (actual harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #2 is being cited at a lower scope and severity of a G. The findings included: Resident #40 was admitted to the facility on [DATE]. His recent diagnosis as of January 2024 included dislocation of the internal left hip and was deaf and mute. Review of a Medical Order for Scope of Treatment dated 7/13/2023 completed by PA #1 revealed Resident #40 did not want to be resuscitated if he had no pulse and was not breathing. The MOST form stated Resident #40 wanted comfort measures to include keep clean, warm dry. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Resident #40 was not to be transferred to the hospital unless comfort needs could not be met in the facility. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was severely cognitively impaired. Resident #40 was coded as no impairment of his upper extremities, impairment on one side of his lower extremities. Resident #40 was coded as maximum assist for chair/bed to chair transfers. Resident #40 was coded as requiring substantial/maximal assistance with bed mobility, sitting to standing, lying to sitting, was not ambulatory, and used a wheelchair. A review of the care plan dated 5/8/2024 revealed Resident #40 required partial to moderate assistance with transfers. An interview was conducted on 6/3/2024 at 10:59 with Resident #44. Resident #44 reported Resident #40 had fallen approximately one week ago. Resident #44 reported he had returned to his room at night after going outside and found Resident #44 lying face down on the floor. Resident #44 stated he yelled for help and multiple staff members arrived. Resident #44 stated he told nursing staff in the room not to move Resident #40 until EMS could assess him because he was afraid Resident #40's leg was broken. Resident #44 stated Resident #40 was sent to the Emergency Department the next day and was found to have a broken leg. An interview was conducted on 6/4/2024 at 4:51 pm with Nurse #1. Nurse #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 on 400 hall and was passing medications when she heard Resident #44 yell that Resident #40 was on the floor. Nurse #1 stated she, NA #1, and NA #2 ran into Resident #40's room. Nurse #1 stated Resident #40 was found lying on his left side in a fetal position and appeared to have his left hand under his left hip. Nurse #1 reported that Nurse #2 arrived in the room, and they all rolled Resident #40 over. Nurse #1 reported she thought that something was wrong with his left hip. Nurse #1 reported she thought Resident #40 had recently had hip surgery and wanted to get him off the hard floor, which is why she had not assessed him and obtained vital signs prior to transferring Resident #40 into bed. Nurse #1 reported that she, in addition to Nurse #2, NA #1, and NA #2 picked Resident #40 off the floor and placed him in bed and recalled his left leg as looking like a limp noodle. An attempt to speak to Nurse #2 was made on 6/4/2024 and was unsuccessful. An interview was conducted on 6/4/2024 at 7:26 pm with NA #2. NA #2 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned to the 400-hall. NA #2 reported she heard Resident #44 yell that Resident #40 was on the floor. NA #2 reported when she arrived in the room, Resident #40 was lying next to the wheelchair and appeared to have his right leg under the wheelchair. She reported Resident #40 was on his left side in a fetal position. NA #2 reported Resident #40's leg was moved when they rolled him onto his back. NA #2 stated that she had assisted Nurse #1, Nurse #2, and NA #1 as they transferred Resident #40 to the bed by helping lift under his arms. NA #2 stated she was not able to recall Nurse #1, Nurse #2, or Nurse #3 assessing Resident #40 until Resident #40 was in the bed. NA #2 stated she observed Resident #40's leg to not look right and appeared to be disfigured. NA #2 reported someone obtained vital signs after Resident #40 was placed back in the bed. An interview was conducted on 6/4/2024 at 7:57 pm with NA #1. NA #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 200 and 400 halls. NA #1 reported she was in the hall when she heard Resident #44 yell that Resident #40 was on the floor. NA #1 stated when she arrived at the room, Resident #40 was laying on his left side and appeared to have his right leg tangled in the wheelchair. NA #1 reported Resident #40's leg was moved from under the wheelchair when they rolled him over in the floor. NA #1 stated Nurse #1 thought Resident #40's leg was broken, and stated Resident #40 needed to be placed in the bed. NA #1 reported she held traction to Resident #40's left leg and kept it straight while the Nurse #1, Nurse #2, and NA #2 picked Resident #40 up using his arms. NA #1 reported traction was the pull and hold the leg in a neutral position. NA #1 reported she had been an Emergency Medical Technician (EMT) in the past, but that she did not function as one at the facility. A review of an incident report dated 5/27/2024 at 10:40 pm completed by Nurse #3 revealed Resident #40 was found lying face down on the floor beside the bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, a small head laceration to the top of the scalp, and a small laceration to the left outer ankle. An interview was conducted on 6/4/2024 at 12:38 pm with Nurse #3. Nurse #3 reported she was passing medications on 300-hall when NA #1 and NA #2 came to tell her that Resident #40 was lying on the floor by the bed. Nurse #3 reported that when she arrived in Resident #40's room, Nurse #1, Nurse #2, NA #1, and NA #2 were transferring Resident #40 into bed. Nurse #3 stated after Resident #40 was in the bed she performed an assessment by asking him if he was okay and got his vital signs. Nurse #3 reported she observed his left leg internally rotated and shorter than his right leg. Nurse #3 stated she instructed another staff member to call 911 and began to print out his paperwork at which time she noticed Resident #40 had a Do not hospitalize order in his Electronic Medical Record (EMR). Nurse #3 reported she immediately called the Director of Nursing (DON) and was instructed by the DON to cancel Emergency Medical Services (EMS) and contact the on-call provider because the family would not want Resident #40 to be sent to the hospital. Nurse #3 stated she cancelled EMS and contacted the on-call provider, PA #2, that Resident #40 had internal rotation and shortening of his left leg, at which time PA #2 ordered Ibuprofen 600 milligrams (mg) one time for pain and was instructed to perform neurological checks every four hours. Nurse #3 stated if she had gotten to the room prior to Nurse #1, Nurse #2, NA #1, and NA #2 transferring Resident #40 to bed, she would have instructed them not to move him until she had assessed him and obtained vital signs. A physician's order dated 5/27/2024 at 10:54 pm for Resident #40 revealed an order for an x-ray of the left hip and pelvis written by the MD. The order was entered by Nurse #3 after she called to report Resident #40's left leg was internally rotated and shorter than his right leg. The pain documentation, on the MAR, from 5/27/2024 through 5/28/2024 revealed Resident #40 experienced pain 6 out of 10 during day shift on 5/28/2024 with no time noted and 8 out of 10 on 5/28/2024 at 12:19 pm prior to being transferred to the hospital. A radiology report dated 5/28/2024 at 9:37 am revealed Resident #40 had a dislocation of a left hip arthroplasty (a surgery to restore the hip joint) and an acute fracture of the proximal (close to the hip) left femur noted as new since 1/12/2024. Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:00 pm, as scheduled (6:00 am, 12:00 pm, 6:00 pm, 12:00 am), and documented a pain assessment of 8 out of 10 for Resident #40. The physician's orders dated 5/28/2024 at 12:15 pm written by PA #1 revealed Resident #40 was to give another dose oxycodone-acetaminophen 5-325 mg tablet, one time only, for increased pain. Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, one time, and documented a pain assessment of 8 out of 10 for Resident #40. A review of a PA #1's progress noted dated 5/28/2024 revealed Resident #40 was seen after he fell from bed during the night (5/27/2024). Resident #40 had complained of pain. An x-ray was obtained that revealed a fracture of the left femur with lateral displacement. The PA spoke with the Resident Representative (RR) who agreed to have Resident #40 sent to the hospital for evaluation and possible reduction. On 5/28/2024 at 1:15 pm, PA #1 ordered Resident #40 to be transferred to the hospital. An interview was conducted on 6/4/2024 at 3:19 pm with PA #1. PA #1 reported she was made aware of Resident #40's fall the following day, 5/28/2024 when she arrived at the facility. PA #1 stated she was very familiar with Resident #40 and could tell on 5/28/2024 he was in a lot of pain and was grimacing. PA #1 reported she ordered an additional pain pill to be administered, and ultimately sent him to the hospital for further evaluation. The PA stated Resident #40's leg did not appear to be in the neutral position it should be in. The PA stated she ordered an x-ray on 5/28/2024 which revealed an old dislocation and a new fracture. The PA reported she was not aware staff had transferred Resident #40 back to bed prior to assessing him and obtaining vital signs. The PA stated that if Resident #40's leg was stabilized she could not see a problem with moving him prior to performing an assessment and obtaining vital signs. The PA reported that the facility staff always do things the way they are supposed to and follow protocol. The PA was unsure of what the facility's protocol was for assessing a resident after a fall. The PA reported after she received the x-ray results, she contacted the family, and sent Resident #40 to the Emergency Department for further evaluation. PA #1 verified she had received the x-ray results on 5/28/2024 at 9:37 am but had difficulty reaching Resident #40's RR to get permission to transfer him to the hospital, which caused a delay in his transfer to the hospital. PA #1 reported she was not an expert in orthopedics and was not familiar with traction. The Emergency Medical Services (EMS) report dated 5/28/2024 at 1:43 pm revealed Resident #40 had pointed to his left leg, and made a grimacing face as if to say that it hurt and there was obvious deformity noted in the left hip with inward rotation. Review of ED department evaluation on 5/28/24 Resident #40 presented to the Emergency department after he fell to the ground while transferring from his bed on 5/27/2024. Documentation revealed Resident #40 was complaining of pain and appeared to be less ambulatory. Resident #40 had an x-ray of his left hip and pelvis that demonstrated left hip arthroplasty with an associated fracture dislocation. Resident #40 was admitted to the facility for further evaluation and pain management medications were adjusted (he was administered hydrocodone-acetaminophen 5-325 mg every 6 hours) and his oxycodone was continued. Resident #40 was recommended nonsurgical interventions, he was not a surgical candidate, and was to follow up in two weeks with outpatient orthopedics. Resident #40 was discharged back to the facility on [DATE]. A review of the June 2024 MAR revealed Resident #40 had received oxycodone-acetaminophen 5-325 mg on 6/4/2024 at 12:00 pm, as scheduled. An observation and interview were conducted on 6/4/2024 at 1:16 pm. Resident #40 was lying in bed turned on his right size and pointed to his left upper outer thigh area, made a grimacing face and a squeezing motion with his hands. Resident #40 nodded yes that he had pain and mouthed the pain medication only helped a little. An interview was conducted on 6/5/2024 at 8:41 am with the Director of Nursing (DON). The DON reported she was aware of Resident #40's fall on 5/27/2024. The DON reported she was not aware Nurse #1, Nurse #2, and Nurse #3 failed to assess Resident #40 and obtain vital signs prior to transferring him to bed. The DON stated she expected staff to assess the resident for physical injury/deformity, pain, mental status changes, and obtain vital signs prior to moving a resident after a fall. The DON acknowledged staff could have caused additional harm to the resident if they were not assessed prior to being moved after a fall. The DON stated a Nurse should have assessed Resident #40 prior to transferring him back to bed. She further stated the facility had not investigated the incident because they knew he had fallen. The DON stated Nurse #3 should have contacted the family about Resident #40's condition and to get permission to send Resident #40 to the hospital on the night of the fall, 5/27/2024. The DON reported there was confusion because his advanced directives said to Do Not Hospitalize, so she advised staff to get RP permission. Nurse #3 was sending the resident out and the DON stopped her. An interview was conducted on 6/5/2024 at 3:09 pm with the MD. The MD reported she had been made aware on 5/28/2024 of Resident #40's fall on 5/27/2024 by PA #1. The MD stated PA #1 had Resident #40 sent to the hospital for evaluation because she was concerned how his leg looked. The MD was not aware Resident #40 had been transferred to the bed prior to being assessed or having vital signs obtained. The MD stated the Nurse should have performed a quick assessment to ensure Resident #40 was breathing and had no obvious deformity prior to moving him. The MD stated if there was obvious deformity staff could cause additional harm to the resident. An interview was conducted on 6/7/2024 at 3:23 pm with the Administrator. The Administrator reported he knew Resident #40 fell on [DATE] but had not been made aware Resident #40 had not been assessed prior to transfer back to his bed. The Administrator agreed Resident #40 should have been assessed prior to moving him from the floor to the bed. The Administrator was made aware of Immediate Jeopardy on 6/5/2024 at 11:35 am. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to thoroughly assess resident #40 on 5/27/24 at 10:40 pm after he fell from his wheelchair to the floor on his left side face down. Resident #40 was discovered by his roommate who summoned assistance from staff. Nurse #1, Nurse #2, NA #1, and NA #2 lifted resident #40 under his arms and held traction to Resident #40's left leg and picked him up from the floor and placed him in the bed. Nurse #3 completely assessed Resident #40 and observed that the left leg was internally rotated and shortened. Nurse #1 described left leg as a limp noodle. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after speaking to the Director of Nursing (DON) Nurse #3 cancelled EMS even though Resident #40 had obvious deformity that warranted a higher level of care to manage the resident's comfort needs which could not be met in the facility. On 5/28/24, Resident #40 was further assessed by the provider and sent to the emergency room . The facility failed to identify the resident's obvious injury status post fall requiring a higher level of care. Starting 6/6/24, the Director of Nursing (DON) will review falls within the last 30 days to ensure residents were assessed by licensed nurses identifying obvious injuries prior to being moved to determine if the resident required a higher level of care. All the current residents with falls are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 6/10/24, the Chief Nursing Officer will educate the DON on directing the staff that call regarding falls with injury to the MOST forms and when to notify family and/or EMS. Starting 6/5/24, the Director of Nursing will educate licensed nurses on assessing resident status post falls, to include vital signs, neuro checks, range of motion, skin assessment and pain assessment, prior to being moved. Residents assessed with obvious injuries will be transferred to a higher level of care warranted by their MOST form. The Director of Nursing and clinical team will review falls daily, in clinical meetings, to ensure assessments were completed and if indicated, resident receive a higher level of care. The MOST forms will be reviewed/updated weekly and/or changes in condition by the Social Workers and kept in a binder at both nursing stations. Residents without a MOST form, Staff will notify Resident/Resident's responsible party, along with the provider, on assessment findings and guidance to determine if a higher level of care and services are warranted. Starting 6/5/24, the Director of Nursing and the SDC will educate the licensed nurses to review resident MOST forms before calling Emergency Medical Services and if obvious deformity to include indications of fracture are observed residents should be immediately transferred to a higher level of care because resident's comfort needs cannot be met at the facility. Starting 6/5/24, the Director of Nursing and the Staff Development Coordinator will educate all staff to include the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapy staff, housekeeping/ laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff on ensuring that residents that experience falls are not moved prior to an assessment by a licensed nurse and reporting any changes from baseline immediately to the nurse. Starting 6/5/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary staff, social services, housekeeping/laundry staff, therapy staff, maintenance staff, administrative staff, weekend staff, agency staff and prn staff receive the education. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Effective 6/5/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 6/12/24 A validation of immediate jeopardy removal was conducted on 06/13/24. The inital audit of falls within the last 30 days was reviewed with no issues noted and no residents that required a higher level of care identified. Nursing staff were able verbalize that they had recieved the education that after a fall, no resident was to be moved until assessed for injury by the licensed nurse. Licensed nurses were able to verbalize the steps to assessment including range of motion, vital signs, and neurological checks. They verbalized that if there was obvious injury that would be indicative of a fracture they were to check the MOST from, consult with the residents medial provider, as well as the residents responsible party for direction and the potential need to transfer to the acute care setting. The nursing staff were aware that the MOST forms were kept in a binder at each nursing station. Non nursing staff were able to verbalize that they had recieved education on not moving or touching a resident that had fallen but to immediately alert the licensed nurse. The education was verified to be a part of the new hire orientation packet. The immediate jeopardy removal date of 06/12/24 was validated. 2. Resident #196 was admitted to the facility on [DATE] with a diagnosis of respiratory failure (condition that makes it difficult to breath independently). A review of a care plan dated 12/18/2023 which revealed Resident #196 had an altered respiratory status and difficulty breathing related to respiratory failure with interventions which included monitoring for signs and symptoms of respiratory distress, increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy (lack of energy), confusion, hemoptysis (bloody sputum), cough, pleuritic pain (chest wall pain), accessory muscle usage, and skin color changes. A review of the 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #196 was severely cognitively impaired with no behaviors. Review of a physician order dated 12/25/2023 read; Obtain chest-ray related to increased confusion per family members observation. A review of a radiology report for a 2-view (from the front and from the side of the body) chest x-ray dated 12/25/2024 at 2:16 pm revealed Resident #196 had left lower airspace disease related to either pneumonia or atelectasis. A review of the December 2023 progress notes revealed no progress note indicating a provider was made aware of the abnormal chest x-ray. Review of a physician order dated 12/25/23 read; Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) related to increased confusion per family members observation. A review of the December 2023 progress notes revealed no progress note indicating a provider was made aware of laboratory results or the inability to obtain laboratory results. A review of the Resident #196's December 2023 Medication Administration Record (MAR) indicated Nurse #6 had collected a CBC and BMP on 12/25/2023 at 1:24 am. A review of Resident #196's vital signs collected on 12/26/2023 at 10:15 am revealed a blood pressure of 147/96, heart rate of 98, a respiration rate of 16 breaths per minute, an oxygen saturation of 92%, and a temperature of 97.6 degrees Fahrenheit. A review of a nursing assessment dated [DATE] at 11:23 am revealed Resident #196 was confused, had crackles/rales (wet sounds), and pitting edema (swelling). A review of Resident #196's vital signs collected on 12/26/2023 at 1:24 pm revealed a blood pressure of 168/89, heart rate of 102, a respiration rate of 16 breaths per minute, no oxygen saturation was obtained, and a temperature of 98.8 degrees Fahrenheit. A review of a nursing note dated 12/26/2023 at 1:47 pm written by Nurse #5 which revealed the MD had been contacted regarding a change in Resident #196's condition and was advised to transfer Resident #196 to the hospital. A review of a nursing note dated 12/26/2023 at 2:03 pm written by Nurse #5 revealed Resident #40 had been transferred to the hospital with Emergency Medical Services. A review of the EMS record dated 12/26/2023 at 2:09 pm revealed Resident #196 was diagnosed with pneumonia via a chest s-ray and staff reported Resident #196 had been lethargic and not acting normally. Nursing staff reported the facility physician requested Resident #196 to be sent to the hospital. EMS documented vital signs which read; heart rate of 104, blood pressure 123/77, and an oxygen saturation of 93% on 3 liters of oxygen per minute. A review of the Emergency Department documentation dated 12/26/2023 revealed Resident #196 had presented with altered mental status and shortness of breath. Resident #196 was admitted to the intensive care unit with acute hypoxemic respiratory failure (decreased oxygen saturation without increased carbon dioxide) and sepsis (severe infection). Resident #196 had an oxygen saturation of 83% on 6 liters of oxygen per minute on arrival to the Emergency Department and was placed on the BiPAP. An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #6. Nurse #6 reported she worked on 12/24/2023 during the night shift (7:00 pm to 7:00 am) and was assigned Resident #196. Nurse #6 stated after she had started her shift, Resident #196's Representative (RR) reported Resident #196 had acted more confused. Nurse #6 stated she called the provider on-call and was given orders to obtain laboratory testing and a chest x-ray. Nurse #6 reported she had not obtained laboratory testing that night because she never drew blood at night and was not able to draw blood. Nurse #6 was not able to recall documenting that she had collected Resident #196's labs, and was not sure why it was documented that she had on the MAR. An interview was conducted on 6/4/2024 at 4:07 pm with PA #2. PA #2 reported she was notified by Nurse #6 on 12/24/2023 that Resident #196 was confused and had a cough. PA #2 reported she ordered laboratory testing and a chest x-ray. PA #2 stated she was never called about the results of the laboratory testing or chest x-ray. PA #2 reported she was not on-call 12/25/2024, and that the on-call provider that day should have been notified. An interview was conducted on 6/4/2024 at 10:23 am with Nurse #5. Nurse #5 stated she worked 12/26/2024 and was assigned Resident #196. Nurse #5 stated she recalled Resident #196 had a chest x-ray performed that day, but she had not seen the results. Nurse #5 stated radiology reports would come over the fax machine and a Nurse or the Director of Nursing (DON) would contact the provider on call. Nurse #5 stated she had not notified the on-call provider because she had not received the radiology report and indicated if she had received it, she would have called the provider on call. Nurse #5 reported she had not called to check the results of the chest x-ray. Nurse #5 reported she had not collected laboratory testing on Resident #196 because she was not prompted to do so on the computer system used in the facility. Nurse #5 stated she thought the labs had been completed since Nurse #6 had checked the collection off on the MAR. Nurse #5 stated when she arrived on shift 12/26/2023, she had given medications to Resident #196 and noticed he was confused but was responsive and answering questions. Nurse #5 reported she had checked on him hourly. Nurse #5 stated around lunchtime (11:30 am) she noticed Resident #196 had pitting edema (swelling), crackles (wet lung sounds), and was only responsive to painful stimuli. Nurse #5 stated Resident #196 continued to wear oxygen at 3 liters per minute. Nurse #5 reported she notified the physician, at the time documented in the Electronic Health Record (EHR), 1:47 pm and received an order to send Resident #196 to the Emergency Department. Nurse #5 was unsure why there was an approximately 2-hour delay in her notification to the MD and she obtained one set of vital signs prior to transfer and was unable to recall if she obtained an oxygen saturation or not. Nurse #5 reported she transferred Resident #196 to the Emergency Department via Emergency Medical Services (EMS) at 2:04 pm. An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #7. Nurse #7 stated she worked on 12/25/2024 on night shift (7:00 pm to 7:00 am). Nurse #7 was assigned Resident #196 and was not able to recall receiving chest x-ray results during her shift and had not called to check on them. Nurse #7 stated if she received it she would called the on call provider with the results. Nurse #7 stated she would assume dayshift had notified the provider since it had resulted during dayshift. Nurse #7 reported she drew blood at night if it was ordered but was not able to recall Resident #196. An interview was conducted on 6/5/2024 at 3:32 pm with the MD. The MD reported she had been contacted by Nurse #5 on 12/26/2023 at 1:47 pm that Resident #196 had a change in condition and was less responsive. The MD stated Nurse #5 had not informed her Resident #196 was only responsive to painful stimuli at 11:23 am on 12/26/2023. The MD stated she would expect Nurses to notify the MD as soon as possible with mental status changes. An interview was conducted on 6/7/2024 at 8:37 am with the Director of Nursing (DON). The DON stated abnormal radiology results were faxed to the facility. The DON stated Nurses checked the fax machine routinely for results and were to notify the on-call provider of any results. The DON also reported she obtained results from labs and radiology every morning and notified the provider as well. The DON confirmed there was no indication in Resident #196's medical record that the on-call provider had been notified of the x-ray or that nursing staff had called to check on the results of the chest x-ray. The DON stated she assumed it was because the report was not marked as alert which would usually indicated to staff the provider should be contacted. The DON reported laboratory tests were to be drawn and sent out. She stated the facility utilized an outside phlebotomist, but that Nurses could draw labs and use the courier until a certain time. The DON stated after the courier hours were over, if the resident had l [TRUNCATED]

Based on observations, record review, staff, and Medical Director interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by Nurse Aide (NA) #3, NA #4, and NA #5 and continued for 7 minutes without a backboard. The backboard creates a hard surface for effective compressions that allow for adequate recoil (allowing the chest to fully expand after compression which pushes the blood to vital organs) and ensure perfusion for vital organs. During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. NA #3 and NA #4 were not certified in CPR for Healthcare Providers. Emergency Medical Services (EMS) arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired. This deficient practice was for 1 of 1 resident reviewed who required CPR. Immediate Jeopardy began on [DATE] when staff administered CPR without the use of backboard and delivered compression that were not effective. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: Review of the facility's CPR policy revised [DATE] read in part, Requirements for CPR: 1. Personnel must provide basic life support, including CPR to a resident who requires such emergency care prior to arrival of emergency medical personnel. 2. Properly certified and trained staff must be available at all times. 3. Supplies (crash cart) a. backboard, b. face shield and resuscitator (ambu bag), c. automated external defibrillator (if available), d. oxygen mask, tubing, cannula, and tank, e. suction machine and equipment, and f. vital sign equipment to include pulse oximetry. Resident #70 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, chronic respiratory failure, and history of pulmonary embolism. Review of a care plan initiated on [DATE] read, Advance Directive Full Code. The intervention included: advance directive will be followed as ordered. A physician order dated [DATE] read, Full code. The quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #70 was cognitively intact, and he required assistance with activities of daily living. An interview was conducted with the Business Office Manager on [DATE] at 10:10 AM, she stated that she was completing her angel rounds in the facility on [DATE] and she went into Resident #70's room and he did not look right. She stated she asked Resident #70 if he was ok, and he did not respond so she went and asked NA #4 to come and check on him. She stated that when NA #4 saw Resident #70's he stated he passed away but all the nurses came and started life saving measures and she stayed out of the way. An interview with the Activity Assistant was conducted on [DATE] at 10:13 AM who stated on [DATE] she was passing out activity information to the residents and the Business Office Manager said Resident #70 does not look right. She stated she went into his room, and he was sitting straight up in bed with his head on the pillow and was white as snow with black lips. The Activity Assistant stated that they grabbed NA #4 and the Director of Nursing (DON), and nursing staff attempted life saving measures. The Scheduling Coordinator was interviewed on [DATE] at 9:45 AM. She stated on [DATE] the DON had instructed her to overhead page Code Blue and to call EMS. She stated she stayed on the phone with EMS until they arrived at the facility with the DON next to her in case, they needed any information that she could not provide. A continuous observation was made on [DATE] at 9:48 AM to 10:13 AM. At 9:48 AM an overhead page was heard in the facility Code Blue Resident #70's room number, Upon arrival at Resident #70's room, the surveyors stood in the hallway outside of Resident #70's room where the scene was visible but not in the way of emergency personnel. There were three male NAs later identified as NA #3, NA #4, and NA #5 starting Cardiopulmonary Resuscitation (CPR). Resident #70 was pale but had no signs of lividity (pooling of blood) and did not appear rigid. After lowering the head of Resident #70's bed NA #5 began performing chest compressions without placing a backboard under Resident #70. When the crash cart arrived at the room at 9:52 AM NA #4 began delivering rescue breathes via an ambu bag (artificial manual breathing unit). NA #4 and NA #5 continued to provide rescue breaths and compression for 5 minutes when NA #5 stopped compressions and NA #3 started compressions. The Staff Development Coordinator who was observed to deliver the facility's crash cart and vital sign machine at 9:52 AM, arrived at the room along with Nurse #4 and began assisting. Nurse #4 was overheard instructing NA #3 that his compressions were not deep enough, and he needed to push harder to create recoil. NA #3 was overheard saying he did not want to break Resident #70's ribs. Nurse #4 continued to coach NA #3 until she took over compressions. At 9:55 AM EMS and fire rescue arrived on scene and began questioning why Resident #70 was not on a backboard. When the Captain of Fire Rescue asked about the backboard, the Staff Development Coordinator began attempting to remove the headboard from the bed but was initially unable to remove it. After multiple attempts to remove the headboard the Staff Development Coordinator realized that there was pins holding the headboard in place, she pulled the pins and the headboard was removed. Staff were observed to remove the headboard of the bed and log roll Resident #70 onto his side and place the headboard under Resident #70 at 9:57 AM and then EMS continued CPR efforts. At 10:03 AM the Captain of the Fire Rescue demanded to see the Director of Nursing (DON) and when she arrived at the room inquired why there was no backboard under Resident #70 when CPR was initiated. He stated, this is a skilled nursing facility, and they should have the needed equipment in place when we get here. EMS continued with rescue efforts, but they were unsuccessful, and they called time of death 10:13 AM. The EMS report dated [DATE] read in part, patient was found by staff pulseless and apneic in his room but still warm to touch. CPR started. Arrived on scene, patient found pulseless and apneic and staff started CPR 5 minutes ago. He has a history of respiratory failure and pulmonary embolism. His skin is mottled, and he appears to have a bluish hue from the neck up. NA #5 was interviewed on [DATE] at 1:53 PM and stated that someone he could not recall who, alerted him that Resident #70 did not have a pulse and was pale. NA #5 stated that he was CPR certified and he went into Resident #70's room and began chest compressions until the crash cart arrived with the ambu bag. He stated that NA #4 began using the ambu bag and he continued chest compressions until he got tired and then he switched off with NA #3. NA #5 stated he did what he was trained to do in his CPR class. NA #5 was also unaware where the crash cart and back board were located. NA #5 stated he had been trained to verify code status and initiate compressions, which is what he did. NA #4 was interviewed on [DATE] at 3:20 PM, who stated on [DATE] he was passing out isolation gowns going from room to room and when he got to Resident #70's room he was sitting straight up in bed and was slumped over. NA #4 stated he immediately went and got the DON from her office and when he returned to the room NA #5 was putting the head of bed down to start chest compressions. Nurse #4 arrived at the room and when the crash cart arrived, she started using the bag and after about 5 minutes NA #5 got tired and they switched off. NA #4 stated he did compressions for a bit and then switched off with NA #3. He added that they did not have a backboard under Resident #70 until EMS arrived and he heard them ask where the backboard was located. NA #4 stated when EMS arrived, he stepped out of the way. He added that he had completed his CPR training online, but his certification had expired. NA #4 stated he had some training when he was hired but could not recall what they trained him on and added he did not do direct patient care very often because his main job was central supply. During compression NA #4 stated he was counting them and someone else was using the bag. NA #3 was interviewed via phone on [DATE] at 8:57 AM. NA #3 stated that on [DATE] he arrived at work at 7:05 AM and started his rounds working from the bottom of the hall to the top. He stated he went in and spoke to Resident #70, and the resident appeared to be his usual self. He stated that breakfast trays arrived at the unit, and he passed those out and began assisting some of the residents that needed assistance. NA #3 stated he had just finished feeding one of his residents and walked out into the hallway and heard two staff members, one from the business office and one from activities but he did not know their names saying that something was wrong with Resident #70, so he went to go and check on him. He stated when he got to the room, he could tell that something was wrong, so he went to alert the DON. He stated that staff began to arrive at the room, and someone began chest compressions until the crash cart arrived, but he was not sure who. NA #3 stated that he did assist with chest compressions and recalled Nurse #4 telling him his chest compressions had to be deeper. NA #3 stated he was hesitant because he did not want to crack Resident #70's bones and the Staff Development Coordinator took over compressions until EMS arrived. He stated that he stayed back out of the way until EMS arrived then he left room. He added that he had only been employed at the facility for a short time and his CPR certification had expired and was no longer valid. NA #3 stated that he did realize that there was no backboard under Resident #70 but was not sure if they needed one or not. A nurses note dated [DATE] at 7:34 PM written by Nurse #4 read; Resident was found unresponsive with brown vomit coming from his mouth. His pulse was checked, and chest compressions initiated and continued until EMS arrived. The time of death was 10:13 AM per EMS and fire department. Resident's family members, the DON and covering Medial Director (MD) were notified. Funeral home was called to pick up the resident body. The body left at 2:06 PM. No medication or treatment rendered. Nurse #4 was interviewed via phone on [DATE] at 9:08 AM. Nurse #4 recalled that on [DATE] she was at her medication cart on the 200 hall, and someone told her that there was a code in the building on the 400 hall. Nurse #4 stated she secured her medication cart and went to Resident #70's room. The Staff Development Coordinator had gone to get the crash cart and vital sign machine. Compressions had already been started by NA #5 and she stated she told NA #5 if he got tired to let her know. She stated when the Staff Development Coordinator returned with the vital sign machine, she checked vital signs and there were none. Nurse #4 stated she realized at that time that there was no backboard under Resident #70. She stated that the staff attempted to get the headboard off the bed to place under him but there were pins holding it in place. Once they were able to get the pins out, they pulled the headboard off, log rolled Resident #70 onto his side and put the headboard under him. Nurse #4 stated it was very chaotic and she could not recall the actual sequence of events but at some point, NA #3 switched over to do compressions on Resident #70 and she realized that his compressions were not effective and there were not creating recoil. Nurse #4 stated NA #3 stated that he did not want to break Resident #70's rib and I coached him and told him to go deeper your compressions have to be effective. When Nurse #4 realized that NA #3's compressions were still not effective they switched off to another staff member. Shortly after that EMS and fire rescue arrived and took over the scene. Nurse #4 stated she was not aware that the facility's backboard was not on the crash cart but knew that it was supposed to be on the cart. Nurse #4 confirmed that she was trained in CPR by the American Heart Association but had not received any training on cardiac arrest or emergency response in the facility. The Staff Development Coordinator was interviewed on [DATE] at 10:27 AM. She stated she started with the facility last week and on Monday morning she saw the DON in the hallway, and she asked her to go to [Resident 70's room] and run the code. The DON asked her to grab the crash cart, but she did not know where it was located and was told it was in the conference room. The Staff Development Coordinator explained after grabbing the crash cart from the conference room she took it to Resident #70's room and handed the ambu bag over to Nurse #4 and the staff that were in the room performing compressions switched positions. She stated when she arrived at Resident #70's room chest compressions were already in progress by Nurse #4, and she believed NA #3 and NA #4 were also in the room. Nurse #4 asked her to get the vital sign machine, so she did and when she returned to the room NA #3 was delivering chest compressions. The Staff Development Coordinator stated that she did realize that there was not a backboard under Resident #70, and she knew that there was not a backboard on the crash cart, and she thought it was better to start chest compressions without it then to take the time to search the building for the backboard. While NA #3 was delivering compressions she realized that his compressions were not effective, and she tried to coach NA #3, but he stated that he was worried about cracking Resident #70's ribs. The Staff Development Coordinator stated she took over compressions from NA #3 until EMS arrived on the scene. She added that they were able to remove the headboard of the bed and place that under Resident #70 and continued CPR with EMS taking over the scene. The DON was interviewed on [DATE] at 11:14 AM. The DON stated on [DATE] NA #4 came to her office and told her to come to Resident #70's room. She stated when she went to Resident #70's room he had no radial pulse and was warm to touch, and the Medication Aide was behind her at her computer and stated Resident #70 was a full code. The DON stated she instructed the Scheduling Coordinator to overhead page code blue and to call EMS. The DON stated all the nursing staff started to arrive at Resident #70's room, the Staff Development Coordinator grabbed the crash cart, and they began CPR. The DON stated she did not participate in CPR and stayed out of the way of the other nursing staff. She was unaware that NA #3 and NA #4 that were participating in CPR were not trained, and that the compressions NA #3 were delivering were not effective until today. The DON stated that anyone that was not trained in CPR should not administer CPR. She explained she had been at the facility since [DATE], and she had not had consistent staff and no one to oversee the training program. The Staff Development Coordinator was only recently hired and had not had time to develop and implement all the things that needed to be done at the facility. The DON further explained the backboard was supposed to be on the crash cart so all the required equipment would be available to the staff and the staff should have put the backboard under Resident #70 before beginning chest compressions. The DON also confirmed that the staff were not aware the crash cart was in the conference room due to the remodeling of the nursing station office and that they should have been aware of where the crash carts were located. An observation of the crash cart at nursing station #1 ([DATE]/400) nursing station on [DATE] at 12:35 PM revealed the cart to be stocked with an ambu bag and backboard along with numerous others supplies that would be required for an emergency. There was no checklist located on the cart. The Administrator was interviewed on [DATE] at 4:10 PM who stated he had been at the facility for a few months. He stated that until recently they had a vacancy in the Staff Development Coordinator position and that there was a lot gaps in the training program that they were trying to get filled. The Administrator stated that if staff were not certified in CPR, then they should not have been participating in CPR and the staff that were involved should have ensured the correct equipment was being used. The Medical Director (MD) was interviewed on [DATE] at 2:55 PM. She stated that the DON had called and told her about Resident #70 on [DATE]. She stated that Resident #70 had severe Parkinson's disease and had declined since coming to the facility. The MD stated that potentially Resident #70 may have aspirated but she was not for sure. The MD stated she was not familiar with the protocol for CPR or Emergency Response in the building, but she had always told the facility to call EMS before calling her. She stated that only staff trained in CPR should be performing CPR and the trained staff should know the basics of CPR which included placing a backboard under the resident to ensure effective chest compressions. The MD stated I do not think that not having a backboard under Resident #70 would have changed his outcome. The Administrator was notified of the immediate jeopardy on [DATE] at 5:13 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered effectively when Resident #70 went into sudden cardiac arrest and CPR was initiated by 3 Nurse Aides (NA) without the use of a backboard and 2 of the NAs were without CPR certification. Starting [DATE], the Staff Development Coordinator (SDC) will complete an audit of the current CPR status of the nursing staff to include licensed nurses, certified nursing assistants, certified medication aides and agency nursing staff. The SDC will provide a CPR list of the nursing staff with current CPR certifications at each nursing station. Only certified CPR staff that are listed on the CPR list will be allowed to perform CPR. The Director of Nursing (DON), SDC, and nursing supervisor will be responsible for reviewing the daily staffing to ensure a CPR certified staff is working each shift. On [DATE], the 2 facility CPR carts were checked by the Staff Development Coordinator to ensure missing supplies were replaced on the carts and both carts have back boards. On [DATE], the DON will place the crash cart checklist on nursing station #1's crash cart and ensure that the crash cart checklist is in place on nursing station #2's crash cart. Starting [DATE], the SDC will educate the night shift licensed nurses on completing the crash cart checklist sheet on nursing station #1(100,200,300, 400 halls) and nursing station #2 (500, 600, 700 halls). The night shift licensed nurses will be responsible for completing the crash cart checklists each night and ensuring the carts are stocked, and the back boards are in place. All the current residents who have full code status are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting [DATE], the Director of Nursing and the Staff Development Coordinator (SDC) will educate the nursing staff to include the licensed nurses, certified medication aides, and the certified nursing assistants on the CPR policy to include ensuring only nursing staff certified to perform CPR with current CPR certification status will be allowed to perform CPR, and making sure the back board is in place before initiating CPR to ensure that chest compressions are effective and allow for chest recoil. A list of the nursing staff with current CPR certifications will be placed at each nursing station. Nursing staff will not be allowed to perform CPR without their name listed on the CPR list and without a current CPR certification. The CPR list will be updated weekly by the SDC, to include newly hired and/or agency staff's CPR expiration and renewal dates. By [DATE], the Director of Nursing/Staff Development Nurse will conduct a mock Code Blue drill for training purposes on the 7am -7pm shift and 7pm- 7am shift. The Director of Nursing/Staff Development Nurse will conduct a mock Code Blue drill monthly thereafter. Starting [DATE], the Staff Development Coordinator (also a Certified CPR instructor) will begin teaching the American Heart Association CPR class and certifying staff pending their post class passing test scores. The class will be provided for staff whose CPR certifications are expired or staff without CPR certification. Starting [DATE], the Director of Nursing and the SDC will educate the licensed nurses on ensuring that the CPR crash carts are being checked daily, after use and the back board is in place. The night shift licensed nurses will be responsible for completing the crash cart checklist sheet each night and ensuring that the CPR crash carts are stocked, and the back boards are in place. The DON will be responsible for checking the CPR crash carts and reviewing the daily CPR crash cart checklist for completion weekly to ensure continual compliance. Starting [DATE], the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all nursing staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), weekend, agency and prn staff receive the CPR education. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] A validation of immediate jeopardy removal was conducted on [DATE]. The list of current staff certified in CPR was located in a binder at each nursing station. In addition, those staff that were certified were highlighted on the daily schedule, so they were easily identified by all staff. Both crash carts were located in the building, one at each nursing station, the logbook was on each cart and had been checked each night since [DATE]. A mock code blue had been conducted on each shift and staff responded accordingly. Interviews with the scheduling coordinator revealed that she ensured staff certified in CPR were scheduled on each shift. Interviews with other nursing staff revealed that they had been educated on where the crash carts were located, their role in emergency response, and how to identify which staff were certified in CRP. They were also able to verbalize that only staff certified in CPR should participate in CPR. The IJ removal date of [DATE] was validated.

Based on record reviews, resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect by failing to comprehensively assess a resident prior to moving the resident off of the floor following a fall with injury, seek immediate medical treatment or hospitalization to provide the necessary care and services to the resident, and provide effective pain management. On 5/27/24 Resident #40 sustained a fall with injury and a comprehensive assessment was not completed prior to transferring the resident to bed. The resident's left leg was observed internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. The resident was medicated with a one-time dose of Ibuprofen (pain medication, decreases inflammation) 600 milligrams (mg) in addition to the resident's routine order for oxycodone-acetaminophen 5-325 mg (narcotic pain medication) every 6 hours. This was not effective to manage the resident's pain as evidenced pain scale ratings of an 8 out of 10 (with 10 being the worst pain possible) and non-verbal signs of pain that included crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. This deficient practice occurred for 1 of 3 residents reviewed for neglect (Resident #40). Immediate jeopardy began on 5/27/2024 when staff neglected to provide the necessary care and services to Resident #40 following a fall with injury. Immediate jeopardy was removed on 06/12/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: This tag is cross-referenced to: F684: Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice was identified for 1 of 3 residents reviewed for change of condition (Resident #40). F697: Based on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of the resident's chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directed that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. Nurse #3 notified the provider on-call and obtained an order for a one-time dose of Ibuprofen (pain medication, decreases inflammation) to be given for pain and a left hip/pelvis x-ray. Nurse #3 administered that medication as well as oxycodone-acetaminophen 5-325 mg (pain medication) that was scheduled (for every 6 hours) at 12:00 am and Resident #40 continued to grimace in pain throughout the remainder of her shift. Nurse #3 administered the 6:00 am oxycodone-acetaminophen. Nurse #10 administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, and documented a pain assessment of 8 out of 10 for Resident #40. An x-ray was performed in the facility on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone) and Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice occurred for 1 of 3 residents (Resident #40) reviewed for pain management. The Administrator was notified of Immediate Jeopardy on 6/5/2024 at 11:35 am. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility neglected to thoroughly assess resident #40 on 5/27/24 at 10:40 pm after he fell from his wheelchair to the floor on his left side face down. Resident #40 was discovered by his roommate who summoned assistance from staff. Nurse #1, Nurse #2, NA #1, and NA #2 lifted resident #40 under his arms and held traction to Resident #40's left leg and picked him up from the floor and placed him in the bed. Nurse #3 completely assessed Resident #40 and observed that the left leg was internally rotated and shortened. Nurse #1 described left leg as a limp noodle. The facility neglected to ensure Resident #40 immediately received the necessary care and services from a higher level of care after sustaining an obvious injury status post fall, effective pain management strategies identified through his assessment, and neglecting to implement identified services according to Resident #40's MOST form. Resident #40 still resides in the facility and continues to participate in his Plan of Care receiving all necessary care and services to include a pending orthopedic follow-up appointment. Awaiting the orthopedics office to review the referral documentation and provide the facility with the appointment date. Resident #40 is currently on an increased frequency of Oxycodone 5/325 mg PO Q4 hours. Resident #40's pain is assessed prior to scheduled routine administration, in addition to his routine pain assessment every shift identifying nonverbal pain including facial grimacing, moaning, and crying. On 6/7/24, the Chief Nursing Officer and Director of Nursing reviewed Resident #40's medical records documentation revealing he's receiving all necessary care and services. All current residents have the potential to be affected by this deficient practice. On 6/7/24, the Chief Nursing Officer and Director of Nursing reviewed risk management events of falls with obvious injuries within the last 30 days, as well as alert and oriented interviewed with pain issues. No residents were identified requiring a higher level of care and/or current ineffective pain management regimens were identified. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 6/7/24, the Chief Nursing Officer educated the Director of Nursing on the process at the time of an event ensuring residents immediately receive a higher level of care for obvious injuries, effective pain management strategies implemented and understanding MOST forms in relation to residents' immediate needs after an event. Education includes when the MOST form indicates comfort measures are to be implemented and the facility's unable to manage, the resident should be provided services and care at a higher level. At no time will the DON direct the facility staff to neglect providing the necessary services required from a higher level of care following an obvious injury or ineffective pain management strategies be acceptable standards of practice. The Director of Nursing, along with the clinical team, will review all falls/incidents daily in the clinical meeting to determine if the event required residents to receive a higher level of care and/or the need for additional care and services. The pain assessment conducted with each event will be reviewed during the clinical meeting for immediate interventions implemented and real time effectiveness. The clinical team will also review the MOST forms to ensure facility's compliance with resident/responsible party's wishes. If the post assessment following pain interventions are not effective, the Director of Nursing, along with the clinical team, will notify the clinicians of its ineffectiveness and implement additional and/or alternative measures as indicated. Starting 6/7/24, The Director of Nursing/Staff Development Coordinator will in-service all facility staff (including contracted agency staff) on Neglect, including failing to provide the necessary care and services from a higher level of care and effective pain management strategies following an event with obvious injuries. The Director of Nursing/Staff Development Coordinator will educate all new hires during orientation and scheduled contracted agency nurses prior to working their shift. The Administrator and Chief Nursing Officer will ensure all facility staff (including contracted agency staff) are educated. Effective 6/10/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 6/12/24 A validation of immediate jeopardy removal was conducted on 06/13/24. The inital audit of residents records and pain interviews with alert and oriented residents were reviewed with no issues noted. Staff interviews across all departments were able to verbalize that they had recieved the education on neglect, how to respond if they were aware of neglect, and who to immediately report it to. The staff were able to verbalize examples of neglect and ways to identify neglect. Nursing staff were able to verbalize the need to review residents MOST forms after falls with injury and the need to contact the residents responsible party if the resident required a higher level of care. Nursing staff were also able to verbalize the pain assessment protocol and who to report any changes in pain or ineffectiveness of currently scheduled pain medication. The immediate jeopardy removal date of 06/12/24 was validated.

Based on record review, and staff and Resident Responsible Party (RP) interviews the facility failed to permit a resident (Resident #346) who required skill nursing services to return to the facility after being sent to the Emergency Department (ED) for evaluation on 07/08/2023 after he cut himself with a soda can. On 7/11/2023, Hospital Social Worker #1 contacted the Admissions Coordinator at the facility and informed her that Resident #346 had been cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued involuntary commitment (IVC) paperwork had been reversed. The facility did not accept Resident #346 for readmission. The hospital sent Resident #346's skilled nursing referrals to 50 other skilled nursing facilities and was unable to place Resident #346. Resident #346 remained in the Emergency Department until he was discharged home on 7/19/2023 with his elderly parents who were not physically able to care for him. Emergency Department documentation revealed Resident #346 had acquired a deep tissue injury to his left heel at the skilled nursing facility, prior to arrival at the Emergency Department on 7/8/2023 that required wound care. The deficient practice was identified for 1 of 3 residents reviewed for discharge (Resident #346). Resident #346 was transferred to the Emergency Department on 07/08/23 and was treated and stabilized on 07/11/23. Resident #346 remained in the Emergency Department from 07/11/23 through 07/19/23 while awaiting discharge plans. The reasonable person would be anxious, scared, and fearful of being the Emergency Department for such an extended period of time. The findings included: A review of an initial referral dated 6/28/2023 for Resident #346 revealed he had been hospitalized since 6/25/2023 for aggression, depressed mood, and suicidal ideation. Documentation revealed Resident #346 had been stabilized in the Emergency Department and was not a candidate for inpatient psychiatric services due to his acute medical needs and total care needs that required management outside the inpatient psychiatric setting. On the cover sheet of the initial referral was a handwritten note that read; patient had behaviors at arrival due to drug resistant Urinary Tract Infection (UTI), he has gotten on the right antibiotics and has had no behaviors since. Resident #346 was admitted to the facility on [DATE] with diagnoses which included bipolar, anxiety, post-traumatic stress disorder, and major depressive disorder. A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #346 was cognitively intact and was coded as feeling down, depressed, and hopeless, had trouble falling asleep, felt tired/little energy, poor appetite, felt bad about self, had trouble concentrating, and had thoughts he would be better off dead. Resident #346 was coded as having physical behavioral symptoms directed towards others (1 to 3 days), verbal behavior symptoms directed towards others (1 to 3 days), and other behavioral symptoms not directed towards others (1 to 3 days). The behaviors were coded as putting Resident #346 at significant risk for physical illness or injury, interfering with Resident #346's care, and interfering with Resident #346's participation in activities and social interactions. Resident #346 was coded as placing others at risk of physical injury. Resident #346 was coded as requiring maximum assistance for toileting (had an indwelling catheter and was always incontinent of bowel), bathing/showering, substantial/maximal assistance with lower body dressing and putting on/taking off footwear, partial/moderate assistance with upper body dressing, supervision/touching assistance with oral hygiene, and was independent for eating. Resident #346 was coded as requiring substantial/maximum assistance with rolling left to right and retuning to lying on back in bed, from lying to sitting and was dependent for chair/bed-to-chair transfers. Resident #346 was coded as using a wheelchair and was not ambulatory. Resident #346 was not coded as having a pressure ulcer or injury. A review of a care plan dated 7/6/2023 revealed Resident #346 was admitted short term, had verbally aggressive behaviors towards staff, had behaviors which included throwing objects, playing loud music, fabricating stories, physically aggression towards staff, and Resident #346 had not been care planned for a history of suicidal ideation. A review of a nursing note dated 7/7/2023 at 12:28 pm written by the DON revealed Resident #346 threw his lunch tray in the hall and refused to take his medications. Staff received orders to send Resident #346 to the Emergency Department due to behaviors and refusal to take medications. A review of a nursing note dated 7/7/2023 at 8:30 pm written by the DON revealed PA #1 was in the facility when Resident #346 struck a staff member in the abdomen. The Social Worker (SW) and nursing staff went to the Magistrate's office where they were denied involuntary commitment (IVC) papers and instructed staff to call law enforcement to report Resident #346 hitting a staff member. A review of a nursing note dated 7/7/2023 at 8:31 pm revealed Resident #346 was found to be in the courtyard where he had thrown garbage and taken the facility's fire extinguisher and sprayed it all over the ground. Resident #346 had refused to take his medications and yelled at a Nurse Aide (NA). A review of a nursing note dated 7/8/2023 at 9:29 pm written by Nurse #8 revealed Resident #346 rang his call bell. When the staff arrived at Resident #346's room, he had cut himself with a soda can and cut himself on the top area of his right leg. Resident #346 then stated, I am suicidal, and I want to go to the hospital. An interview was conducted on 6/6/2024 at 3:55 pm with Nurse #8. Nurse #8 stated she worked on 7/8/2024 during night shift (7:00 pm to 7:00 am) and was assigned Resident #346. Nurse #8 stated a staff member had come and gotten her to check on Resident #346. Nurse #6 stated when she arrived at Resident #346's room, she observed blood on his upper thigh and had been cutting himself with a soda can. Nurse #8 reported she removed the can from Resident #346's room, had a staff member stay with him and contacted the Director of Nursing (DON). Nurse #8 stated the DON told her to contact law enforcement and Emergency Medical Services (EMS) to have him sent to the Emergency Department. Nurse #8 reported she given report to EMS, notified Resident #346's RP and transferred him to the hospital. A review of the Emergency Department records revealed the following: An Emergency Department note dated 7/8/2023 at 11:46 pm revealed Resident #346 was presented to the Emergency Department via EMS for suicidal ideation. An Emergency Department note dated 7/11/2023 at 10:30 pm revealed Resident #346 had been seen by mental health staff and was started on a mood stabilizer. An Emergency Department note dated 7/12/2023 at 10:59 am revealed Resident #346 had rested comfortably overnight without any issues. Resident #346 was found to have a Urinary Tract Infection (UTI) and was started on antibiotics. The medical team discussed Resident #346 was not homicidal or suicidal and continued to seek placement in a skilled nursing facility. A review of the Emergency Department record dated 7/19/2023 at 1:02 pm revealed Resident #346 was discharged home with his RP. An interview was conducted on 6/7/2024 at 11:49 am with Hospital Social Worker #1. Hospital Social Worker #1 stated she contacted the facility's Admissions Coordinator on 7/11/2023 and was told that the facility would not accept Resident #346 back until he had received in-patient psychiatric services. Hospital Social Worker #1 informed the Admissions Coordinator that Resident #346 was cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued IVC had been reversed and the Admissions Coordinator stated the facility would not take Resident #346 back. The Hospital Social Worker stated she had sent referrals to over 50 skilled nursing facilities and was never able to place Resident #346. The Hospital Social Worker stated Resident #346 was sent home to be cared for by his parents on 7/19/2023. An interview was conducted on 6/6/2024 at 4:54 pm with the Admissions Coordinator. The Admissions Coordinator stated she was employed at the facility on 7/11/2023 and no longer worked at the facility. The Admissions Coordinator stated she remembered Resident #346's RP really wanted him to reside long term at the facility when he was admitted . The Admissions Coordinator stated the facility had sent Resident #346 to the hospital for psychiatric reasons and was told by the DON not to accept Resident #346 back to the facility because he needed to be in a psychiatric facility. The Admissions Coordinator was unable to recall any communication with the hospital after Resident #346 was transferred for evaluation. A telephone interview was conducted on 6/6/2023 at 11:17 am with Resident #346's RP. The RP stated Resident #346 was sent to the Emergency Department on 07/08/23 because the facility staff had stated he was suicidal. The RP reported that while Resident #346 was being stabilized in the hospital he went to the facility to speak with the DON about Resident #346 returning after discharge and was told by the DON, they would not take him back. The RP stated the hospital never could find Resident #346 anywhere to go, and that he (the RP) would have to take him home. The RP stated he was the primary caregiver for Resident #346 after discharge and struggled to take care of Resident #346 and his elderly spouse who had end-stage Parkinson's disease, while he continued to work fulltime. An interview was conducted on 6/6/2024 at 9:22 am with facility Social Worker (SW) #1. SW #1 reported she remembered Resident #346 and his transfer to the hospital. SW #1 reported she had not called the hospital, sent a transfer/discharge notice, or bed hold documentation to the family because the hospital was his safe discharge. SW #1 was unable to recall if the DON had informed her, they would not accept Resident #346 back to the facility. An interview was conducted on 6/6/2024 at 9:28 am with the DON. The DON reported Resident #346 had been sent to the hospital for suicidal ideation on 7/8/2023. The DON stated prior to his transfer to the ED he had been aggressive towards the staff and had hit one of the nurses. The DON reported the facility was not able to manage his behaviors. The DON reported she discharged him to the hospital with the intent of not taking him back to the facility because she was worried about the safety of the residents and staff. The DON stated the Admissions Director was aware that he had a history of behaviors, aggression, and suicidal ideation, but had not informed her until right before he arrived at the facility on 06/29/23. The DON stated she never would have accepted Resident #346 if she had known that prior to his admission. The DON reported she never followed up with the hospital once he was transferred and stated the RP had come to the facility and asked multiple times for Resident #346 to be taken back and she informed the RP she would not accept him back to the facility. An interview was conducted on 6/6/2024 at 6:00 pm with the Previous Administrator. The Previous Administrator reported he was employed at the facility on 7/8/2023, but was not able to recall Resident #346, his transfer, or discharge.

Based on record review, staff, and Medical Director (MD) interviews the facility failed to ensure the MD was aware of resident care policies related to Cardiopulmonary Resuscitation (CPR) and Emergency Response. This deficient practice had the potential to affect all current residents in the facility. The findings included: A review of the Medial Director service agreement signed by the facility's Medical Director (MD) on [DATE] included the following under duties and obligations of Medical Director: Medical Director shall be responsible for implementation of resident care policies, coordination of medical care in the facility and shall perform such other duties and responsibilities customary for a medical director in a facility of comparable size to the facility. The Medical Director (MD) was interviewed on [DATE] at 2:55 PM. The MD stated she was not familiar with the protocol for CPR or Emergency Response in the building, but she had always told the facility to call EMS before calling her. The Administrator was interviewed on [DATE] at 4:46 PM. The Administrator stated the MD was a contracted employee and evaluated residents as outlined by the regulation and as needed. The MD visited the facility each week and played a part in every major medical decision made, had input on policies, attended the Quality Assurance meeting and made recommendations as needed. The Administrator stated the MD had access to all the facility policies and then staff would supplement that with any education needed. He stated, it is very important for her to be informed of the policies of this building and anything to do with the residents in our building.

Based on observations, record reviews and staff interviews the facility failed to remove open and expired medications from 2 of 2 medication rooms (front and back medication rooms), failed to remove open and undated medication from 1 of 4 medication carts (300 hall medication cart), failed to secure medications in 1 of 4 medication carts (500/700 hall medication cart) and failed to secure a controlled substance medication under double lock (back medication room) in 1 of 2 medication rooms (back medication room) for review of medication storage. The findings included: 1a. On 06/03/24 from 11:51 AM to 11:52 AM an observation was made of the unlocked medication cart for 500/700 halls parked in the 700 hallway with 8 residents' insulin pens left unattended on top of the medication cart. Multiple staff and a visitor were observed to walk past the unlocked medication cart. An interview was conducted with Nurse #13 on 06/03/24 at 11:52 AM as she exited a resident's room. Nurse #13 acknowledged the cart was left unlocked and the insulin pens were left unsecured on top of the cart while she went into the resident's room to administer insulin. The Nurse explained that she should not have left the insulin pens on top of the cart because the pens should be secured and locked. 1b. On 06/05/24 at 3:25 PM an observation was made of the 300 hall medication cart accompanied by Nurse #10. The observation yielded one open and undated foil pouch of albuterol sulfate and ipratropium bromide (duoneb vials, breathing medication) that were available and ready for use. An interview with Nurse #10 on 06/05/24 at 3:25 PM revealed she acknowledged the foil pouch was open and undated and stated she did not know how long the duobeb vials could remain in the open pouch undated. 1c. On 06/07/24 at 4:30 PM an observation was made of the 500/700 halls medication cart which was left unattended at the nursing desk. The medication cart had 4 insulin pens on top of the cart. Multiple staff were observed to walk by the medication cart and a resident was seated in his wheelchair near the desk. An interview was conducted with Nurse #14 on 06/07/24 at 4:36 PM who confirmed she was responsible for leaving the insulin pens unattended on top of the medication cart. She stated she had to step away from the cart for a few minutes and that she should have secured the pens in the locked cart before she walked away. During an interview with the Director of Nursing (DON) on 06/07/24 at 9:38 AM and 4:57 PM and a follow-up interview on 06/13/24 at 5:25 PM the DON explained that the insulin pens should never be left unattended on the medication carts, and Nurse #14 should have put them in the cart before she walked away from the cart. 2a. A review of the front medication room was made on 06/04/24 at 4:01 PM along with Nurse # 12 and revealed the following expired medications that were on the shelf or in the refrigerator and available for use: -2 unopened bottles of bisacodyl (laxative) 5 milligrams (mg) that expired on 02/24. -1 unopened bottle of melatonin 1 mg that expired on 04/24. -1 opened and partially used three fluid ounce bottle of omeprazole powder 2mg that stated do not use after 05/06/24. -1 vial of tuberculin protein derivative 1 milliliters (ml) vial that was opened on 04/30/24 and labeled with a discard date of 05/30/24. -1 bottled of opened cephalexin (antibiotic) 250 mg/5 milliliters (ml) 100 ml bottle labeled to discard after 03/12/24. Nurse #12 was interviewed on 06/04/24 at 4:08 PM. Nurse #12 stated it was her second day at the facility via an agency. She had no idea what to do with the expired items, but she would take them and find out. She was also unaware of who was responsible for checking the medication room and refrigerator for expired medication. 2b. An observation was made of the refrigerator in the back medication room on 06/05/24 at 2:57 PM accompanied by Nurse #5. The observation yielded: -1 open vial of Tuberculin solution (PPD) with an open date of 05/01/24. -The controlled substance box affixed to the refrigerator was not locked and contained 32 lorazepam gel packs. -1 lorazepam vial in the emergency medication box that was not affixed to the refrigerator and was not locked. An interview was conducted with Nurse #5 on 06/05/24 at 2:58 PM who confirmed that she counted the controlled substance medication in the box affixed to the refrigerator that morning during change of shifts and forgot to lock the box afterwards. Nurse #5 stated she did not realize the facility kept the lorazepam vial in the unlocked box but that it probably needed to be in the locked box as well. Nurse #5 acknowledged the date on the PPD solution and stated it should only be kept for 28-30 days and stated she would throw it away. She stated that third shift was responsible for checking the refrigerator. During an interview with the Director of Nursing (DON) on 06/07/24 at 9:38 AM and 4:57 PM and a follow-up interview on 06/13/24 at 5:25 PM the DON explained that she had posted pharmacy medication storage sheets on the medication carts for the nurses to use as a guide to assist them in knowing how and where the medications should be stored. The DON stated the medication rooms and refrigerators were checked weekly by the day shift nurses and should have found the out-of-date medications and disposed of them. She indicated the controlled substances should always be behind double lock and key.

Based on observations, record reviews and staff interviews, the facility failed to ensure a resident was administered oxygen per physician order, failed to clean oxygen concentrators, and failed to post cautionary and safety signs that indicated oxygen was in use for 3 of 3 residents reviewed for respiratory care (Residents #34, #40 and #45). The findings included: 1. Resident #40 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disorder (COPD, chronic inflammation of the lungs leading to an obstruction of airflow to the lungs). A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was severely cognitively impaired. Resident #40 was documented as receiving oxygen therapy. a. A review of a physician's order dated 2/14/2023 revealed Resident #40 was ordered oxygen to be delivered at 2 liters/minute continuously. A review of the physician's orders dated 6/15/2023 revealed Resident #40 was to have vital signs checked every Thursday during day shift. A review of the care plan dated 5/8/2024 revealed Resident #40 was at risk for ineffective breathing patterns due to a diagnosis of COPD with interventions which included administering oxygen per order. Resident #40 was not documented for a history of removing oxygen or any behaviors. A review of the May 2023 vital signs records revealed Resident #40's last oxygen saturation had been checked on 5/30/2024, which read: 94%. There was no indication of oxygen usage when the oxygen saturation was obtained. An observation was conducted on 6/3/2024 at 10:59 am. Resident #40 was observed without oxygen on. Resident #40's nasal canula was draped over his nightstand, out of his reach. Resident #40's oxygen concentrator was observed to be white with dust. An observation was conducted on 6/4/2024 at 8:51 am. Resident #40 was observed without oxygen on. Resident #40's nasal canula was draped over his nightstand, out of his reach. An observation was conducted on 6/5/2024 at 2:27 pm. Resident #40 was observed without oxygen on. Resident #40's nasal canula was draped over his nightstand, out of his reach. An observation was conducted on 6/6/2024 at 9:16 am. Resident #40 was observed to have his oxygen on, and his oxygen concentrator set to deliver at 2 liters per minute. An observation was conducted on 6/6/2024 at 10:58 am. Resident #40 was observed wearing his oxygen at 2 liters per minute. 1b. An observation was conducted on 6/4/2024 at 8:51 am. Resident #40's oxygen concentrator was observed to be white with dust. An observation was conducted on 6/5/2024 at 2:27 pm. Resident #40's oxygen concentrator was observed to be white with dust. An observation was conducted on 6/6/2024 at 9:16 am. Resident #40's oxygen concentrator's external filter was noted to be white with dust. An observation was conducted on 6/6/2024 at 10:58 am. Resident #40's oxygen concentrator external filter was observed to be clean and free of dust. An interview was conducted on 6/5/2024 at 3:49 pm with Nurse #10. Nurse #10 reported if a resident was ordered oxygen, there would be an order in the Electronic Health Record (EHR), and oxygen would be listed on the MAR. Nurse #10 verified Resident #40 was ordered continuous oxygen. Nurse #10 reported she checked oxygen saturations every shift, before/after breathing treatments, and on an as needed basis. Nurse #10 stated oxygen concentrator filters were supposed to be cleaned and oxygen tubing was supposed to be changed weekly on night shift or as needed. Nurse #10 verified Resident #40 had an order for oxygen to be delivered at 2 liters/per minute continuously. Nurse #10 was asked to observe Resident #40 and agreed he was not wearing oxygen and should have been. Nurse #10 noted his oxygen tubing draped over his nightstand out of his reach and stated she was not sure why it was laying there. Nurse #10 stated Resident #40 had not had a history of removing his oxygen and would usually leave it in place. Nurse #10 checked Resident #40's oxygen saturation level on his right index finger and noted the result to be 89%. Nurse #10 immediately placed Resident #40 on 2 liters of oxygen, and his oxygen saturation rose to 92%. Nurse #10 was asked to observe the oxygen concentrator filter and agreed the external filter was white with dust and needed to be cleaned. Nurse #10 stated the external filter should have been cleaned on night shift and reported she would clean it. An interview was conducted on 6/6/2024 at 9:19 am with Nurse #11. Nurse #11 stated if a resident was supposed to wear oxygen there would be an order for oxygen in the EHR and would be on the MAR as well. Nurse #11 verified oxygen was on Resident #40's MAR. Nurse #11 stated she was unsure who was responsible for cleaning oxygen concentrator filters and reported she assumed it was maintenance. Nurse #11 reported oxygen tubing was changed weekly. Nurse #11 was asked to observe Resident #40's oxygen concentrator filter, and agreed it was white with dust. Nurse #11 stated she would clean Resident #40's filter. An interview was conducted on 6/6/2024 at 12:30 pm with the Unit Manager (UM). The UM reported if a resident was ordered oxygen, they should be wearing it. The UM stated night shift nurses were responsible for cleaning oxygen concentrator filters and changing oxygen tubing weekly or on an as needed basis. The UM reported she had not been monitoring to ensure staff had cleaned filters and changed tubing. The UM stated Nurses were to monitor that it was done. The UM was not aware Resident #40 had, had a dusty oxygen concentrator external filter and reported it should have been cleaned on night shift. An interview was conducted on 6/6/2024 at 8:39 am with the Director of Nursing (DON). The DON stated if a resident was supposed to be wearing oxygen it would show up on the MAR. The DON stated if a resident was ordered oxygen they should be wearing and there were orders in the Electronic Health Record and MAR for continuous oxygen to be administered at 2 liters per minute via nasal canula. The DON stated if the resident was able to remove their own oxygen, it should be care planned for that behavior. The DON stated oxygen concentrator external filters and tubing were to be changed on Wednesdays by night shift Nurses. The DON was not aware Resident #40 had not worn his oxygen on 6/3/2024, 6/4/2024, and part of the shift on 6/5/2024 and verified he should have been. The DON stated Resident #40 was not care planned or known for removing his own oxygen. The DON was also not aware Resident #40's external filter on his concentrator had been dusty, and agreed it should have been cleaned when it was observed. An interview was conducted on 6/7/2024 at 3:24 pm with the Administrator. The Administrator stated he was unsure when oxygen concentrator filters should be cleaned but that he was looking into it and was going to add it to their Quality Assurance (QA). The Administrator agreed oxygen should be administered per order. The Administrator was not aware Resident #40 had not worn his oxygen and had a dusty external filter on his oxygen concentrator. 2. Resident #45 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure and Chronic Obstructive Pulmonary Disorder (COPD, chronic inflammation of the lungs leading to an obstruction of airflow to the lungs). A review of a physician's order dated 4/1/2024 revealed Resident #45 was ordered oxygen to be administered at 2 liters per minute via nasal canula continuously. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact with no behaviors. Resident #45 was documented as receiving oxygen therapy. A review of a care plan dated 4/5/2024 revealed Resident #45 had respiratory failure with interventions which included administering oxygen at 2 liters per minute. An observation was conducted on 6/3/2024 at 11:15 am. Resident #45 was observed lying in bed wearing oxygen in her nose. Resident #45's oxygen concentrator was set to deliver oxygen at 2 liters per minute. There was no oxygen signage outside of Resident #45's room indicating she was on oxygen. An observation was conducted on 6/4/2024 at 2:49 pm. Resident #45 was observed lying in bed wearing oxygen in her nose. Resident #45's oxygen concentrator was set to deliver oxygen at 2 liters per minute. There was no oxygen signage outside of Resident #45's room indicating she was on oxygen. An observation was conducted on 6/5/2024 at 2:25 pm. Resident #45 was sitting in a wheelchair beside her bed, wearing oxygen in her nose. Resident #45's oxygen concentrator was set to deliver oxygen at 2 liters per minute. There was no oxygen signage outside of Resident #45's room indicating she was on oxygen. An interview was conducted on 6/5/2024 at 2:40 pm with Nurse #12. Nurse #12 stated she was assigned Resident #45 and verified she was ordered to wear oxygen at 2 liters per minute. Nurse #12 reported she was unsure if signage had to be placed outside of a room where oxygen was in use. Resident #12 verified there was no oxygen signage outside of Resident #45's room. An interview was conducted on 6/7/2024 at 8:39 am with the Director of Nursing (DON). The DON stated if a resident was wearing oxygen there should be signage outside of their room placed by the nurse upon admission. The DON was not aware there had not been oxygen signage outside of Resident #45's room and stated there should have been. An interview was conducted on 6/7/2024 at 3:24 pm with the Administrator. The Administrator was not aware Resident #45's room did not have signage indicating oxygen was in use and agreed there should have been a sign on the door. 37280 3. Review of Resident #34's care plan dated 01/08/24 revealed the Resident has oxygen therapy related to respiratory therapy. The goal that Resident #34 will have no signs or symptoms of poor oxygenation will be attained by providing oxygen via nasal cannula. Resident #34 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure. The quarterly Minimum Data assessment dated [DATE] revealed Resident #34 was cognitively intact and required oxygen. A review of Resident #34's physician order dated 04/01/24 for oxygen to be delivered at 4 liters per minute via nasal cannula. There was also an order to rinse or replace oxygen filters weekly and as needed on Wednesday nights. A review of Resident #34's 05/2024 Treatment Administration Record (TAR) revealed the order for the oxygen filters to be rinsed or replaced weekly on Wednesday night was initialed as being completed. The 06/2024 TAR revealed the order for the oxygen filters to be rinsed or replaced weekly on Wednesday nights was initialed on 06/05/24 as being completed by Nurse #15. On 06/03/24 at 11:03 AM an observation was made of Resident #34 wearing supplemental oxygen via nasal cannula. The oxygen concentrator had bilateral black external filters on the concentrator that were dusty and appeared gray. Also, there was no cautionary sign posted on the Resident's door to indicate oxygen was in use. Subsequent observations of Resident #34's oxygen concentrator filters and door on 06/04/24 at 10:29 AM and 06/05/24 at 2:29 PM revealed the filters remained dusty and there was no signage posted on the door. On 06/05/24 at 3:57 PM an interview was conducted with Nurse #12 who was the Nurse on duty. The Nurse acknowledged the dirty filters and stated, oh my goodness, they are dirty. The Nurse explained that she had only been employed a short time at the facility and did not know the policy for the oxygen filters. She also stated the admitting nurse should have posted the oxygen sign on the Resident's door. An observation was made on 06/06/24 at 10:11 AM of Resident #34's oxygen concentrator filters. The filters remained dusty gray. An interview was conducted with Nurse #15 on 06/06/24 at 10:54 AM who acknowledged he took care of Resident #34 on the night of 06/05/24. The Nurse stated that he got busy and did not get to check the filters on the Resident's concentrator. During an interview with the Director of Nursing (DON) on 06/07/24 at 9:46 AM the DON explained the oxygen concentrator filters should be cleaned once a week on Wednesday third shift and as needed in case they need cleaning more than weekly. She stated the admitting nurse should place the oxygen in use sign on the residents' door when they were admitted . The DON stated Resident #34 had changed rooms recently and the nurses must have missed moving the oxygen sign to her new room.

Based on medical record review, staff interviews, and review of the facility's Advance Directive policy the facility failed to provide written advance directive information and/or opportunity to formulate an advance directive and also failed to ensure a resident's code status election was evident and accurately documented in the medical record for 6 of 6 (Resident #81, #83, #86, #68, #32, and #72) residents reviewed for advance directive. Findings included: 1. Resident #81 was admitted to the facility on [DATE]. A review of Resident #81's electronic health record revealed an advanced directive order for Full Code dated 02/24/23. A review of Resident #81's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #81 was severely cognitively impaired. A review of the Code Status notebook maintained at the nursing desk on 06/04/24 revealed there was no advanced directive in the code status notebook for Resident #81. During an interview with the Physician Assistant (PA) on 06/04/24 5:34 PM she explained that she addressed the residents' advanced directives after they were admitted and completed the Medical Order for Scope of Treatment (MOST) and Do Not Resuscitate (DNR) forms then gave the forms to the Director of Nursing to put in the Code State notebook. The PA stated she had not completed Resident #81's advanced directive paperwork yet because the Resident's cognition was impaired, and she had been unable to connect with his family. An interview was conducted with the Director of Nursing (DON) on 06/08/24 at 9:38 AM. The DON reported the PA addressed the residents' advanced directives when they were admitted to the facility and the paperwork was placed in the code status notebook at the nursing desk. The DON stated she was not aware that Resident #81's advanced directive forms had not been placed in the code status notebook and remarked that the Resident had been in the facility long enough for the paperwork to be completed. 2. Resident #83 was readmitted to the facility on [DATE]. A review of Resident #83's electronic health record revealed an advanced directive order for Do Not Resuscitate (DNR) dated 11/09/23. Review of a care plan revised on 12/26/23 read, Advance Directive, Full Code. The intervention stated advance directives will be followed as ordered. A review of Resident #83's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #83 was cognitively intact. A review of the Code Status notebook maintained at the nursing desk on 06/04/24 revealed there was no advanced directive in the code status notebook for Resident #83. Social Worker (SW) #1 was interviewed on 06/04/24 at 2:01 PM. She confirmed that she was responsible for updating advance directive care plans. She explained that the medical provider addressed advance directives upon admission and then it was discussed with each care plan meeting or as needed. SW #1 stated she was not sure how Resident #83's care plan was missed when updating his other care plan but stated she would correct it promptly. During an interview with the Physician Assistant (PA) on 06/04/24 5:34 PM she explained that she addressed the residents' advanced directives after they were admitted and completed the Medical Order for Scope of Treatment (MOST) and Do Not Resuscitate (DNR) forms then gave the forms to the Director of Nursing to put in the Code State notebook. The PA was not sure why Resident #83's advance directive paperwork was not where it should be but stated it may not have come back from the hospital with him and she would need readdress that with him. An interview was conducted with the Director of Nursing (DON) on 06/08/24 at 9:38 AM. The DON reported the PA addressed the residents' advanced directives when they were admitted to the facility and the paperwork was placed in the code status notebook at the nursing desk. The DON stated she was not aware that Resident #83's advanced directive forms had not been placed in the code status notebook and that his care plan had not been updated. The DON remarked that the Resident had been in the facility long enough for the paperwork to be completed and his care plan to have been revised. 3. Resident #86 was admitted to the facility on [DATE]. A review of Resident #86's electronic health record revealed an advanced directive order for Full Code dated 04/06/24. A review of Resident #86's Admission Minimum Data Set assessment dated [DATE] revealed Resident #86 was severely cognitively impaired. A review of the Code Status notebook maintained at the nursing desk on 06/04/24 revealed there was no advanced directive in the code status notebook for Resident #86. During an interview with the Physician Assistant (PA) on 06/04/24 5:34 PM she explained that she addressed the residents' advanced directives after they were admitted and completed the Medical Order for Scope of Treatment (MOST) and Do Not Resuscitate (DNR) forms then gave the forms to the Director of Nursing to put in the Code State notebook. The PA stated she had not completed Resident #86's advanced directive paperwork yet because the Resident's cognition was impaired, and she had needed to connect with her family. An interview was conducted with the Director of Nursing (DON) on 06/08/24 at 9:38 AM. The DON reported the PA addressed the residents' advanced directives when they were admitted to the facility and the paperwork was placed in the code status notebook at the nursing desk. The DON stated she was not aware that Resident #86's advanced directive forms had not been placed in the code status notebook and remarked that the Resident had been in the facility long enough for the paperwork to be completed. 50045 4. Resident #68 was admitted to the facility on [DATE]. A review of the facility's code status book revealed Resident #68 had a MOST form dated 7/13/2023 and was a full code with full scope of treatment to include intubation, advanced airway interventions, mechanical ventilation, cardioversion as indicated, medical treatment, intravenous fluids, and to transfer to the hospital if indicated and was signed by PA #1. A review of a physician's order dated 7/13/2023 revealed Resident #68 was a full code and Do Not Intubate (DNI). An annual Minimum Data Set (MDS) dated [DATE] revealed Resident #68 was moderately impaired. A review of a care plan dated 3/5/2024 revealed Resident #68 wished to be a full code. An interview was conducted on 6/4/2024 at 2:01 pm with Social Worker (SW) #1. SW #1 reported when a resident was admitted , she would enter that information into the Electronic Health Record (EHR). SW #1 stated PA #1 discusses code status with the resident and their family upon admission and stated PA #1 completed the MOST form. SW #1 stated the MOST form should match the physician's orders. An interview was conducted on 6/4/2024 at 3:31 pm with PA #1. PA #1 reported she addressed code status with residents and their families upon admission to the facility and routinely addresses code status as changes arise. PA #1 stated she completed MOST forms after she had spoken with the resident and explained the document in detail. PA #1 stated if a resident was a full code and DNI, the MOST form should indicate to initiate chest compressions and to perform limited interventions. PA #1 verified Resident #68 had a physician's order for full code and DNI. PA #1 reported that was an error because she was not able to recall Resident #68 requesting to not be intubated. A follow-up interview was conducted on 6/4/2024 at 4:16 pm with PA #1. PA #1 had spoken with Resident #68, and she had requested to be a full code with all interventions completed. She reported she had entered the physician's order in the EHR incorrectly. An interview was conducted on 6/7/2024 at 8:27 am with the Director of Nursing (DON). The DON stated PA #1 primarily completed the MOST forms when a resident was admitted to the facility or if the resident had changes in condition. The DON was not aware Resident #68 had an order for full code and DNI, and agreed the MOST form and the physician's orders should match. An interview was conducted on 6/7/2024 at 3:13 pm with the Administrator. The Administrator was not aware that the physician's orders and MOST form had not matched for Resident #68, and agreed they should have. The Administrator was not aware that PA #1 was solely responsible for completing the MOST form and indicated SW should be participating in this process as well. 37280 5. Resident #32 was admitted to the facility on [DATE]. A review of Resident #32's electronic health record revealed an advanced directive order for Full Code dated 11/20/23. A review of Resident #32's Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. A review of the Code Status notebook maintained at the nursing desk on 06/04/24 at 1:56 PM revealed there was no advanced directive in the code status notebook for Resident #32. During an interview with the Physician Assistant (PA) on 06/04/24 5:02 PM she explained that she addressed the residents' advanced directives after they were admitted and completed the Medical Order for Scope of Treatment (MOST) and Do Not Resuscitate (DNR) forms then gave the forms to the Director of Nursing to put in the Code State notebook. The PA stated she had not completed Resident #32's advanced directive paperwork yet because the Resident's cognition wavered, and she had not found her stable enough to address it with her. An interview was conducted with the Director of Nursing (DON) on 06/08/24 at 9:38 AM. The DON reported the PA addressed the residents' advanced directives when they were admitted to the facility and the paperwork was placed in the code status notebook at the nursing desk. The DON stated she was not aware that Resident #32's advanced directive forms had not been placed in the code status notebook and remarked that the Resident had been in the facility long enough for the paperwork to be completed. 6. Resident #72 was admitted to the facility on [DATE]. A review of Resident #72's electronic health record (EHR) revealed an advanced directive order for Full Code dated 01/09/24. A review of Resident #72's Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired. A review of the Code Status notebook maintained at the nursing desk on 06/03/24 at 7:31 PM revealed there was no advanced directive in the code status notebook for Resident #72. On 06/04/24 at 4:42 PM an interview was conducted with the Physician Assistant (PA) who explained that she addressed the residents' advanced directives after they were admitted and completed the MOST and DNR forms then gave the forms to the Director of Nursing to put in the Code Status notebook. The PA stated she had not completed Resident #72's advanced directive paperwork yet because she was just this last week or two been able to talk with the Resident's responsible party who was the Resident's guardian and she had not been able to complete the process. During an interview with the Director of Nursing (DON) on 06/07/24 at 10:03 AM the DON reported the PA addressed the residents' advanced directives when they were admitted to the facility and the paperwork was placed in the code status notebook at the nursing desk. The DON stated she was not aware that Resident #72's advanced directive forms had not been placed in the code status notebook and remarked that the Resident had been in the facility long enough for the paperwork to be completed.

Based on record review, resident, staff interviews, the facility Administration failed to provide effective leadership and oversight to ensure effective systems were in place to have trained dietary staff available to prepare meals for residents. On 1/22/23 dietary staff did not arrive to work and the Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without serving 9 of 9 residents mechanically altered meals as ordered (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). This led to the high likelihood of aspiration or choking. The Immediate Jeopardy (IJ) began on 1/22/23 when systems were not in place to ensure trained dietary staff were available to prepare resident meals. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: Cross Refer to F802 Based on staff interviews and record reviews, the facility failed to have effective systems in place to ensure there were dietary staff to prepare meals when dietary staff did not arrive to work on the 1/22/23. The Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving, did not serve resident mechanically altered diets as ordered, and did not ensure kitchen items were sanitized. This led to the high likelihood for residents to be at risk of choking or aspiration. This situation affected 91 of 91 residents for 3 of 3 meals. Cross Refer to F805 Based on record reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. The Administrator was notified of the Immediate Jeopardy on 2/3/23 at 9:14 AM. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. The Administration failed to ensure that an acceptable plan was implemented during the kitchen emergency of no kitchen staff. On, 1/22/2023 at about 8:45 am, the facility staff identified that there was no dietary staff in the kitchen to prepare breakfast. The Administrator was notified immediately about 9:00 am. The Administrator notified corporate leadership at 9:00 am. The Administrator also attempted to notify the dietary manager at about 9:05 am and was unable to reach the dietary manager. Dietary regional support was notified by the Administrator about 9:15am who was able to reach the dietary manager. Later that afternoon, the Administrator was made aware that the dietary manager was unable to be reached due to a personal medical emergency by the dietary regional manager. Facility leadership staff to include the Assistant Director of Nursing (ADON), the Activity Director, Maintenance and the Supply Manager were called on 1/22/2023 by the Administrator about 9:20 am and began coming to the facility to assist with resident meals about 9:35am. The identified facility leadership attempted to obtain breakfast from an outside vendor when they arrived in the building about 9:35 am. The Administrator arrived at the facility to assist with meals after lunch. On 1/22/2023, the Administrator notified the Dietary Facility Regional manager who provided assistance by phone by attempting to call the dietary staff to come to assist with the meals. This was not successful. Starting 1/23/2023 the Dietary Regional support was in the facility to provide ongoing leadership in the dietary Department to ensure the safe preparation of the residents' physician ordered diets. The facility residents on 1/22/2023 were at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 1/22/2023, the Administrator and Maple Health Group Corporate leadership will provide ongoing follow up to ensure that the dietary department continues to be staffed as required. On 2/4/2023, the Administrator was educated by the Chief Nursing Officer on the emergency preparedness plan updates to include the dietary staffing schedule review process and that the dietary manager and the Administrator contact information will be provided to the dietary staff and posted on the nursing units and in the kitchen so that the facility will be aware of dietary staff call outs. The Administrator is aware that he is responsible for ensuring the emergency plan is being followed. Starting 2/4/2023, the Dietary Kitchen Oversight checklist which includes monitoring for dietary staffing, dietary staffing competencies completion, residents' receiving pureed diets, dish machine at appropriate temperature, and dietary supervision will be completed by the facility interdisciplinary team staff. The interdisciplinary team to include social services, Assistant Director of Nursing, Medical Records, maintenance, Business office, admissions, supply clerk, and activities were educated on the oversight checklist by the Administrator. On 2/6/2023, the facility Emergency Preparedness Plan updates will be reviewed in the Quality Improvement meeting by the Administrator to include the dietary staffing schedule review process and that the dietary manager and the Administrator contact information will be provided to the dietary staff and posted on the nursing units and in the kitchen so that the facility will be aware of dietary staff call outs. The Administrator is aware that he is responsible for ensuring the emergency plan is being followed. Starting 2/6/2023, the Maple Health Group Chief Nursing Officer or the Chief Operation Officer will complete facility rounds to include the kitchen at least monthly to ensure the updated Kitchen /dietary Emergency Preparedness Plan continues to be followed as required. Starting 2/3/23, all current dietary staff and new hire dietary staff will be required to complete the facility education related to ensuring residents receive diets as ordered, foods temps checks are completed, training on the use of the kitchen equipment, and notification of Administrator and Dietary Management with staff concerns occur by 2/6/2023 by the Regional Dietary Manager. The emergency phone numbers of the Dietary Manager and the Administrator will be posted in the kitchen and on each nursing unit by 2/6/2023. Effective 2/3/2023 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 2/07/2023

Based on record reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. The Immediate Jeopardy (IJ) began on 1/22/23 when residents with orders for a puree diet were not served 3 of 3 meals pureed to a smooth consistency. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: a. Resident #53 was admitted to the facility on [DATE] with diagnosis that included dementia, protein calorie malnutrition, and diabetes. A physician's order dated 9/8/22 indicated Resident #53 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] revealed Resident #53 was cognitively intact and required set-up assistance with eating. An interview with Resident #53 was conducted on 1/26/23 at 5:25 PM which revealed she was ordered a puree diet and was delivered items such as French toast and sausage for breakfast, roast beef, sweet potato casserole, spinach and peaches for lunch, and meat loaf, squash casserole, and orange slices which she realized she could not have on her prescribed diet and was unable to eat and no other food items were available to be served on 1/22/23 which was of the puree consistency due to kitchen staff not being available. b. Resident #1 was readmitted to the facility on [DATE] with diagnoses that included a cerebral infarction and abnormal weight loss. A physician's order dated 10/12/22 indicated Resident #1 was to receive a puree diet with thin liquids. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively impaired with short- and long-term memory problems and required extensive assistance with eating. c. Resident #22 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia. A physician's order dated 2/14/22 indicated Resident #22 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] revealed Resident #22 was cognitively impaired with short- and long-term memory problems and required extensive assistance with eating. d. Resident #69 was admitted to the facility on [DATE] with diagnoses that included esophageal obstruction, dysphagia, and dementia. A physician's order dated 1/4/23 indicated Resident #69 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] revealed Resident #69 was cognitively impaired and required minimal assistance with eating. e. Resident #31 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's, Parkinson's disease, and malnutrition. A physician's order dated 10/7/21 indicted Resident #31 was to receive a puree diet with nectar thickened liquids. A quarterly MDS dated [DATE] revealed Resident #31 was cognitively impaired and required extensive assistance with eating. f. Resident #57 was admitted to the facility on [DATE] with diagnoses that included dementia, cerebral infarction, and abnormal weight loss. A physician's order dated 11/19/22 revealed Resident #57 was to receive a Regular diet with puree meats and thin liquids. A quarterly MDS dated [DATE] indicated Resident #57 was mildly cognitively impaired and required supervision assistance with eating. g. Resident #8 was readmitted to the facility on [DATE] with diagnosis that included functional quadriplegia, dementia, and protein calorie malnutrition. A physician's order dated 8/31/22 indicated Resident #8 was to receive a puree diet with thin liquids. A quarterly MD dated 10/29/22 indicated Resident #8 had short and long-term memory problems and required extensive assistance from staff for eating. h. Resident #17 was readmitted to the facility on [DATE] with diagnoses that included dementia and gastrointestinal esophageal reflux disease. A physician's order dated 2/19/21 indicated Resident #17 was to receive a puree diet with thin liquids. A quarterly MDS dated [DATE] indicated Resident #17 had short- and long-term memory problems and was dependent for eating. i. Resident #26 was admitted to the facility 9/7/22 with diagnoses that include malnutrition and end of life care. A physician's order dated 12/30/22 indicated Resident #26 was to receive a mechanical soft diet with puree meats and thin liquids. A Significant Change MDS dated [DATE] indicated Resident #26 was cognitively intact and required supervision assistance for eating. A brief interview with the Regional Dietary Consultant was conducted on 1/23/23 at 10:08 AM. She indicated she was contacted on 1/22/23 by the facility Administrator who notified her that the staff from the dietary department had not shown up to prepare food on 1/22/23 and that facility nursing staff were attempting to prepare meals for all residents in the facility. The Regional Dietary Consultant stated she attempted to contact the former Dietary Manager and the Regional Dietary Manager but did not come to the facility to assist with meal service or offer instructions on how to prepare meals via phone on 1/22/23 when she gained knowledge no dietary personnel were present and was unaware kitchen equipment was unable to be properly used to mechanically alter diets as prescribed. An interview with the Administrator was conducted on 1/23/23 at 12:30 PM. The Administrator indicated he became aware staff from the dietary department had not arrived at work on the morning of 1/22/23 at approximately 8:45 AM when nursing staff and the central supply clerk discovered no meal trays had been delivered to the units and no residents had received their breakfast meal which should have been delivered beginning at 7:30 AM. He indicated he lived out of state but arrived at the facility later in the day at approximately 2-3 PM on 1/22/23 to ensure meals were delivered to residents. The Administrator had no previous dietary experience and therefore did not offer additional direction on meal service other than to follow the dietary meal tickets. The Administrator was unable to reach the Dietary Manager to determine why staff did not arrive to the facility on [DATE]. An interview with the Central Supply clerk was conducted on 1/24/23 at 1:30 PM. The Central Supply clerk indicated he was working in the facility on 1/22/23 as a medication aide when he and other nursing staff discovered the meal trays for the breakfast meal had not arrived at the floor for distribution at around 8:45 AM. The Central Supply Clerk indicated they were able to locate the meal tickets which had been printed the day before to determine what foods would need to be prepared. The Central Supply clerk explained since he and NA #11 had some kitchen experience from a previous employment, they went to the walk-in fridge and walk-in-freezer and began pulling items they recalled were normally served to the residents for the breakfast meal and began prepping them to cook. He stated the following items were prepped and cooked: omelets, sausage patties, oatmeal, grits, scrambled eggs, and French toast sticks. The Central Supply clerk indicated they were unable to use the grinder machine that day and instead attempted to cut items in very small pieces and then mash them with a potato masher to serve to residents on mechanically altered diets such as chopped or ground meats, and puree. The Central Supply clerk described them to be more of a chopped or ground consistency. The Central Supply clerk further explained no one else from the dietary department arrived to assist with meal preparation on 1/22/23 and therefore, he and NA #11 prepared all meals for residents on that day. The Central Supply clerk verified that Dietary Aide #2 arrived at his scheduled time of 10:30 AM; however, he only washed dishes during his shift and did not assist with meal preparation on 1/22/23. The Central Supply clerk stated they prepared and served the following: lunch - roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. The Central Supply clerk stated the roast beef had been thawing to serve on Monday and therefore he selected that item because it was readily accessible for lunch, and they made the consistency as close to chopped and ground as possible. An interview with NA #11 on 1/25/23 at 10:45 AM revealed he worked on 1/22/23 when he was notified the dietary department had not arrived at the facility to prepare meals to the residents. NA #11 stated they were not able to use the kitchen equipment and therefore they were unable to properly prepare the texture for the puree consistency and therefore cut the items up as small as possible and then mashed them with a potato masher before serving the item to the resident on prescribed puree diets. NA #11 described the consistency of the meats to be chopped. NA #11 acknowledged they did not follow a menu on 1/22/23; they strictly looked in the walk-in-fridge and walk-in-freezer to find items that were accessible and verified they prepared the following items for residents for breakfast were: scrambled eggs, omelets, oatmeal, grits, French toast, and sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. Multiple attempts were made to contact Dietary Aide #2 were unsuccessful. An interview with NA #10 on 1/24/23 at 1:59 PM revealed she worked on 1/22/23 and she was asked to help plate and serve food in the dietary department when dietary staff did not arrive at work that morning. NA #10 said she entered the kitchen along with the Central Supply clerk and 2 other NAs and began assisting to ensure the breakfast meal could be served to residents. She explained that the Central Supply clerk and NA #11 cooked the food; however, no one was able to use the grinder machine that day and therefore, they attempted to make the puree items as small and fine as possible by cutting it in very mall bites and some items were mashed using a potato masher before delivering the meal to the resident for consumption. NA #10 verified they served the following items to residents on 1/22/23 and none of the items were of the traditional puree consistency and texture: scrambled eggs, oatmeal, grits, sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. NA #10 described the consistency of most items served as chopped. An interview with NA #5 on 1/25/23 at 10:30 AM revealed she worked on 1/22/23 when she learned the dietary staff members had not arrived to work and residents had not yet had breakfast at around 9 AM. NA #5 stated they did the best they could to get residents something to eat although she acknowledged she was aware they were unable to use the kitchen equipment to mechanically alter the foods for residents on a puree diet and therefore those items were cut up finely and mashed with a potato masher to get as best consistency as possible. NA #5 indicated the following items were served, but they were unable to puree them: scrambled eggs, omelets, oatmeal, grits, French toast, and sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. NA #5 indicated most food items served were of a ground consistency. An interview with the Medical Director was conducted on 1/26/23 at 1:00 PM which revealed she had been notified of the residents receiving the wrong texture diet when they were prescribed a puree diet but had not been made aware of any adverse effects from not receiving a puree diet on 1/22/23 nor did she know full details of why residents did not receive the correct consistency. A follow-up interview with the Administrator on 1/26/23 at 3:00 PM revealed he was not made aware the staff were unable to use the kitchen equipment which resulted in being unable to ensure the proper textures were provided to residents with a mechanically altered consistency and indicated staff should have made administration aware before delivering meals to those residents ordered a puree diet for safety. The Administrator was notified of the Immediate Jeopardy on 2/3/23 at 9:14 AM. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. F805 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure 9 of 9 residents prescribed a puree diet received the correct texture on 1/22/2023 for 3 of 3 meals when non dietary staff were unable to utilize the kitchen equipment needed to provide residents menu items which required puree textures. On 2/3/23, the current facility residents on puree diets were reviewed by the Director of Nursing and Assistant Director of Nursing to identify any changes of condition related to unsafe food preparation and the wide range of dietary restrictions for the pureed diets with no concerns noted. On 2/3/2023, the Nurse Practitioner was made aware. The current residents on puree diets are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 2/3/23, All facility staff will be educated to call the Administrator and the Dietary Manager immediately if dietary staff is not available to prepare meals to ensure trained dietary staff to include dietary staff that are scheduled off, dietary contract staff, and dietary staff from other sister facilities can be called in to prepare, cook, and serve the prescribed diets to include pureed diets by 2/6/2023. Starting 2/3/23, the dietary staff will be educated by the dietary manager in food preparation and use of the kitchen equipment to puree prescribed diets to ensure residents received the prescribed pureed diets by 2/6/2023. Starting 2/3/23, the dietary staff will be educated by the Dietary Manager to ensure staff that prepare and serve food are competent in preparing all textures of diets including puree diets by 2/6/2023. Starting 2/3/23, All facility staff will be educated by the Administrator or designee related to only trained staff in safe food service preparation are allowed to prepare, cook, and serve resident prescribed diets to include pureed diets by 2/6/2023. Starting 2/3/2023, The education for the facility staff to include the dietary staff will continue at the beginning of each shift until each staff member receives the education. No staff member including agency staff, dietary and new hire will be permitted to work until the education is completed. Starting 2/6/2023, The Administrator and the Dietary Manager will review the dietary weekly and monthly staffing schedules during morning report to ensure that the dietary department is adequately staffed. On Fridays, the Administrator and the Dietary Manager will review the weekend schedule to ensure weekend staffing concerns have been addressed. By 2/6/2023, the Dietary Manager will be educated by the Administrator related to ensuring that the Administrator is notified of any dietary staffing concerns. Starting 2/6/2023, the Director of Nursing/designee will observe the current residents' meal trays that receive pureed diets at least 3 times a week for breakfast, lunch, and dinner to ensure that the residents continue to receive their prescribed pureed diets for at least 12 weeks. Effective 2/3/2023 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 2/07/2023 On 2/8/23 the credible allegation of IJ removal with a completion date of 2/7/23 was validated through staff interview and review of in-service training records. Staff were able to verbalize and demonstrate examples of how to prepare and serve meals, how to use the dish machine and 3-in-1 sink chemical test strips, how to properly read meal tickets to ensure residents received the correct consistency of diet as ordered, able to identify symptoms of a foodborne illness and potential risk of a resident receiving the incorrect texture of food for consumption. Each were able to verbalize they were to report anytime the dietary department staff were not present in the building by the start of day shift to the Administrator and the Director of Nursing to include weekends.

Based on staff interviews and record reviews, the facility failed to have effective systems in place to ensure there were dietary staff to prepare meals when dietary staff did not arrive to work on the 1/22/23. The Central Supply Clerk and three Nurse Aides (NAs) prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving and did not serve resident mechanically altered diets as ordered. This led to the high likelihood for residents to be at risk of choking or aspiration. This situation affected 9 of 9 residents (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26) for 3 of 3 meals. The staff also prepared breakfast, lunch, and dinner resident meals without checking the internal temperature of cooked foods before serving for 91 of 91 residents. The Immediate Jeopardy (IJ) began on 1/22/23 when dietary staff did not arrive to work their scheduled shift to ensure meal service was provided by trained and competent staff. This resulted in 9 of 9 residents not receiving a pureed diet for 3 of 3 meals. The immediate jeopardy was removed on 2/7/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. Findings included: An interview with the Central Supply clerk was conducted on Sunday, 1/24/23 at 1:30 PM. The Central Supply clerk indicated he was working in the facility on 1/22/23 as a medication aide when he and other nursing staff discovered the meal trays for the breakfast meal had not arrived at the floor for distribution around 8:45 AM. He indicated the breakfast meal trays should begin arriving on the unit shortly after 7:30 AM each morning. The Central Supply clerk stated he, along with Nurse Aide #5, went to the dietary department and began knocking on the door. They discovered there were no visible lights on and both doors were securely locked. Following this observation, the Central Supply clerk notified the Administrator via text message that no dietary staff had arrived to prepare food for the residents. The Administrator directed him, NA #5, NA #10, and NA #11 to obtain a master key to enter the dietary department and prepare the breakfast meal. Central Supply clerk explained since he and NA #11 had worked in a kitchen during employment with other companies, they went to the walk-in fridge and walk-in-freezer and began pulling items they recalled were normally served to the residents for the breakfast meal and began prepping them to cook. He stated the following items were prepped and cooked: omelets, sausage patties, oatmeal, grits, scrambled eggs, and French toast sticks. The Central Supply clerk indicated they were unable to puree food, so they cut it in very small pieces and then mashed it with a potato masher to serve to residents on mechanically altered diets such as chopped or ground meats, and puree. The Central Supply clerk stated meal tickets had already been printed which allowed them to serve items based on the tray card; however, they did not call the Dietary Manager, Regional Dietary Manager nor the Consulting Registered Dietician when the menu was altered and to let them know they were unable to use of all kitchen equipment. Central Supply clerk indicated the breakfast meal was delivered to the units for residents shortly after 10 AM on 1/22/23. He acknowledged he and the other staff improvised the best they could and did not obtain temperatures of the food before delivery nor provide the proper textured diets for each resident. The Central Supply clerk indicated at approximately 10:30 AM, a dietary aide (Dietary Aide #2) arrived to work who attempted to assist the nursing staff to wash dishes in the dish machine; however, no one checked to ensure the temperatures were meeting required levels for sanitation during usage. The Central Supply clerk stated he and NA #11 also used the 3-in-1 sink to wash cook wear but did not perform the chemical strip controls to ensure proper levels of chemicals were used to maintain sanitation. The Central Supply clerk further explained no one else from the dietary department arrived to assist on 1/22/23 and therefore, he and NA #11 prepared all meals for residents on that day. He stated they prepared and served the following: lunch- roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. An interview with the Administrator was conducted on 1/23/23 at 12:30 PM. The Administrator indicated he became aware staff from the dietary department had not arrived at work on the morning of 1/22/23 at approximately 8:45 AM when nursing staff and the central supply clerk discovered no meal trays had been delivered to the units and no residents had received their breakfast meal which should have been delivered beginning at 7:30 AM. He indicated he lived out of state came back to the facility as soon as he could. The Administrator gave the authorization for the Central Supply Clerk and the 3 nurse aides (NA #5, NA #10, and NA #11) to begin meal preparation and delivery of the breakfast meal. He arrived at the facility several hours later that day between 2:00-3:00 PM on 1/22/23 at which time breakfast and lunch had already been served to all residents. The Administrator indicated he contacted the Regional Dietary Consultant after being unable to reach the DM on 1/22/23 but was not assisted with providing staff to cover the meal delivery in the facility. The Administrator did not have previous food service experience and told the Central Supply clerk to serve meals based on the residents' meal ticket but was unable to provide any further guidance on preparation or meal service. He did not give any directive regarding preparing snacks at the time. A telephone interview with Cook #1 was conducted on 1/26/23 at 10:17 AM. Cook #1 revealed he had worked on 1/21/23. Cook #1 indicated on 1/21/23 at 4:28 PM, he tried to contact the DM by telephone without success so he followed the call with a text message which would alert the DM he could not work his scheduled shift of 5:30 AM to 5 PM on 1/22/23. Cook #1 stated he had not been contacted by the facility to answer any questions about what food was to be prepared or how to use the kitchen equipment on 1/22/23 and did not receive a return call from the DM. Cook #1 was also able to verify that they frequently only had 1 cook and 2 dietary aides scheduled to work on the weekends. A review of the monthly dietary schedule revealed the following for 1/22/23: Cook #1 was assigned from 5:30 AM to 5:00 PM. Dietary Aide #1 was assigned from 6:30 AM to 2:30 PM. Dietary Aide #2 was assigned from 10:30 AM to 7:30 PM. A review of the monthly dietary scheduled reflected this was the schedule every other week on Sunday and on the opposite Sunday revealed one cook would be scheduled from 5:30 AM to 2 PM and an additional cook would be scheduled to work from 12:30 PM to 7:30 PM. An interview with Dietary Aide #1 (DA) was conducted on 1/25/23 at 11:30 AM. DA #1 indicated she was scheduled to work on the morning of 1/22/23; however, informed the DM around 3 AM that she would not be able to work her scheduled shift for that day. The DA #1 stated she initially called the DM with no response and then followed it with a text message on 1/22/23 and did not receive a reply from the DM. Multiple attempts were made to contact Dietary Aide #2 without success. Multiple attempts were made to contact the former DM without success as she no longer works with the contracted food service company. An interview with NA # 10 on 1/24/23 at 1:59 PM revealed she arrived to work on 1/22/23 at around 7:00 AM and she along with other nursing staff members began noticing residents' meals had not been delivered around 8:30 AM. NA #10 stated the Central Supply clerk and NA #11 went in the kitchen and began cooking the food and she and NA #5 plated additional items such as drinks and desserts before they were delivered to each unit. NA #10 stated she assisted to serve both breakfast and lunch on 1/22/23, but did not aide in the evening meal because she was scheduled to leave at 4:00 PM. NA #10 explained they were not able to use all of the kitchen equipment and therefore attempted to mechanically alter the puree diet trays by cutting up items really small and then using a potato masher to get the food as smooth as possible before delivering it to the residents. NA #10 reviewed the items listed that were served to the Central Supply clerk's list and agreed those were the items served and that single use disposable wear was used because of lack of dishes and trays. NA #10 also indicated during the lunch meal a few pizzas were ordered by a staff member but the pizza's delivered were too hard for most residents and they instead consumed the meal served by the nursing staff who prepared the meal that day for lunch. An interview with NA #5 on 1/25/23 at 10:30 AM revealed she was assigned to work the unit as a nurse aide on 1/22/23 when she learned the dietary staff members had not arrived to work and residents had not yet had breakfast at around 9 AM. NA #5 indicated she along with the Central Supply clerk (who was assigned to work as a medication aide on 1/22/23), NA #10, and NA #11 went to the kitchen and began getting breakfast ready so residents could have something to eat. NA #5 stated they did the best they could to get residents something to eat although she acknowledged she was aware they were unable to use the kitchen equipment to mechanically alter the foods for residents on a puree diet and therefore those items were cut up finely and mashed with a potato masher to get as best consistency as possible and all meals served were delivered on single serve disposable wear. NA #5 recalled providing residents the food items provided by the Central Supply clerk during his interview. An interview with NA #11 on 1/25/23 at 10:45 AM revealed he was scheduled to work as a nurse aide on 1/22/23 when he was notified the dietary department had not arrived at the facility to prepare meals to the residents. NA #11 stated he, the Central Supply clerk, NA #5, and NA #10 then obtained a key to enter the dietary department where he and the Central Supply clerk had realized they each had some previous culinary experience and therefore they the two of them were the staff members who prepared the food items while NA #5 and NA #10 plated additional items such as desserts and drinks. NA #11 stated they were not able to use the kitchen equipment and therefore they were unable to properly prepare the texture for the puree consistency and therefore cut the items up as small as possible and then mashed them with a potato masher before serving the item to the resident on prescribed puree diets. NA #11 acknowledged they did not follow a menu on 1/22/23; they strictly looked in the walk-in-fridge and walk-in-freezer to find items that were accessible and verified they prepared the following items for residents for breakfast were: scrambled eggs, omelets, oatmeal, grits, French toast, and sausage; for lunch: roast beef, sweet potato casserole, spinach, peaches, and cornbread and for supper they served: meatloaf, mashed potatoes, squash casserole, mandarin oranges, and a biscuit. An interview with the Regional Dietary Consultant was conducted on 1/23/23 at 10:08 AM. She indicated she was contacted on 1/22/23 by the facility Administrator who notified her that the staff from the dietary department had not shown up to prepare food on 1/22/23 and that facility nursing staff were attempting to prepare meals for all residents in the facility. The Consultant indicated she was unsure at the time what occurred further than the staff did not arrive to work. An interview with the Regional Dietary Manager on 1/24/23 at 9:28 AM revealed she was without a phone over the weekend and did not learn of the events of 1/22/23 until the morning of 1/23/23 when she was asked to come to the facility by the Regional Dietary Consultant therefore she did not come to the facility on [DATE] to aide in meal service and was unsure what was prepared or what occurred in the department on 1/22/23. She provided the surveyor the monthly schedule and verified it was accurate in how staff were scheduled in the department at the time. A follow-up interview was conducted with the Regional Dietary Manager on 1/24/23 at 2:30 PM. She indicated she was not made aware the dietary cook had made the Dietary Manager (DM) aware on 1/21/23 that he would not be able to work his shift on 1/22/23 and further indicated when the DM was made aware, she should have ensured coverage was obtained with other dietary staff. A telephone interview with the Consulting Registered Dietician (CRD) was conducted on 1/25/23 at 9:27 AM. She stated she was not involved in dietary staffing, schedules, or menu alterations in the facility and had not been contacted regarding the foods to be prepared by nursing staff on 1/22/23. The Administrator was notified of the Immediate Jeopardy on 2/3/23 at 9:14 AM. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. The facility provided the following credible allegation of compliance with a compliance date of 2/7/23. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure adequately trained and competent staff were on duty for meal preparation and service and failed to ensure dishes were sanitized correctly on 1/22/23. On 1/22/23, one untrained Central supply Clerk and 3 Nurse aides prepared 3 meals for 91 of 91 residents when the scheduled dietary staff did not show up for work. In addition, the one untrained Central supply Clerk and 3 Nurse aides prepared 3 meals for 91 of 91 residents without taking food temperatures, without being trained on the use of the dish machine and unaware of the 3-sink compartment dish sanitization procedure. As a result, the identified staff were unaware that the dish machine was not working properly, and dishes were not sanitized as required. On 2/3/23 the Director of Nursing, Assistant Director of Nursing, and Charge Nurses completed assessments of the current facility residents to include the 91 residents on 1/22/2023 that still remain in the facility. No signs/symptoms of foodborne illnesses were identified. On 2/3/23, the current facility residents were reviewed by the Director of Nursing and Assistant Director of Nursing to identify any changes of condition related to unsafe food preparation and the wide range of dietary restrictions and diets. The results of this failure impacted all 91 of the facility residents on 1/22/2023. The current residents are at risk as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 2/3/23, the nursing staff will be educated by the Director of Nursing/ designee related to identifying the signs and symptoms of foodborne illnesses. The education will continue at the beginning of each shift until each staff member receives the education by 2/6/2023. No staff member including agency staff and new hires will be permitted to work until the education is received. Starting 2/3/23, the facility staff will be educated by the Director of Nursing and Assistant Director of Nursing to call the Administrator and the Dietary Manager immediately if dietary staff is not available to prepare meals to ensure trained dietary staff to include dietary staff that are scheduled off, dietary contract staff, and dietary staff from other sister facilities can be called in to prepare, cook, and serve the meals by 2/6/2023. The Administrator and the Dietary Manager contact information will be posted at each nursing station. The Dietary Manager and the Administrator will have the dietary staff contact information to include other sister facilities contact information to assist with managing dietary call out when they are in or out of the building. The Administrator and the Dietary Manager will review the dietary staffing weekly and monthly schedule during morning report to ensure that the dietary department is adequately staff. On each Friday, the Administrator and the Dietary Manager will review the weekend dietary staffing schedule to ensure any staffing concerns have been addressed. By 2/5/2023, the Dietary Manager to include the dietary staff will be educated by the Administrator related to ensuring that the Administrator is notified of any dietary staffing concerns. The Administrator and the Dietary Manager contact information will be posted in the kitchen and on each facility nursing unit. In addition, the dietary manager will ensure the dietary staff has the dietary manager and the administrator's contact information in addition to calling the facility if they are unable to locate the contact information. Effective 2/3/2023 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 2/07/2023 On 2/8/23 the credible allegation of IJ removal with a completion date of 2/7/23 was validated through staff interview and review of in-service training records. Staff were able to verbalize and demonstrate examples of how to prepare and serve meals, read meal tickets to ensure residents received the correct consistency of diet as ordered, able to identify symptoms of a foodborne illness and potential risk of a resident receiving the incorrect texture of food for consumption. Each were able to verbalize they were to report anytime the dietary department staff were not present in the building by the start of day shift to the Administrator and the Director of Nursing to include weekends.

Based on observations, record reviews, staff, Resident, Neurologist, Medical Director and Emergency Medical Service (EMS) Paramedic interviews, the facility failed to train a Transportation Aide (TA) to use the securement system during a facility van transport per manufacturer's instructions which resulted in the Resident becoming dislodged from the wheelchair, striking her head on the permanently affixed row of seats then requiring emergency transport to the local hospital for 1 of 1 resident (Resident #1) reviewed for [CONDITION(S)]. Resident #1 was diagnosed with a left temporal subdural hematoma (a condition due to the bleeding under the membrane of the brain usually caused by surgery or injury) that required surgical removal. The facility further failed to train a newly hired Receptionist on the systems in place to prevent a severely cognitively impaired Resident from leaving the facility unattended for 1 of 5 residents (Resident #2) who wandered. Receptionist #1 did not recognize Resident #2 was a resident and opened the door and let him out and when the door alarm sounded the Receptionist did not know what the alarm meant. Resident #2 walked to a nearby sidewalk and lost his balance and fell hitting his head and sustained lacerations to his nose and forehead and was transferred to the local emergency room and received 6 sutures before returning to the facility. The findings included: 1. The undated manufacturer's instructions utilized by the facility and titled, Vehicle Anchorages and Accessories for 4-Point Wheelchair Securement Systems, read in part: Securing Wheelchair: Center wheelchair facing forward in securement zone and apply wheel locks. Attach tie-downs into floor anchorages and ensure they are locked in. Attach the four tie-downs hooks to solid frame members or weldments (near seat level). Ensure tie-downs are fixed at approximately 45 degrees and are within the appropriate angles of 10 inches for the back and 25 inches for the front and locked into place. Tie-downs should never pass through the wheels of the wheelchair and should have a clear path from the floor anchorages to the wheelchair frame. Completely pull out each webbing and attach J-hook to solid frame member. Move wheelchair forward and back to remove webbing slack or manual tension webbing with retractor knobs. Attach retractable combination lap/shoulder belt: attach tongue on end of shoulder belt to buckle stalk closest to the wall. Pull the shoulder belt over occupant's chest and insert tongue into the buckle stalk closest to the aisle. Adjust shoulder belt height so that shoulder belt rests on occupant's shoulder, making sure the shoulder belt does not rub against the occupant's neck. Resident #1 was admitted to the facility on [DATE] with diagnoses of end stage [CONDITION(S)] requiring [CONDITION(S)] three times a week, [CONDITION(S)] and seizures. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] indicated the Resident was cognitively intact and was totally dependent on 2 persons for transfers. Resident #1 required a wheelchair for mobility. A review of a facility reported incident submitted by Administrator #1 on 02/10/22 indicated, Resident #1 was being transported to [CONDITION(S)] on 02/09/22 when there was a van accident. The Resident was first sent to the regional hospital and then sent to a more acute hospital related to a subdural hematoma. The Transportation Aide (TA) was experienced in driving the van but also had a gap in service. The TA was not currently driving (the van), and the transportation had been contracted out. A review of an Emergency Medical Services report dated 02/09/22 revealed the EMS arrived on the scene to find Resident #1 lying in the aisle between two rows of seats. The Resident's head was towards the driver's seat and her legs were wrapped around the last row of seats on the left side. The Resident was lying on her left side with her head on a pillow and complained of left shoulder, bilateral hip and bilateral leg pain. The Resident was assessed to have a hematoma on the left side of her head. The Resident stated she did not believe she was wearing a seatbelt. The report continued to explain that Resident #1 was in a confined spot and difficult to roll over so a cervical collar and pain medication was administered before a pelvic binding apparatus could be applied to the Resident. The Resident was then slid down the aisle to the back of the van and placed onto the stretcher and transported to the local hospital. An interview was conducted with Emergency Medical Services (EMS) Paramedic #1 on 04/29/22 at 10:10 AM. The Paramedic reported she and her partner arrived on the scene of the incident early morning on 02/09/22 and observed the Administrator removing the wheelchair from the van. The Paramedic stated the local fire department had arrived a few minutes before the EMS arrived and had already removed the wheelchair from the hooks and reported the wheelchair was in lock down position when they arrived. The Paramedic explained that Resident #1 had fallen headfirst out of her wheelchair and landed on her left side in the isle between the two rows of seats. She continued to explain that the Resident's head was toward the front of the van and her legs were wrapped around the seat post which caused them concern because they thought her legs might have been fractured. The Paramedic stated Resident #1 had a hematoma on the left side of her head. The Paramedic continued to explain that because of the confined position Resident #1 was lying in, they had to administer pain medication and roll her onto a pelvic apparatus before they could slide her to the back of the van and lift her out of the van and onto the stretcher then transported her to the local hospital. The Paramedic stated that Resident #1 reported several times that she did not believe she was wearing a seatbelt. A review of Resident #1's discharge summary from the local hospital dated 02/09/22 revealed Resident #1 would be transferred to a more acute hospital due to the need for a higher level of care in neurosurgery for a traumatic left subdural hematoma measuring 13 millimeters in thickness and 6 millimeters rightward midline shift. A review of Resident #1 discharge summary dated 03/07/22 from the more acute hospital revealed Resident #1 was admitted to the Neuro Intensive Care Unit on 02/09/22 for a traumatic left subdural hematoma which measured 13 millimeters in thickness and 6 millimeters rightward midline shift. Resident #1 required a craniotomy on 02/21/22 for an increasing left subacute and chronic mixed density subdural hematoma. The Resident remained on the ventilator for two days because of postoperative [CONDITION(S)] and was successfully extubated on 02/22/22. An interview was conducted with Resident #1 on 04/24/22 at 4:10 PM. The Resident explained that on 02/09/22 while she was being transported to her [CONDITION(S)] appointment the TA turned left onto Main street and she fell forward then to the right out of her wheelchair and hit her head on the post that held up the row of seats in the back of the van. The Resident continued to explain that the TA did not put the seatbelt or the shoulder strap on her that she just strapped the wheelchair down to the floor of the van, but she didn't realize that she didn't have the shoulder strap or seatbelt on until she had fallen. She stated that the TA was fairly new in driving her to [CONDITION(S)] and she had never had an issue with not being strapped down in the wheelchair before that day. The Resident stated that after she fell out of the wheelchair the TA stopped the van and went back to her and called the Administrator who told her to call 911. The Resident stated the TA stayed with her until the EMS came to her. Resident #1 explained that she had a headache (pointing to the left side of her head) but it did not bleed. The Resident continued to explain that the paramedics took her to the hospital. She stated the hospital ran several CT (computerized tomography) scans on her and discovered she had subdural hematoma on the left side of her head. Resident #1 explained that she was transported to another hospital that was more equipped to treat the subdural hematoma and had to have surgery to remove the hematoma and ended up being admitted to the intensive care unit and remained on the ventilator for several days. The Resident stated she stayed in the hospital until 03/07/22 when she was discharged back to the facility. An interview was conducted with the Transportation Aide (TA) on 04/25/22 at 11:15 AM. The TA explained that she was hired on 01/25/22 to be the TA and the extent of her orientation to the position was the previous Administrator (Administrator #1) taking her out to the van and showing her how to make sure the side mirrors were adjusted correctly for her and that the safety buttons had to be in the correct position before the lift to the van could be raised or lowered. The TA continued to explain that the Administrator sat in the front passenger seat next to her and directed her to drive to the common places where she would be transporting the residents more often such as the [CONDITION(S)] center, the hospitals, the doctor's offices and around town in order to get practice driving the van. She stated that when they returned to the facility, she asked the Administrator when she would receive training on the securement system and the Administrator told her that it will come later. The TA stated that she started to hand the van keys back to the Administrator and he told her to keep them because she was now the van driver and she started that day. The TA stated she could not remember what day that was because she did not write it down but she remembered that later that same day the [CONDITION(S)] center called her and told her that Resident #1 was finished with her [CONDITION(S)] and was ready to be picked up. The TA explained that when she picked Resident #1 up from [CONDITION(S)] she hooked her up to the securement system as best as she could (which she later learned that it wasn't the correct way) and brought the Resident back to the facility without incident. The TA continued to explain that one day, she did not remember which day, she was transporting Resident #1 in the van and the Resident started to slide down out of her wheelchair and she had to stop the van and reposition the Resident back into her wheelchair. The TA stated when she got back to the facility, she asked the Administrator again for orientation on the securement system but was told again that they would get to it. The TA explained that on the morning of 02/09/22 she was transporting Resident #1 to [CONDITION(S)] and she drove over a section of road construction that caused the van to bounce. The Resident stated to the TA that she was sliding out of the wheelchair and the TA looked into the rearview mirror and saw that the Resident was sliding out of her wheelchair. The TA then stopped the van on the road and went back to the Resident but by the time the TA got back to the Resident she had already slid out of the wheelchair and onto the floor of the van but the wheelchair remained in upright position. The TA stated she could not remember how the Resident was lying on the van floor, but she did remember that she put her sweater under the Resident's head and called the previous Administrator #1 and reported what had happened. The TA stated the Administrator instructed her to call 911 so that she could report her location to them which she did, and the EMS arrived within a few minutes. The TA reported that on that same day (02/09/22) the van was taken out of service and was eventually taken to a specialty company to be inspected to make sure the van was in good working condition. She stated she received a detailed training on the securement system which included watching a video, taking a written test and she had to return demonstration to the Maintenance Supervisor (MS) and received a certificate of completion on 02/15/22. She indicated all the training had to be completed before she could resume driving the van for resident transportation. She stated the first transportation she conducted was 02/21/22. The TA expressed that after she received the detailed training on the securement system, she knew that she had not been applying the system correctly when she transported the residents. A telephone interview was conducted with Administrator #1 on 04/25/22 at 5:15 PM. The Administrator explained that on the morning of 02/09/22 he was notified by the TA that she was transporting Resident #1 to [CONDITION(S)] and the Resident started to slide out wheelchair when she drove over a section of road construction and by the time the TA stopped the van and went back to the Resident, she had slid out of the wheelchair and onto the van floor. The Administrator stated he instructed the TA to call 911 and let them know her location so they could assist, and he would be there as soon as he could get there. The Administrator stated he arrived about the same time as the EMS. The Administrator continued to explain that Resident #1 sustained a subdural hematoma which required surgery to be removed and was hospitalized for about a month. The Administrator explained that on that same day after the incident he along with the Maintenance Supervisor (MS) from a sister facility had the TA demonstrate to them how she strapped Resident #1 into the wheelchair that morning and after her demonstration and it was determined that the TA did not apply the shoulder strap and the seatbelt properly on Resident #1, the TA only applied the shoulder strap. Therefore, the Administrator stated the Root Cause Analysis (RCA) was determined to be user error. The Administrator stated the MS from the sister facility inspected the van's securement system and it was determined to be in safe working order on 02/09/22. Just for precaution the Administrator explained the van was taken out of service on 02/09/22 and an outside transportation company was utilized until the facility's van was taken to a special mobility van dealership on 02/14/22 for a full safety inspection where again the securement system was determined to be safe and fully functional. The facility van was placed back in service on 02/14/22. The Administrator was asked about the education the TA received on how to drive the facility van and apply the securement system on residents and the Administrator explained that the TA was hired to drive the van because she had prior experience in transporting residents at another facility. He continued to explain that he had previously watched the securement system video and remembered how to apply the securement system so and he oriented the TA on how to drive the van and how to apply the securement system correctly one day before she made her first transport with a resident. The Administrator explained that he had the TA strap him in a wheelchair in the back of the van as if he was the resident and had the TA drive to the most common places that she would frequently be transporting the residents to such as the [CONDITION(S)] center, doctor's offices and hospitals. He stated he did not have the TA watch the securement system video because he did not have the video at the time and did not know how to access it. The Administrator explained that he did not review the TA's driving record before she was hired for the position. He explained that after the incident the TA asked for more training on how to apply the securement system and it was provided. The Administrator explained that the facility purchased the securement system training course and the TA, the MS from the sister facility (who now was the MS at the facility) and himself completed the training on the securement system by watching the video, taking a written test and returned demonstration which they received a certificate of completion. The TA completed the course on 02/15/22 and made her first transport on 02/21/22 and the MS and Administrator completed the course on 02/16/22. The Administrator stated future staff hired to drive the van will be required to complete the securement system course. On 04/27/22 at 11:20 AM a meeting was held in person with the Transportation Aide (TA), the Director of Nursing (DON) and the previous Administrator (Administrator #1) via telephone. An explanation was given to the parties that there were discrepancies with their account of the type and amount of orientation to the TA position and the utilization of the securement system. The TA repeated her account of the extent of her orientation to the van driving process which was driving the Administrator around town to the frequent places that she would be transporting the residents. The TA was adamant that she was not in-serviced on the securement system until after the incident involving Resident #1 occurred. The TA stated she asked the Administrator several times for in servicing on the securement system but was always told it will come, or it will come later. The Administrator explained that he remembered that he had the TA return demonstration to him on how to properly utilize the securement system and had her drive the van around town to the most frequent places she would be transporting the residents with him as the resident in the wheelchair and strapped down in the back of the van. The Administrator stated after that demonstration on him, he felt that the TA was good to go. The Administrator did not recall the TA requesting additional training on the securement system until after the incident with Resident #1. When the Administrator was asked to explain the differences in the accounts given by himself and the TA the Administrator stated he had a lot going on at the facility at the time of the incident and he explained the situation as best as he remembered it. During an interview with the Director of Nursing (DON) on 04/29/22 at 11:25 AM the DON that she was present in Administrator #1's office one day when the TA stepped into the office and asked the Administrator if she could have training on the securement system in the van and the Administrator told the TA that more training would come later. The DON did not recall the date this conversation occurred. On 04/25/22 at 1:30 PM an interview was conducted with the Maintenance Supervisor (MS) hired on 02/13/22 who at the time of the van incident on 02/09/22 was the MS at a sister facility. The MS reported that he had over 2.5 years of experience with the securement system in the van having been in charge of the van at his previous employment. The MS explained that he was called to assist the facility on 02/09/22 when the incident happened with Resident #1. The MS continued to explain that the TA, the Administrator and himself met at the van the afternoon of 02/09/22 to conduct a reenactment of how the TA strapped the Resident in the van. The MS explained that as soon as he opened the back door of the van he knew that the procedure had not been conducted properly because the floor anchorages were in the center of the back of the van and not on the side behind the driver therefore, the tie-downs were not applied correctly. The MS stated the wheelchair had to be positioned close to the side of the van in order for the shoulder strap to be applied correctly. He continued to explain that he asked the TA to demonstrate how she applied the seatbelt and the TA positioned the seat belt through the side of the wheelchair panel and he knew instantly that it was not the correct way to apply the shoulder or the seat belt. The MS stated he strapped the Administrator in the wheelchair correctly and drove around the parking lot slamming on the van brakes to demonstrate that if the Administrator stayed upright in the wheelchair then the securement system had been applied correctly which he did. The MS continued to explain that the facility took the van out of service and utilized an outside transportation company to transport the residents. On 02/14/22 he took the van to special mobility distribution and had it serviced and checked out to make sure the securement system was working properly, and the van checked out with no problems. He stated the van was back in service as of 02/14/22. The MS explained that the facility purchased the securement system training course and the TA, the Administrator and himself completed the course which involved watching the video, taking the written test and demonstration and received a certificate of completion before they could drive the facility van. The MS stated anyone designated to drive the van and apply the securement system would have to complete the securement system course before they would be allowed to drive the van and transport a resident. On 04/25/22 at 3:10 PM the Transportation Aide, with the Maintenance Supervisor present, was asked to conduct a reenactment of how the TA applied the securement system to Resident #1 on the morning of 02/09/22. The TA explained that the anchorages and tie-downs were in the center of the van at the time of the incident which meant she had to stretch the shoulder strap too far over to the Resident which prevented her from securing the shoulder strap correctly to the seatbelt and to the Resident. The TA then demonstrated that she had been putting the seatbelt straps through the side panels of the wheelchair instead of putting them straight behind the residents then hooking them to the tie-downs. The TA demonstrated that she had been securing the J-hooks to the outside of the wheelchair frames instead of the insides of the wheelchair frames. The MS then had the TA demonstrate how to apply the securement system according to the manufacturer's instructions. During an interview with the Neurologist on 04/26/22 at 8:55 AM the Neurologist explained that Resident #1 sustained a left temporal subdural hematoma when she fell from her wheelchair during a transportation. The Neurologist stated the Resident did not have to hit her head hard on the surface to cause the subdural hematoma because everybody reacts differently to the impact. He continued to explain that at first, they thought the hematoma would subside but the CT scans showed that the hematoma was growing and she was transferred to a more acute hospital for placement in the Neuro Intensive Care Unit where he managed her condition. The Neurologist explained that Resident #1 underwent a craniotomy to evacuate the subdural hematoma and progressed to discharge back to the nursing facility. He stated he had seen her once in his office since her discharge to remove the sutures and the Resident was doing well from the craniotomy. An interview was conducted with the Medical Director (MD) on 04/27/22 at 3:00 PM. The MD indicated that Resident #1 was hospitalized for approximately a month for a subdural hematoma related to a van incident during transportation to a [CONDITION(S)] session. The MD explained that the Resident was first assessed at a local hospital but was sent to the more acute hospital because of the need for the Neurosurgery unit. The MD stated Resident #1 underwent a craniotomy to remove the subdural hematoma and because of her lungs being in poor condition she remained on the ventilator for a couple of days before she could be successfully weaned from the ventilator. The facility provided the following Corrective Action Plan with a completion date of 02/16/22. The plan of correcting the specific deficiency * The deficient practice of failing to prevent an accident occurred when the facility failed to ensure proper securement of the wheelchair occupant in the facility van. * On 02/09/22 while Resident #1 was being transported to [CONDITION(S)] from the facility via the facility van, the van driver over a metal construction plate in the road, causing the van to bounce. The resident alerted the van driver that she was sliding out of the wheelchair and the van driver responded by quickly stopping the van to assist the resident. The resident had already slid out of the wheelchair before the van driver was able to stop. The wheelchair straps were noted to be secured on all four corners of the wheelchair, however the shoulder and lap restraint failed to keep the resident in the wheelchair. * The van driver immediately called 911 and the facility Administrator. The Administrator arrived at the scene of the incident as emergency medical services (EMS) arrived. The resident was assessed by the emergency medical staff, transported from the scene via EMS and was evaluated by a physician in the emergency room . The resident was admitted to the hospital on 02/09/22. * The investigation of the incident was initiated on 02/09/22 by the Administrator. As a result of a re-enactment of the incident and the van inspection by the Maintenance Supervisor, the facility determined that the incident was related to securement equipment being improperly placed on the resident. A root cause analysis was performed, and it was determined the van driver had been inadequately trained and required additional education. As a result of the incident and of the root cause analysis the following actions were immediately taken: * The facility van was immediately taken out of service after the incident on 02/09/22. * A vendor took over the transport duties for the facility during the investigation. Administrator observed a patient being loaded and properly secured on the vendor's van on 02/10/22. The driver confirmed he had viewed a video on proper securement of wheelchair passengers using the Q-Straint system prior to the transport. Owner reported that all drivers are required to view securement video and perform return demonstration of securement knowledge prior to transporting any wheelchair occupants. Administrator requested that the vendor submit training documentation for operators/drivers from the company owner. * The facility van's entire wheelchair securement system was inspected by the Maintenance Supervisor from a sister facility on 02/09/22. It was determined to be safe. * The facility van was taken to a specialty mobility van dealership, special mobility van dealership on 02/14/22 for a full safety inspection. The securement system was determined to be safe and fully functional. * The Medical Director and the family of Resident #1 were notified of the incident on 02/09/22. * On 02/09/22 education was provided to Administrator #1 and the TA by the Maintenance Supervisor from a sister facility. The Maintenance Supervisor will also be responsible to provide education to other designated team members who may operate the facility van to ensure authorized operators have complete knowledge and ability to operate the wheelchair securement system with a return demonstration, and that each is familiar with the facility transport vehicle policy. Staff will not be allowed to drive the van or transport residents until the facility van training is completed and the van is determined to be safe to operate. Newly hired transportation drivers and maintenance staff will also be required to complete training in orientation. * The van was placed back in service on 02/14/22. The Van Driver had the first appointment with the van on 02/21/22. 2. Implementing the plan of correction will be completed through the following actions: * On 02/09/22 the Administrator reeducated the Maintenance Supervisor from the sister facility and the transport driver on the proper application/alignment of the Q-Straint Wheelchair Securement System using the manufacturer's training video, the manufacture's Operator's Manual, and the Facility Transport Vehicle Policy education tools. The Administrator and the transport driver demonstrated competency in using the system to properly secure a wheelchair passenger for transport in the facility van. * The Van Driver completed the Q'Straint video education on 02/15/22. * The Maintenance Supervisor will utilize the transport safety education from the Operator's manual, the manufacturer's training video, and the facility transport Vehicle Policy to educate current and future van drivers. The education will include a return demonstration/competency. Van drivers will not be allowed to drive the facility van until the education is completed. 3. Monitoring the plan of Correction for Compliance with Safety Standards and the policy and procedures for preventing accidents will include the following: * Weekly random boarding/un-boarding observation audits will be conducted by the Maintenance Supervisor/designee who has been trained in the Wheelchair Securement System. * Audits will be presented to the Quality Assurance Performance Improvement (QAPI) Committee Assurance Performance Improvement (QAPI) Committee during monthly meetings for at least 3 months. The plan will be reviewed and revised as needed to maintain compliance. 4. The Administrator will be accountable for ensuring the implementation of this plan of correction. * The Van Driver education was completed on 02/15/22. * The van was available for appointments on 02/16/22. * Currently the Van Driver and the Maintenance Supervisor are the only staff members allowed to drive the van. * All immediate actions have been completed or started within the timeline of the Plan of Compliance. The alleges compliance as of 02/16/22. The Corrective Action Plan was validated on 04/29/22 and concluded the facility implemented an acceptable corrective action plan on 02/16/22. The facility provided training to the Transportation Aide, Administrator #1 and the Maintenance Supervisor on the specific securement system utilized in van transportations which was evident by a certificate of completion. The facility van was taken out of service on 02/09/22 and an outside transportation company was utilized until 02/14/22 and the first transportation with the facility van was 02/21/22 which was verified by van logs. The facility van was taken to a special mobility distribution service and the securement system was inspected and was determined to be in good working order on 02/14/22. The Maintenance Supervisor will be the person in charge of orientation of the securement system anyone hired to drive the van and transport the residents. The weekly random boarding and unboarding observation audits were reviewed for accuracy and completion. The audits were presented in the monthly (March/April) Quality Assurance Performance Improvement (QAPI) Committee during monthly meeting by the Administrator with no revisions necessary. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, lack of coordination, difficulty in walking, and repeated falls. Review of a wandering assessment dated [DATE] indicated Resident #2 was low risk for wandering. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 was severely cognitively impaired and required limited assistance with walking in the room and in the corridor. The MDS further revealed that Resident #2 had no behaviors, rejection of care or wandering. Review of an incident report dated 04/22/22 at 4:15 PM by Nurse # 2 read in part, Resident #2 was let out of facility by the staff member assigned to the front desk (Receptionist #1) who didn't realize that he was a resident and had a wanderguard (used to keep wandering resident from exiting facility unattended) in place. The door alarm was sounding when Resident #2 exited the building and began to run across the parking lot as staff was attempting to redirect him back to the facility. Resident #2 lost his balance and fell on the pavement. Staff assisted Resident #2 up and he was able to ambulate back into facility without difficulty. He was noted to have a laceration to his mid nose/ forehead. The Medical Doctor (MD) was notified, and an order was given to send Resident #2 to the emergency room (ER) for evaluation. Review of Receptionist #1's personnel file revealed that she was hired by the facility on 04/17/22. The file revealed no education was given to Receptionist #1 upon hire on the facility's wanderguard system or the door alarms that were present in the facility or what the alarms meant or what to do if the alarm sounded. Receptionist #1 was interviewed on 04/26/2

Based on observations, record review, resident, and staff interview the facility failed to treat Resident #40 in a dignified manner when she turned her call light on for assistance and three staff members entered her room without asking Resident #40 what she needed and turned her call light off without meeting Resident #40's need which made her feel sad and worthless like the staff did not care about her or her needs. The facility also failed to treat Resident #15 in a dignified manner when a Cook at the facility spoke loudly to Resident #15. This affected 2 of 4 residents reviewed for dignity. The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact with the ability to make her needs known and needed extensive to total care for her activities of daily living (ADL) to include transfers, bed mobility, and toileting. It further indicated Resident #40 was always incontinent of bowel and bladder and had no behavioral issues such as rejection of care. Resident #40 had a fall care plan dated 05/14/20 which indicated she was to have her call light in reach at all times and encouraged her to use it. A continuous observation and interview with Resident #40 on 06/21/21 beginning at 3:23 PM and ending at 4:00 PM in Resident #40's room revealed she was sitting up in her wheelchair facing the bed with the call light on. The signage on the door indicated Resident #40 was on Enhanced Droplet Isolation Precautions. Resident #40 mentioned she had her call light on to request assistance from staff and she felt staff were reluctant to answer her call light because they had to garb up (don full personal protective equipment-PPE) just to provide her pain medications or assist her to the toilet. Resident #40 continued to say staff did not answer her call light recently when she slid from her wheelchair and another resident went to obtain help after she had hollered for a while. She stated when there were substantial delays in answering her call light almost daily and staff not addressing her needs when they did enter her room, it made her feel sad, worthless, and as though staff did not care about her or what her needs were. Resident #40 mentioned she had complained in the past (although she could not recall an exact date) to the former Director of Nursing about staff not answering lights timely and was told they would monitor this, but while being on the quarantine unit it was taking longer again. At approximately 3:35 PM, the facility Administrator opened the door without knocking and looked in the room and made eye contact with the surveyor in the room, did not address Resident #40's needs, and turned and shut the door. Shortly following that at 3:47 PM, Laundry Worker (LW) #1 and Nurse Aide (NA) #2 entered the room to return a mesh bag of laundry belonging to Resident #40. NA #2 then turned off Resident #40's call light without asking how she could address her needs and turned and left the room with LW #1. During the 37- minute continuous observation, Resident #40's needs were not addressed by a staff member. An interview on 06/21/21 at 4:05 PM with NA #2 revealed she was assigned to work with Resident #40 on that shift. She acknowledged she had entered the room to return the laundry provided by LW #1 and had turned the call light off without thinking about asking what Resident #40 may have needed. NA #2 indicated she was aware she had sustained multiple falls and was a high fall risk and required assistance with her ADL. NA #2 stated she had been taught to answer all call lights timely and address the request of the resident. She indicated she was not to turn off the call light unless she was able to address the need of the resident, but all staff were to answer resident call lights. NA #2 stated she would try to do a better job in addressing her needs timely. An interview on 06/24/21 at 2:00 PM with the Director of Nursing (DON) revealed all staff had been trained to answer and address call lights timely. She acknowledged Resident #40's call light should have been addressed before she waited over 30 minutes with the light on and NA #2 should not have turned the call light off without helping Resident #40. The DON was unaware Resident #40 felt as though staff did not care about her or her needs, but indicated it was unacceptable to not assist a resident or get the appropriate person to help before turning a call light off. An interview on 06/25/21 at 2:46 PM with the Administrator revealed he did not recall opening the door to Resident #40's room without knocking or addressing her needs on 06/21/21. He elaborated he expected all staff to address call lights timely and treat all residents with dignity and respect. 2. Resident #15 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #15 was cognitively intact for daily decision making and required extensive assistance with activities of daily living. An interview was conducted with Resident #15 on 06/21/21 at 12:50 PM. Resident #15 stated that on April 05, 2021 Cook #1 was in the hallway and she stated to him that he had prepared a salad a few days prior that was not acceptable. Resident #15 explained that it was a chef salad that did not have any meat on it and the lettuce was wilted. She stated that Cook #1 began to speak very loudly and rudely and began to argue with her and stated that she was the reason he was going to quit. Resident #15 also stated that Cook #1 stated that he was not going to do anything else to accommodate Resident #15 before leaving the hallway directly in front of her room. She added that the Director of Nursing (DON) was in her office next door to Resident #15 and overheard the verbal exchange. Resident #15 stated that she was fearful of eating anything he served and when he was cooking, she generally would order outside food. An interview was conducted with Cook #1 on 06/23/21 at 12:15 PM. Cook #1 stated that a few days prior to April 05, 2021 he was preparing salads for the evening meal and was running low on salad mix and had to split it up between all the residents that ordered salads that night. Cook #1 stated that Resident #15 got the skimpy one and was not up to Resident #15's standards. Cook #1 continued to say that on April 05, 2021 he was in the hallway and Resident #15 began to complain about her salad that she received a few days prior and he took it very personal and raised my voice with Resident #15. Cook #1 stated that he could not recall the exact words that were used but stated there were no curse words but the way he spoke to Resident #15 was inappropriate. He added that he prepared Resident #15's meal just as he did all the other residents and he had taken it personal that she did not enjoy the salad he had prepared for her despite it being skimpy. An interview was conducted with the DON on 06/24/21 at 3:06 PM. The DON stated that on April 05, 2021 she was in her office with the door open which was next door to Resident #15's room. The DON stated that she heard Cook #1 very loudly say, I am not going to do anything extra for you anymore. The DON stated that it shocked her because no staff member should be that loud in the hallway while speaking to a resident. The DON stated she got up and went to the hallway and Cook #1 had already reached the nurses station and was on his way back to the kitchen. She stated she went into Resident #15's room and she was very upset and stated that she did not want Cook #1 preparing her meals anymore. The DON stated she never spoke to Cook #1 about the incident but did report it to the previous Administrator. The DON stated she did not want the staff speaking to the residents in the manner and tone that Cook #1 spoke to Resident #15 in on that day. An interview was conducted with the Administrator on 06/25/21 at 2:46 PM. The Administrator stated that he expected the staff to treat the resident with respect and dignity and it was not appropriate to speak to Resident #15 in a loud/rude tone.

Based on record review and staff interviews the facility failed to respond to a residents nonverbal signs of pain while providing incontinent care for 1 of 3 residents sampled for well-being (Resident #69). Resident #69 was discharged to the hospital on [DATE] and diagnosed with [REDACTED]. The finding included: Resident #69 was most recently readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #69's medical revealed that he had been present in the facility from 09/20/17 to 10/10/17 and again from 10/12/17 to 10/17/17. Resident #69 was discharged back to the hospital on [DATE]. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #69 was rarely/never understood and had no speech. Resident #69 was also severely cognitively impaired for daily decision making and required total assistance of 2 staff members for bed mobility. The MDS further indicated that Resident #69 had no non-verbal indicators of pain during the reference period. Review of Situation Background Assessment and Recommendation (SBAR) dated 10/10/17 indicated that at 4:25 PM a Nursing Assistant (NA) reported to the nurse that Resident #69 did not look right and was making facial expression and was tearful when turned and repositioned. Resident #69 was assessed by the nurse and the unit manager. Upon assessment Resident #69 was observed with abnormal posture and abnormal positioning. When right leg was moved Resident #69 was observed grimacing and noted to have labored breathing and a single tear was noted to his face. Resident #69 was reassessed around 5:45 PM and no facial grimacing, no labored breathing, and no crying was noted. No further signs of pain were noted and he was resting comfortably in bed. Family and Nurse Practitioner (NP) made aware. Review of a physician order [REDACTED]. Review of a radiology report dated 10/10/17 read, acute displaced right femoral neck fracture. Review of a physician order [REDACTED]. Review of a radiology report from the hospital dated 10/11/17 read, likely chronic nonunion displaced right femoral neck fracture. Review of an Orthopedic consultation dated 10/16/17 read in part, Resident #69 has an old femoral neck fracture. No orthopedic intervention needed. Interviews were conducted with NA #1 on 10/26/17 at 5:05 PM and again on 10/27/17 at 2:37 PM. NA #1 indicated that on 10/10/17 the Wound Nurse (WN) had stated that they had just finished wound care on Resident #69 and he needed incontinent care. NA #1 stated she entered Resident #69's room and he was resting in bed and she started to provide incontinent care to Resident #69 he began making facial expressions and became very tense and scrunched his face and was moaning and frowning. NA #1 stated that the facial expression got much worse while she was providing the incontinent care but she was right in the middle of care and she had to finish the care. NA #1 stated that immediately after she finished the care Resident #69 was finally able to relax from the pain and she alerted Nurse #2. NA #1 stated that she checked on Resident #69 during the rest of her shift but did not have to provide any care to him. An interview was conducted with the WN on 10/27/17 at 9:12 AM. The WN stated that on 10/10/17 she and the wound doctor had been in to provide wound care to Resident #69. She added that the wound care was uneventful and Resident #69 tolerated the treatment well with no signs or symptoms of pain or discomfort and indicated they had been in the room for approximately 10 to 15 minutes. She added that while performing wound care to Resident #69's sacrum they noted some feces that needed to be cleaned up and so when they had finished wound care and exited the room she had told NA #1 that Resident #69 needed incontinent care. An interview was conducted with the Director of Nursing (DON) on 10/27/17 at 11:23 AM. The DON stated that NA #1 was providing care to Resident #69 had noticed that he did not look right and she went and asked Nurse #2 to come and check on him. She added that after Nurse #2 had assessed him she wanted Nurse #1 to come and take a look at Resident #69. After both nurses had assessed Resident #69 they agreed that the NP on call needed to be made aware. The NP ordered x-ray and those were obtained and came back with a fracture and Resident #69 was sent to the ER for evaluation. The DON stated that she was at the facility working and was notified of the situation and at the end of NA#1's shift she was interviewed and she then left the facility. The DON stated she needed to conduct further interviews to validate what was going on. The DON stated she would expect that if Resident #69 was displaying signs and symptoms of pain that they stop what they were doing and notify the nurse. An interview was conducted with Nurse #2 on 10/27/17 at 12:51 PM. Nurse #1 stated that she was working on 2nd shift on 10/10/17 when NA #1 reported that Resident #69 did not look right and was making facial expressions. Nurse #2 stated she went to Resident #69's room to assess him and when she pulled back the covers he did not look right laying in the bed he did not appear to be in any pain at that time but I ran to get Nurse #1 who was the supervisor. When Nurse #1 and I reassessed Resident #69 we agreed that we needed to contact the NP that was on call. Nurse #1 stated that she called the NP and got an order to X-ray both hips and when the X-ray technician came Resident #69 was resting comfortably in bed and did not appear to be any pain. An interview was conducted with Nurse #1 on 10/27/17 at 2:05 PM. Nurse #1 stated she was the supervisor on 10/10/17 when Nurse #2 had asked me to come to Resident #69's room and assess him. Nurse #1 stated that when she entered Resident #69's room NA #1 stated there is something wrong with him and stated he is not normally positioned like this. Nurse #1 stated she did not manipulate Resident #69 at all and due to the statements made by NA #1 and Nurse #2's previous assessment she went and called the NP. Nurse #1 stated that at the time she saw Resident #69 he was resting in bed and did not appear to be in any pain, there was no frowning, moaning, or crying that she noted. An interview was conducted with the NP on 10/27/17 at 1:49 PM. The NP stated that she had received a call from the facility on 10/10/17 and was made aware that Resident #69 looked differently and they wanted to get X-ray and that was what we did. The NP stated that when the facility called her they did not indicate that Resident #69 was in any pain and if they had she stated she would have went ahead and sent him to the ER for evaluation. The facility provided credible evidence of the corrective measure implemented after the incident. The measures included: - Disciplinary action for NA #1 and education how to determine non-verbal signs of pain or discomfort that if noted during care to stop and report it to the nurse. The following was completed after the alleged deficient practice was identified: - Audits of all Residents who were non-verbal were completed on 10/12/17 by the Director of Nursing and Nurse Managers. - Pain assessments were completed for all residents by the Director of Nursing and Nurse Managers on 10/12/17. - Pain Observation orders obtained and entered into the electronic medical record by the Director of Nursing and Nurse Managers on 10/12/17. - Resident with Pressure Ulcers were also assessed for pain and new orders obtained as needed by the Director of Nursing and Nurse Managers on 10/12/17. On 10/12/17 education was provided to all licenses nurses on pain management and provided them pain management symptom handouts. On 10/12/17 all staff was educated on Abuse and Neglect. On 10/12/17 the therapy staff was educated on reporting pain to nurses using the Stop and Watch tool. On 10/12/17 all licenses nurses, NAs, and therapy staff were educated on the non-verbal signs of pain in residents. Monitoring: - The Social Worker (SW) will complete the abuse and neglect monitoring for 5 residents weekly for 4 weeks for 1 month. - Nurse Managers to monitor 5 non-verbal residents for pain weekly for 4 weeks then weekly for 1 month. - All the finding will be presented Quality Assurance Performance Improvement (QAPI) for 3 months. During the investigation validation of the corrective measures through interviews with staff, observations and record review indicated the facility had implemented measures to identify non- verbal signs of pain and how to respond.

Based on observation, record reviews, staff and family interviews the facility failed to assess and provide treatment to prevent development of pressure ulcer for one of four sampled residents (Resident # 69). The resident was readmitted on [DATE] to the facility with a reddened area on left heel. The area on the left heel was not reassessed until 06/25/17 at which time the left heel area was black in color. The findings included: Resident #69 readmitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] for the quarterly assessment indicated that resident #69 was severely impaired cognitively. The resident also required extensive assistance for bed mobility/positioning and transfers from bed. He was dependent for all personal care. The resident received nutrition through a feeding tube and was dependent on supplemental oxygen. Review of physician order [REDACTED]. Review of skin assessment form dated 6/15/17 revealed resident had reddened areas on left heel. Review of treatment administration record for June 2017 revealed wound care for left heel wound initiated 06/25/17 with use of skin protective wipe. Review of Evaluation and Management report by Wound Care Specialist dated 06/27/17 revealed resident had an unstageable pressure ulcer on left heel which measured 7 centimeters in length, 6 centimeters in width and estimated depth of 0.2 centimeter. The wound was documented as having excessive necrotic tissue and drainage. Treatment ordered included Silver-alginate dressing and prevention of pressure on the wound area. Review of Wound Management report by Wound Care Specialist dated 07/11/17 revealed left heel wound was Stage III pressure ulcer and contained necrotic tissue. The wound care treatment order was changed to Santyl to enzymatically debride necrotic tissue. An observation of Nurse #3 was made on 07/12/17 at 11:24 AM performing wound care on left heel of Resident #69. The old dressing observed to have red and watery yellowish drainage on it. The wound had an area of greyish tissue surrounded with pink tissues. The edges of the wound had darkened, flaky skin. The wound was cleaned and Santyl ointment applied, and the area on left heel covered with dry dressing. An interview was conducted on 07/13/17 with Nurse #2 at 11:25 AM who had performed assessment at time of readmission. Nurse # 2 stated that Resident #69 had a reddened area on left heel at the time of skin admission assessment was completed on 06/15/17. Nurse #2 also stated that measurements and description of the area had not been entered on the form entitled Nursing Admission Data Collection form in the area for Skin assessment. During the interview with Nurse #2 it was stated that referral had not been made to the Wound Treatment registered nurse for assessment of the reddened area on the left heel of Resident #69. Nurse #2 confirmed that the medical record did not include a reassessment of the left heel during the week of 06/18/17 through 06/24/17. An interview was conducted with a family member on 07/13/17 at 1:20 PM who stated that he had been informed on 06/25/17 that Resident #69 had been referred to Wound Care Specialist. The family member stated that he had observed the resident on 06/25/17 with a blackened area on his left heel and did not have protective boots on either the right or left foot. The family member reported that the left heel was turned inward and rested against the heel of the right foot when observed on 06/25/17. An interview was conducted on 7/13/17 at 3:18 PM with Nurse #3 who functioned as wound care/treatment nurse. Nurse #3 stated that it was her expectation to be notified when a resident had a reddened area on skin. Nurse #3 also stated that she had been notified about the left heel wound on 06/25/17 and she observed the wound was black in color. Nurse #3 stated that a referral had been made to the Wound Specialist who did initial assessment of left heel wound on 06/27/17. On 07/14/17 at 11:07 AM an interview was conducted with Wound Care Specialist who stated that she had first evaluated wound on 06/27/17. The Wound Care Specialist stated during that interview that the wound on the left heel of Resident #69 had been a blackened, opened, but unstageable wound when first evaluated. The Wound Care Specialist stated that after treatment the wound was assessed as a Stage III pressure ulcer on 07/11/17. On 07/14/17 at 3:51 PM an interview was conducted with the Assistant Director of Nursing (ADON) because the Director of Nursing was not available. The ADON stated it was the expectation that wound assessments be completed and include measurements and description of areas of reddened skin observed by nursing staff. It was also stated by ADON that it was her expectation that wound care/treatment registered nurse be notified if a resident developed reddened skin area.

Based on observations, record reviews and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in November 2016 following a recertification and complaint survey and subsequently recited in July 2017 on the current recertification and complaint survey. The repeat deficiencies are in the areas of notification (F157), environment (F253), activities of daily living (F312), store/prepare/serve food under sanitary conditions (F371), and medication storage (F431). These deficiencies were recited during the facility's current recertification and complaint survey. The continued failure of the facility during 2 federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: 1a. This tag is cross referred to: F-157; Based on record reviews, staff interviews, nurse practitioner and Medical Doctor (MD) interviews, the facility failed to notify the nurse practitioner and the physician of development of pressure ulcer in 1 of 4 sampled residents. (Resident #69). During the recertification and complaint survey of 11/03/16, this regulation was cited for failing to notify the physician of a residents eye enucleation (removal of the eye) that began draining purulent drainage for 1 of 2 sampled residents (Resident #25) and failed to notify the physician of a blood sugar that exceeded the ordered parameters for 1 of 2 sampled residents (Resident #38). During the current recertification and complaint survey this regulation was cited for failing to notify the physician of a pressure ulcer. 1b. This is a cross refer to: F-253; Based on observations and staff interviews the facility failed to repair broken and splintered laminate on resident room doors and a bathroom door on 4 of 12 resident rooms and 1 of 1 common bathroom door (Rooms 205, 401, 408 and bathroom on the 300 hall), failed to repair broken floor tile in 1 of 12 resident rooms (room [ROOM NUMBER]), failed to repair patches on walls in 4 of 12 resident rooms (room [ROOM NUMBER], 202, 206, and 404) and failed to repair water damage on the ceiling in 1 of 12 resident rooms (room [ROOM NUMBER]). During the recertification and complaint survey of 11/03/16, the regulation was cited for failing to label a urinal and a fracture bed pan in 2 resident bathrooms (room [ROOM NUMBER] and #310) on 2 of 7 resident hallways, failed to repair 13 resident doors (Resident room [ROOM NUMBER], #201, #205, #207, #305, #310, #311, #401, #405, #512, #601, #700 and #706) with broken and splintered laminate and wood on the edges of the bottom half of the doors (100, 200, 300, 400, 500, 600 and 700 halls), failed to repair 1 of 2 doors to the recreation room with broken and splintered laminate on the lower edges of the door (100 hallway), failed to repair a set of smoke prevention doors (700 hall) with broken and splintered laminate on the lower edges of the doors on 1 of 7 hallways and failed to repair a wall behind a resident's bed with deep gouges into the sheet rock (room [ROOM NUMBER]-A) on 1 of 7 resident hallways. During the current recertification and complaint survey this regulation was cited for failing to repair broken and splintered laminate on resident room doors and a bathroom door on 4 of 12 resident rooms and 1 of 1 common bathroom door (Rooms 205, 401, 408 and bathroom on the 300 hall), failed to repair broken floor tile in 1 of 12 resident rooms (room [ROOM NUMBER]), failed to repair patches on walls in 4 of 12 resident rooms (room [ROOM NUMBER], 202, 206, and 404) and failed to repair water damage on the ceiling in 1 of 12 resident rooms (room [ROOM NUMBER]). 1c. This is a cross refer to F-312; Based on observations, record review, family, and staff interviews the facility failed to trim and clean a dependent residents fingernails for 1 of 5 residents sampled for activities of daily living (Resident # 69). During the recertification and complaint survey of 11/03/16 this regulation was cited for failing to trim a dependent residents fingernails for 1 of 3 residents sampled for activities of daily living (Resident #97). During the current recertification and complaint survey this regulation was cited for failed to trim and clean a dependent residents fingernails. 1d. This is a cross refer to F-371; Based on observations and staff interviews the facility failed to keep flies out of the kitchen area during food production and meal service, failed to discard opened containers of milk that were not dated when opened and failed to remove 3 cartons of ice cream from the floor of the walk in freezer. During the recertification and complaint survey of 11/03/16 this regulation was cited for failing to clean a fan that contained gray debris hanging from the metal grates on the front and back of the fan that was in use and located in a food preparation area next to clean pots and pans and the facility failed to clean a dirty microwave located in 1 of 2 nourishment rooms (700 hall). During the current recertification and complaint survey this regulation was cited for failing to keep flies out of the kitchen area during food production and meal service, failing to discard open containers of milk that were not dated when opened and failing to remove 3 cartons of ice cream off the floor of the walk in freezer. 1e. This is a cross refer to F-431; Based on observations, record review, and staff interviews the facility failed to keep medications securely in the original packaging for 6 of 6 medications cart (100 cart, 200 cart, 300 cart, 400 cart, 500/600 cart and 700 cart) that were noted to have loose pills in the drawers and failed to discard expired/undated insulin on of 2 of 6 medication carts (100 cart and 400 cart). During the recertification survey and complaint survey of 11/03/16 this regulation was cited for failing to remove expired medications from 1 of 4 medication carts. During the current recertification and complaint survey this regulation was cited for loose pills in 6 of 6 medication carts and for expired/undated insulin in 2 of 6 medication carts. An interview was conducted with the Administrator on 07/14/17 at 5:18 PM. The Administrator stated she had only been at the facility for 2 weeks and they have had 1 Quality Assurance (QA) meeting since she had been present. She stated that the Director of Nursing (DON) ran the meeting and each department head was present. She further explained that each team member brought their own information to the meeting and present the information to the group. The Administrator stated she had not reviewed the finding from the previous recertification survey and was unaware of the monitoring tools that were and were not being completed. The Administrator stated she was going to go to sister facility soon for training on the company's QA process and would bring that information back to the facility and implement as needed.

Based on observations, record reviews, family, and staff interviews the facility's administration failed to manage the care and needs of residents in the building for 4 of 6 residents sampled (Resident #93, #29, #147, and #69). The findings included: 1. Cross Reference F-166: Based on record review and staff interviews the facility failed to ensure the grievance investigations and resolutions were provided in writing to 3 of 3 sampled residents and/or their responsible parties (Residents #93, #29 and #147). 2. Cross Reference F-224: Based on observation, record reviews, staff and family interviews the facility neglected to assess and provide treatment for [REDACTED].# 69). The facility neglected to assess and seek treatment for [REDACTED]. 3. Cross Reference F-353: Based on observations, record reviews, family, significant other, and staff interviews the facility failed to have sufficient quantity of staff to ensure a dependent resident was provided pressure ulcer care, nail care, and apply splint as ordered to prevent further contractures (Resident #69) for 1 of 4 sampled residents. The Director of Nursing (DON) was unavailable for interview on 07/14/17 at 10:00 AM. An interview was conducted with the Administrator on 07/14/17 at 2:37 PM. The Administrator stated that she had only been at the facility for 2 weeks and was still trying to figure out all the processes in the facility. She added that she had not even had time to read the reports from the prior survey and honestly she had no idea if the facility was at a point to stop their monitoring tools or not. She added that she had not yet been trained on all the polices and was not even sure how or where to pull the facilities policies.

Based on observation, record reviews, staff and family interviews the facility neglected to assess and provide treatment for [REDACTED]. (Resident # 69). The facility neglected to assess and seek treatment for [REDACTED]. The findings Included: 1. Resident #69 readmitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set quarterly assessment dated [DATE] indicated that resident #69 was severely impaired cognitively. The resident also required extensive assistance for bed mobility/positioning and transfers from bed. He was dependent on staff for all personal care. The resident received nutrition through a feeding tube and was dependent on supplemental oxygen. Review of skin assessment form dated 06/15/17 revealed resident had an area of reddened skin on right heel. The form was not completed in the area intended for documentation of size, type, and description of the wound. Review of medical record revealed follow up weekly skin assessment was dated 06/25/17. Review of MD orders for Resident #69 revealed wound care orders which were initiated on 06/25/17 for an unstageable pressure ulcer on the left heel. An observation was made of the wound on the left heel of Resident #69 on 07/12/17 at 2:17 PM. The wound on the resident's left heel had pink and greyish tissue and the wound was surrounded by darkened flaky skin. An interview was conducted with Nurse #2 who stated that she had completed the skin assessment of Resident #69 on date of readmission 06/15/17. Nurse #2 stated that she had marked the form incorrectly. Nurse # 2 stated that the reddened area had been on the left heel of Resident #69. Nurse #2 also stated that she had not documented the description or size of the area on the left heel. An interview was conducted with Wound Care Specialist on 07/14/17 at 11:07 AM. The Wound Care Specialist stated that the resident had a Stage III pressure ulcer on his left heel. The Wound Care Specialist stated also that it was her expectation that wounds would be assessed and documented in the medical record. The Assistant Director of Nursing (ADON) was interviewed on 07/13/17 at 3:51 PM. The ADON stated it was her expectation that a skin assessment would be filled out completely to include description of and measurement of wounds for residents with wounds. The ADON stated it was also her expectation that wounds had follow up assessment completed weekly or whenever the condition of the wound changed. An interview was conducted with the facility Medial Doctor (MD) on 07/14/17 at 5:53 PM. The MD stated that it was the expectation that wounds be assessed and MD be notified of wounds. 2. Resident #69 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #69 was severely cognitively impaired for daily decision making. The MDS also revealed that Resident #69 required total assistance of 1 staff member for personal hygiene. An interview and observation was conducted on 07/11/17 at 2:51 PM with Nursing Assistant (NA) #1. NA #1 stated she routinely cared for Resident #69 on first shift. She stated that she had bathed Resident #69 this am and she had not noticed that his nails needed to be trimmed but after looking at them confirmed that they definitely need to be trimmed and cleaned. NA #1 added that she checked fingernails every other day and had just not noticed Resident #69's but she would take care of them right away. An observation of Resident #69 was made on 07/11/17 at 3:43 PM. All of Resident #69's fingernails were noted to be a quarter inch long and had dried brown substance under them. An observation of Resident #69 was made on 07/12/17 at 9:38 AM. All of Resident #69's fingernails were noted to be a quarter inch long and had dried brown substance under them. A follow up interview was conducted with NA #1 on 07/13/17 at 10:24 PM. NA #1 stated she had not had the time to go back to clip or clean Resident #69's fingernails. NA #1 added she would take care of it right away. An observation of Resident #69 was made on 07/14/17 at 9:52 AM. All of Resident #69's fingernails were noted to be a quarter inch long and had dried brown substance under them. The Assistant Director of Nursing (ADON) was unavailable for interview on 07/14/17 at 10:00 AM. The Director of Nursing (DON) was unavailable for interview on 07/14/17 at 10:00 AM. An interview was conducted with the Administrator on 07/14/17 at 10:32 AM. The Administrator stated that she expected the staff to cut, clean, and trim residents fingernails and toenails as needed. An interview was conducted with the District Director of Clinical Services (DDCS) on 07/14/17 at 4:04 PM. The DDCS stated the staff was expected to check fingernails on a daily basis and trim and clean them as needed.

Based on record reviews, staff interviews, nurse practitioner and Medical Doctor (MD) interviews, the facility failed to notify the nurse practitioner and the physician of development of pressure ulcer in 1 of 4 sampled residents. (Resident #69). The findings included: Resident #69 readmitted on [DATE] to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] for the quarterly assessment indicated that resident was severely impaired cognitively. The resident also required extensive assistance for bed mobility/positioning and transfers from bed. He was dependent for all personal care. The resident received nutrition through a feeding tube and was dependent on supplemental oxygen. Review of skin assessment form dated 06/15/17 revealed Resident #69 had an reddened area on left heel. Review of physician order [REDACTED]. Review of MD orders for Resident #69 revealed no orders for left heel pressure ulcer until after nurse assessment dated [DATE]. Review of treatment administration record for June 2017 revealed wound care initiated for left heel unstageable pressure ulcer on 06/25/17 by Wound Treatment Nurse Practitioner. Interview conducted with Nurse # 3 on 07/13/17/ at 11:25 AM. Nurse #3 stated that the reddened area on the left heel of Resident #69 was not reported to the Nurse Practitioner or the MD after the skin assessment dated [DATE]. Interview conducted on 07/14/17 at 10:04 AM with Nurse Practitioner (NP). NP stated that she was not aware that Resident #69 had a pressure ulcer on his left heel. The NP stated it was her expectation to be notified of new wounds or other changes in the condition of residents. An interview was conducted on 07/14/17 at 5: 53 PM with MD. MD stated it was her expectation to be notified if residents developed new wounds.

Based on observations, record reviews, family and staff interviews the facility failed to have sufficient quantity of staff to ensure a dependent resident was provided pressure ulcer care, nail care, and had splints applied to prevent further contractures (Resident #69) for 1 of 4 sampled residents. The findings included: 1. Cross reference F-224: Based on observation, record reviews, staff and family interviews the facility neglected to assess and provide treatment for [REDACTED]. (Resident # 69). The facility neglected to assess and seek treatment for [REDACTED]. 2. Cross reference F-314: Based on observation, record review, staff and family interviews the facility failed to assess and provide treatment to prevent development of pressure ulcer for 1 of 4 sampled residents (Resident #69). The resident was readmitted on [DATE] to the facility with reddened area on left heel. The area on the left heel was not reassessed until 06/25/17 at which time the left heel was black in color. 3. Cross reference F-312: Based on observations, record review, family, and staff interviews the facility failed to trim and clean a dependent residents fingernails for 1 of 5 residents sampled for activities of daily living (Resident # 69). 4. Cross reference F-318: Based on observations, record reviews, family, and staff interviews the facility failed to apply physician ordered splints to prevent worsening contractures for 1 of 1 residents sampled for range of motion (Resident #69). An interview was conducted with a family member of Resident #69 on 07/12/17 at 9:31 AM. The family member stated there was not enough staff in the facility to take care of his family member. The family member stated that the facility did not dress his family member like they were supposed to and they did not have enough staff to trim his fingernails or put lotion on his skin. The family member stated that there was not enough staff to put his loved ones splints on, they are always lying next to the bed but were not on the resident. An interview was conducted with Nurse #1 on 07/12/17 at 6:30 PM. Nurse #1 confirmed that she was actually the unit manager at the facility. She stated that staffing was an on-going issue. Nurse #1 stated that she recalled in June 2016 more specifically the weekend of June 17-18, 2017 she was the supervisor and was dealing with alot of staffing issues. She indicated that the facility had a couple of call outs and they were working short and it was a busy weekend with lots of extra visitors. Nurse #1 stated she had some very upset family members because they discovered their loved ones were soiled and disheveled when they came to visit. She added that she was trying to get the staff that was available in the correct location so that all the residents could get cared for adequately. Nurse #1 stated she was relatively new to the facility and she had taken the family ' s member concerns and placed them on concern form and given them to the Director of Nursing for follow up. Nurse #1 stated that she felt like that weekend the staff could have done a better job of taking care of the residents. An interview was conducted with Nurse #9 on 07/14/17 at 6:11 AM. Nurse #9 stated that at times the staff had to work short staffed due to call outs. She added when there were short staffed everyone had to pull together to get things done. Nurse #9 stated that when a staff member called out she would let the facility scheduler know and she would try to find a replacement which was not always possible. An interview was conducted with NA #8 on 07/14/17 at 6:22 AM. NA#8 stated that at times the facility was short staffed due to call outs. She added that sometimes they were able to replace the call out but at times they were not. When they were short staffed NA #8 stated they all had to pull together to get the care done. She added that the care was usually provided but we have to do each round more quickly to get it all done and could not spend good quality time with residents. An interview was conducted with Nursing Assistant (NA) #6 on 07/14/17 at 6:23 AM. NA #6 stated that staffing at night was not good and it is getting worse. She stated she had worked night shift for [AGE] years and she worked a lot of overtime hours in stressful situations. NA #6 stated that she had to rush through her assignment and did not get to spend any time with the residents. An interview was conducted with NA #7 on 07/14/17 at 6:30 AM. NA #7 indicated he was agency staff. NA #7 stated that at times staffing was iffy and during those times they really have to pick up the slack and had to hurry to get everything completed before the end of the shift. He added that usually there were 3 NAs on the 300 hall but due to a call out on 07/14/17 it was just him and another NA on the 300. He stated I guess they could not find anyone to work. The Director of Nursing (DON) was unavailable for interview. An interview was conducted with the Administrator on 07/14/17 at 10:59 AM. The Administrator stated she had only been at the facility for 2 weeks and she really did not know anything about staffing. She stated that she routinely asked about staffing in the facility's morning meeting and nothing had been brought to her attention. She added that she was not aware if call-outs were a big issue at the facility or not and she had not been their long enough to assess the situation. The Administrator stated that when she questioned the DON about staffing she was always told it was fine. She also stated she was aware that the facility currently used agency staff and she did not want to use them long term. The Administrator added she was not aware if call-outs were replaced or not but her expectation was that the facility was staffed appropriately to meet the needs of the residents. An interview was conducted with the District Director of Clinical Services (DDCS) on 07/14/17 at 4:03 PM. The DDCS stated she expected the facility to be staffed to meet all the needs of all the residents. An interview was conducted with the scheduler on 07/14/17 at 4:12 PM. The Scheduler explained that she staffed the building based on resident to NA ratios. Those ratios were as followed: 1st shift no more than 12 residents to 1 NA, 2nd shift no more than 14 residents per NA, and 3rd shift no more than 25 residents per NA. So the number of staff needed changed on a daily basis as the census changed. The scheduler stated that they used a computer software call on shift and when there was a call-out, a message was sent out to all available NAs alerting them. She also added that she would send out text to staff members to see if anyone wanted to work. The scheduler stated she did a good job of making sure all the call-outs were covered. She added that the ADON monitored the call-outs and disciplinary action was taken after a certain number of call outs. The scheduler stated that she currently had 8 full time NA positions and 4 full time nurse positions. She also added that she was a NA and at times she covered call-outs or open shifts if needed. She explained that the facility contracted with 2 staffing agencies and she would call them and tell what the needs of the facility were. The scheduler felt like the 2 staffing agencies were able to adequately meet the needs of the facility. She did say that the facility had some turn over recently and they just could not hire new staff quick enough to replace those that left. She added that the facility was currently running an advertisements for new staff and was offering a sign on bonus for new staff. She added that the staff was able to complete their assignment and still get their lunches. She was unaware of any care that was not being completed due to the shortage of staff.

Based on observations, resident and staff interviews and record review, a facility staff member failed to report her knowledge of resident to resident physical abuse to the nursing home's administration for 1 of 2 residents with a history of being physically abusive (Resident #9). Immediate jeopardy began on 09/17/14 when therapy staff member #1 failed to report an allegation of physical abuse to the nursing home's administration. Immediate jeopardy was removed on 09/26/14 at 6:39 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: A document titled, "Abuse and Neglect Prohibition" revised June 2013 read in part: Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. 1. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident did not have impaired cognition. On 09/22/14 at 1:38 PM Resident #103 was interviewed and asked if he saw any resident being abused. Resident #103 replied, "Yes." Resident #103 explained that he had observed Resident #9 hit Resident #34 on two separate occasions. Resident #103 explained that he was unable to recall exact dates because he had difficulty remembering dates but that "about 6 months ago" he was in bed and Resident #34 was in his wheelchair parked in the doorway. Resident #9 approached Resident #34 and slapped him across the face, knocking his hat off. Resident #103 stated he yelled for Resident #34 to get inside the room and Resident #9 left. Resident #103 described a second incident he witnessed 2-3 months ago in which he was in the hallway and watched as Resident #9 hit Resident #34 with a closed fist. Resident #103 propelled his wheelchair closer to the residents which caused Resident #9 to stop hitting Resident #34. Resident #103 stated he did not report either incident to a staff member. He offered no explanation why he did not report the incidents but stated that therapy staff member #1 was aware that Resident #9 was abusive toward Resident #34 because they had discussed it. Resident #103 reported that Resident #9 hated Resident #34 and was repeatedly mean to Resident #34. Resident #103 was unaware if any staff members had observed the incidents. On 09/23/14 at 3:45 PM the Director of Nursing (DON) was interviewed and reported that she was unaware of allegations of abuse involving Resident #9 and Resident #34. Resident #103's observed incidents were reported to the DON and she stated she was unaware and had not received reports of alleged abuse between Resident #9 and Resident #34. She stated she would have expected Resident #103 to tell a staff member immediately of any allegations of abuse. 2. On 09/23/14 at 2:52 PM therapy staff member #1 was interviewed and explained that she received regular training on prevention of abuse and neglect. She stated that she was trained to report any suspicion of abuse to her supervisor and/or Administrator. Therapy staff member #1 reported that on 09/17/14 she arrived for work and was greeted by Resident #9. Resident #9 reported to therapy staff member #1 that he had hit Resident #34. Therapy staff member #1 added that Resident #9 had a temper and was at times verbally abusive towards her and other staff members. Therapy staff member #1 stated she could tell when Resident #9 was getting mad and angry but that Resident #34 did not. She added that Resident #34 was unable to defend himself against Resident #9. Therapy staff member #1 admitted that she failed to report the allegation to the Director of Nursing or the Administrator because she didn't believe Resident #9 was telling the truth. On 09/23/14 at 3:45 PM the Director of Nursing (DON) was interviewed and reported she was unaware Resident #9 told therapy staff member #1 he had hit Resident #34. The DON stated she expected therapy staff member #1 to report the concern immediately to her or the Administrator. The DON added that the abuse policy did not allow staff the freedom to discern what was truthful; all allegations were to be reported. On 09/25/14 at 1:05 PM the Administrator was notified of immediate jeopardy for therapy staff member #1's failing to report allegations of physical abuse to the nursing home's administration so that appropriate investigation and follow up could be initiated. The facility provided an acceptable credible allegation of compliance on 09/26/14 at 4:56 PM. The following interventions were put into place to remove the immediate jeopardy. Allegation of Compliance: 1. Therapy staff member #1 was suspended by Rehabilitation Director on 09/23/14 for failing to report an allegation of abuse. Therapy staff member #1 was re-educated on 09/23/14 by Rehabilitation Director on mandated reporting of abuse and neglect prohibition including resident to resident altercation. Resident #109 and #103 were re-educated on 09/25/14 by the Social Services Director on reporting observations of alleged abuse, suspected abuse or rumors of abuse to any facility employee. Residents #109 and #103 verbalized understanding to the Director of Social Services of reporting allegations of abuse. 2. All current employees have been interviewed by the Director of Nursing, Assistant Director of Nursing or Staff Development Coordinator on 09/26/14 to verify reporting of all allegations of abuse. All allegations and reports received as a result of these staff interviews have been investigated by the Administrator or Director of Nursing according to the facility's policy and procedure regarding Abuse and Neglect Prohibition. Interviews conducted by the SDC, ADON and SW on 09/25/14 and completed on 09/26/14. All residents with a BIMS greater than 10 have been interviewed by the Social Services Director, Social Services Assistant or the Administrator to verify reporting of all allegations of abuse and observed resident to resident altercations. These interviews were completed on 09/26/14. At the completion of the interviews the residents verbalized understanding to report allegations of abuse. All allegations and reports received as a result of these resident interviews have been investigated by the Administrator or Director of Nursing according to the facility's policy and procedure regarding Abuse and Neglect Prohibition. Interviews conducted by the SDC, ADON and SW on 09/25/14 and completed on 09/26/14. 3. Beginning on 09/25/14 all facility employees will be re-educated by the Assistant Director of Nursing or Staff Development Coordinator on the Facility Policy for Abuse and Neglect Prohibition and mandated reporting of allegations of resident abuse and neglect to the Administrator, Director of Nursing or the employee's immediate supervisor. This re-education will also include reporting resident to resident altercation, providing separation and a safe environment for both residents involved in the altercation while the investigation is completed and appropriate interventions are care planned and implemented. No facility employee shall work after 09/25/14 without receiving this re-education. Beginning on 09/25/14, all newly hired facility staff will be educated prior to beginning work in the resident care area by the Assistant Director of Nursing or Staff Development Coordinator on the Facility Policy for Abuse and Neglect Prohibition and mandated reporting of allegations of resident abuse and neglect to the Administrator, Director of Nursing or the employees immediate Supervisor. This re-education will also include reporting resident to resident altercation, providing separation and a safe environment for both residents involved in the altercation while the investigation is completed and appropriate interventions are care planned and implemented. Beginning on 09/25/14, new resident admissions into the facility will be educated by the Social Services Director, Social Services Assistant or Admissions Coordinator during the admission process, on the facility policy for Prohibition of Abuse including education on reporting observations of alleged abuse, suspected abuse or rumors of abuse to any facility employee. The Quality Assurance and Performance Improvement Committee met on 9/25/14 to discuss the findings identified by the surveyor and to review this action plan. Immediate Jeopardy was removed on 09/26/14 at 6:39 PM when the facility provided evidence of additional training provided to residents and staff on the importance of reporting all observed, suspected and/or alleged allegations of abuse. Interviews with alert and oriented residents and staff revealed they were trained on when and whom to report allegations of abuse.

Based on observations, staff and resident interviews and record review the facility failed to monitor and implement interventions to protect one of one dependant resident (Resident #34) from other residents with physically violent behaviors. Immediate jeopardy began on 12/10/13 when Resident #9 punched Resident #34 and the facility failed to monitor interventions to prevent reoccurrences to protect Resident #34. Immediate jeopardy was removed on 09/26/14 at 6:39 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #34's care plan initiated on 05/22/13 and last updated on 08/12/14 for behavior symptoms specified the resident had loud laughter and grunting. Approaches specified on the care plan included: - give simple, clear directions, repeat as needed - check for pain and discomfort - modify environment, situations and or treatment to minimize external stressors Resident #34 had a communication care plan initiated on 06/13/13 related to the resident's inability to communicate due to cognitive impairment. Interventions included: - staff to make eye contact when communicating for the resident to be able to read lips - staff will speak clearly and slowly - staff will use gestures to assist in communication Resident #34's most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had severely impaired cognition but no mood or behaviors exhibited. 1a. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's care plan for behaviors initiated 11/12/13, updated on 02/19/14, 05/12/14 and 08/01/14 specified the resident exhibited verbal abuse, physical abuse and resisted care at times. The care plan identified behaviors that included threatening to hit other residents and hitting other residents. Interventions specified in the care plan included: - ignore verbal outbursts - allow choices within individual's decision making abilities - redirect as needed - be alert for triggers of potential evidence of pending behavioral episodes Review of Resident #9's medical record revealed a nurse's entry made by nurse #1 dated 12/11/13 at 7:00 PM that read in part, on 12/10/13 at 6:00 PM Resident #9 struck Resident #34 in the head because Resident #34 would not sit down. Resident #9 told nurse #1, "I don't give a _____. I do what the ____ I want to do." The residents were separated; the doctor and the Director of Nursing were notified. A document titled "Incident/Accident Report" dated 12/10/13 was reviewed and specified new interventions to address the incident included separating the Resident #9 and #34, and moving Resident #9's room, Resident #9 was referred to physician for medication review and Resident #34 was assessed for injury and none noted. Further review of Resident #9's medical record revealed an entry made by the Psychologist dated 01/06/14, "Patient displays episodic irritability aggressiveness when frustrated. There was no evidence of bizarre mentation. Patient was switched to another room. 'The (former) Social Worker told me that if I messed up again I would be out of here.' Initially he declined sharing the reason for changing rooms however; he described 'I punched Resident #34.' Patient initially attempted to soften the incident however; he acknowledged that he lost control of his anger." Resident #9's most recent MDS dated [DATE] specified his cognition was intact, no mood indicators present, verbal behaviors directed at others 1 to 3 days and the resident received antianxiety and antidepressant medications daily. Nurse #1 was unavailable for an interview. The Psychologist was unavailable for an interview. On 09/23/14 at 4:08 PM Resident #9 was interviewed with the Director of Nursing and Assistant Director of Nursing (ADON) present. Resident #9 admitted he hit Resident #34 with a closed fist "about a year ago." Resident #9 stated he could not recall hitting Resident #34 any other times but recalled other incidents in which he got angry with other residents but denied becoming physical. Resident #9 explained that he had problems with his anger but knew to remove himself from upsetting situations. On 09/25/14 at 10:00 AM the Director of Nursing (DON) was interviewed. She reported that nurse #1 notified her of the incident on 12/10/13. The DON explained that the following day on 12/11/13 she investigated the incident and implemented every 15 minute checks for Resident #9 for 2 days, notified the physician to review for medication changes and notified Resident #9's psychologist. She added that Resident #34 was assessed and showed no injuries. She reported that Resident #9's physical behaviors were better but that he still had difficulty with verbally abusive behaviors. The DON explained that Resident #9 was not alert and oriented and had poor cognition and memory. 1b. Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had no impaired cognition and no mood or behaviors exhibited. Review of Resident #113's care plan initially dated 01/30/14 revealed he had a care plan to address insomnia and withdrawal. Interventions included monitoring for signs of behaviors and notifying the physician. Review of Resident #113's medical records revealed an entry dated 04/09/14 that specified he had slapped Resident #34 in the face. A document titled "Incident/Accident Report" dated 04/09/14 specified that Resident #34 was in the hallway when Resident #113 approached him and slapped Resident #34 across the face. Neither resident was able to communicate the reason for the incident. The incident was witnessed by an alert and oriented resident and staff. The residents were immediately separated and Resident #113 was placed on every 15 minute checks. On 09/25/14 at 10:00 AM the Director of Nursing (DON) was interviewed and reported that staff notified her of the incident involving Resident #113 and Resident #34. She stated that the incident was isolated and she was unable to determine what caused Resident #113 to slap Resident #34. She reported that neither resident was able to describe the incident. The DON provided evidence of immediate actions taken to prevent a reoccurrence that included changing Resident #113's room, referring to psychology and notifying the physician. The DON added that there had been no further incidents of physical violence between Resident #113 and Resident #34. 1c. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident did not have impaired cognition. On 09/22/14 at 1:38 PM Resident #103 was interviewed and asked if he saw any resident being abused. Resident #103 replied, "Yes." Resident #103 explained that he had observed Resident #9 hit Resident #34 on two separate occasions. He described both of the incidents. Resident #103 explained that he was unable to recall exact dates because he had difficulty remembering dates but that "about 6 months ago" he was in bed and Resident #34 was in his wheelchair parked the doorway. Resident #9 approached Resident #34 slapped him across the face, knocking his hat off. Resident #103 stated he yelled for Resident #34 to get inside the room but Resident #9 left. Resident #103 described a second incident he witnessed 2 to 3 months ago in which he was in the hallway and watched as Resident #9 started hitting Resident #34 with a closed fist. Resident #103 propelled his wheelchair closer to the residents which caused Resident #9 to stop hitting Resident #34. Resident #103 stated he did not report either incident to a staff member. He offered no explanation why he did not report the incidents but stated that therapy staff member #1 was aware that Resident #9 was abusive toward Resident #34 because they had discussed it. On 09/23/14 at 2:52 PM therapy staff member #1 was interviewed and explained that she received regular training on prevention of abuse and neglect. She stated that she was trained to report any suspicion of abuse to her supervisor and/or Administrator. Therapy staff member #1 reported that on 09/17/14 she arrived for work and was greeted by Resident #9. Resident #9 reported to therapy staff member #1 that he had hit Resident #34. Therapy staff member #1 added that Resident #9 had a temper and was at times verbally abusive towards her and other staff members. Therapy staff member #1 stated she could tell when Resident #9 was getting mad and angry but that Resident #34 could not. She added that Resident #34 was unable to defend himself against Resident #9. Therapy staff member #1 admitted that she failed to report the allegation to the Director of Nursing or the Administrator because she didn't believe Resident #9 was telling the truth. On 09/23/14 at 3:45 PM the Director of Nursing (DON) was interviewed and reported that she was unaware of allegations of abuse involving Resident #9 and Resident #34 since 12/10/13. Resident #103's observed incidents were reported to the DON and she stated she was unaware and had not received reports of alleged abuse between Resident #9 and Resident #34. She stated she would have expected Resident #103 to tell a staff member immediately of any allegations of abuse. During the interview the DON reported that she was unaware Resident #9 told therapy staff member #1 he had hit Resident #34. The DON stated she expected therapy staff member #1 to report the concern immediately to her or the Administrator. The DON added that the abuse policy did not allow staff the freedom to discern what was truthful; all allegations were to be reported. 1d. on 09/22/14 at 3:30 PM Resident #9 and Resident #34 were together in the dining room for a group activity. During the activity Resident #9 was seated in his wheelchair behind Resident #34; Resident #9 gestured for Resident #34 to move out of his way. Resident #34 was not facing Resident #9 and was unable to propel his wheelchair. Resident #9 threw his hands up in the air, rolled his eyes and then swatted his hand in the air as to mimic slapping Resident #34. The activity assistant moved Resident #34 to the side of the room. On 09/24/14 at 2:00 PM the Activity Assistant was interviewed and reported that she was unaware of any concerns with Resident #9 and Resident #34. She stated that they were allowed to interact with one another and that she was unaware of any additional monitoring or special precautions to take if the residents were in a group activity together. On 09/24/14 at 3:05 PM Nurse #2 was interviewed and reported that Resident #9 was verbally and physically abusive towards staff cussing, kicking and trying to punch but denied that he was abusive towards residents. She reported that when Resident #9 became verbally abusive she implemented a "cool off period" which did not work. She explained that "cool off" meant she allowed the resident time to be alone and diffuse the anger in a safe place. She stated she was unaware of any interventions to keep him separated from other residents. Nurse #2 reported that Resident #9 stated he had been to prison and was not afraid to go back. Nurse #2 explained she believed Resident #9 was alert but not oriented but was aware of his actions. On 09/25/14 at 1:05 PM the Administrator was notified of immediate jeopardy for failing to monitor and implement effective measures to keep Resident #34 safe from Resident #9 and Resident #113 after Resident #9 hit Resident #34 on 12/10/13. The facility provided an acceptable credible allegation of compliance on 09/26/14 at 4:56 PM. The following interventions were put into place to remove the immediate jeopardy. Allegation of compliance: 1. The Assistant Director of Nursing completed a head to toe nursing assessment of Resident # 34 on 09/23/14 with no abnormal findings identified. On 09/25/14The Social Services Director initiated a referral to Psychiatric Services for evaluation of Residents #34, #113, and #9. The evaluations were completed on 09/26/14. On 09/26/14 the psychologist determined that Resident #9 was not a danger to himself or others and was not appropriate for inpatient psychiatric services. On 09/26/14 the psychologist assessed Resident #113 to be stable. On 09/26/14 the psychologist was unable to assess Resident #34 due to his impaired cognition. On 09/26/14 at 11:00 AM the Director of Nursing scheduled continuous One on One direct Supervision for Resident #9, provided by facility staff following completion of Psychiatric evaluation and implementation of recommendations. The one on one supervision will continue through 09/29/14 if the resident does not have any physical outbursts. If physical outbursts occur then the one on one supervision will continue until no physical outbursts are demonstrated for 3 days. After one on one supervision the resident will be placed on every 15 minute checks until discharge. On 09/26/14 the facility has initiated discharge planning for Resident #9 to an Assisted Living Facility. Resident #34 has been assessed by the physician and determined that a lower level of care was appropriate. All facility staff will be re-educated on 09/26/14 by the Assistant Director of Nursing or Staff Development Coordinator regarding keeping resident #34 and Resident #9 separated during waking hours, in the event Residents #34 and #9 are in the same location staff will provide supervision to monitor for escalating behaviors and intervene as appropriate. No facility staff member shall work after 09/26/14 without receiving this re-education. No other residents in the facility were identified as having physical abusive behaviors. Resident #113's care plan was updated on 09/25/14 to reflect his history of being physically abusive. All staff were notified of Resident #113's potential to be physically abusive toward Resident #34. Resident #34 and Resident #9 have refused room changes. Resident #9 remains on one to one supervision. 2. The Director of Nursing, Assistant Director of Nursing, Unit Manager, and MDS Coordinator completed an audit of the most recent MDS, active care plans and current medication administration records to identify those residents who have the potential to exhibit verbally abusive, physically abusive, and socially inappropriate or disruptive behaviors. All staff have been educated on 09/26/14 by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator to increase vigilance when residents identified as having abusive behaviors are in close proximity to dependant residents. Following the identification of these residents each will be assessed by the Director of Nursing, Assistant Director of Nursing or Unit Manager for episodes of Behaviors, Psychiatric Services, appropriate care planning and implementation of recommended interventions. This was completed on 09/26/14. All Incident Reports completed during the last 30 days were reviewed by the Director of Nursing to validate a complete investigation was conducted and recommended interventions were care planned and implemented. These audits and any required interventions were completed on 9-26-14. Staff were notified of the care plan updates and changes. 3. Following this review the Administrator, Director of Nursing, or Manager on Duty will ensure interventions are care planned and implemented to provide for the safety of residents while an investigation is completed and implement further interventions as required. Nurse aides care grids will be updated with all new changes. Nurse aides are given care grids are given daily. The Assistant Director of Nursing and Staff Development Coordinator will re-educate all Nursing Staff to observe residents for signs of escalating behavior and appropriate interventions for management, to include reporting these observations to the Director of Nursing, Assistant Director of Nursing or Unit Manager. No Nursing Staff member shall work after 09/26/14 without receiving this re-education. This action was completed 09/26/14. The Quality Assessment and Performance Improvement Committee met on 9/26/14 to discuss the findings identified by the surveyor and to review this action plan. Immediate Jeopardy was removed on 09/26/14 at 6:39 PM when the facility provided evidence of discharge planning for Resident #9, one on one supervision for Resident #9, frequent monitoring of Resident #34's location to ensure he was safe. The facility also provided evidence of completion of audits that included auditing incident reports, MDS assessments and care plans. Interviews and observations revealed staff were aware of Resident #9's behaviors and the need for one on one supervision; and the need to monitor Resident #34. Medical records for residents were reviewed and revealed updated care plans were in place.