Every finding on record at Dahlia Gardens Center for Nursing and Rehabilitati

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening Resident Review (PASRR) determination for a resident with a newly diagnosed serious mental illness for 1 of 2 residents reviewed for PASRR (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and unspecified depression. A level I PASRR was completed on 5/8/24 prior to admission.A review of a psychiatric assessment note dated 3/20/25 indicated Resident #4 was seen by the psychiatrist and diagnosed with bipolar disorder. A review of a psychiatry note dated 6/3/25 indicated a new medication order for Risperidone 0.25 milligrams (mg) by mouth once daily for behaviors related to psychosis based off the resident's self-reported mood swings, confusion, and crying. Resident #4's Representative provided informed verbal consent by phone on 6/3/25 for the psychiatric provider to begin the medication. A psychiatry note dated 6/9/25 indicated the staff reported Resident #4 continued to have mood swings, and the psychiatric provider included in his note an increase of Risperidone to 0.5 mg once daily.Review of the electronic medical record revealed there was no evidence that a level II PASRR screening was requested.A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #4 was severely cognitively impaired without behavioral concerns. Resident #4 was coded with bipolar disorder.On 12/4/25 at 12:01 PM the MDS Nurse was interviewed and stated she usually saw new mental health diagnoses and medication orders when she reviewed the providers' notes for gradual dose reductions of certain medications. She stated when she completed the quarterly MDS for Resident #4 she saw the new diagnosis of bipolar disorder for Resident #4 when she reviewed her orders and entered the diagnosis into the electronic medical record but clarified it did not dawn on me that she needed to notify the Administrator needed to submit a request for a Level II PASRR evaluation for Resident #4. She stated, I just missed it. Resident #4's annual Minimum Data Set, dated [DATE] assessed the resident was severely cognitively impaired and revealed she was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. The MDS coded Resident #4 with bipolar disorder.An interview was conducted with the Social Worker (SW) on 12/4/25 at 10:46 AM, and she stated she did not have access to North Carolina's MUST (Medicaid Uniform Screening System) system since being hired almost two months ago. The SW indicated the Administrator had been submitting PASRR requests to NCMUST during that timeframe.The Director of Nursing (DON) was interviewed on 12/4/25 at 11:40 AM and stated the facility's providers entered their own orders for medication changes and new diagnoses in the electronic medical record, and she confirmed the new orders once they were entered. The DON stated she tried to catch new orders and new diagnoses to inform the MDS Nurse. She further stated she kept a list of residents who needed a level II PASRR screening and thought Resident #4 already had a level II PASRR determination.On 12/4/25 at 11:07 AM, the Administrator was interviewed and affirmed she had been submitting requests for PASRR evaluations since the previous SW left. The Administrator stated the last PASRR for Resident #4 was completed prior to her admission on [DATE], and she had not submitted a request for a level II PASRR screening. She stated she was not aware Resident #4 needed a level II PASRR assessment, and the Administrator indicated she relied on the Director of Nursing and the Minimum Data Set (MDS) nurse to notify her of changes in a resident's condition so she could submit requests for PASRR screenings when needed.

Based on observations and staff interviews, the facility failed to dispose of a stained urine collection hat stored underneath a sink on the floor in a resident's bathroom. This deficient practice affected 1 of 7 residents on the 400 hall memory care unit who were reviewed for a safe, clean, comfortable, homelike environment (Resident #74).The findings included:An initial observation completed on 12/1/25 at 1:03 PM, and a follow-up observation on 12/2/25 at 11:28 AM, revealed a yellow stained white urine collection hat (a device placed inside the commode to collect urine for sampling) with a tissue inside lying on the floor underneath the sink in Resident #74's bathroom. The device was not labeled with a resident's name or stored in a bag. Resident #74 resided in the memory care unit and was in his room during both observations, and he was unable to state if the device belonged to him.On 12/2/25 at 11:32 AM an interview was conducted with Nurse Aide (NA) #3 who stated she was unaware there was a urine collection hat on the floor of Resident #74's bathroom and stated she would take care of it. NA #1indicated the hat was one used on the unit to collect urine samples for testing, and it should have been cleaned after use and labeled with the resident's name and stored in a closed bag if it was meant for reuse. NA #3 further stated it was the responsibility of the NA to remove urine collection hats from resident's rooms after use.The Unit Manager was interviewed on 12/3/25 at 2:11 PM and stated if a urine collection hat was used for obtaining a urine sample, then it should be thrown away. However, if one was kept for a resident then it should be labeled with the resident's name and stored in a plastic bag once cleaned after use.On 12/3/25 at 3:08 PM the Director of Nursing (DON) was interviewed and stated the urine collection hat should have been thrown away after use.The Administrator was interviewed on 12/4/25 at 1:42 PM and stated urine collection hats were typically used to obtain a sample for urine testing. She indicated once staff obtained the sample, the device should have been thrown away. The Administrator stated the used hat should not have been stored in the resident's bathroom, and she would expect the staff to obtain a new urine collection hat if the resident required a follow up sample.

Based on record review, and Nurse Practitioner, Pharmacist, and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication (methadone) prescribed to treat pain. This affected 1 of 3 residents reviewed for misappropriation (Resident #17).The findings included: A review of the facility's policy entitled Abuse, Neglect, and Exploitation implemented 12/1/22 and revised 1/1/25 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.Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent. Resident #17 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type II with diabetic polyneuropathy and chronic pain due to trauma. A review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #17 to be cognitively intact without behaviors. The active medication orders for Resident #17 during the month of 2/2025 revealed an order for methadone 10 mg (milligrams) with an ordered date of 1/1/25 given by mouth three times a day for pain. A review of the medication administration record (MAR) for the month of 2/2025 revealed Resident #17 was administered methadone 10 mg three times daily by the facility staff except for the leave of absence (LOA) from 2/24/25 to 2/27/25. The facility sent ten tablets of methadone with the party responsible for the resident during her LOA. Resident #17's ordered methadone was signed as being received at the facility by Medication Tech #1 on 1/28/25. The medication count sheets were listed as having 30 tablets of methadone on each medication card. A review of the narcotic count sheets for Resident #17's methadone filled on 1/28/25 indicated the pharmacy sent one count sheet for each 30-tablet card. A review of the methadone count sheets for Resident #17 revealed count sheet #1 and count sheet #3 were present but count sheet #2 was missing. An initial allegation report was received by the State from the facility's Administrator on 2/25/25 at 7:05 PM. The report read that the facility initially became aware of the incident on 2/25/25 at 2:53 PM and alleged during reconciliation of Resident #17's medications post discharge, it was identified a methadone card was misplaced. Police were notified and the facility investigation was initiated. The incident was reported to local law enforcement on 2/25/25 at 6:46 PM. On 12/2/25 at 10:46 AM an interview was conducted with Resident #17 who stated she had become aware her methadone tablets were missing when the Director of Nursing (DON) and Administrator spoke with her about it. The resident stated as far as she knew, she received her methadone as she was supposed to and denied having uncontrolled pain during the month of 2/2025. Former Nurse Practitioner (NP) #1 was interviewed by phone on 12/3/25 at 1:18 PM. She stated on 2/22/25 she received a request from a nurse at the facility requesting a refill of methadone for Resident #17 (she was unsure of the nurse's name who called). NP #1 stated she submitted a refill request to pharmacy for the methadone, but later pharmacy notified her it was too soon to refill the medication. She stated she immediately notified the DON of a possible drug diversion. According to the NP, she had no previous cause for concern related to missing narcotic medications. Pharmacist #1 was interviewed by phone on 12/3/25 at 1:32 PM and stated he was notified of the missing methadone at the facility. He stated the pharmacy confirmed with the facility that no methadone had been returned for Resident #17, and he played a support role as the facility worked through their investigation regarding possible drug diversion. The Pharmacy Supervisor was interviewed by phone on 12/3/25 at 2:48 PM and stated the pharmacy filled a 90-tablet methadone prescription for Resident #17 on 1/28/25. She indicated the facility tried to submit a refill request around 2/22/25 for methadone 10 mg for Resident #17, but it was too soon to refill the medication. She stated the record showed the pharmacy did fill and deliver 10 tablets of methadone on 2/22/25 to the facility. The Pharmacy Supervisor stated their role was to support the facility as they investigated possible drug diversion. On 12/3/25 at 3:08 PM an interview was conducted with the Director of Nursing (DON) who stated she completed an investigation into possible drug diversion when the NP notified her on 2/25/25 of a refill request for Resident #17's methadone 10 mg being denied by pharmacy as being too soon to refill. The DON explained after researching the discrepancy it was found to have occurred when Nurse #1 last worked on 2/13/25. Nurse #1 had administered the last dose of methadone to Resident #17 from card #1. During the investigation she learned Resident #17's methadone card #2 was missing along with the methadone narcotic count sheet #2. She stated Nurse #1 had begun administering the methadone from card #3 and count sheet #3. The DON indicated the end of shift narcotic count came out correct due to both methadone medication card #2 and count sheet #2 being missing. The DON stated Nurse #1 stopped coming into work once the facility began investigating the incident, and Nurse #1 was terminated. Medication Tech #1 who received the methadone from pharmacy on 1/28/25 was interviewed on 12/3/25 at 3:28 PM and stated she was off the weekend the methadone went missing and had no first-hand knowledge of the incident. Multiple attempts were made to contact Nurse #1 by phone for an interview. Voice mail messages left requesting a return call were not returned. The Administrator was interviewed on 12/4/25 at 11:18 AM and stated the DON informed her on 2/25/25 that she believed there was a drug diversion due to the NP notifying her an order to refill methadone for Resident #17 was denied by pharmacy for being too early. She stated the DON investigation found a card of methadone was missing along with the count sheet for Resident #17's medication. The Administrator affirmed there was never a time when the resident went without the medications that were ordered for her by the Nurse Practitioner. The facility provided a plan of correction that was not acceptable to the State Agency as the facility did not include a systemic approach to prevent future incidents of misappropriation of residents' property. The audits included in the corrective action plan would not prevent further misappropriation.

Based on record review, observations, and resident and staff interview, the facility failed to ensure a resident who was dependent on staff assistance for nail care received assistance when needed for 1 of 5 residents reviewed for activities of daily living (ADL) (Resident #14).The findings included:Resident #14 was admitted to the facility on [DATE] with diagnoses that included a permanent neurological disorder affecting movement, posture, and coordination, contracture of left arm, and vascular dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14's cognition was severely impaired. He exhibited behaviors that occurred for 1 to 3 days during the look-back period that included behavioral symptoms not directed towards others. He required moderate assistance with eating and was dependent on staff with personal hygiene, dressing, toilet hygiene, oral hygiene, shower/bath, bed mobility, and transfers. He was not coded for rejection of care. Resident #14 had range of motion impairment to both sides of his upper and lower extremities. Resident #14's active care plan, last revised on 10/10/25, included the focus area of an activity of daily living (ADL) self-care deficit and required assistance with ADL. Interventions included Resident required total assistance from staff for bathing and for staff to check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse.A review of Resident #14's nursing progress notes from 11/01/25 to 12/02/25 revealed no refusals of nail care documented.Record review revealed Resident #14's shower/bathing were scheduled for Wednesday and Saturday on night shift. Resident #14's shower schedule revealed no refusals from 11/01/25 through 12/02/25. Unsuccessful attempts were made to contact Resident #14's direct care NA for 11/29/25 (Resident #14's last scheduled shower day).An observation and interview were conducted on 12/01/25 at 11:10 AM with Resident #14. The observation revealed Resident #14's fingernails on his left and right hands extended approximately 1/4 to 1/2 of an inch beyond his fingertips and were jagged. A brown substance was observed under the pointer fingernail on the right hand. Resident #14 held his right hand up and stated, they need to be cut. When asked if he had asked anyone to cut his fingernails he did not respond.An observation of Resident #14 was conducted on 12/02/25 at 12:01 PM. He was observed sitting in his wheelchair watching television. The observation revealed Resident #14's fingernails were still long and jagged. A brown substance was observed under the pointer fingernail on the right hand.An observation of Resident #14 was conducted on 12/02/25 at 2:25 PM. Resident #14 was observed sitting in his wheelchair watching television. The observation revealed Resident #14's fingernails were still long and jagged. A brown substance was observed under the pointer fingernail on the right hand.An interview was conducted on 12/03/25 at 1:45 PM with Nursing Assistant (NA) #1. He verified he was the direct care NA for Resident #14 from 7:00 AM to 7:00 PM that day. He confirmed Resident #14's fingernails on his right and left hands were long, jagged, and the pointer fingernail had a brownish substance under it. He stated he did not realize Resident #14's nails needed to be cleaned and cut. An interview was conducted on 12/03/25 at 2:02 PM with the Director of Nursing (DON). She verified Resident #14's fingernails on his right and left hands were long, jagged, and the pointer fingernail had a brownish substance under it. She stated his showers are on 2nd shift however nailcare was everyone's responsibility. Staff normally performed nailcare on shower days, during morning care, and as needed. She indicated Resident #14's fingernails needed to be cut, filed, and cleaned. She indicated there was no reason his nails had not been tended to.An interview was conducted on 12/03/25 at 2:10 PM with Medication Aide (MA) #1. She verified she had been the direct care MA for Resident #14 since 12/01/25. She stated staff normally perform nailcare on shower days and as needed. She also stated she did not notice Resident #14's fingernails needed to be cut, filed, and cleaned. She indicated Resident #14 did not refuse nail care or showers.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of rejection of care (Resident #35) for 1 of 19 MDS assessments reviewed.The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. A review of Resident #35's medical record revealed that she had refused medications a total of seven days prior to 10/27/25 for medication administration times of 6:30 AM, 8:00 AM and 8:00 PM. Review of the October 2025 Medication Administration Record (MAR) from 10/27/25 to 10/31/25, revealed that Resident #35 was marked as refused for the following: 10/27/25 at 8:00 PM for Ferrous Sulfate 220 milligrams (mg) per 5 milliliters (ml). Give 5 ml via feeding tube every morning and at bedtime for supplementation. 10/27/25 at 8:00 PM for Sennosides 8.6 mg. Give two tablets by mouth two times a day for constipation. 10/28/25 at 8:00 PM for inspection of surrounding skin to feeding tube area every morning and at bedtime. A MDS assessment dated [DATE] indicated Resident #35 had moderately impaired cognition and was not coded for rejection of care. Resident #35's active care plan, last reviewed 11/10/25, included a focus area for having a behavior problem related to attention seeking behaviors, noncompliance with tube feedings and ordered oral diet. The focus area was initiated on 12/15/23. Attempts to call Nurse #1 occurred during the survey but were unsuccessful. She was scheduled to care for Resident #35 on 10/27/25 and 10/28/25 when refusals were noted on the MAR. An interview with Nurse #2 occurred on 12/3/25 at 10:45 AM and stated that she frequently cared for Resident #35 during the day shift. Nurse #2 stated that Resident #35 would refuse care and medication. An interview with the MDS Nurse was conducted on 12/4/25 at 11:22 AM and stated that the Social Worker (SW) was responsible for completing the section of the MDS assessment that addressed rejection of care. On 12/4/25 at 11:29 AM, an interview occurred with the SW, who explained that she had been in the role for about two and half months and was responsible for completing the section addressing rejection of care on the MDS assessment. She explained that she looked at the nurses' notes only for this information and didn't review the MARs to see if a resident refused medications or treatments. The SW stated she wasn't sure where to look in the medical records for rejection of care. She reviewed Resident #35's MDS assessment dated [DATE] as well as the October 2025 MAR and verified that Resident #35 was marked as refusing medications and care on 10/27/25 and 10/28/25 which would have been during the MDS seven-day look back period and should have been coded on the 10/31/25 MDS assessment as rejection of care occurring one to three days. The Administrator was interviewed on 12/4/25 at 12:51 PM and stated she expected the MDS assessment to be coded accurately.

Based on record review and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff schedule for 32 out of 32 days (11/01/25 through 12/02/25) reviewed. The findings included:a) A review of the facility's daily posting for nursing staff for the past 32 days (11/01/25 through 12/02/25) as compared to the daily staffing schedule revealed the total of actual hours worked for day shift, evening shift, and night shift, for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides were blank. b) A review of the facility's daily posting for nursing staff for the past 32 days as compared to the daily staffing schedule included an inaccurate total number of licensed staff working. These included the following:-The number of licensed staff on 1st shift was incorrect for the following dates: 11/03/25-11/07/25, 11/10/25-11/14/25, 11/17/25-11/22/25, and 11/24/25-12/02/25. -The number of licensed staff on 2nd shift was incorrect for the following dates: 11/23/25 and 12/02/25.-The number of licensed staff on 3rd shift was incorrect for the following dates: 11/01/25, 11/11/25, 11/19/25, 11/24,25, and 11/30/25.c) A review of the facility's daily posting for nursing staff for the past 32 days as compared to the daily staffing schedule included an inaccurate total number of unlicensed staff working. These included the following:-The number of unlicensed staff on 1st shift was incorrect for the following dates: 11/04/25-11/12/25, 11/14/25, 11/17/25, and 11/24/25-12/02/25.-The number of unlicensed staff on 2nd shift was incorrect for the following dates: 11/07/25-11/06/25, 11/12/25-11/10/25, 11/19/25, 11/24/25-11/26/25, and 11/28/25-11/30/25.-The number of unlicensed staff on 3rd shift was incorrect for the following dates: 11/01/25, 11/02/25, 11/07/25, and 11/25/25. An interview was conducted on 12/03/25 at 3:16 PM with the Receptionist. She stated she completed the daily nurse staffing summary sheets that were posted daily. She stated she did not complete the area of total hours for licensed or unlicensed staff because the facility got a new time clock system and she did not have access to the totals anymore. She explained that was how she added the hours up. It was an oversite that she forgot to add the census total on some of the sheets. She stated she was unaware she was to add the wound nurse and nurse supervisors to the licensed staff totals for each shift or the medication aide (MA) to the unlicensed staff totals. An interview was conducted on 12/04/25 at 11:22 AM with the DON. She reviewed and confirmed the daily Posted Nurse Staffing Information sheets were inaccurate and did not reflect the actual working hours or the correct number of staff. She stated the time totals should have been added to the total hours worked columns for each shift. She explained that the hours should have been calculated with 12 or 8 hours for each working employee, not the actual punch time totals. The census also should have been added and if a member of staff called out the sheet should have been adjusted to reflect the correct number of employees working. She explained she was unaware the posting sheets were not correct or completed accurately. An interview was conducted on 12/03/25 at 3:16 PM with the Administrator. She was unaware the staff sheets were not being filled out completely or correctly as the Director of Nursing (DON) oversees the task. A follow-up interview was conducted on 12/04/25 at 12:35 PM with the Administrator. She stated she was not involved in the staff posting sheets however she would expect them to display the correct information.

Based on record review and staff interviews, the facility failed to provide abuse training to Nurse #2 prior to her working at the facility. This was for 1 of 5 employees reviewed for abuse training. The findings included: An interview with the Director of Nursing (DON) was conducted on 08/06/24 at 1:15 PM. She stated there was an incident of resident to resident abuse on 07/21/24 at 2:45 AM. Nurse #2, agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. The DON explained Nurse #2 did not notify the administration after the incident because she did not feel it was abuse. The DON further explained that orientation training, which included the abuse policy, was given to Nurse #2 on 07/21/24. Review of orientation training, dated 07/19/24 through 07/22/24, which included the abuse policy, was signed by Nurse #2 on 07/21/24 at 7:00 PM. A phone interview was conducted on 08/08/24 at 4:20 PM with Nurse #2. She verified 07/20/24 was the first time she worked at the facility and then returned on 07/21/24 from 7:00 PM until 7:00 AM. She also verified she was the nurse for Resident #19 and #9 on the night of 07/21/24. She stated at approximately 2:45 AM on 07/21/24 Nursing Assistant (NA) #3 informed her Resident #19 slapped Resident #9 and she immediately separated the two residents. She moved Resident #9 to a different room. Nurse #2 further stated she did not call to report the incident to the Administrator because she was unaware of the facility policy regarding abuse. Nurse #2 then stated she received orientation education from the Director of Nursing which included the abuse policy on 07/21/24 at 7:00 PM. An interview with the Administrator was conducted on 08/06/24 at 1:39 PM. She explained that Nurse #2, an agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. She stated she had Nurse #2 come to the facility on [DATE] to write a statement related to the incident. When the Administrator questioned her on why she did not notify administration after Resident #19 slapped Resident #9, Nurse #2 told her because she did not feel it was abuse. Nurse #2 was reeducated on the abuse policy on 07/22/24 by Administrator. The Administrator indicated the goal was for agency staff to be provided orientation prior to working their first shift by the DON.

Based on staff, Medical Director (MD) interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) after 2 areas of significant decline. This was for 1 of 19 residents reviewed for MDS accuracy (Resident #24). The findings included: Resident #24 was admitted on [DATE] with cumulative diagnoses congestive heart failure, chronic obstructive pulmonary disease, and dementia. Review of his quarterly MDS dated [DATE] indicated Resident #24 had severe cognitive impairment and required substantial staff assistance with Activities of Daily Living (ADLs). He was coded as frequently incontinent of bladder and always incontinent of bowel, weight of 111 pounds with no known weight loss, and no pressure ulcers. A review of Resident #24's medical record revealed he developed a stage 3 ulcer described as pressure to his sacrum on 6/7/24. A review of Resident #24's weights for the last 3 months from 5/2/24 (113.2 pounds) to 7/25/24 (102.6 pounds) was a loss of 10.6 pounds or 9.36% weight loss in 3 months. Review of Resident #24's comprehensive care plan revealed a care area revised on 6/10/24 regarding a pressure ulcer to his sacrum related to incontinence, cognitive decline. New interventions included to assess, record and monitor wound healing and report improvements or declines to the MD, and to educate family and caregivers on importance of positioning/repositioning, mobility, nutrition and incontinence care. Another care area which had been revised on 6/14/24 regarding his potential for nutritional problems related to his mechanically altered and therapeutic diet and include significant weight changes. There were new interventions in place including a protein supplement and zinc added to aid in his wound healing. An interview was completed on 8/6/24 at 12:20 PM with the MD. He stated Resident #24 has had an overall physical decline in the last 3 months or so and his family had decided to go with comfort care rather than hospice. He stated as his condition progressed, the facility would continue to treat his pressure ulcer and his weight loss, but his family stated they did not want Resident #24 sent out to the hospital. The MD stated his pressure ulcer and weight loss were unavoidable. An interview was completed on 8/7/24 at 11:45 AM with the MDS Nurse. She stated she revised Resident #24's care plan for his newly developed pressure ulcer and weight loss in June and then opened a quarterly MDS on 7/23/24 and should have realized that a significant change MDS was needed instead of the quarterly. She stated it was her oversight. An interview was completed on 8/7/24 at 12:24 PM with the Administrator and the Director of Nursing (DON). The DON stated Resident #24 has had a continuous decline in recent months and a significant change MDS would have been expected before now. The Administrator stated she expected the MDS Nurse to have caught the 2 area of decline since those areas had already been captured in his care plan in June.

Based on record review and staff interviews, Nurse #2 failed to implement the reporting portion of the abuse policy after Nurse Aide #3 (NA #3) told her Resident #19 slapped Resident #9 on the right hand/forearm. The facility also failed to notify Adult Protective Services (APS) regarding an allegation of abuse. This was for 1 of 4 Residents (Resident #9) reviewed for abuse. The findings included: a. A review of the facility's Abuse policy, last revised 2023, revealed new employees will be educated on the reporting process for abuse during the initial orientation. The policy read in part: 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 phone interview was conducted on 08/08/24 at 4:20 PM with Nurse #2. She verified she was the nurse for Resident #19 and #9 on the night of 07/21/24. She stated at approximately 2:45 AM NA #3 informed her Resident #19 slapped Resident #9, and she immediately separated the two residents. She moved Resident #9 to a different room. She also stated Resident #9 stated Resident #19 hit him and denied pain after he was slapped. She indicated prior to the incident Resident #9 was talking to himself while he was in bed. He was not yelling or cussing. She further stated she did not call to report the incident to the Administrator because she was unaware of the facility policy. Her main concern was to keep Resident #9 safe. Review of the orientation training, dated 07/19/24 through 07/22/24, which included the abuse policy, fire safety and emergency preparedness, was signed by Nurse #2 on 07/21/24 (after the incident). An interview with the Director of Nursing was conducted on 08/06/24 at 1:15 PM. She stated Nurse #2, agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. She explained Nurse #2 did not notify the administration after the incident because she did not feel it was abuse. The DON further explained that orientation training was given to Nurse #2 on 07/21/24 (after the incident). An interview with the Administrator was conducted on 08/06/24 at 1:39 PM. She explained that Nurse #2, an agency nurse, was the nurse on duty when Resident #19 slapped Resident #9. She stated she had Nurse #2 come to the facility on [DATE] to write a statement related to the incident. When she questioned her on why she did not notify administration after Resident #19 slapped Resident #9 Nurse #2 told her because she did not feel it was abuse. Nurse #2 was reeducated on the abuse policy at that time. The Administrator then stated she expected nursing staff to report any type of abuse to the Administrator and/or the Director of Nursing immediately. b. An interview with the Administrator was conducted on 08/06/24 at 1:39 PM. She stated she submitted an initial report of abuse to the state regulatory agency on 07/22/24 regarding Resident #19 slapping Resident #9. She explained that she did not notify APS until 07/29/24 because she was unaware that she needed to report to APS. She indicated that she recently moved to North Carolina and her former state did not have to report to APS.

Based on record review, resident and staff interviews, the facility failed to protect 1 of 4 residents (Resident #19), for his right to be free from physical abuse as evidence by another resident (Resident #9) slapping him with an open hand to the side of his head. The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses that included schizophrenia and hemiplegia and hemiparesis of the left non-dominant side. Resident #9 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact. He exhibited no behavior during the look-back period. Resident #9 ' s care plan, last reviewed on 07/29/24 revealed a focus that read he was verbally aggressive related to poor impulse control. Resident was verbally aggressive and threatened bodily harm to staff and other residents. The interventions included when Resident #9 became agitated for staff to intervene before agitation escalated, guide him away from source of distress, and engage calmly in conversation. Resident #19 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, depression, and manic depression (bipolar disease). Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact. He exhibited no behavior during the look-back period. Resident #19 ' s care plan, last reviewed on 07/19/24 revealed a focus for him having a behavior problem. Resident #19 was easily agitated, episodes of refusing care, and hitting self when agitated. The interventions included he had episodes noted where he would yell out, [NAME], [NAME], bang, bang at inappropriate times and for staff to monitor behavior episodes and attempt to determine underlying cause. Another focus read that he had a communication problem related to him usually understanding verbal content, he usually understood others, and he had unclear speech. The interventions included to ensure/provide a safe environment and avoid isolation. The Facility Reported Incident (FRI) dated 07/22/24, revealed Resident #19 was witnessed striking his roommate, Resident #9. The report indicated the residents were immediately separated and an investigation began. The report also indicated there was no physical or mental injury or harm. Law enforcement was notified on 07/22/24 at 10:50 AM. A Behavior note dated 07/21/24 revealed Nursing Assistant (NA) #3 was walking past Resident #19 & #9 ' s room and witness Resident #19 slap Resident #9 in the face. Resident #19 stated he slapped Resident #9 because he wanted him to shut up. Resident #19 was educated to keep his hands to himself and stay on his side of the room. Attempts to interview NA #3 were unsuccessful. A statement written by Nursing Assistant #3 dated 07/22/24 revealed on 07/21/24 as she was walking down the hall, she could hear Resident #9 talking to himself as he did every night. She stopped at the room door and witnessed Resident #19 at Resident #9 ' s bed and he yelled, shut the f**k up. She immediately went into the room to intervene but before she could get to the residents Resident #19 slapped Resident #9 with an open hand on his right hand/forearm. Resident #9 ' s right arm was up near his face and when his arm came down it hit his face. She yelled for the nurse to assist. A phone interview was conducted on 08/08/24 at 4:20 PM with Nurse #2. She verified she was the nurse for Resident #19 and #9 on 07/21/24. She stated the Nursing Assistant (NA) #3 informed her Resident #19 slapped Resident #9 and she immediately separated the two residents. Nurse #2 explained Resident #19 stated he slapped Resident #9 because he would not stop talking. She moved Resident #9 to a different room. She indicated prior to the incident Resident #9 was talking to himself while he was in bed. He was not yelling or cussing. An interview with Resident #19 was conducted on 08/06/24 at 11:40 AM. He explained that Resident #9 was cussing him on 07/21/24 so he got up from his bed and slapped him across the head. He further explained Resident #9 just kept repeating the same words over and over and would not shut up, he was tired of hearing him. He stated he was not trying to hurt Resident #9 he just wanted him to be quiet. An interview with Resident #9 was conducted on 08/06/24 at 11:55 AM. His speech was very hard to understand due to talking very low and he mumbled at times. He answered yes and no questions appropriately. He stated Resident #19 slapped him with an open hand but did not explain why or any other details. He denied being in pain or being fearful when Resident #19 slapped him or afterwards. Interview with the Administrator was conducted on 08/07/24 at 12:43 PM. She indicated the residents had been a good match for roommates up until that point and she never expected an altercation would occur. She stated Nurse #2 moved Resident #9 to a different room immediately and the nurse started the investigation, which was what she would expect the nurse to do. She further stated Resident #19 and Resident #9 have continued to reside at the facility on different halls. However, the nurse should have called her to notify her of the incident.

Based on observation, record review, resident and staff interviews, the facility failed to place a resident's (Resident #83) call light within reach to allow for the resident to request staff assistance this was for 1 of 7 residents reviewed for accommodation of needs. The findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) affecting left side, need for assistance with personal care, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 was cognitively intact. He was dependent on staff for toileting hygiene, transfers, and dressing. He required maximum assistance with shower/baths, bed mobility, and dressing and moderate assistance with personal hygiene. He was always incontinent of bowel and bladder. He had functional limitation with range of motion of one side of his upper extremities. Resident #83 ' s care plan, last reviewed on 07/18/24, indicated he had an activities of daily living (ADL) self-care performance deficit related to hemiplegia and stroke. The interventions included for staff to encourage the resident to use bell to call for assistance. Another focus read Resident #83 had an actual fall and was at risk for further falls related to poor trunk control. The interventions included for staff to ensure resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. A continuous observation was conducted on 08/05/24 from 12:11 PM through 12:32 PM of Resident #83. Resident #83 was lying in bed watching television. His lunch tray was brought in by Nursing Assistant (NA) #1. NA #1 raised the head of the bed up and assisted Resident #83 with setting his meal tray up and then exited the room. Resident 83 ' s call bell was on the floor out of his reach. An interview was conducted on 08/05/24 at 12:45 AM with Resident #83. He stated his call bell falls to the floor a lot and staff often forget to give it to him. He explained that he would wait for the nurse to bring in his medications or he would yell when he saw someone in the hall if he needed assistance. He also stated the call bell doesn ' t do any good if it was on the floor and it made him uneasy when he couldn ' t reach it. An observation and interview were conducted with Nursing Assistant (NA) #1 on 08/05/24 at 2:41 PM. He verified he was the direct care NA for Resident #83. He also verified the call bell in Resident #83 ' s room was on the floor beside the bed and out of his reach. He explained that he was in his room to give him his lunch try earlier but forgot to check call bell placement at that time. NA #1 then stated he did not realize Resident #83 ' s call bell was on the floor. He indicated he usually checks the call bell before leaving the rooms. NA #1 could not recall when Resident #83 last had his call bell. An interview was conducted on 08/07/24 at 12:43 PM with the Administrator and the Director of Nursing. They both stated the call bell should always be within the residents ' reach.

Based on record review, observation, physician and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of urinary status, and upper extremity range of motion. This was for 2 of 19 MDS assessments reviewed (Resident #37 and Resident #49). The findings included: 1. Resident #37 was admitted to the facility on [DATE]. Her diagnoses included neuromuscular dysfunction of the bladder. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #37 was cognitively intact. She was coded with an indwelling catheter and always incontinent of bladder. A review of the July 2024 physician orders included indwelling urinary catheter to straight drainage related to urinary retention. On 8/7/24 at 11:46 AM, an interview occurred with the MDS Nurse who reviewed the 7/7/24 admission MDS assessment and indicated Resident #37 should have been marked as not rated for urinary continence since she had a urinary catheter during the MDS 7-day look back period. She felt the error was an oversight. The Administrator and Director of Nursing were interviewed on 8/7/24 at 12:24 PM and stated they would expect the MDS to be coded accurately. 31227 2. Resident #49 was admitted on [DATE] with a diagnosis of dementia with severe behavioral disturbance. An observation was completed on 8/5/24 at 11:48 AM. Resident #49 was sitting at a table in the common area waiting for his lunch tray. There was no evidence of any problems with his range of motion to either of his hands. A review of his quarterly Minimum Data Set (MDS) dated [DATE] was coded for limited range of motion on one side of his upper extremities. A review of his previous quarterly MDS dated [DATE] indicated he was not coded for impairment to either of his upper extremities. A review of Resident #49's comprehensive care last revised on 8/4/24 did not include information or interventions to include a right upper extremity range of motion impairment. A review of a Medical Director (MD) progress note dated 5/31/24 read Resident #49 was being seen via video link. The note did not include a diagnosis of right sided hemiparesis but did note under the neurological section there was right hemiparesis with a right hand contracture on visual assessment. An interview and observation of Resident #49 was completed on 8/5/24 at 2:40 PM with Nursing Assistant (NA) #2. While observing Resident #49, NA #2 stated the resident did not have a hand contracture or any decrease in range of motion in any of his extremities. An interview and observation of Resident #49 was completed with the MD on 8/6/24 at 12:00 PM. Upon observation, the MD stated during the video visit on 5/31/24, it must have been the way Resident #49 was holding his right hand that lead him the believe he had a right hand contracture but on assessment today (8/6/24), he had been mistaken and Resident #49 did not have right sided hemiparesis or a right hand contracture and was sorry if he caused any confusion. An interview was completed on 8/6/24 at 3:25 PM with Nurse #1. She stated she always worked this unit and was familiar with all of the residents. She confirmed Resident #49 had never hand a right hand contracture. An interview was completed on 8/7/24 at 11:45 AM with the MDS Nurse. When asked about the quarterly MDS dated [DATE] compared to the previous quarterly dated 3/8/24 in the area of upper extremity range of motion, she explained she read the MD progress note dated 5/31/24 and coded the assessment based on that note. When asked if she observed Resident #49's right hand, she stated she had but did not think she should question the MD. An interview was completed on 8/7/24 at 12:24 PM with the Administrator and the Director of Nursing (DON). The DON stated she expected the MDS to question the MD if she knew his documentation was inaccurate or if she was not comfortable in doing so, she should have come to her and she would have done it. The Administrator stated she expected Resident #49's quarterly MDS dated [DATE] to be coded accurately in the area of range of motion.

Based on record review and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within the required time frame for 1 of 4 residents reviewed for MDS assessments (Residents #61). The findings included: Resident #61 was admitted to the facility on [DATE]. A review of Resident #61's most recent MDS assessment was dated 7/20/24 and was coded as a discharge assessment. The electronic medical record indicated the assessment was in progress and had not been transmitted. An interview was conducted on 08/07/24 at 11:48 AM with the MDS nurse. She stated the discharge MDS assessment for Resident #61 had not been completed as required. She explained that there had been a lot of admissions and discharges, and she had gotten behind. The MDS nurse stated she was in the process of getting the assessment completed and transmitted. An interview was conducted on 08/07/24 at 11:52 AM with the Administrator and Director of Nursing. They stated the MDS assessment should be completed within the required time frame.

Based on record reviews and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for 5 of 19 resident MDS assessments reviewed (Residents #17, #81, #24, #42 and #19). The findings included: a. Resident #17 was admitted to the facility on [DATE]. A review of Resident #17's most recent MDS assessment was dated 7/19/24 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in progress and had not been completed. b. Resident #81 was admitted to the facility on [DATE]. A review of Resident #81's most recent MDS assessment was dated 7/16/24 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in progress and had not been completed. 31227 c. Resident #42 was admitted to the facility on [DATE]. A review of Resident #42's most recent MDS assessment was dated 7/20/24 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in progress and had not been completed. d. Resident #24 was admitted to the facility on [DATE]. A review of Resident #24's most recent MDS assessment was dated 7/23/24 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in progress and had not been completed. 46095 e. Resident #19 was admitted to the facility on [DATE]. A review of the medical record revealed a quarterly MDS assessment was completed on 4/23/24. A review of Resident #19's most recent MDS assessment was dated 7/20/24 and was coded as a quarterly assessment. The electronic medical record indicated the assessment was in progress and had not been completed. An interview occurred with the MDS nurse on 8/7/24 at 11:46 AM, who stated the quarterly MDS assessments for Residents #17, #81, #42, #24 and #19 had not been completed as required. She explained that there had been a lot of admissions and discharges, and she had gotten behind. The MDS nurse stated she was in the process of getting the assessments completed and transmitted. On 8/7/24 at 12:24 PM, the Administrator and Director of Nursing were interviewed and stated they expected the MDS assessments to be completed within the required time frame.

Based on record reviews and staff interviews, the facility failed to complete an annual Minimum Data Set (MDS) assessment within the required time frame for 1 of 19 residents reviewed for MDS assessments (Residents #9). The findings included: Resident #9 was admitted to the facility on [DATE]. A review of Resident #9's most recent MDS assessment was dated 7/12/24 and was coded as a annual assessment. The electronic medical record indicated the assessment was export ready and had not been transmitted. An interview was conducted on 08/07/24 at 11:48 AM with the MDS nurse. She stated the annual MDS assessments for Residents #9 had not been transmitted as required. She explained that there had been a lot of admissions and discharges, and she had gotten behind. The MDS nurse stated she was in the process of getting the assessments completed and transmitted. An interview was conducted on 08/07/24 at 11:52 AM with the Administrator and Director of Nursing. They stated the MDS assessments should be transmitted within the required time frame.

Based on observations and staff interviews the facility failed to ensure resident rooms were in good repair. Rooms #304 and #308 had several patched areas of sheetrock putty exposed on walls and room [ROOM NUMBER] had a missing plank panel on wall behind the headboard. This was for 3 of 8 rooms reviewed for comfortable, clean, and homelike environment. The findings included: a. During the initial tour on 08/05/24 at 10:50 AM, an observation of rooms [ROOM NUMBERS] revealed the walls were patched in multiple areas with what appeared to be putty in preparation for painting. Observations were conducted during a round with the Maintenance Director on 08/07/24 at 11:37 AM. He verified rooms [ROOM NUMBERS] had patched areas that needed to be painted. He stated the rooms were on his to do list but could not provide a date or timeframe he thought he would get to the projects. b. On 08/05/24 at 10:50 AM, an observation of room [ROOM NUMBER] revealed plank vinyl floor panels on the wall behind the headboard of the bed. One of the panels had fallen off exposing a dried clear substance that appeared to be glue. Observations were conducted during a round with the Maintenance Director on 08/07/24 at 11:37 AM. He verified room [ROOM NUMBER] had exposed glue from one of the vinyl panels falling off the wall. He stated the room was on his to do list but could not provide a date or timeframe he thought he would get to the projects. The Administrator was interviewed on 08/07/24 at 12:43 PM, and stated it was important for the environment to be well repaired and homelike. The Administrator indicated since she started working at the facility in April, they have been fixing many concerns that were present. She also stated the Maintenance Director was responsible for the concerns.

Based on record reviews, observations, resident, and staff interviews, the facility failed to protect a resident's right to be free from sexual abuse for 2 of 2 residents investigated for resident-to-resident sexual abuse (Resident #1, resident #2). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarct, traumatic brain injury, and dementia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely visually impaired and severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident required extensive assistance of one person to complete bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS reflected the resident did not have behavioral symptoms directed toward others, to include public sexual acts, during the assessment period. Resident #1's care plan last revised on 9/12/2023 contained a focus for impaired cognition related to history of cerebral vascular accident (stroke) and traumatic brain injury. Interventions included verbal cueing and reorientation as needed. The care plan also had a focus for inappropriate sexual behaviors as evidence by masturbating in public/common areas. Interventions included redirecting the resident and removing the resident from public areas to a more private area. Resident #1 was followed by the Psychiatric Mental Health Nurse Practitioner (PMHNP). An after-visit summary dated 9/28/2023 indicated the resident was seen for neurocognitive disorder due to dementia without behaviors. Staff reported no concerns or behaviors. No apparent changes in behavior were noted by the PMHNP. Resident #1 was receiving Aricept for cognitive support and Depakote for mood stabilization. He also received fluoxetine for mood and anxiety symptoms. Recommendations were to continue current medications and redirection as needed. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors, psychotic disturbance, mood disturbance, and anxiety. The resident's MDS dated [DATE] documented Resident #2 was cognitively intact with a BIMS of 14 out of 15. Resident #2 required minimum assistance with dressing, toileting, and personal hygiene during the assessment period. He required supervision only for ambulation. He received no medications and had no behaviors during the assessment period. Resident #2's care plan was last updated on 8/10/2023. The care plan contained a focus for risk of impaired thought process related to dementia. Interventions included administering medications as ordered and monitoring for changes in behaviors and side effects. On 10/5/2023 the care plan was revised to include a focus for inappropriate sexual behavior. The interventions included the use of redirection and monitoring for behaviors. Resident #2 was followed by the PMHNP. An after visit summary dated 10/2/2023 indicated the resident was seen for neurocognitive disorder related to Alzheimer's type dementia. He was receiving Namenda and Aricept for cognitive support and was tolerating medication. Staff reported no concerns or issues. The PMHNP recommended no medications changes at that time. Record review revealed Resident #1 and Resident #2 were roommates from 5/3/2023 until 10/5/2023. The resident's medical record included a nursing note dated 10/5/2023. A Nurse Assistant (NA) observed Resident #2 standing next to Resident #1's bed. Resident #1 was lying in his bed. Resident #2 has his penis in Resident #1's mouth. The Medical Director (MD) was notified of the incident. Both residents' Responsible Party (RP) were notified by the Social Worker (SW) and the residents were separated and placed on every 15-minute (Q15) safety checks. The medical record contained a nursing note by the Unit Manager dated 10/5/2023 noted Resident #1 made a statement about letting Resident #2 come back to finish. Resident #1 was assessed. There was no oral trauma or evidence of semen when oral care was completed. A nursing progress note by the Unit Manager dated 10/5/2023 revealed Resident #2 was assessed to have no injury. He was immediately relocated to another room. The resident was angry, agitated, and yelling out in response to being moved into another room. Resident #1 was assessed by PMHNP on 10/11/2023. Per the visit summary, when the PMHNP asked Resident #1 about the incident with his roommate, he indicated it was consensual but would not disclose any additional information or answer any other questions regarding the incident. Resident #2 was assessed by the PMHNP on 10/11/2023. Per the visit summary, the resident could not recall the incident when asked about staff reports of Resident #2 participating in oral sex with his roommate. An interview was conducted with Resident #2 on 10/11/2023 at 8:15AM. He was in a private room. There was no staff in the room or outside the door of Resident #2's room. Resident #2 stated he did not recall an incident on 10/5/2023. He stated he did have a roommate up until 10/5/2023. He did not know why the facility staff moved him to another room. An interview was conducted with Resident #1 on 10/11/2023 at 11:00AM. He stated he did not recall the incident between him and his roommate on 10/5/2023. He further stated he had not been asked to participate in sexual activities against his will. He felt he was in a safe place. A second interview with Resident #1 at 2:06PM. He stated he could not recall the incident that occurred on 10/5/2023. He denied being asked to participate in sexual activity against his will. He stated he felt he was in a safe place. Nurse Assistant (NA) #1 was interviewed on 10/11/2023 at 11:15AM. She stated she entered the room of Resident #1 and Resident #2 to obtain a weight on Resident #2. She stated when she entered the room, the curtain between the beds was pulled. As she looked around the curtain, she saw Resident #2 standing at the top of Resident #1's bed. Resident #2 had his penis in Resident #1's mouth. NA#1 stated she was startled, apologized, and backed out of the room. NA#1 stated as she exited the room she saw Nurse #1 was across the hall and she reported her observation to Nurse #1. While NA#1 was speaking with Nurse#1 in the hall, Resident #2 exited the room and walked down the hall to the nurse's station. She and Nurse #1 then walked down the hall and reported the incident to the Unit Manger. NA#1 stated she did not ask either resident about the incident. She stated Resident #1 kept the covers over his head or kept looking down while staff moved Resident #2 and his personal belongings into another room. Resident #2 became angry and agitated over being moved into another room. He was yelling and making derogatory statements about the facility and the staff to the point it was disrupting to other residents. NA#1 stated she had never observed any sexual behaviors between Resident #1 and Resident #2 in the past. An interview was conducted with Unit Manger #1 on 10/11/2023 at 11:30AM. She stated Nurse #1 informed her of the incident. She immediately went to the room and Resident #1 was alone. She made sure Resident #1 was safe. During her assessment, Resident #1 stated he was fine and asked if Resident #2 was going to come back so they could finish. Unit Manager #1 stated Resident #1 had previous behaviors that included masturbating in public areas. She had never observed any sexual behaviors between Resident #1 and Resident #2 in the past. A telephone interview was conducted with Nurse #1 on 10/11/2023 at 12:22PM. She stated she was across the hall from Resident #1 and Resident #2's room when NA#1 alerted her to the situation. By that time Resident #2 was in the hall making his way to the nurse station. She immediately notified the Unit Manger. The residents were separated and placed on Q15 minute safety checks. She further stated Resident #2 was immediately moved into a private room. He became very agitated over the move. Nurse #1 stated she was very familiar with both residents and had never observed any sexual behaviors between them in the past. The Director of Nursing was not available for interview. On 10/11/2023 at 12:31PM an interview was conducted with the Administrator. She stated when she was made aware of the incident, the residents were immediately separated and assessed for injury. When the residents were interviewed independently, neither would indicate who initiated the interaction but neither appeared to be in any distress. Resident #2 was placed in a private room. She stated the Medical Director (MD), each resident's Responsible Party (RP) were made aware of the incident. The police department was contacted and declined to complete a report on the incident and the staff were provided in-service education on prevention of abuse. The Administrator stated mandatory reports to Adult Protection Services (APS) and DHHS were completed on 10/5/2023.

Based on observation, record review, staff interviews and interview with Nurse Practitioner (NP), Medical Director (MD), and Dental Office Customer Service Representative, the facility failed to refer a medically complex resident with multiple caries and broken teeth to an oral surgical center for recommended extractions in 1 of 1 resident (Resident #2) reviewed for dental care. The findings included: Resident #2 as admitted to the facility on [DATE] for diagnoses that included cerebral vascular accidents (stroke). The residents quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely or never understood and her cognitive skills for daily decision making were severely impaired. Resident #2 required extensive assistance with activities of daily living and personal hygiene during the assessment period. On 8/8/2023 at 10:30AM Resident #2 was observed sitting up in her bed with her smart phone in her hand. Resident #2 did not speak when spoken to but she did open her mouth when writer demonstrated mouth opening. The resident was observed to have several discolored teeth and a strong odor coming from her mouth. Resident #2 was observed 8/8/2023 at 8:45AM. She was sitting up in her bed asleep. Her breakfast tray was still in front of her. The resident had eaten scrambled eggs, grits, and bacon. She had consumed 75% of her meal. At 12:00PM on 8/8/2023 Resident #2 was observed eating her lunch tray which included wide flat buttered noodles, and meatballs with brown gravy. The resident did not express discomfort while eating her meal. The resident's active physician orders did not contain a referral for oral surgery consult. Review of the resident's medical record revealed no weight loss. On 1/10/2023 the NP noted Resident #2 had dental caries and untreated dental caries could lead to bacteremia and subsequent heart valve vegetation (bacteria that settle on and destroy the heart valve). The medical record contained a progress noted dated 1/24/2023 that indicated the resident was seen by the dentist on that date and new orders were received. The note also indicated a follow up appointment would be scheduled by the provider. The facility provided a paper copy of an after-visit summary from an offsite dental office dated 5/25/2023 indicated the resident was seen at an offsite dental office for sedation and extractions. The summary indicated the dentist reviewed the resident's medical record and discovered she was on an anticoagulant. The dentist requested medical clearance from the MD prior to sedation and extractions. The resident returned to the facility without receiving treatment. The facility also provided a paper copy of a note from the dental office dated 6/12/2023. The note indicated a phone conversation took place between the dentist and the MD regarding exactly what treatment the resident required. The note indicated the MD did not want the resident to undergo sedation and extractions at the dental office due to the resident's medically complex condition. The note further indicated the MD would send over her recommendation of a dental surgical center and the dentist would send the referral to the dental surgical center of her choice. The medical record contained a note by the NP dated 6/13/2023. The note read in part, patient with significant need for dental intervention. Local dentist requesting extraction of 20 teeth under conscious sedation. MD requested that patient receive services in the outpatient surgical center. Patient has been treated for multiple abscesses and underwent multiple antibiotic therapy due to oral infection. Awaiting referral from dental surgeon in outpatient surgery center. On 6/19/2023 the NP again noted in the medical record she was awaiting referral to local oral surgeon. The medical record indicated Resident #2 was seen by the MD on 7/10/2023. The MD noted, pending referral to oral surgeon. Resident #2 was evaluated by the NP on 7/12/2023 and indicated again, currently awaiting referral from an ambulatory surgical clinic for patient to receive extractions in a medical facility. An interview was conducted with the Social Worker on 8/8/2023 at 12:24PM. She stated she is responsible for making sure residents are scheduled to see the dentist. She further stated Resident #2 was scheduled to see an offsite dentist in May but due to a miscommunication, the resident's anticoagulant was not stopped, and she could not get treatment that day. She stated Resident #2 did not have an existing appointment to a dentist or referral to an oral surgeon to her knowledge. A phone interview was conducted with the scheduler and transporter on 8/8/2023 at 1:00PM. She stated Resident #2 did not have an existing appointment with a dentist or oral surgeon. She further stated she was told the facility was waiting on a referral from the dental office. On 8/8/2023 a phone interview was conducted with the NP at 4:45PM. She stated Resident #2 was medically complex, on anticoagulants and had a history of strokes. The dental office requested medical clearance from the facility back in May. She stated she spoke with the MD regarding medical clearance and the MD called the dental office. The MD was not comfortable with the resident undergoing sedation and extraction of over 20 broken or infected teeth in the dental office so she requested the resident have the procedure performed in a dental surgical center when the resident could be monitored closely. The NP stated she had tried multiple times to reach the resident's family to determine if the resident had required prophylactic antibiotics for dental care in the past. She further stated that was not holding up the resident's referral to an oral surgeon. The NP stated she was waiting for the dental office to make the referral to a dental surgical center. The NP acknowledged that she had not reached out to the dental office to follow up on the referral, but she would do so. A phone interview was conducted 8/9/2023 at 8:05AM with a Customer Service Representative from the dental offices. She stated the dentist was waiting for the facility to contact them regarding what oral surgical center the resident's referral and records needed to be forwarded to. On 8/9/2023 at 8:50AM an phone interview was conducted with the MD. She stated when the dental office requested medical clearance for Resident #2, she called and spoke with the dentist regarding what dental treatment the resident required. She was informed the resident needed over 20 broken or infected teeth extracted. The MD stated Resident #2 was on anticoagulant and has had multiple strokes in the past, she was not comfortable with the treatment being completed in a dental office. She felt the resident needed to be monitored more closely and a dental surgical center or outpatient surgical center would be more appropriate. The MD stated she sat down with the NP and the Unit Manager and discussed finding a dental surgical center or outpatient surgical center. She stated the NP and the Unit Manger were to follow up with the resident's dental care. She was not aware the referral had not been made. The Unit Manager was no longer employed with the facility and attempts to contact her were not successful.

Based on observations, record reviews, and interviews with residents and staff, the facility failed to maintain an effective pest control program that was free of fly activity for 3 of 3 (Residents # 4, #8, and #11) residents reviewed for pest control. The findings included: A customer service report by the pest control complany dated 5/17/2023 indicated interior area floor drains in the kitchen were in need of cleaning. Recommended cleaning in and around drains frequently to prevent pest breeding sites. Spot applications of pest control were applied to interior dining, interior halls, interior kitchen, interior offices, and entry points. a. Resident #4 was admitted to the facility on [DATE]. Resident #4's annual Minimum Data Set (MDS) dated [DATE] indicated the resident was mildly cognitively impaired and required extensive assistance with activities of daily living. On 6/20/2023 at 9:00AM Resident #4 was observed in his room, in his bed with his breakfast tray in front of him. There was a large black fly observed on the resident's grits and another large black fly on the corner of his plate next to eggs. The resident had his fork in his hand and was actively eating his meal. Resident #4 was interviewed during the observations and stated flies had been a problem for a while and they were getting worse. He could not remember the exact day or week he noticed the flies in his room. On 6/21/2023 at 9:05AM Nurse Assistant (NA) #1 was observed on Resident #4's hall. She was observed using her hand to swat at a fly. NA#1 was interviewed at the time of the observation and stated the facility did have a fly problem. She worked in the facility two days prior and the flies were not as bad then. She did not know why the flies were getting worse or how they might be entering the facility. b.Resident #8 was admitted to the facility on [DATE]. Resident #8's entry Minimum Data Set (MDS) dated [DATE]indicated the resident was mildly cognitively impaired and required some assistance with activities of daily living. On 6/20/2023 at 9:15AM Resident #8 was observed in his room, in his bed. There were multiple flies in his room. Observed grits on the floor to the left of Resident #8's bed. There were two large black flies on the grits. The resident was observed to have a visibly large wound with wound vac on his right lower extremity. An interview was conducted with Resident #8 at the time of the observation. He stated the facility did have a problem with flies. The problem seemed to be getting worse. He could not recall when he first saw flies in his room. At 10:00AM on 6/20/2023 an interview was conducted with Nurse #1, who was assigned to Resident #8. The interview was conducted in Resident #8's room. Nurse #1 stated the facility did have a problem with flies. He further stated the problem seemed to get worse as the outside weather warmed. He did not know how the flies might be entering the facility. He stated he saw the pest control company in the facility recently. c.Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (stroke). Resident #11's quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact and required extensive assistance with activities of daily living. On 6/21/2023 at 2:30PM Resident #11 was observed sitting in her room looking through a book of word find puzzles. She was observed picking up a yellow fly swatter and swinging at a black fly. An interview was conducted with Resident #11 at the time of the observation. Resident #11 stated the fly problem had been going on for several weeks and seemed to be getting worse. She further stated her room is next to a door that opens to the outside so that may have increased the number of flies in her room. An interview was conducted with Nurse #3, who was assigned to Resident #11's hall. She stated the facility did have a problem with flies. The problem was facility wide and not just one area. At 3:00PM an observation of the nurse station was conducted. Multiple flies were observed at the nurse station. At 4:00PM an interview was conducted with Unit Manager #2. She stated she was aware of the fly problem. She believed the flies could have entered the facility when residents enter and exit the facility to the smoking area. Some of the residents were in wheelchairs and the door was held open for an extended period of time. The flies could have entered the facility on the wheelchairs. She stated the facility had routine pest control services. At interview was conducted with the Administrator. She stated the facility conducted routine pest control and evidence of a pest control program was provided.

Based on observations and interviews with resident and staff, the facility failed to maintain a clean and homelike environment for 1 of 3 residents (Resident #8) reviewed for clean, sanitary, and homelike environment. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis. The resident's admission Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment, required supervision for completion of activities of daily living, and received IV antibiotics during the assessment period. On 6/20/2023 at 9:15AM Resident #8 was observed in his room, in his bed. A bag of IV Daptomycin (antibiotic) was observed lying on the bedside dresser. The bedside table was on the resident's left and held paper trash, a spray bottle of wound cleaning solution, and the lid to his bedside commode. On the floor beneath the bedside table were grits. There were two black flies on the grits. On the floor at the foot of the bed and to the right of a negative pressure wound therapy machine (wound vac) were several dried brownish red spots. On the floor beneath the bed laid a piece of dark grey foam (like that used with the wound vac) and more paper trash. The trash can was empty and did not have a liner. An interview was conducted with Resident #8 at the time of the observation. He stated the paper trash, and the wound care spray were left after his wound care the day prior. He did not know how long the dried reddish-brown spots had been on the floor, but he thought the spots were dried blood from either his wound or the wound vac machine. Resident #8 stated he understood staff were busy, but he would like his room to be cleaner. Nurse #1, assigned to Resident #8, entered the room around 9:20AM and stated the condition of the room was bad and a mess. He further stated the room was in that condition when he began his shift at 7:00AM. He explained that he did not have time to provide care and clean rooms. He denied notifying housekeeping or the Nurse Assistant of the condition of the resident's room. On 6/20/2023 at 11:32AM an interview was conducted with Nurse #2. She stated she completed wound care on Resident #8 on 6/19/2023. She did not recall leaving trash or the spray bottle of wound cleaner in the room. She stated the grey foam observed on the floor was from the wound care and she just overlooked it. She stated she did not recall if there was a liner in the trash can when she conducted wound care the previous day. At 4:00PM on 6/20/2023 and interview was conducted with Unit Manager #2. She stated Nurse #1 could have reached out to her, housekeeping, or other staff members to address the condition of Resident #8's room.

Based on staff and Wound Doctor interviews, record review and observations, the facility failed to safely position a resident in bed without injury when Resident #7 fell from a resident bed raised to the waist high position resulting in a subarachnoid hemorrhage (bleeding in the space that surrounds the brain). This was for 1 (Resident #7) of 3 residents reviewed for accidents. The findings included: Resident #7 was admitted on [DATE] with a traumatic brain injury (TBI), seizure disorder, left side hemiplegia, muscle spasms and contractures to his left arm, elbow and leg. Resident #7's comprehensive care plan included a care area dated 4/21/21 for assistance with his activities of daily living (ADLs) because he was dependent on staff to turn and reposition with 2 staff while in the bed for safety. On 10/21/22, the intervention of grabs bars to promote independence was added. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #7 had severe cognitive impairment required extensive assistance of 2 staff for bed mobility and coded for a pressure ulcer. An incident report dated 1/4/23 at 8:29 AM completed by Nurse #2 read Resident #7 fell to the floor next to the bed with a head injury. Resident #7 stated I grabbed the rail while rolling for wound care with my good arm and rolled out of the bed. The report read a staff member was getting ready to do wound care when he turned and repositioned himself by grabbing the rail, extended himself over and fell out of the bed. A nursing note dated 1/4/23 at 8:29 AM completed by Nurse #2 read Resident #7 was using his right arm to turn in bed and fell off the edge to the floor striking his head with an injury. The nurse called emergency medical services (EMS) and controlled the bleeding. Per the hospital report, Resident #7 was admitted with a brain bleed. Both the physician and the responsible party were notified. An interview was completed on 2/23/23 at 12:37 PM with Nurse #2. He stated at the time of Resident #7's fall, he was in the middle of his medication pass so the Unit Manager (UM) assisted the wound nurse with Resident #7 and sent him out to the hospital. An interview was completed on 2/23/23 at 10:40 AM with the Unit Manager (UM). She stated she was under the impression that the Wound Doctor was present in the room when Resident #7 fell from the bed. She stated she assessed Resident #7. The UM recalled seeing the Wound Doctor in the hallway and not the room. She noted a laceration to his right side of his head was bleeding. She got the bleeding stopped, performed neurological checks and contacted EMS to take Resident #7 to the hospital for an evaluation for his injury. The UM stated Resident #7 was not able to turn himself in the bed and she had not known him to regularly use his grab bar to roll himself over with staff assistance. An interview was completed on 2/23/23 at 10:00 AM with the wound nurse. She stated she raised the bed to waist level for the Wound Doctor to assess Resident #7's wound. She stated she assisted him onto his right side, and he grabbed the rail and rolled out of the bed. The wound nurse stated it happened so fast when the Wound Doctor came into the room, and she was changing places with him to allow for his wound assessment. She stated she had her hand on Resident #7 until she walked around to the other side of the bed and that was when he grabbed the grab bar and rolled himself out of the bed. The wound nurse stated she thought she positioned Resident #7 in the middle of the be prior to rolling him over. Review of the education dated 1/4/23 provided by the DON to the wound nurse read she was educated that Resident #7 should have 2 staff assisting with bed mobility at all times to ensure safety while doing his wound care. An interview was completed with the DON on 2/23/23 at 9:30 AM. She stated the wound nurse was rounding with the wound Physician. She turned Resident #7, and he grabbed the rail (grab bar) and rolled out of the bed. She stated at the time of the fall, she educated the wound nurse, but she did not provide any staff education, observations, staff interviews or auditing. The hospital discharge summary dated 1/6/23 read Resident #7 was being evaluated by the Wound Doctor for a pressure ulcer to his back when he rolled over to expose the area, Resident #7 rolled off the bed and hit the posterior aspect of his head. He did not lose consciousness. At the time of his admission on 1/4/23 Resident #7 was absent of pain, neck pain, headache, dizziness or changes in his vision. The CT scan completed on 1/4/23 revealed a right frontal and temporal hyper-density reflecting a small volume intraparenchymal hemorrhage (when blood pools in the tissues of the brain). He was consulted by neurosurgery and conservative management was recommended. The repeat CT scan completed on 1/6/23 revealed resolution or redistribution of the subdural blood, stable condition and a return to his baseline. While in the hospital, it was noted that Resident #7's Valproic Acid levels (medication used to treat seizures) were trending downward and adjustments in the dosage were done. His aspirin was held for 2 weeks, and he was discharged back to the facility on [DATE] with order to obtain. A nursing note dated 1/9/23 at 4:10 PM completed by the Director of Nursing (DON) read the interdisciplinary team met to discuss the occurrence on 1/4/23 when Resident #7 had a witnessed fall with an injury to his forehead. He was sent out to the hospital and returned on 1/6/23 with new interventions to ensure Resident #7 was properly positioned while in the bed and to ensure the bed is in the lowest position. An observation was completed on 2/23/23 at 10:20 AM of Resident #7. He was lying in the with bed a left arm and hand contracture. There was a grab bar (rail) observed at the head level on the right side of his bed and another grab bar in the middle side of his left side of the bed. He recalled falling out of the bed but did not recall the circumstances. An interview was completed on 2/23/23 at 10:30 AM with Nursing Assistant (NA) # 1. She stated Resident #7 has grab bars on his bed, but he was not able to roll over by himself and there were supposed to be 2 staff to assist with his bed mobility for safety. An interview was completed on 2/23/23 at 4:20 PM with the DON. The DON stated there should have been 2 staff assisting with Resident #7's turning and positioning prior to the Wound Doctor's assessment. A telephone interview was completed on 2/23/23 at 6:25 PM with the Wound Doctor. He stated he was reading his previous assessment data in the hallway when he heard Resident #7 fall. He stated he had not yet entered the room because the wound nurse was getting Resident #7 prepped by positioning him and removing his old dressing.

Based on observations, facility staff, rehabilitation staff and Physician #1 interviews and record review, the facility failed to assess a resident for the worsening of bilateral hand contractures (Resident #24) and also failed to obtain Physician orders for splint management (Resident #32). This was for 2 of 6 residents reviewed for range of motion. The findings included: 1. Resident #24 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Admission/Re-Admission Screening dated 2/4/20 did not include any evidence that Resident #24 was admitted with bilateral hand contractures. Review of an Occupational Therapy (OT) Evaluation and Plan of Treatment report dated 3/4/21, under the musculoskeletal System Assessment, read Resident #24 did not have any contractures present. The evaluation read he was referred by nursing due to an increased need for assistance, decrease in strength and coordination. He was discharged from OT on 4/2/21 with no recommendations. Review of another OT Evaluation and Plan of Treatment report, dated 4/22/21, read OT would treat and address contractures by passive range of motion (PROM)/stretching, joint mobilization techniques and assess for upper bilateral orthotics. The reason for the OT referral was for decreased independence with self-feeding and decreased ROM in his bilateral upper extremities. Review of the OT Treatment encounter notes from 4/22/21 to 5/12/21 read, manual joint mobilization techniques and stretching of shortened connective tissue and PROM was provided to Resident #24' bilateral upper extremities to reduce stiffness and increase blood flow. The notes did not specify if the bilateral shoulders or hands were addressed. Review of the OT Discharge Summary dated 5/12/21 read the ROM performed was to his bilateral shoulders and did not mention his bilateral hand contractures. The goal of Resident #24 was to safely wear the least restrictive splinting/orthotic device during daily task without complaints of discomfort, in order to improve his ability to participate in self-feeding. A scoop dish with a plate guard and divided plate was implemented. He was discharged with no change in his dependence and there was no documented evidence provided that the scoop dish with a plate guard and a divided plate were ever implemented. Review of Resident #24's care plan, last revised on 6/30/21, did not include a care plan for contractures or the risk for contracture development. Resident #24's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had severe cognitive impairment and exhibited no behaviors. He was coded for total assistance with his activities of daily living as well as impairment to his bilateral upper extremities. An observation was conducted on 9/27/21 at 10:00 AM. There were no splints or protective devices observed to Resident #24's bilateral hand contractures. An observation was conducted on 9/28/21 at 8:43 AM, where wash clothes were noted to be inserted into Resident #24's bilateral hands. An observation was made on 9/28/21 at 12:10 PM. There were no splints or protective devices observed in Resident #24's bilateral hand contractures. An observation was conducted on 9/28/21 at 4:00 PM. There were no splints or protective devices observed in Resident #24's bilateral hand contractures. An observation was conducted on 9/29/21 at 8:47 AM. There were no splints or protective devices observed in Resident #24's bilateral hand contractures. In an interview on 9/29/21 at 12:32 PM, the OT who treated Resident #24 stated she received a referral yesterday to evaluate Resident #24's hands. The OT stated when she discharged him from services on 5/12/21, he was using his hands and she only saw him to determine his eating skills and needs. She denied any contractures to his bilateral hands at that time and stated she assessed Resident #24 today and noted worsening of the ROM in his bilateral hands since May 2021. She stated she normally received a referral from nursing for any changes in a resident's ROM but had not received a referral for Resident #24. In an interview on 9/29/21 at 12:40 PM, the Rehabilitation Director stated the normal process was the nurse would fill out a referral form and give it to her and she would give the referral to the proper therapy discipline. She stated at one time, the therapist were completing a quarterly screening for changes in a resident, but it stopped. She continued to explain, she felt with the management transition, COVID-19, and staff turn-over, that was when the therapy screening stopped. She confirmed Resident #24 was being evaluated today by the OT. Review of the OT Evaluation and Plan of Treatment report dated 9/29/21, the reason for the referral was due to an exacerbation of decreased ROM in Resident #24's bilateral hands. It read Resident #24 would safely wear a resting hand splint on his right fingers, right hand, and right wrist for up to 2 hours with a target time of 6 hours, as well as would wear a resting hand splint on his left fingers, left hand, and left wrist for up to 2 hours with a target time of 6 hours. In an interview on 9/30/21 at 9:00 AM, Nursing Assistant (NA) #5 stated Resident #24 had recently been transferred from the secured unit and had required total assistance with his meals in the unit and now on the 300 hall. She stated she did not recall any special plates or utensils delivered from dietary because he was unable to assist with eating due to his hand contractures. NA #5 stated she was uncertain when Resident #24's hand contractures developed but she had never seen any splints or protection in his hands until the past few days when wash clothes were added to his hands for protection. In an interview on 9/30/21 at 9:30 AM, Nurse #1 stated Resident #24 required total staff assistance with his meals. He stated therapy picked him up yesterday for contracture management. In an interview on 9/30/21 at 9:40 AM, NA #6 stated Resident #24 had to be fed and he did not use any adaptive equipment for his meals or for his bilateral hand contractures. 2. Resident #32 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Therapy Communication to Nursing form dated 7/29/21, read for the staff to apply Resident #32's resting hand splint as tolerated. The form was signed by the Occupational Therapist (OT), however, there were no signatures by the nurse acknowledging the need for a physician's order in order to ensure the aides were aware of the need to apply Resident #32's right hand splint. Attached to the communication form was a in-service education and training dated 8/5/21 of a right-hand resting hand splint but there was no documented resident's name, and there were no signatures by the Unit Manager (UM) or a nurse acknowledging the need for a physician's orders for splinting. Review of Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with all his activities of daily living and was not coded for any impairment to his bilateral upper extremities. Review of an Occupational Therapy (OT) Discharge Summary dated 8/17/21 read Resident #32 would safely wear a resting hand splint on his right fingers, right hand, and right wrist for up to 4 with a target of 8 hours. The summary read he was discharged to staff, who were trained in his splinting program. Review of Resident #32's care plan last revised on 9/9/21 did not include a care plan for any contractures. Review of an undated Resident Care Guide did not include any instructions for the floor staff to put on and/or remove Resident #32's right hand splint. Review of Resident #32's August 2021 and September 2021 physician orders did not include any orders for splinting of his right hand. An observation was conducted on 9/27/21 at 10:00 AM. There was no splint observed to Resident #32's right hand. An observation was conducted on 9/28/21 at 8:43 AM. There was observed a resting hand splint on Resident #32's right hand. An observation was conducted on 9/28/21 at 12:10 PM. There were no resting hand splint observed on Resident #32's right hand. In an interview on 9/28/21 at 3:25 PM, Nursing Assistant (NA) #4 stated she was under the impression that therapy was applying Resident #32' resting hand splint. NA #4 stated if there was nothing in the electronic task area or on the Resident Care Guide about a right-hand splint, the aides would have no way of knowing to apply, remove and document his right-hand splint. An observation was conducted on 9/28/21 at 4:00 PM. There were no resting hand splint observed on Resident #32's right hand. An observation was conducted on 9/29/21 at 8:47 AM. There was a resting hand splint on Resident #32's right hand. In an interview on 9/29/21 at 12:32 PM, the OT stated Resident #32 was established with a splinting schedule in August 2021 and she notified the UM that she had completed the staff training and was discharging Resident #32 from OT services. The OT stated it was the responsibility of the UM or floor nurse to obtain the physician order and enter the order into the electronic medical record so the aides would know to apply his right-hand splint daily. In an interview on 9/29/21 at 2:00 PM, the Director of Nursing (DON) stated she was unable to locate any physician orders or documentation regarding Resident #32' right resting hand splint. She normally stated the therapy department would give the UM or the nurses the therapy communication form and the nurses or UM would enter the physician orders into the electronic medical record so that the aides would know to apply the splint. She stated she was uncertain as to why the process did not work for Resident #32. In an interview on 9/29/21 at 3:29 PM, the UM stated when therapy discharged a resident from therapy services to the nursing staff with orders to implement a splinting program, the therapist was to complete a referral form and give it to her after the therapist educated the floor staff on any recommendations such as splinting. She stated after the therapist educated the staff, she was given the referral form along with the in-service sign in sheet. The UM stated at that point, the orders would be written and entered into the electronic medical record and added to the aide's task list. The UM stated the OT never gave her a referral form because she would have signed the form acknowledging the need for physician orders. In an interview on 9/30/21 at 9:40 AM, NA #6 stated she was aware that Resident #32 wore a right-hand splint but there was no place to document that the staff were applying his splint. In an interview on 9/30/21 at 1:47 PM, the Administrator and Director of Nursing stated it was their expectation that the facility would have obtained and entered Resident #32's right hand splinting orders into the electronic medical record to ensure his splint application.

Based on record review and interviews with the Medical Examiner, attending physician, Responsible Party (RP), and staff, the facility neglected to monitor and assess Resident #1 ' s neurological condition and vital signs following a fall in which the resident hit his head on concrete. The facility also neglected to provide accurate information to Resident #1 ' s attending physician and the RP on the details of the fall by reporting that the resident fell on to a grass surface rather than concrete. This failure caused the physician to keep the resident at the facility for monitoring rather than sending the resident out for evaluation at the emergency room (ER). Resident #1 fell and hit his head on concrete on [DATE] at 9:55 AM and was found unresponsive at 12:48 PM. The Certificate of Death, dated [DATE], indicated the cause of death was [MEDICATION NAME] force head trauma. Additionally, the facility neglected to complete neurological assessments for Residents #2, #3, #4, and #5 after unwitnessed falls. This was for 5 of 5 residents reviewed for falls. Immediate Jeopardy began on [DATE] when Dietary Staff #1 witnessed Resident #1 fall backward in his wheelchair hitting his head on a concrete walkway outside of the facility and his assigned nurse, Nurse #1, neglected to obtain information from the witness to the fall (Dietary Staff #1) and subsequently reported inaccurate information to Resident #1 ' s physician stating that he fell and hit his head on a grass surface. Nurse #1 then neglected to follow the physician's order [REDACTED].#1 and completing neurological assessments (including vital signs) per facility protocol. Nurse #1 neglected to complete 5 of the neurological assessments that were due on [DATE] between 10:15 AM and 12:48 PM (10:15 AM, 10:45 AM, 11:30 AM, and 12:00 PM) with her last assessment of Resident #1 being completed at 10:30 AM. At 12:48 PM ([DATE]) Resident #1 was found unresponsive in bed in his room. The cause of Resident #1 ' s death on the Death Certificate was [MEDICATION NAME] force head trauma. Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy Removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) for Examples #2, #3, #4, and #5 to correct the deficient practice and to ensure that the education and the monitoring systems put in place to remove the Immediate Jeopardy are effective. The findings included: 1. Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] indicated Resident #1 was hospitalized from [DATE] through [DATE] for COVID pneumonia (PNA) complicated by acute hypoxic [MEDICAL CONDITION] and new onset of [MEDICAL CONDITION]. He was previously on [MEDICATION NAME] (antiplatelet medication) and aspirin for secondary stroke prevention. This was changed to aspirin and Xarelto (anticoagulant medication) during the [DATE] to [DATE] hospitalization . On [DATE] Resident #1 presented to the hospital with melena (black, tarry stool usually associated with GI bleed) which was confirmed by emergency room (ER) rectal exam. He was admitted to the hospital and a colonoscopy was conducted which revealed diverticulitis and 3 small polyps were resected from his [MEDICATION NAME] colon. Following the procedure there was no active bleeding and [MEDICATION NAME] felt it was okay to resume his anticoagulant (Xarelto). His hemoglobin was stable, and he was discharged back to the facility on [DATE]. His discharge medication orders included Xarelto 15 milligrams (mg) once daily. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 ' s cognition was severely impaired. He required extensive assistance of 1 with bed mobility and transferred only once or twice with the assistance of 2 or more. He was coded for locomotion on/off unit as only happening once or twice with 1 assist. Resident #1 had no functional impairment with range of motion and utilized a wheelchair. The Care Area Assessment (CAA) related to cognitive loss for Resident #1 ' s [DATE] MDS indicated he had difficulty with completing thoughts or ideas but was able to complete them when prompted and given ample time. He was noted to be incontinent of bowel and bladder, wore an adult brief, and had bowel movements that had blood present since his last hospital stay. He was at risk for falls related to poor balance, poor safety awareness, and impaired cognition. A nursing note dated [DATE] completed by Nurse #9 indicated the Nursing Assistant (NA) reported Resident #1 had a bowel movement which had a significant amount of blood in it. The physician gave order to send resident to the hospital to evaluate and treat. The emergency room (ER) evaluation dated [DATE] indicated Resident #1 was on Xarelto and presented for worsening rectal bleed. Resident #1 was noted to refuse a rectal exam stating that this bleeding was no different from when he was hospitalized and requesting to go back to the facility. His vital signs were within normal limits and his hemoglobin was stable compared to prior values. Resident #1 ' s Responsible Party (RP) was spoken with and she agreed with discharge back to the facility. She stated she would discuss the discontinuation of Xarelto with his attending physician. A physician's order [REDACTED].#1 ' s Xarelto was discontinued due to bleeding. Resident #1 ' s care plan, with a review date of [DATE], included the focus area of bowel incontinence related to immobility and limited range of motion and being sent to the ER related to bloody stool with clots. The interventions included ER evaluation and removal of colon polyps while hospitalized . This care plan also included the risk for falls related to gait/balance problems and incontinence. The interventions included anticipating and meeting Resident #1 ' s needs. A nursing note dated [DATE] at 10:25 AM completed by Nurse #1 indicated that staff witnessed Resident #1 outside on the ground in his wheelchair. The wheelchair had flipped backward onto the ground. The resident remained in wheelchair as it flipped. Resident #1 had not lost consciousness. He was noted with an abrasion on the back of his head the size of a quarter. Resident #1 was taken to his room and transferred back to bed via a mechanical lift with 2 staff assist. Resident #1 had no complaints of pain or discomfort and no open areas. Vital signs were obtained: blood pressure (bp) ,[DATE], pulse 101, respirations 20, temperature 97.1, Oxygen (O2) 98% room air. Resident #1 ' s RP and physician were notified, and the physician gave a new order to monitor the abrasion to the back of his head for 7 days and to complete neurological checks per facility protocol. The resident was noted to be in bed watching television. A review of the neurological assessment record in the Electronic Medical Record (EMR) indicated neurological assessments were supposed to be completed as follows: - every (q) 15 minutes 4 times - q 30 minutes 2 times - q 60 minutes 4 times - q 4 hours 6 times - q shift 2 times The neurological assessment record dated [DATE] for Resident #1 revealed no assessments had been completed. A review of the vital signs record in the EMR indicated the vital signs were obtained twice for Resident #1 after his [DATE] fall. These vitals indicated the following: - [DATE] at 9:56 AM completed by Nurse #1: respirations 20, temperature 97.1, pulse 101 - [DATE] at 10:10 AM completed by the Director of Nursing (DON): bp ,[DATE] - [DATE] at 10:30 AM completed by the DON: bp ,[DATE], respirations 20, temperature 96.4, and pulse 92 A nursing note dated [DATE] at 12:50 PM completed by Nurse #1 indicated that NA #1 picked up Resident #1 ' s lunch tray and informed the nurse that the resident was not responding. Nurse #1 observed Resident #1 who had no pulse, respiration, blood pressure, or O2. Resident #1 had a Do Not Resuscitate (DNR) order. A nursing note dated [DATE] at 2:26 PM (noted as a late entry note) indicated Unit Manager (UM) #2 notified the RP of Resident #1 ' s passing that occurred at approximately 12:48 PM. A Certificate of Death dated [DATE] completed by the Medical Examiner identified the immediate cause of Resident #1 ' s death as [MEDICATION NAME] force head trauma. The Medical Examiner noted that the injury occurred from Resident #1 falling backward in wheelchair onto concrete. The time of death was 12:50 PM. A handwritten statement dated [DATE] completed by Dietary Staff #1 indicated she was approaching the sidewalk in back of the facility and saw Resident #1 flip his wheelchair on its back causing him to bump his head on the concrete sidewalk. Dietary Staff #1 stated she called his name and the resident opened his eyes and moaned a little. She then ran into the building and asked Nurse #2 to provide assistance. Dietary Staff #1 indicated after she got Nurse #2 she returned to the dietary department. On [DATE] at 12:14 PM an interview was conducted with the witness to Resident #1 ' s [DATE] fall, Dietary Staff #1. She verified that she was outside on [DATE] and observed Resident #1 ' s fall. She explained that she was coming back from her break and she saw Resident #1 seated in his wheelchair on the sidewalk. She indicated that this was a normal activity for the resident as he frequently went outside independently. She reported that it looked like Resident #1 had one of the wheels from his wheelchair stuck in the grass off the edge of the concrete sidewalk and he was making a rocking movement to get it back on the sidewalk. Dietary Staff #1 stated that Resident #1 must have rocked with too much force and the wheelchair tipped all the way back and the resident landed on the concrete with his back on the ground still seated in the wheelchair. She revealed that she saw Resident #1 hit his head on the concrete. She indicated she asked Resident #1 if he was alright and he responded to his name and said he was okay. She stated she then went into the facility to get nursing staff and she saw Nurse #2 at the nurse ' s station and she told him what happened, and he ran outside to assist Resident #1. She reported that this was the extent of her involvement as she then returned to the dietary department. She indicated Nurse #1, Resident #1 ' s assigned nurse, had not asked her any questions about Resident #1 ' s fall. Dietary Staff #1 reported that she wrote a statement about what she observed for facility management. A physician ' s note dated [DATE] at 7:23 AM indicated she was informed by staff on [DATE] that Resident #1 had fallen outside onto grass striking the back of his head. The physician wrote that the staff member (Nurse #1) was asked if Resident #1 fell on concrete or the grass and she confirmed it was the grass. The physician indicated that Nurse #1 reported he was cognizant to his surroundings, had not lost consciousness, and had no raised area on his head. The physician further indicated she decided that neurological checks were to be performed for Resident #1 every 15 minutes in accordance with the facility protocol and any changes in mentation were to be reported to her. An interview was conducted with the DON on [DATE] at 1:30 PM. When asked about the facility ' s protocol for neurological checks she stated that the assigned nurse was to complete the neurological assessment in the EMR at the following frequency: q 15 minutes x 4, q 30 minutes x 2, q 1 hour x 4, q 4 hours x 6, and q shift x 2. She reported the neurological assessment included vital signs. She stated that the assigned NA was able to obtain vital signs for the nurse, but the NAs were not able to complete the remainder of the neurological assessment as it required a nurse ' s clinical assessment. The DON reported that ultimately it was the assigned nurse ' s duty to ensure neurological assessments with vital signs were conducted in accordance with this protocol. An interview was conducted with Nurse #2 on [DATE] at 12:20 PM. He stated that on [DATE] Dietary Staff #1 ran in from outside and asked for help stating that Resident #1 had flipped his wheelchair. He reported that he and NA #1, NA #2, and the Activities Staff/NA #3 immediately ran out to assist the resident. He reported that Resident #1 was observed seated in his wheelchair with his wheelchair ' s back on the concrete ground. He explained that it was almost the position an astronaut would be in during takeoff as his back was on the ground and his feet were supported by the chair in the air and he was looking up towards the sky. Nurse #2 stated that Resident #1 was responsive and was at his baseline cognitive status. He reported that he asked Resident #1 if he hit his head and the resident said no. He stated that the NAs assisted him with putting the resident and his wheelchair upright. He indicated that at that time he noticed an abrasion to the back of Resident #1 ' s head. Nurse #2 reported that by this time Resident #1 ' s assigned nurse, Nurse #1, came outside and assumed responsibility for his care from there. He stated that Nurse #1 had not asked for any information about the fall but instead began yelling to NA #1 and NA #2 telling them to take Resident #1 inside to lay him down, so she could assess him. Nurse #2 added that it was a normal occurrence for Resident #1 to go outside on his own. A phone interview was conducted with Nurse #1 (an agency nurse) on [DATE] at 11:16 AM. She stated that she had not witnessed Resident #1 ' s fall on [DATE]. She reported that she was in a room with another resident when she heard some commotion. She indicated that she completed what she was doing and ran outside. Nurse #1 indicated that when she got outside she saw Nurse #2 and the NAs (NA #1, NA #2, and NA #3) getting Resident #1 ' s wheelchair upright. Nurse #1 indicated that Nurse #2 said Resident #1 just flipped his wheelchair over on the sidewalk, was fine, and that he had a small abrasion to the back of his head. She said she observed an abrasion the size of a quarter to the back of his head. She reported that she thought Resident #1 fell on the grass as the resident had some grass on him. She stated she told NA #1 and NA #2 to take Resident #1 inside and put him in bed, so she could take his vitals. She reported she asked Resident #1 if he wanted to go to the hospital and he said no. She stated that she took his vitals and completed a neurological check around 10:00 AM and these were within normal limits. Nurse #1 was unable to explain why this initial neurological assessment was not in the medical record. She reported that after she completed her assessment she called the physician and told her that Resident #1 fell and hit his head on grass. She stated that she also provided the vitals to the physician. She indicated that the physician ordered neurological checks every 15 minutes per protocol. She reported she then called the RP and told her that Resident #1 had fallen outside and hit his head on grass and was doing fine. Nurse #1 revealed she had not spoken to Dietary Staff #1 who witnessed the fall. When asked why she had not spoken to Dietary Staff #1 she stated that she had not known she witnessed Resident #1 ' s fall. She reiterated that she assumed Resident #1 had fallen on the grass since he had grass on him. This interview with Nurse #1 continued. Resident #1 ' s medical record that indicated no neurological assessments were completed after Resident #1 ' s [DATE] fall was reviewed with Nurse #1. Nurse #1 revealed that she conducted only 2 neurological checks for Resident #1 on [DATE], the initial check that occurred soon after the fall around 10:00 AM and a subsequent check around 10:30 AM. She indicated that there were no irregularities with these assessments. Nurse #1 was unable to explain why the neurological check she said she conducted at 10:30 AM was also not in the medical record. When asked why she had not completed the neurological assessments that were due on [DATE] at 10:15 AM, 10:45 AM, 11:30 AM, and 12:00 PM Nurse #1 explained that she got very busy that morning and she didn ' t have time to complete the rest of the neurological assessments. She stated that she asked NA #1 to complete the vitals per protocol. She acknowledged that she was aware NA #1 was not able to complete the neurological assessments. During an interview with NA #1 on [DATE] at 12:00 PM she reported that on [DATE] she heard Dietary Staff #1 report to Nurse #2 that Resident #1 had fallen so she went outside to provide assistance. She confirmed that Resident #1 was seated in his wheelchair with the back of the wheelchair laying on the concrete ground. She stated she observed the abrasion to the back of his head. NA #1 stated that Nurse #1 came outside as she and the other staff (Nurse #2, NA #2, and NA #3) were putting the resident and his wheelchair upright on the concrete. She reported that Nurse #1 had not asked what happened, but rather she told her and NA #2 to take Resident #1 inside, lay him down in bed, and to take his vitals. NA #1 stated that Nurse #1 then instructed her to continue to take Resident #1 ' s vitals every 15 minutes after that. She stated that she had taken Resident #1 ' s vitals twice, around 10:00 AM and 10:30 AM, and she documented them on a hard copy sheet of paper at the nurse ' s station. She explained that this was the normal process for NA documentation of vitals as they had no access to the EMR, so they wrote them down and then the nurse was supposed to enter them into the EMR. NA #1 revealed that she had taken no further vitals for Resident #1 after 10:30 AM as she was very busy that morning. She stated that one of the NAs scheduled to work that day had called off, so the nurses were instructed to take the residents ' vitals that day to alleviate some of the NAs ' work. NA #1 reported that Nurse #1 was aware one of the NAs had called off, but she expected her to take the vitals anyway. NA #1 stated that after 10:30 AM she saw Resident #1 in his room a couple of times as she walked up and down the hall and when she delivered his lunch tray and he seemed to be his normal self. During a phone interview with Resident #1 ' s physician on [DATE] at 4:10 PM she stated that the nurse who called her on [DATE] (Nurse #1) said Resident #1 fell and hit his head on grass. She reported that she was familiar with the area outside where Resident #1 was at and she knew that the grass and ground were very soft in that area. She indicated she specifically asked the staff (Nurse #1) if he fell on the concrete or on grass and they stated grass. The physician explained that a fall onto concrete was very different and if she knew he had fallen on concrete she would have immediately ordered them to send Resident #1 to the hospital. She further explained that Resident #1 could have suffered internal injuries that were not able to be observed on the initial assessment. She reported that she instructed the staff (Nurse #1) to perform neurological checks according to protocol. Resident #1 ' s physician revealed she was unaware the neurological checks had not been completed per protocol. The physician spoke about Resident #1 ' s medical condition stating that he recently had COVID, was hospitalized for [REDACTED]. She indicated that with these medical issues it was pertinent to maintain close monitoring and complete neurological checks per the facility ' s protocol as she ordered the nurse (Nurse #1) who contacted her on [DATE]. A phone interview was conducted with Resident #1 ' s RP on [DATE] at 4:50 PM. She stated that the nurse who called her on [DATE] (Nurse #1) said Resident #1 fell and hit his head on grass and that he was doing fine. She reported that if the staff had informed her that he fell on to concrete and hit his head she would have asked them to send him to the emergency room (ER). She explained that Resident #1 may not have wanted to go to the hospital, but if she had spoken with him herself that he would have agreed to go to the ER to be evaluated. The RP spoke about Resident #1 ' s recent issues with a GI bleed. She stated that she believed this risk factor should have made staff take extra precautions with monitoring Resident #1 ' s status after a fall with head injury. During an interview with the Medical Examiner she confirmed that she completed the Certificate of Death for Resident #1 and indicated the cause of death was [MEDICATION NAME] force head trauma. She reported that no autopsy was done as autopsies were normally only done for suspicious deaths and this death was not deemed suspicious as the resident had a fall in which he hit his head on concrete and less than 3 hours later he was deceased . She stated that it was highly unlikely the fall was not the cause of the death and that at a minimum it was part of the causation that led to the death. The Medical Examiner spoke about Resident #1 ' s medical comorbidities that included recent COVID infection and hospitalization due to rectal bleeding. She stated that these multiple medical conditions put Resident #1 at a higher risk for severe complications after a fall with head injury which made it essential to his well-being for staff to monitor him closely by completing neurological checks and vital signs. The Medical Examiner explained that although Resident #1 presented at baseline following the fall, it was necessary to continue to monitor him closely to see if there were any changes to indicate an injury that would not have presented immediately after a fall, such as a subdural brain bleed. She reported that she spoke with facility staff, unable to recall staff ' s name, and questioned how frequently Resident #1 had been assessed prior to death and they were unable to provide a specific answer to the number of assessments and/or frequency. The Medical Examiner stated that if the neurological checks were not completed as ordered by the physician after Resident #1 ' s fall that this was neglect by the nursing staff. During an interview with the DON on [DATE] at 1:30 PM the vital sign record in the EMR for Resident #1 was reviewed. The DON revealed that after Resident #1 ' s death she began an investigation in accordance with normal facility protocol and realized that there was only one set of vitals ([DATE] at 9:56 AM respirations 20, temperature 97.1, pulse 101) in the EMR for [DATE] after the fall. She indicated that Nurse #1 entered the first set of vitals after Resident #1 ' s fall in the EMR with a date of [DATE] at 9:56 AM. She indicated that she spoke to NA #1 who reported that she took two sets of vitals, one at approximately 10:00 AM and the other at approximately 10:30 AM. The DON stated that she reviewed the vital signs for Resident #1 that NA #1 recorded on a hard copy paper. She reported that the respirations, temperature, and pulse that NA #1 recorded at approximately 10:00 AM for Resident #1 matched Nurse #1 ' s documentation in the EMR dated [DATE] at 9:56 AM. The DON explained that she believed the vital signs that were recorded in the EMR by Nurse #1 were transcribed from the vitals NA #1 recorded on the hard copy paper. The DON further explained that Resident #1 ' s blood pressure (,[DATE]) from this set of vitals taken by NA #1 had not been documented in the EMR so she entered this into the EMR with a time of 10:10 AM. She reported that she should have entered the time as 10:00 AM to match the time that NA #1 indicated she obtained these vital signs. The DON stated that since second set of vitals completed by NA #1 (obtained [DATE] at approximately 10:30 AM) were not in the EMR she entered them herself. The DON reported that her documentation in the EMR was completed after Resident #1 ' s death. The neurological assessment record in the EMR dated [DATE] for Resident #1 that indicated no assessments had been completed after his [DATE] fall was reviewed with the DON. The DON revealed she was aware there were no neurological assessments in the EMR for Resident #1 after his [DATE] fall. She was unable to explain why the neurological assessments were not completed by his assigned Nurse (Nurse #1). The record review and interviews that revealed Resident #1 had fallen and hit his head on concrete, but that the physician and RP were notified by Nurse #1 that he hit his head on grass were reviewed with the DON. She was unable to explain why Nurse #1 had not obtained the details of the fall from the witness (Dietary Staff #1). The DON stated that Nurse #1 no longer worked at the facility. An interview was conducted with the DON and Administrator on [DATE] at 10:35 AM. The DON revealed that neurological checks were essential to monitor a resident for deviations from their baseline. She explained that after a fall with head injury there could be things going on internally that were not able to be seen with a visual observation. She further revealed that it was essential to inform the physician of all details known about a fall in order for the physician to be able to make sound treatment decisions for follow up care/monitoring. The DON and Administrator acknowledged that it was also important to inform a resident ' s RP of all known details of a fall as the RP could influence a resident ' s decision on whether or not to seek evaluation at the hospital. The Administrator stated that he felt this incident should not be classified as neglect as Nurse #1 acted with poor judgement and did not willfully intend to provide the physician with an inaccurate accounting of Resident #1 ' s fall and she also had not willfully intended not to complete neurological checks as ordered by the physician. The Administrator explained that it was his understanding that neglect had to be willful and intentional. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 11:12 AM. On [DATE] at 3:39 PM the facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was re-admitted to the facility on [DATE] for long term care services. Resident was evaluated by PT, OT, and ST on [DATE]. Resident was noted by staff to be able to self-propel wheelchair and was able to get outside by himself without assistance. Resident frequently went outside and had not had any prior incidents leading to this event. Resident did not have a history of falls. Residents last fall was on [DATE]. Resident had [DIAGNOSES REDACTED]. On [DATE] at approx. 9:55 AM Resident was witnessed to have fallen backwards in wheelchair outside on sidewalk area off patio witnessed by a dietary worker #1 coming in from the parking lot. Witness observed patient ' s left wheel of his wheelchair came off the sidewalk and when he attempted to get the wheel back onto the sidewalk, he tipped backwards in his wheelchair hitting his head on the sidewalk. Witness ran up to resident to make sure he was ok and ran to get help. Licensed nurse #2 ran out to asses resident and noted a small scrape on the back of his head. Patient was coherent and did not exhibit any change in cognitive behavior and stated he did not hit his head. Patient did not complain of any pain and no other injuries were noted. Resident was assisted back up into wheelchair by the nurse #2 and other staff members. Resident was subsequently taken back to his room for further evaluation for any additional injuries by his primary nurse, nurse #1, along with initiation of neuro checks. No other injuries were noted, and patient remained at his baseline for cognitive behavior and when asked if he would like to go to the hospital to be evaluated stated no. Residents ' Physician was notified by nurse #1 who initially thought that the resident may have hit his head on the grass because she noted grass on the resident. The residents ' representative (RP) was also notified by nurse #1 that resident had fallen outside and hit his head at approximately 10:25 AM. The RP did not ask any further questions. There was no further communication with the RP regarding the fall. Nurse 1 notified the physician at approximately 10:10 AM based on the facts she knew after speaking and assessing the resident at the time and she had not spoken with the dietary aide that was the witness at the time. It was when the Director of nursing started the full investigation immediately after the incident but the facility was not aware that the resident hit his head on the concrete during the initial investigation, and this was determined after the dietary aide was interviewed. The medical director was notified of the results of the investigation and was made aware that the resident hit his head on the concrete. Nurse #1 was not aware that the resident hit his head on the concrete based on her statement. The physician is the attending for this resident and sees this resident almost monthly. The physician recommended to continue to monitor the resident and notify her of any changes which included neuro checks to be done every 15 minutes x4, 30 minutes x2, 60 minutes x4, four hours x6, shift 1 then shift 2. Statements from nurse #1 did not show that the physician asked if he hit his head on the concrete. Resident #1 also stated that he did not want to go to the hospital as well. Resident also stated that he did not hit his head. At approx. 12:48 PM the certified nursing assistant (CNA) went in to retrieve his lunch tray and noticed that the resident was unresponsive. CNA ran to get the nurse. Upon arrival to the residents ' room the attending nurse, the Director of Nursing (DON), and unit manager discovered that the resident had a faint pulse. Resident was a Do Not Resuscitate (DNR) and subsequently passed. Primary Physician and RP were notified. The CNAs had been in the residents ' room at approximately every 30 minutes starting at 10 am until 1245pm and vital signs were obtained during two of these observations with the second set being obtained at 10:30 AM which were the last vitals taken. After 10:30 the CNA was under the impression that the vital signs would be included with the neuro-checks by nurse #1. At no time did any observation conclude with a change in condition of the resident prior to 1245 pm. The Certified nursing assistants observed the resident to be able to answer simple questions and did not note any change in the resident ' s normal everyday status. Nurse #1 stated the neurological checks were completed twice at 10:00 AM and 10:30 AM and of which she failed to completely document. Based on the statement of nurse #1 she did intend to complete and document the neurological checks but became busy with several other residents. The number of times due of neurological checks with vitals not complete by nurse #1 as instructed by the physician and in accordance with the facility protocol included 10:15 AM for the Q (every) 15 minutes check #2, 10:45 AM for the Q 15 minutes check #4, 11:00 AM for the Q 30 minutes check #1, 11:30 AM for the Q 30 minutes check #2, 12:00 PM for the Q 30 minutes #3. Patient remained at his cognitive baseline the entire time according to all non-clinical statements of the NAs working on the floor. There were no clinical assessments by licensed nursing staff after the 10:30 AM neurological assessment completed by Nurse #1. There were no clinical assessments documented by licensed nursing staff after the 10:30 AM neurologica (TRUNCATED)

Based on observation, record review, staff interview, psychiatric nurse practitioner interview, and physician interview the facility failed to prevent a resident (Resident #1) who had multiple incidents of agitated behaviors of hitting residents, threatening residents, pushing residents, kicking a resident, and throwing objects at others from abusing 5 (Residents #3, #4, #5, #6 and #7) of 5 sampled residents reviewed for abuse. Resident #3 sustained a large [MEDICAL CONDITION] when she had a fall while near Resident #1 and Resident # 1 said he hit her. Resident #3 was taken to a hospital for treatment and it required 5 staples to close her [MEDICAL CONDITION]. Resident # 5 sustained a [MEDICAL CONDITION] and hematoma when Resident # 1 threw a toy after he became agitated which hit Resident #5 in the head. Resident #5 was taken to a hospital for treatment and it took 3 staples to close the [MEDICAL CONDITION]. Resident #4 sustained a red eye after being hit in the eye by Resident #1. Resident #6 expressed his hand hurt after his hand was caught in a door that was slammed by Resident #1. Resident #3 sustained a skin tear when she fell after being shoved by Resident #1 and Resident #3 was kicked in the face by Resident #1. Resident #7 was hit in the back by Resident #1. The findings included: Immediate Jeopardy began on 8/2/19 when Resident #3 was found on the floor with a large [MEDICAL CONDITION] and Resident #1 stated he hit Resident #3 because she deserved it. Resident # 3 was in close proximity to Resident #1 at the time of her fall. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Record review revealed Resident # 1 was admitted to the facility on [DATE] to the facility's secured unit. The resident had [DIAGNOSES REDACTED]. Resident # 1's 8/4/19 quarterly Minimum Data Set (MDS) assessment coded the resident as having severe cognitive impairment. The resident's last quarterly MDS assessment, dated 11/4/19, also coded the resident as having severe cognitive impairment. On the 11/4/19 MDS, Resident # 1 was also coded as having physical, verbal, and other behavioral symptoms, rejecting care; and ambulatory. According to the 11/4/19 MDS assessment, the frequency of the behaviors occurred as follows: physical behaviors were displayed for one to three days during the assessment period, verbal behaviors were displayed on four to six days of the assessment period, and other behaviors were displayed on one to three days of the assessment period. Resident # 1's care plan which was initiated on 4/26/19, and most recently updated on 1/24/20, revealed the facility included the following problem which had originated at the time of Resident # 1's admission. The problem remained current. (Resident) has a behavior problem and has a LEVEL II PASARR (The Level II PASARR screening is triggered by evidence of a serious mental illness (MI), Intellectual or Developmental Disabilities (IDD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by state and federal guidelines.). He has inappropriate verbal and physical behaviors, wandering, invading others personal space and disorganized thinking related to dementia. Initial interventions, which were placed on the care plan on 4/26/19 and which remained as an active part of the care plan were as follows: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Praise any indication of the resident's progress/improvement in behavior. The resident's care plan also noted he used [MEDICAL CONDITION] medications for his behaviors. The goal for the resident was that he would have fewer episodes of inappropriate verbal and physical behaviors, wandering, invading others personal space and disorganized thinking by review date. On 8/2/19 Nurse # 2 documented at 4:45 PM in Resident # 1's record, Resident was in close proximity of another resident that fell . This resident stated, 'I hit her and she deserved it.' Resident was noted to be aggressive towards staff and was medicated with PRN (as needed) Klonopin. (Klonopin is a drug used to treat anxiety. According to Resident # 1's physician orders [REDACTED].# 1 was receiving Klonopin on an as needed basis, [MEDICATION NAME], a medication for mood, on a scheduled basis; and [MEDICATION NAME], a medication for Alzheimer's dementia, on a scheduled basis.) During an interview with the Director of Nursing (DON) on 2/5/20 at 8:45 the DON stated the resident who had fallen on 8/2/19 was Resident # 3. Review of Resident # 3's record revealed she had a [DIAGNOSES REDACTED].#3 was assessed as having severe cognitive impairment on her 8/5/19 quarterly MDS and 11/5/19 MDS assessments. She was coded as ambulatory on both of these MDS assessments. According to Resident # 3's nursing notes she was transferred to the hospital on [DATE] at 5:05 PM following the incident due to sustaining a large laceration to the back of her head during her fall. Nurse # 2 noted in Resident # 3's nursing notes, the resident returned to the facility on [DATE] at 10:45 PM with five staples to the back of her head. During the interview with the DON on 2/5/20 at 8:45 AM, the DON reported the following. Resident # 3 had a history of [REDACTED].# 1 had anything to do with Resident # 3's fall. There was no investigation regarding where the two residents were in relation to each other before the incident occurred. Resident # 1 was severely demented and he often took blame for things he did not do. She did not think that just because he said he had hit Resident # 1 meant that he had actually done so. On 2/5/20 at 5:00 PM, it was validated with the DON that she had not spoken to all of the staff members who had been working on the secured unit during the 8/2/19 incident before concluding that Resident # 1 had nothing to do with Resident # 3's fall and injury. Nurse # 2 was interviewed on 2/4/20 at 5:00 PM and again on 2/5/20 at 11:10 AM and reported the following about the 8/2/19 incident. When she last looked at the residents prior to the 8/2/19 incident, Resident # 1 had been seated on the couch. Resident # 3 had been diagonally in front of him about five or six feet away. When she next looked up, Resident # 3 was on the floor and hurt near Resident # 1. When she went to check Resident # 3, Resident # 1 then made the statement he had hit her and she deserved it. Nurse # 2 stated Resident # 1 could be aggressive, and he could go from zero to sixty in a minute; indicating he was without behaviors one minute and within [AGE] seconds could be displaying aggressive behavior. The nurse stated he did threaten other residents, but he was confused. The nurse stated Resident # 1 would not always give signs that he was about to become combative or strike out. At other times, he would start talking about the dead and at times this indicated he was starting to get agitated and threatening to others. A psychiatric Nurse Practitioner (NP), who sees Resident # 1 for care on a monthly basis, was interviewed on 2/5/20 at 3:00 PM. The NP was interviewed regarding Resident # 1's ability to recall his actions. The psychiatric NP stated he did still recall his family, and she felt his short term memory was intact for the immediate moment to the point if he said he did something, she felt he had the ability to recall for the moment he had done so. On 8/25/19 a nurse noted at 6:45 PM in Resident # 1's nursing notes the resident was getting really aggressive threatening to hit others. Staff has moved him away to a different area to diffuse the situation. He puts his fist up threatening to hit, talking about killing. There was no documentation Resident # 1 hurt anyone on 8/25/19. On 9/8/19 Nurse # 5 noted at 6:00 PM in Resident # 1's nursing notes he was threatening to hit another resident. Cursing, talking loudly and waving his arms about. Saying he will take them out. Threatened writer, when writer intervened. Resident taken to room and is lying down now. The nurse noted she would continue to monitor his behavior. There was no documentation Resident # 1 harmed anyone on 9/8/19. On 9/17/19 Nurse # 1 documented in Resident # 1's nursing notes (with no time entry), Resident observed resting on couch when this nurse heard a resident yell out in pain observed resident with his hand balled up into a fist. While separating resident's resident states 'I will hit you again' with his fist balled up. Refused vital signs. According to the note the physician and family were notified. Nurse # 1 was interviewed on 2/5/20 at 10:15 AM and reported the following. On the date of 9/17/19 Resident # 1 was seated on the couch as Resident # 4 went by him. She (the nurse) heard Resident # 4 yell out. She had not seen Resident # 1 actually hit the resident but saw him have his fist balled up and say he had done so. She saw Resident # 4's eye was red. A review of Resident # 4's record revealed she had a [DIAGNOSES REDACTED].# 4 had severe cognitive impairment. A nursing note in Resident # 4's record regarding the incident read, Resident noted to be propelling around unit. This nurse heard resident yell out in pain. Observed Resident moving her hand towards her right eye sitting in front of couch where another resident was resting on. Residents separated and this resident assessed. Area surrounding rt (right) eye red, non-tender to touch. When asked what happened Resident states, 'He hit me' and points to her right eye. During an interview with the DON on 2/5/20 at 8:45 AM, the DON stated the incident had occurred at 12:10 PM according to the incident report. She stated Resident # 4 propelled herself in a wheelchair and stopped in front of the couch where Resident # 1 was seated. Resident # 4's eye was reddened when Resident # 1 hit Resident # 4 in the eye. The residents were immediately separated. On 9/17/19 at 9:00 PM Nurse # 2 noted in Resident # 1's nursing notes he had been up most of the shift and at 6:00 PM had been agitated, yelling and threatening other residents. He was medicated with Klonopin per a PRN order to do so and had no further behaviors after the PRN medication. There was no documentation anyone was hurt on 9/17/19. On 9/26/19 at 2:11 PM Nurse # 3 documented in Resident # 1's nursing notes, Resident was sitting on the sofa in the common area near the dining room. He was fussing at a female resident as well as kicking at her. This caused other resident to stumble and fall. He then stated, 'That's why I kicked her.' Residents were separated and redirected. Nurse # 3 further noted the resident's physician was notified. Nurse # 3 was interviewed on 2/5/20 at 11:28 AM and reported the following. The resident who fell on [DATE] was Resident # 3. Prior to the fall, Resident # 1 had already been agitated that morning. He was on the couch at the time of the incident and Resident # 3 went up to him and tried to talk to him. He started to kick at her upper legs in a manner to signify go away. She was facing him as he was kicking at her. As he kicked, she turned, stumbled and fell . Nurse # 3 stated she could not tell if the actual kick made Resident # 3 fall or if in turning to get away from him she fell . Resident # 3 was not hurt. A review of Resident # 3's nursing notes for 9/26/19 and 9/27/19 revealed no injuries had been sustained from the incident and fall. According to Resident # 1's care plan, an update was made noting the incident. Under interventions, a notation was made for the 9/26/19 incident which read, Residents were separated by staff. Activities provided to divert residents attention. During an interview with the DON on 2/5/20 at 8:45 AM, the DON stated the residents were separated on 9/26/19 and provided activities on that day as an intervention. On 9/26/19 at 5:15 PM Nurse # 2 documented in Resident # 1's nursing notes, agitated, yelling at other residents making verbal threats. Nurse # 2 noted he could not be redirected and therefore was medicated with PRN Klonopin with some effect. There was no documentation a resident was harmed at that time. On 9/27/19 at 10:20 PM Nurse # 2 documented in Resident # 1's nursing notes, heard a banging noise coming from resident's room then the door opened, and resident came out cursing and yelling at roommate. He then slammed the door catching roommates hand. He then stated, 'I hit him.' Staff separated the residents. Nurse # 2 further documented the physician was called and Resident # 1's [MEDICATION NAME] was increased to 250 mg twice per day. (His prior dosage had been 125 mg twice per day.) Nurse # 2 was interviewed on 2/5/20 at 11:10 AM and reported the following about the 9/27/19 incident. She (Nurse # 2) had been standing at the nursing desk facing Resident # 1's room when the door was opened. Resident # 1 stood inside the doorway facing out towards her and the desk. Resident # 6 (the resident's roommate) was outside the doorway facing towards their room and therefore had his back towards the nurse. She saw Resident # 1 slam the door and then Resident # 6 held his hand as if it was hurt. Although Resident # 1 said he hit Resident # 6, she had not witnessed this and saw no evidence of an injury from a hit. Resident # 1's care plan was updated to reflect the physician reviewed Resident # 1's medication and his medication ([MEDICATION NAME]) was increased on 9/27/19. During an interview with the DON on 2/5/20 at 8:45 AM, the DON stated Resident # 6's hand had been x-rayed by a mobile company after the 9/27/19 incident and Resident # 6 had no broken bones from the incident. She did not feel Resident # 1 deliberately slammed the door on Resident # 6's hand. According to physician orders, Resident # 1 was begun on [MEDICATION NAME] 25 mg twice per day on 10/4/19. On 10/10/19 Nurse # 2 documented in Resident # 1's nursing notes for the 3-11 shift, Became agitated with a female resident when she tried to pass by him. He threw a cup of water on her when she tried to pass by him and called her derogatory names including racial slurs. There was no documentation the resident was physically hurt. On 10/14/19 at 11:50 AM Nurse # 1 documented in Resident # 1's nursing notes, Resident threatening to hit other resident (2). Punching the walls. Knocking over side table. Cursing and telling people he's going to kill them dead. Nurse # 2 noted the physician was called and an order for [REDACTED]. On 10/28/19 Nurse # 1 documented at 10:00 AM in Resident # 1's nursing notes he was quietly cursing at residents as they walked by from time to time. He would stand up and walk towards staff and threaten to hit someone in the head and kill the dead. The nurse noted she was able to distract Resident # 1 with a magazine. On 10/28/19 at 11:30 AM Nurse # 1 documented Resident # 1 was threatening other residents and his cursing at staff was increasing. He had attempted to hit another resident on the couch who was asleep and he had thrown the side table around. The nurse noted she tried to medicate Resident # 1 with PRN Klonopin and he spit it out. A call was placed to the physician. At 12:25 PM on 10/28/19 Nurse # 1 noted the behaviors were still present and no return call had been received. At 12:33 PM on 10/28/19, Nurse # 1 noted an order was obtained from the medical director to administer an IM dose of [MEDICATION NAME] 5 mg. The medication was given at 12:35 PM with great difficulty as Resident # 1 hit and kicked staff. There was no documentation a resident was harmed on this date. Nurse # 1 was interviewed on 2/5/20 at 10:15 AM and recalled the table that Resident # 1 had thrown was a bedside table. She did not recall specific residents he had threatened in particular or used racial slurs towards. According to the nurse he threatened different residents, and the resident who had been asleep on the couch had not been bothering him. According to Nurse # 1 he was not targeting any particular resident. He just became upset with others and at times there was no apparent reason or trigger. On [DATE] at 5:30 AM a night shift nurse documented in Resident # 1's nursing notes he had been up most of the night and that he was nice one minute and not nice the next. On 11/5/19 at 6:00 AM Nurse # 4 documented in Resident # 1's nursing notes, Resident is very agitated, pacing, cursing, threatening staff and other residents. Nurse # 5 documented she administered the resident's PRN Klonopin with little effect. There was no documentation a resident was hurt on this date. On [DATE] at 7:10 AM Nurse # 1 documented in Resident # 1's nursing notes, Resident came out of his room and rolled a wheelchair into a seated resident at a table. Nurse # 1 noted the social worker was on the unit and helped distract the resident. The nurse noted she tried to administer Resident # 1's PRN Klonopin but he refused to take it. On [DATE] at 7:25 AM, Nurse # 1 documented Resident pushing resident in wheelchair cursing and trying to push him into the table. Refusing to let wheelchair handles go. Able to distract resident with needing him to look at work order. Resident still cursing, calling people names, and threatening to kill people. Nurse # 1 noted on [DATE] at 7:35 AM that she was able to administer the PRN Klonopin to the resident. The nurse noted on [DATE] at 7:41 AM that the physician would be in to see Resident # 1. Nurse # 1 was interviewed on 2/5/20 at 10:15 AM and reported the following. She did not recall who the resident was that was seated at the table. The staff kept a wheelchair available in the common area for emergency purposes. On [DATE] Resident # 1 had taken the empty wheelchair and rolled it into the back of a resident's chair as he was seated at a table, thereby pushing the resident into the table. On 11/12/19 at 12:00 PM Nurse # 1 documented in Resident # 1's nursing notes he was cursing threatening to hit staff and residents. Unable to distract resident with food, music and fixing a table. The resident was given PRN Klonopin. There was no indication anyone was hurt. On 11/12/19 at 9:15 PM Nurse # 2 noted in Resident # 1's nursing noted he had been combative and threatening others earlier in the shift and was medicated with Klonopin. There was no documentation he harmed anyone. On 11/14/19 at 8:30 PM Nurse # 2 documented in Resident # 1's nursing notes, agitated, yelling, threatening other residents and trying to hit staff. He was medicated with PRN Klonopin. There was no documentation he harmed anyone. On 12/5/19 at 3:15 PM, Nurse # 2 documented in Resident # 1's nursing notes he was agitated and making verbal threats 'I'm going to kill you' to other residents. Nurse # 2 documented Resident # 1 was given PRN Klonopin and it had some effect. There was no documentation anyone was harmed on this date. On [DATE] at 1:30 AM Nurse # 4 documented in Resident # 1's chart, Resident awake and came out of room very agitated; cursing and threatening 'to kill' and hit staff and residents awake in common area. Redirection unsuccessful, all attempts to calm resident unsuccessful. The nurse noted she medicated Resident # 1 with PRN Klonopin and it was seem-effective. There was no documentation he harmed anyone at that time. On [DATE] at 4 PM Nurse # 1 documented that at 2:40 PM Resident pushed another resident that was trying to sit down next to him on the couch. Then Resident punched a resident in the back (middle) when resident had stopped propelling to talk to another resident. Nurse # 1 noted she medicated Resident # 1 with PRN Klonopin. Nurse # 1 was interviewed on 2/5/20 at 10:15 AM and reported the following about the incident of [DATE]. Resident # 1 had been on the couch and Resident # 3 had walked up to the couch to sit down beside of him. Resident # 1 hit Resident # 3 in the back causing her to fall forward. She would have fallen forward but Resident # 7 was in a wheelchair in front of them and caught Resident # 3 as she fell . As Resident # 7 leaned forward to catch Resident # 3, then Resident # 1 also hit Resident # 7 in the back. Resident # 7 was not hurt. Resident # 3 had a red imprint from the hit to her back which was blanchable and disappeared in a short time. She did not bruise. On 12/11/19 at 5:40 PM Nurse # 2 documented in Resident # 1's nursing notes he was agitated, cursing, and verbally threatening other residents. The nurse noted Resident # 1 continues to state he is going to kill them. The resident was medicated with PRN Klonopin. There was no documentation anyone was harmed on this date. On 12/13/19 at 10:30 AM Nurse # 1 documented in Resident # 1's nursing notes he was agitated, cursing and yelling with staff and other resident. Threatening and following with objects in hand behind staff and other resident. Unsuccessful with distractions of offering food and redirection. Nurse # 1 documented she administered PRN Klonopin and Resident # 1 stopped threatening and following others. Nurse # 1 was interviewed on 2/5/20 at 10:15 AM and reported she remembered just that one day that he followed residents around with objects and would shake the objects, but he did not harm anyone that day. The objects were metal utensils and plastic plates and cups. The nurse did not recall any specific resident that Resident # 1 was following or targeting but followed different ones around on 12/13/19 with the objects. On 12/13/19 at 10:00 PM Nurse # 1 documented in Resident # 1's nursing notes he was cursing, yelling and saying derogatory and racial slurs to another resident. He attempted to hit the resident. There was no documentation the other resident was hit or harmed. On 1[DATE] at 6:05 PM Nurse # 2 documented in Resident # 1's nursing notes, This writer heard a bang and came out of another resident's room. O.T. (Occupational Therapist) reported that the resident had shoved another resident knocking her to the floor. The nurse noted the physician was notified. During an interview with the DON on 2/5/20 at 8:45 AM, the DON stated the resident who had been knocked to the floor was Resident # 3 and she had sustained a skin tear. The O.T., who had witnessed the incident, was interviewed on 2/5/20 at 2:00 PM and reported the following. She (the O.T.) had been in the common area and there were other staff members at other tables helping other residents. Resident # 1 was at a table in the common area by himself. He had his elbow propped on the table and his face in his hand as if he was about to fall asleep. He was not agitated in anyway. Resident # 3 routinely walked around the common area. As Resident # 3 came up beside Resident # 1 from the rear of where Resident # 1 was sitting, Resident # 1 swung his arm outward and backward; thereby backhanding Resident # 3. The OT pointed to a wall partition in the middle of the secured unit's common area during the interview. The partition was about four feet from where the OT stated Resident # 1 had been sitting. The O.T said she heard a thunk as Resident # 3 hit the partition and landed on the floor from the hit. The O. T. said Resident # 3 never knew Resident # 1 was in the world before the hit. She was just walking in her normal manner by him and he in turn had showed no signs of agitation. The swing was sudden and unanticipated by any staff in the area. Resident # 1 had not been looking at Resident # 3 before he hit her. Part of the interview with the O. T. was held on the unit. At the end of the interview, Resident # 3 was observed to be walking independently around the unit. She came up to the O. T., hugged the O. T. and touched her clothing. She appeared very confused and affectionately wanted to be close and touch the O. T. Twelve hours and forty minutes after the 1[DATE] incident, Nurse # 4 documented on [DATE] at 6:45 AM in Resident # 1's nursing notes, Resident told fell ow resident (Resident # 3) he was going to 'knock her on her ass again.' CNAs (certified nursing assistants) aware to watch for resident behavior. Will continue to monitor. Nurse # 4 was interviewed on 2/5/20 at 10:53 AM and reported the following. She did not know if Resident # 1 recalled hitting Resident # 3 on the previous shift when he threatened her on the morning of [DATE]. Nurse # 4 stated she just documented what Resident # 1 said. Nurse # 4 was interviewed regarding the resident's behaviors in general. Nurse # 4 reported that during the night shift, most residents were asleep and therefore it was easier to supervise him regarding other residents, but he was very combative with care. Nurse # 4 reported Resident # 1 could be fine and then before you can blink he changes and starts swinging. According to the resident's care plan, on 1[DATE] one on one staff was placed with the resident after the 1[DATE] incident. On [DATE] Klonopin was added to Resident # 1's regularly scheduled medications in the dosage of .25 mg every six hours. Also, a PRN order was given for a topical [MEDICAL CONDITION] medication to be added to the medication regimen; ABH gel every twelve hours as needed. (It is a combination medication of [MEDICATION NAME], and [MEDICATION NAME]). Interview with the DON on 2/5/20 at 3:30 PM revealed a one on one staff member was placed with Resident # 1 for three days after the 1[DATE] incident in which he backhanded Resident # 3. After three days Resident # 1 was cleared by his physician before the staff member was removed. The topical ABH gel was a totally new medication for the resident also. It had to be compounded in the pharmacy, and it could be applied to the resident's skin when he was agitated. On 12/26/19 at 2:30 PM Nurse # 1 documented in Resident # 1's nursing notes, Resident sitting on the couch kicked another resident in the face when other resident bent over to pick up something on the floor. According to the nursing note, the physician was contacted and increased Resident # 1's Klonopin dosage. (According to orders, it was increased from .25 mg to .5 mg every six hours.) According to Resident # 3's nursing notes, she was the resident kicked in the face on 12/26/19. The resident was not documented as injured. On 1/24/20 at 7:34 PM a nursing note read in Resident # 1's record, Resident was noted to be chewing on a large object thought to be paper. NA (nurse aide) attempted to look in resident's mouth and resident became angry and started yelling and grabbed a wooden and metal toy to throw at NA, but the toy went the other way and struck another resident in the back of the head. Resident continues to yell and swing at anyone nearby. Review of Resident # 5's nursing notes revealed she was the resident who was hit in the head on 1/24/20. According to her nursing notes, she was sent to the hospital because the toy caused a hematoma and laceration to her head. She returned to the facility on [DATE] at 12:30 AM with three staples to her head due to the [MEDICAL CONDITION]. Review of Resident # 1's care plan revealed it was updated on 1/24/20 to reflect Resident # 1 had been redirected, given ice cream, and medicated with PRN medication for behaviors following the incident. Residents were removed from the area. Staff were educated to step away from the resident when he becomes belligerent and give him time to de-escalate. Staff were educated to refrain from physically trying to remove objects from resident if he is not in harms way or causing harm to others. NA # 1 was interviewed on 2/4/20 at 4:20 PM and reported the following. She had been concerned about Resident # 1 on 1/24/20 because he had put a wad of paper napkin/towel in his mouth. The wad was such that if he had swallowed it, he would have probably choked. At times the resident would trade food and give up to staff what he had in his mouth, but that did not work that night. Therefore, NA # 2 held his hands and she (NA #1) removed the wad of paper so he would not choke. He got mad after that, walked away, picked up the toy and threw it hitting Resident # 5 in the head. NA # 1 reported there had been other times she had witnessed Resident # 1 sitting quietly and then for no reason he would start cursing and become agitated. It did not always take a specific reason for him to have behaviors. NA # 2 was interviewed on 2/4/20 at 4:40 PM and reported the following regarding the 1/24/20 incident. Following the removal of the wad of paper from Resident # 1's mouth, he became angry. He picked up the toy and slung it. The NA said she thought Resident # 1 was intending to hit her with it, but it hit Resident # 5 instead. NA #2 reported she had witnessed Resident # 1 throw objects before the incident such as plastic cups, glasses and a plate. She said he talked about killing people. She said the staff were trained to try to get other residents away from him when he became agitated. Nurse # 2 had been the nurse on duty at the time of the 1/24/20 incident. Nurse # 2 was interviewed on 2/4/20 at 5:00 PM and reported the following. She had been coming out of another room to the nursing desk when she saw Resident # 1 throw the toy and hit Resident # 5 in the head. Nurse # 2 showed the toy that had been thrown. The toy was observed to be a roller coaster toy which had a wooden base approximately 12 inches in length and 5-8 inches in width. From the base, there were wires attached in a roller coaster pattern of curves, and pegs could be maneuvered along the wires. According to Nurse # 2 when the resident threw the toy, he threw the whole toy. NA # 3 was interviewed on 2/5/20 at 8:20 AM and reported the following. She usually worked on the secured unit. She had witnessed Resident # 1 throw objects such as metal utensils and plastic cups before. Sometimes there were no clear reasons why he became agitated and it could happen suddenly. They tried to monitor him the best they can. NA # 4 was interviewed on 2/5/20 at 9:55 AM and reported Resident # 3 swings at everybody. She did not think he targeted any one person. Within the past 2 months she had witnessed Resident # 1 throw the roller coaster toy twice before he threw it on 1/24/20. The first two times he threw it, it did not hit anyone. She had witnessed that when Resident # 1 got agitated, he would just grab whatever he saw and had thrown plastic things as well. The staff tried to let him walk until he calmed down. Walking sometimes helped him calm down and other times it didn't. During an interview with the DON on 2/5/20 at 8:45 AM and a follow up interview on 2/5/20 at 3:30 PM, the DON reported the following. On the incident of 1/24/20, Resident # 1 had not been aiming at a resident when he threw the toy and the toy ricocheted off a partition before it hit Resident # 5. The DON was not aware Resident # 1 had thrown the roller coaster toy before the incident of 1/24/20. She reported another cognitively impaired resident spent a great deal of time with the roller coaster toy and it helped to engage this other resident. The facility had tried multiple medication adjustments with Resident # 1. Having worked with Resident # 1 she did not think his actions were targeted towards any resident. They had educated their staff to remove other residents from the area when he became agitated so they would be out of harm's way. Resident # 1's medical

Based on observation, record review, and staff interview, the facility neglected to provide effective monitoring of a cognitively impaired resident with known exit seeking behaviors to prevent an elopement from the facility for 1 (Resident #99) of 3 residents reviewed for accidents. On 4/12/17 Resident #99, unsupervised by staff, exited the facility through the front door by wheelchair and traveled approximately 228 feet (76 yards) across the parking lot within 2 feet of a well-traveled roadway. Resident #99 was located by staff with no injuries after an undetermined amount of time outside of the facility. Immediate Jeopardy began on 4/12/17 when Resident #99 exited the facility unsupervised and was found outside by facility staff after an undetermined amount of time. The Immediate Jeopardy was lifted on 6/2/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: Resident #99 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #99's cognition was significantly impaired. He had physical behaviors, other behavioral symptoms, and wandering behaviors 1 to 3 days during the review period. Resident #99 was assessed as dependent on 1 staff for assistance with bed mobility and the extensive assistance of 1 staff for transfers. Resident #99 required supervision/set up help only for locomotion on and off the unit. Resident #99 utilized a wheelchair. The comprehensive plan of care for Resident #99, most recently reviewed on 3/15/17, had not addressed the problem of exit seeking behavior. A review of Resident #99's Nursing Assistant (NA) Kardex, undated, had not indicated he had exit seeking behavior. A nursing note dated 4/12/17 at 8:00 PM written by Nurse #3 indicated Resident #99 was found in the parking lot by the road in his wheelchair. Resident #99 was brought back into the building by staff and placed in the secured unit for the night. Resident #99's Responsible Party (RP), his physician, the Director of Nursing (DON) and the Administrator were notified. An Accident/Incident Report dated 4/12/17 at 8:00 PM written by Nurse #3 indicated an elopement for Resident #99. Resident #99 was noted to have been found in the parking lot of the facility. Resident #99 was assessed as memory impaired, decision making impaired, physically impaired, and hearing impaired. He was noted to be confused and disoriented. Resident #99 was seen outside of the facility in the parking lot by the road. The recommended steps to prevent reoccurrence indicated Resident #99 was moved to the secured unit for the night. A review of the facility's wandering book, a book that contained a color photo of all residents who had wandering behaviors, was conducted on 5/31/17 at 9:30 AM. The wandering book included a photo of Resident #99 dated March 2017. An interview was conducted with Nurse #1 on 5/31/17 at 9:55 AM. She reported she was unaware of any residents who were high risk for elopement. An interview was conducted with the Administrator on 5/31/17 at 10:15 AM. The incident report dated 4/12/17 that indicated Resident #99 eloped from the facility and was found in the parking lot was reviewed with the Administrator. She revealed she had not known how Resident #99 was able to exit the facility unsupervised by staff. The Administrator stated the previous Director of Nursing (DON) completed the investigation into this incident, but she was unable to locate any of the documentation from the investigation. She indicated the previous DON was no longer working at the facility. The Administrator reported she was responsible for maintaining the documentation related to all investigations of incidents. An interview was conducted with Assistant Director of Nursing (ADON) on 5/31/17 at 1:24 PM. She stated Resident #99 was alert and oriented to self, he was able to self-propel in his wheelchair, and he wandered daily. She reported she was working at the time of Resident #99's elopement on 4/12/17. She stated she was in the conference room with several other Administrative staff at the time of the elopement. The ADON reported that several staff were seen coming down the hallway of the facility toward the front door and one of them stated that Resident #99 had gone out the front door. She stated that she was unsure of all of the staff members who were present, but she was aware NA #1 brought Resident #99 back into the facility. The ADON indicated the former Dietary Manager (DM) had initially found Resident #99 in the parking lot when she was leaving work. She called into the facility by mobile phone to alert staff. She reported Resident #99 was initially found outside around 8:00 PM. The ADON revealed it was unknown how long Resident #99 was outside. She additionally revealed she had not known how Resident #99 was able to exit the facility unsupervised by staff. This interview with the ADON continued on 5/31/17 at 1:30 PM. She reported Resident #99's RP and physician were notified by phone of the incident. Resident #99 was placed in the secured unit for the night and a meeting was scheduled for the following day with his RP. The ADON indicated the facility had wanted to move Resident #99 to the locked unit permanently as he met the criteria: Alzheimer's/dementia, able to propel self/ambulate, and an elopement risk. She revealed she had felt Resident #99 required placement in the secured unit since she began working at the facility (September 2016), but she indicated his RP had refused placement in the secured unit. The ADON additionally revealed she felt Resident #99's safety was not able to be guaranteed on the unsecured unit as he was at high risk for elopement. She stated that without Resident #99 being moved to the secured unit, the staff had done their best to observe and monitor Resident #99's whereabouts to ensure his safety. She explained the staff observed and monitored Resident #99's whereabouts throughout their shift (no specific timeframe for the monitoring) and if he was noted wandering toward the lobby area he was redirected toward the nurse's station so he was more easily observed. She indicated there was normally at least one staff member near the nurse's station which allowed Resident #99 to be observed more frequently. She stated there were occasions when staff members were occupied with other residents and there was no staff present at the nurse's station to monitor Resident #99. The ADON revealed it was this monitoring and observation that was in place at the time of Resident #99's elopement and she noted it had not been effective. A phone interview was conducted with the former DM on 5/31/17 at 2:00 PM. She stated she found Resident #99 outside of the facility on 4/12/17 sometime during the second shift (3:00 PM to 11:00 PM). She reported she was in her car leaving work for the day and as she drove up toward the exit of the parking lot she saw Resident #99 in his wheelchair approximately one to two feet from the roadway. She indicated she quickly got out of her car and moved Resident #99 away from the roadway as he was at risk of being hit by a car. The former DM reported Resident #99 was confused. She stated she called into the facility by mobile phone to alert staff that Resident #99 was found outside. She indicated several staff members came out of the facility to check on Resident #99. She stated that she was unsure of all of the staff members that were present, but she recalled NA #1 brought Resident #99 back into the facility. A review of the NA schedule indicated NA #1 or NA #2 was assigned to Resident #2 on 4/12/17. An interview was conducted with NA #1 on 5/31/17 at 3:22 PM. He stated he was familiar with Resident #99. He indicated Resident #99 was pleasantly confused, he was able to self-propel his wheelchair, and he wandered all the time all throughout the facility. NA #1 reported sometimes Resident #99 self-propelled into the lobby area of the facility. He indicated when that occurred, the staff had to redirect Resident #99 toward the nurse's station so he was more easily observed. He reported he tried to monitor Resident #99's whereabouts throughout his shift to make sure he had not wandered toward the lobby area, but he revealed there were occasions when he was working with another resident and he was unable to monitor Resident #99. NA #2 stated he was working on Resident #99's hall (200 hall) on 4/12/17 at the time of the elopement, but he did not think he was assigned to him. He indicated the former DM had phoned the facility from the parking lot to alert staff Resident #99 was found in the parking lot. NA #1 reported that he and several other staff members (he was unable to recall the other staff present) ran out of the building to attend to Resident #99. He stated when he got outside the former DM had moved Resident #99 toward the middle of the parking lot and he assisted her by transporting Resident #99 the remainder of the way inside of the building. He reported that Resident #99 was disoriented as evidenced by him singing and appearing unaware that he should not have been outside of the building unsupervised. Resident #99 was not injured. NA #1 indicated it was dangerous for Resident #99 to be outside on his own. He added that the roadway was well traveled and the speed limit was 45 miles per hour. NA #1 revealed he was unable to say for sure how long Resident #99 was outside of the building. He stated he was unable to recall what NA was assigned to Resident #99 on 4/12/17 at the time of the elopement. The interview with NA #1 continued on 5/31/17 at 3:30 PM. NA #1 revealed he had not known how Resident #99 had exited the building without being noticed by staff. He indicated that following the elopement the staff continued the same method of monitoring which included observing Resident #99's whereabouts throughout their shifts (no timeframe for the monitoring) and if he was noted traveling toward the lobby area of the facility he was redirected toward the nurse's station so he was more easily observed. An interview was conducted with NA #2 on 5/31/17 at 3:52 PM. She stated she was familiar with Resident #99. She indicated Resident #99 was alert and confused, he was able to self-propel his wheelchair, and he wandered all the time all throughout the halls of the facility, into other resident's rooms, and into the lobby area. NA #2 reported the staff observed Resident #99 throughout their shifts (no specified timeframe for the observations) and if he was noted to wander toward the lobby area he was redirected toward the nurse's station so he was more easily observed. She stated she had done her best to observe Resident #99's whereabouts, but revealed she was not able to watch him at all times as there were instances when she was assisting other residents. NA #2 stated she was working on Resident #9 s hall (200 hall) on 4/12/17 when Resident #99 had eloped. She indicated she may have been assigned to Resident #99, but she was unable to recall for certain. She reported that she was in another resident's room when one staff member (she was unable to recall the staff member) came into the room and said Resident #99 was outside. NA #2 indicated she and several other staff ran out to the parking lot as Resident #99 was not supposed to be outside unsupervised. She stated that she and NA #1 spoke with Resident #99 when he was brought back inside and he was very confused. Resident #99 was not injured. NA #2 revealed she was unable to say for sure how long Resident #99 was outside of the building. She stated she had last observed Resident #99 at the nurse's station, but she was unable to estimate the time of when she last saw him prior to time of the elopement. The interview with NA #2 continued on 5/31/17 at 4:00 PM. NA #2 revealed she had not known how Resident #99 had exited the building without being noticed by staff. She indicated that following the elopement the staff continued the same method of monitoring which included observing Resident #99's whereabouts throughout their shifts (no timeframe for the monitoring) and if he was noted traveling toward the lobby area of the facility he was brought back to the nurse's station so he was more easily observed. An interview was conducted with the Nurse Unit Manager (UM) on 5/31/17 at 4:29 PM. She indicated Resident #99 was alert with confusion, he was able to self-propel his wheelchair, and he wandered daily throughout the halls, into other resident's rooms, and sometimes he wandered toward the lobby area. She reported that she was the Nurse UM on 4/12/17 at the time of Resident #99's elopement, but that she had not been involved in any of the events during or after the elopement. An interview was conducted with Nurse #3 on 5/31/17 at 4:35 PM. She stated she was familiar with Resident #99. She indicated he was very confused, he was able to self-propel his wheelchair, and he wandered daily. She stated the wandering was up and down the hall ways and occasionally she saw him wandering up toward the lobby area and she had to go get Resident #99 and return him to the area around the nurse's station so he was able to be observed easily. Nurse #3 indicated she was assigned to Resident #99 on 4/12/17 at the time of his elopement. She reported that she had heard a staff member (she was unable to recall the staff member) say Resident #99 was outside. She indicated she had not observed Resident #99 when he was outside. Nurse #3 stated she was unable to recall where or when she had last seen Resident #99 prior to the elopement. She revealed she had not known how Resident #99 had exited the building without being noticed by staff. She indicated it was a safety risk for Resident #99 to have been outside alone. She reported she had completed the nursing note and the incident report related to the 4/12/17 elopement. Resident #99 was not injured. A second interview was conducted with the ADON on 5/31/17 at 5:35 PM. The NA schedule for 4/12/17 at the time of the elopement that indicated NA #1 or NA #2 was assigned to Resident #99 was reviewed with the ADON. The interviews with NA #1 and NA #2 that indicated they had not recalled who was assigned to Resident #99 on 4/12/17 was reviewed with the ADON. She stated that there was no record of who was actually assigned, but she confirmed it was either NA #1 or NA #2. Resident #99 was observed on 5/31/17 at 6:18 PM in his wheelchair near the nurse's station. He was alert with confusion. An interview was unable to be completed as Resident #99 was unable to respond intelligibly to questions. An interview was conducted with the Administrator on 5/31/17 at 6:46 PM. The 4/12/17 elopement incident for Resident #99 was reviewed with the Administrator. She confirmed the statements made by staff members related to the 4/12/17 elopement of Resident #99. The Administrator revealed the monitoring that was in place for Resident #99's wandering and exit seeking behaviors had not been effective as evidenced by his elopement on 4/12/17. An observation of the building on 6/1/17 at 10:00 AM revealed the front entrance doors had to be pushed open. The roadway was approximately 230 feet from the front entrance door. The speed limit on this road was 45 miles per hour. The temperature on 4/12/17 at 8:00 PM was 69 degrees (wunderground.com). An interview was conducted with the Assistant Director of Maintenance on 6/1/17 at 2:56 PM. She indicated she measured the distance from the front door of the facility to the roadway as 230 feet. The Administrator, ADON, Corporate Nurse Consultant, Corporate Administrator Consultant, and Corporate MDS Consultant were notified of Immediate Jeopardy on 6/1/17 at 9:41 AM. On 6/2/17 at 5:30 PM the facility provided the following credible allegation of compliance: This allegation of compliance constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Allegation of Compliance (AoC) is not an admission that a deficiency exists or that one was cited correctly. This AoC is submitted to meet requirements established by state and federal law. On 4/12/17, resident #99 was noted in parking lot at 7:50 pm by the Dietary Manager as she was leaving. Resident was sitting at the beginning of the drive way. He was just looking around. The Dietary Manager called into the facility by mobile phone. She parked her car and approached resident. Eight staff members responded to the call and they assisted resident back into the building. Resident #99 did not resist. Facility nursing staff met them and returned him to the nursing unit. Upon re-entry into the building, Nurse #3 completed an assessment of the resident and he was placed on the secured unit. Nurse #3, assessed him and determined he had no injuries or adverse effects related to being outside. Resident exited front entrance door and the amount of time outside was unable to be determined. An Incident Report was completed on 4/12/17 by Nurse #3. Resident's Responsible Party (RP) was notified by phone at 8:15pm by the previous Director of Nursing (DON). His physician was notified by phone on 4/12/17 at 8:30pm by Nurse #3. The Administrator was in the facility at the time of occurrence and was notified immediately by the Assistant Director of Nursing (ADON). The ADON completed a Wandering Assessment on 4/12/17. The assessment indicated resident is a Definite Risk for elopement. The Administrator, DON and ADON made the decision that resident should be moved to the secured unit. The Administrator completed the initial 24 hour report for the state and faxed it in on 4/12/17 at 9:18pm. The Administrator met with Resident #99's RP on 4/13/17 at 2:00pm to discuss interventions. Resident #99's RP agreed for resident to be placed in secured unit at night and remain in unsecured nursing unit during the day. Resident #99's RP refused for him to be in the secured unit at all times as recommended by the Administrator. Resident #99's RP was upset that resident was continuing to stay on the secured unit at night. She felt resident was being confused by the movement between the front and the back of the building. During the daytime hours, resident's whereabouts was monitored by staff. Resident #99's RP, the Administrator and attending physician met on 4/26/17 to discuss his case. His physician and Resident #99's RP felt resident's behavior should be managed by medication since she was so adamant that she did not want him in the secured unit. Resident #99's RP and physician agreed to let him stay on the secured unit for two weeks to give the medication time to work. [MEDICATION NAME] 0.25 milligrams was ordered at 6 pm on 4/26/17 for signs and symptoms of sun downing. Due to nursing observation of resident becoming more anxious, roaming in and out of residents' rooms and restlessness from 2pm to 6pm in the afternoons, the physician increased the [MEDICATION NAME] on 5/24/17 to 0.5 mg and the administration time to 4 pm to manage his sun downing symptoms. The resident's anxiety and restlessness was improved with the increase in the [MEDICATION NAME]. 1. A physician's orders [REDACTED].#99 to the secured dementia unit. He was moved to the unit on 6/1/2017. 2. New wandering assessments were completed on all residents on 6/1/17 to identify all residents at risk of elopement. The Assistant Director of Nursing (ADON) and licensed nurses completed the assessments. Three residents residing in the unsecured part of the facility were identified. Alarms were installed on 4 exit doors that did not have alarms. The CNA's and Nurses were educated on the three newly identified residents at risk for elopement on 6/2/17 before 1:00pm. The Kardex was updated for those residents to show potential for elopement on 6/2/17 before 1:00pm. On 6/2/17, before 1:00pm, care plans for potential for elopement were developed for all identified resident's, including those in the secured unit. The elopement book was updated on 6/2/17 before 1:00pm by the Medical Records Clerk. 3. The wandering/elopement notebook will be reviewed/updated with all residents identified at risk for elopement as the assessments are completed. A picture will be placed with each resident's profile. This was done by the Medical Records Clerk and on 6/2/17 by 1:00 pm. The wandering/elopement notebook will be kept at the nurse's station. 4. Door alarms will be installed on the four exit doors that currently do not have alarms. The four doors are the exit door in the dining room, inside door to the service hall, the activity room and the front entrance door. The alarms were installed on 6/1/17 by the Administrator. These alarms will sound when the door is opened. The staff, to include weekend, prn and part time licensed and unlicensed, was educated by 6/2/17 at 1:00pm on alarms being placed on all exit doors, how to respond when an alarm is heard, including verifying who is opening the door and if no one is seen, then making sure to assess the outside area for a resident. 5. Care plans for resident's identified at risk will be reviewed and updated if indicated by the Nurse Assessment Coordinator (NAC) on 6/2/17 by 1:00pm. 6. The wandering and elopement policy was revised on 6/1/17 by the Corporate Clinical Nurse Consultant. Revisions to the policy included: assessment of residents at risk of elopement, reporting practices, correctible risk factors, care planning, documentation of unsafe actions of residents, reporting responsibilities, nursing service duties, what to do upon return of a resident who was observed leaving the facility, and discovery of a missing resident. Staff, to include weekend, prn and part time licensed and unlicensed, will be in-serviced on the facility's wandering and elopement policy by 6/2/17 at 1:00 pm. Education will address the following: The prevention of and response to a resident elopement as well as what should be done when a resident is newly identified as an elopement risk to prevent neglect. The staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or DON as directed in the facility policy; If an employee observes a resident attempting to leave the premises, he/she should attempt to prevent the departure, get help from other staff members in the immediate vicinity, if necessary and instruct another staff member to inform the charge nurse or DON that a resident has left the premises; what to do upon return of resident who was observed leaving the facility; and nursing services duties upon return of a missing resident. Education will be provided by the Administrator and ADON. Education will be placed in orientation for new employees. Any staff not in-serviced by this date and time will be required to complete the education prior to next shift worked. The credible allegation was validated on 6/2/17 at 5:30 PM. The survey team confirmed Resident #99 had a physician's orders [REDACTED]. The completion of wandering assessments, the updated Kardex for residents with potential for elopement, the updated care plans for residents with potential for elopement, and the updated wandering/elopement notebook was verified. The installation of alarms on the four exit doors was confirmed and observed to be working properly. Staff interviews verified education on the door alarms and the wandering and elopement policy that was revised on 6/1/17.

Based on observation, staff and resident interviews and record review, the facility failed to investigate the root cause of 2 falls and failed to monitor for delayed complications related to a fall for 1 of 2 sampled residents reviewed for accidents. Findings included: Resident #42 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #42's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment with no behaviors. He was coded as independent with transfers, bed mobility and ambulating in his room. Resident #42 was coded for supervision with ambulating in the halls, toileting, hygiene and bathing. He was coded as continent of bladder and bowel and not coded for any falls. Resident #42's Fall Risk Assessment was last updated 11/22/16 and it indicated moderate risk for falls. Resident #42 was care planned on 9/14/16 for a moderate risk for falls. This care plan was last reviewed on 11/29/16. Resident #42's care plan was updated on 1/25/17 to include actual falls with interventions to include frequent rounds, non-skid socks, re-education to call for assistance and a therapy referral. The most recent care plan revision dated 2/10/17 indicated Resident #42 was receiving physical therapy for muscle weakness and unsteady gait. A review of the facility policy titled Assessing Falls and Their Causes last revised October 2010 read nursing staff were to observe a resident after a fall for a delayed complication for approximately 48 hours after an observed or suspected fall. The policy also read that nursing staff were to identify the possible cause of the fall. A review of the incidents logs revealed Resident #42 sustained falls on 1/23/17, 1/25/17, and 2/6/17 and again on 2/22/17. The incident reports indicated the following: -1/23/17 at 5:10 PM, Resident #42 was found on the floor in front of his recliner. He stated he was getting up from the recliner to get into his wheelchair when he slipped onto the floor. There were no injuries. The root cause was indicated as poor safety awareness and unassisted transfer. It noted increased swelling to bilateral feet. Interventions included a therapy consult, neurological checks and he was encouraged to call for assistance with transfers. A review of the paper medical record revealed the nursing staff obtained neurological checks and monitored Resident #42 as ordered for the fall that occurred on 1/23/17 from his personal recliner. There was no mention of an assessment of how he transfers from his personal recliner as a potential fall hazard. -1/25/17 at 7:45 AM. Resident #42 was observed sitting on the floor in front of the toilet. He stated the wheelchair folded up behind him with the wheelchair brakes on. There were no injuries. He was barefooted. The root cause was listed as improper footwear and poor safety awareness. Interventions included a therapy consult, neurological check and non-skid socks. Resident #42 was also re-educated to call for assistance. A review of the paper medical record revealed the nursing staff failed to obtain neurological checks or document any monitoring after the fall that occurred on 1/25/17 while toileting. A therapy screen was completed and he was referred to restorative nursing for ambulation on 2/3/17. A review of the Restorative Care Flow Record for February 2017 in the paper medical record listed ambulation and active range of motion 6 days a week starting on 2/6/17 and indicated Resident #42 was discharged from restorative on 2/15/17. There were no minutes listed and no restorative aide (RA) initials indicating Resident #42 received services. -2/6/17 at 4:30 PM Resident #42 was observed sitting on the floor with his back against the wall next to the bathroom. He stated he was getting something in the closet and his legs became weak. He stated he leaned against the closet door and slid to the floor. There were no injuries. The root cause was identified as unsteady gait and lower extremity weakness. Resident #42 was encouraged to call for assistance with getting his clothes out of the closet, a therapy consult and neurological checks. A review of the paper medical record revealed the nursing staff obtained neurological checks and monitored Resident #42 as ordered for the fall that occurred on 2/6/17 while trying to retrieve clothes from his closet. -2/21/17 at 10:05 PM, Resident #42 was observed sitting upright in front of his recliner. He stated he was transferring from the recliner to the wheelchair to go to bed. The root cause was unsteady gait, unassisted transfers and poor safety awareness. Interventions included therapy consult, neurological check and re-education to call for assistance. The form indicated Resident #42 was already receiving physical therapy. A review of the paper medical record revealed the nursing staff obtained neurological checks and monitored Resident #42 as ordered for the fall that occurred on 2/21/17 from his personal recliner. There was no mention of an assessment of how he transfers from his personal recliner as a potential fall hazard. A review of the physical therapy discharge summary indicated Resident #42 was on caseload from 2/10/17 until 2/24/17 when he reached his maximum potential. A restorative referral was completed on 2/24/17. In an interview on 2/27/17 at 9:17 AM, Resident #42 cautioned the surveyor against sitting in his personal recliner because it would tip forward and it was easy to slide out onto the floor. He stated he had fallen twice trying to get up from the recliner. In an interview on 3/1/17 at 10:10 AM, RA #1 and RA #2 stated they did not recall doing restorative with Resident #42. RA #1 stated if he was on their caseload, they would have documented their minutes on the Restorative Care Flow Record. RA #1 and RA #2 stated they normally got their assignments from either the MDS nurse or the Staff Development Coordinator (SDC). In an interview on 3/1/17 at 3:00 PM, the rehabilitation director stated the facility met and reviewed falls weekly to find the root cause. She stated she did not realize until 3/1/17 that two of Resident #42 ' s occurred from his personal recliner. The rehabilitation director stated Resident #42 ' s family brought the recliner from home but it should have been assessed for safety and it should have been evaluated after he fell from it on 1/23/17. In an interview on 3/1/17 at 3:40 PM, the SDC stated he did not realize the fall on 1/23/17 and 2/21/17 were from Resident #42 ' s personal recliner. He stated the recliner should have been assessed for safety and if it needed some non-skid material in the seat or maybe needed to be removed, it should have been addressed before 3/1/17. The SDC stated it was the facility practice to do neurological checks and monitor residents who fall for 48 hours after the fall but was unable to explain why no follow up monitoring or assessment was done after the fall on 1/25/17. In an interview on 3/2/17 at 9:30 AM, the Director of Nursing stated it was her expectation that Resident #42's personal recliner would have been assessed for a possible fall hazard. She further stated it was her expectation that Resident #42 would have been monitored for 48 hours after his fall on 1/25/17.

Based on observation, record review, family interview, physician interview, and staff interview, the facility's administration failed to establish an effective system to ensure the needs of the residents were met. The facility also failed to manage and have an effective system in place to consistently maintain compliance with F323 as evidenced by repeated citations at F323 with immediate jeopardy deficiencies cited on the recertification surveys of 3/26/15 and 2/4/16 and the complaint investigation survey of 9/23/16. The facility was also cited F323 at scope and severity level D on the recertification survey of 3/9/17 and the follow up recertification survey of 5/4/17. Immediate Jeopardy began on 4/12/17 when Resident #99 exited the facility unsupervised and was found outside by facility staff after an undetermined amount of time. The Immediate Jeopardy was lifted on 6/2/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: This tag is cross referenced to: F323: Based on observation, record review, family interview, staff interview, and physician interview, the facility failed to supervise a cognitively impaired resident with known exit seeking behaviors to prevent an elopement from the facility for 1 (Resident #99) of 3 residents reviewed for accidents. On 4/12/17 Resident #99, unsupervised by staff, exited the facility through the front door by wheelchair and traveled approximately 228 feet (76 yards) across the parking lot within 2 feet of a well-traveled roadway. Resident #99 was located by staff with no injuries after an undetermined amount of time outside of the facility. The facility was cited F323 during the recertification survey of 3/26/15 at immediate jeopardy level for not maintaining the water temperatures at or less than 116 degrees Fahrenheit. The facility was cited F323 during the recertification survey of 2/4/16 at immediate jeopardy level for not securing the resident and the wheelchair in the transportation van during transport causing the resident to have a fall. The facility was cited F323 during the complaint investigation survey of 9/23/16 at immediate jeopardy level for failing to raise the lift gate up before pushing the resident who was sitting in a wheelchair out of the transport van causing the resident to fall backward resulting in a head injury and cervical strain from the fall. The facility was cited F323 during the recertification survey of 3/9/17 at D level for failing to investigate the root cause of falls and failing to monitor for delayed complications related to a fall. The facility was cited F323 during the follow recertification survey of 5/4/17 at D level for failing to investigate the root cause of a fall and failing to provide supervision to prevent falls by failing to follow the physician's orders [REDACTED]. An interview was conducted with the Administrator on 6/2/17 at 2:07 PM. She indicated a Corporate Administrator Consultant, Corporate Nurse Consultant, and Corporate MDS Consultant were working with the facility to sustain and maintain compliance. She reported that accidents was a broad category and she felt this deficiency was different than the previous deficiencies cited at F323. The Administrator, Assistant Director of Nursing, Corporate Nurse Consultant, Corporate Administrator Consultant, and Corporate MDS Consultant were notified of Immediate Jeopardy on 6/1/17 at 9:41 AM. On 6/2/17 at 5:30 PM the facility provided the following credible allegation of compliance: This allegation of compliance constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Allegation of Compliance (AoC) is not an admission that a deficiency exists or that one was cited correctly. This AoC is submitted to meet requirements established by state and federal law. On 4/12/17, resident #99 was noted in parking lot at 7:50 pm by the Dietary Manager as she was leaving. Resident was sitting at the beginning of the drive way. He was just looking around. The Dietary Manager called into the facility by mobile phone. She parked her car and approached resident. Eight staff members responded to the call and they assisted resident back into the building. Resident #99 did not resist. Facility nursing staff met them and returned him to the nursing unit. Upon re-entry into the building, Nurse #3 completed an assessment of the resident and he was placed on the secured unit. Nurse #3, assessed him and determined he had no injuries or adverse effects related to being outside. Resident exited front entrance door and the amount of time outside was unable to be determined. An Incident Report was completed on 4/12/17 by Nurse #3. Resident's Responsible Party (RP) was notified by phone at 8:15pm by the previous Director of Nursing (DON). His physician was notified by phone on 4/12/17 at 8:30pm by Nurse #3. The Administrator was in the facility at the time of occurrence and was notified immediately by the Assistant Director of Nursing (ADON). The ADON completed a Wandering Assessment on 4/12/17. The assessment indicated resident is a Definite Risk for elopement. The Administrator, DON and ADON made the decision that resident should be moved to the secured unit. The Administrator completed the initial 24 hour report for the state and faxed it in on 4/12/17 at 9:18pm. The Administrator met with Resident #99's RP on 4/13/17 at 2:00pm to discuss interventions. Resident #99's RP agreed for resident to be placed in secured unit at night and remain in unsecured nursing unit during the day. Resident #99's RP refused for him to be in the secured unit at all times as recommended by the Administrator. Resident #99's RP was upset that resident was continuing to stay on the secured unit at night. She felt resident was being confused by the movement between the front and the back of the building. During the daytime hours, resident ' s whereabouts was monitored by staff. Resident #99's RP, the Administrator and attending physician met on 4/26/17 to discuss his case. His physician and Resident #99's RP felt resident's behavior should be managed by medication since she was so adamant that she did not want him in the secured unit. Resident #99's RP and physician agreed to let him stay on the secured unit for two weeks to give the medication time to work. [MEDICATION NAME] 0.25 milligrams was ordered at 6 pm on 4/26/17 for signs and symptoms of sun downing. Due to nursing observation of resident becoming more anxious, roaming in and out of residents' rooms and restlessness from 2pm to 6pm in the afternoons, the physician increased the [MEDICATION NAME] on 5/24/17 to 0.5 mg and the administration time to 4 pm to manage his sun downing symptoms. The resident's anxiety and restlessness was improved with the increase in the [MEDICATION NAME]. 1. A physician's orders [REDACTED].#99 to the secured dementia unit. He was moved to the unit on 6/1/2017. 2. New wandering assessments were completed on all residents on 6/1/17 to identify all residents at risk of elopement. The Assistant Director of Nursing (ADON) and licensed nurses completed the assessments. Three residents residing in the unsecured part of the facility were identified. Alarms were installed on 4 exit doors that did not have alarms. The CNA's and Nurses were educated on the three newly identified residents at risk for elopement on 6/2/17 before 1:00pm. The Kardex was updated for those residents to show potential for elopement on 6/2/17 before 1:00pm. On 6/2/17, before 1:00pm, care plans for potential for elopement were developed for all identified resident's, including those in the secured unit. The elopement book was updated on 6/2/17 before 1:00pm by the Medical Records Clerk. 3. The wandering/elopement notebook will be reviewed/updated with all residents identified at risk for elopement as the assessments are completed. A picture will be placed with each resident's profile. This was done by the Medical Records Clerk and on 6/2/17 by 1:00 pm. The wandering/elopement notebook will be kept at the nurse's station. 4. Door alarms will be installed on the four exit doors that currently do not have alarms. The four doors are the exit door in the dining room, inside door to the service hall, the activity room and the front entrance door. The alarms were installed on 6/1/17 by the Administrator. These alarms will sound when the door is opened. The staff, to include weekend, prn, and part time licensed and unlicensed, were educated by 6/2/17 at 1:00pm on alarms being placed on all exit doors, how to respond when an alarm is heard, including verifying who is opening the door and if no one is seen, then making sure to assess the outside area for a resident. 5. Care plans for resident's identified at risk will be reviewed and updated if indicated by the Nurse Assessment Coordinator (NAC) on 6/2/17 by 1:00pm. 6. The wandering and elopement policy was revised on 6/1/17 by the Corporate Clinical Nurse Consultant. Revisions included: assessment of residents at risk of elopement, reporting practices, correctible risk factors, care planning, documentation of unsafe actions of residents, reporting responsibilities, nursing service duties, what to do upon return of a resident who was observed leaving the facility, and discovery of a missing resident. Staff, to include weekend, prn and part time licensed and unlicensed, will be in-serviced on the facility's wandering and elopement policy by 6/2/17 at 1:00 pm. Any staff member not receiving the education will be educated before their next shift worked. Education will address the prevention of and response to a resident elopement as well as what should be done when a resident is newly identified as an elopement risk. Education will be provided by the Administrator and ADON. Education will be placed in orientation for new employees. Any staff not in-serviced by this date and time will be required to complete the education prior to next shift worked. 7. The regional director will visit the facility every other week to provide oversight of the Administrator in regards to regulatory compliance to ensure Plan of Corrections (POCs) are followed. Oversight will also include the Quality Assurance and Performance Improvement (QAPI) program. The QAPI committee has assigned teams to each deficiency cited. These teams meet a minimum of monthly prior to the monthly QAPI meeting, to review the action plans and ensure POC is being followed. Action plans are updated as indicated by the team assigned to that plan. The action plans along with the corresponding audits are then reviewed by the committee in the monthly QAPI meeting. The QAPI committee either approves the action plans or advises if revisions are needed based on audit results. The credible allegation was validated on 6/2/17 at 5:30 PM. The survey team confirmed Resident #99 had a physician's orders [REDACTED]. The completion of wandering assessments, the updated Kardex for residents with potential for elopement, the updated care plans for residents with potential for elopement, and the updated wandering/elopement notebook was verified. The installation of alarms on the four exit doors was confirmed and observed to be working properly. Staff interviews verified education on the door alarms and the wandering and elopement policy that was revised on 6/1/17.

Based on record review, observations, physician, pharmacy, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 2/4/16 recertification survey and the 9/23/16 complaint investigation for 3 recited deficiencies in the areas of services provided as care planned (F282), well-being (F309), and accidents (F323); following the 2/4/16 recertification survey for 5 recited deficiencies in the areas of assessment accuracy (F278), comprehensive care plans (F279), nutrition (F325), unnecessary medications (F329), and complete and accurate clinical records (F514); and following the 11/23/16 complaint investigation for 1 recited deficiency in area of urinary catheter care (F315). These 9 deficiencies were cited again on the current recertification survey of 3/3/17. The continued failure of the facility during 2 or more federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. The findings included: This tag is cross referenced to: 1. F278: Assessment Accuracy - Based on record review, observation, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of pressure ulcer for 1 (Resident #4) of 4 sampled residents reviewed for pressure ulcer and in the area of hospice for 2 (Residents #86 and #81) of 2 sampled residents reviewed for hospice. During the recertification survey of 2/4/16 the facility was cited F278 for failure to accurately code the MDS assessment for medications. On the current recertification survey of 3/3/17 the facility failed to accurately code the MDS assessment in the areas of pressure ulcer and hospice. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their Plan of Correction (POC) included. She stated as of 2/20/17 a new MDS Coordinator was hired to replace the previous MDS Coordinator. She indicated there were issues with the previous MDS Coordinator's evaluation of residents that effected MDS coding and care plans. 2. F279 - Comprehensive Care Plan: Based on record review, resident and staff interview, the facility failed to develop a care plan for the use of antipsychotic and hypnotic medication for two of five residents reviewed for unnecessary medication use (Residents #39 and #44). During the recertification survey of 2/4/16 the facility was cited F279 for failure to develop a care plan for falls. On the current recertification survey of 3/3/17 the facility failed to develop care plans for the use of antipsychotic medication and hypnotic medication. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated as of 2/20/17 a new MDS Coordinator was hired to replace the previous MDS Coordinator. She indicated there were issues with the previous MDS Coordinator's evaluation of residents that effected MDS coding and care plans. 3. F282 - Services Provided as Care Planned: Based on observation, staff interview, and record review, the facility failed to follow the care planned interventions for anticoagulant medication (Resident #81), dietary supplements (Resident #117), and restorative nursing services (Resident #42) for 3 of 17 care plans reviewed. During the recertification survey of 2/4/16 the facility was cited F282 for failure to follow the care plan interventions for obtaining a psychiatric consultation and monitoring behaviors for residents on [MEDICAL CONDITION] medications. During the complaint investigation survey of 9/23/16 the facility was again cited F282 for failure to follow the care plan for wound care. On the current recertification survey of 3/3/17 the facility failed to follow the care planned interventions for anticoagulant medication, dietary supplements, and restorative nursing services. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated their POC from the 9/23/16 complaint investigation included daily Treatment Administration Record (TAR) audits completed by Administrative staff, they hired a new treatment nurse, and implemented a Standards of Care (SOC) Meeting once weekly to review residents based on their needs. She stated this meeting included herself, the Director of Nursing (DON), Social Worker, Treatment Nurse, Dietary Manager, MDS, and Staff Development Coordinator. She additionally stated the floor nurses were responsible for monitoring care plan interventions. 4. F309 - Well-Being: Based on record review, physician interview, and staff interviews, the facility failed to administer a [MEDICATION NAME] (pain medication) for a resident which resulted in increased pain and increased need and request for an as needed [MEDICATION NAME] (pain medication) for 1 of 2 residents (Resident #40). During the 2/4/16 recertification survey the failed was cited F309 for failure to provide psychological interventions for residents with behavioral issues. During the complaint investigation survey of 9/23/16 the facility was again cited F309 for the failure to have the resident assessed/examined by a qualified person for possible injuries before moving a resident after the fall and the failure to treat wounds as ordered. On the current recertification survey of 3/3/17 the facility failed to administer a [MEDICATION NAME] to resident. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated the POC from the 9/23/16 complaint investigation included daily TAR audits completed by Administrative staff, they hired a new treatment nurse, and implemented a SOC Meeting once weekly to review residents based on their needs. She indicated they provided education to staff about their policy and procedure related to accidents/incidents. She stated she believed the current citation was unrelated the previous POC. She additionally stated she believed the previous deficiencies had been corrected. 5. F315 - Urinary Catheters: Based on record review, observation, and staff interview, the facility failed to provide catheter care and failed to secure the catheter tubing for 1 (Resident #4) of 1 sampled resident with an indwelling urinary catheter. Resident #4 had three hospitalization s with [DIAGNOSES REDACTED]. During the complaint investigation of 11/23/16 the facility was cited F315 for the failure to obtain Urinalysis (UA) with Culture and Sensitivity (C&S) as ordered by the physician and the failure to initiate treatment for [REDACTED]. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated the POC from the 11/23/16 complaint investigation included a new logging and monitoring system for all laboratory tests ordered by the physician as well as daily follow up with the laboratory. She stated the DON was responsible for this monitoring system. She indicated she was unsure why it was a repeat deficiency. 6. F323 - Accidents: Based on observation, staff and resident interviews, and record review, the facility failed to investigate the root cause of 2 falls and failed to monitor for delayed complications related to a fall for 1 of 2 residents (Resident #42) reviewed for accidents. During the recertification survey of 2/4/16 the facility was cited F323 for failure to properly secure a resident and the wheelchair in the transportation van according, failed to notify the Administrator about the incident, and failed to complete a root cause analysis of the incident. During the 9/23/16 complaint investigation the facility was again cited F323 for failure to raise the lift gate up before pushing a resident who was sitting in a wheelchair out of the transportation van causing the resident to fall backward. On the current recertification survey of 3/3/17 the facility failed to investigate the root cause analysis of falls and failed to monitor for delayed complications related to a fall. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She reported their POC for the 9/23/16 complaint investigation included discontinuing the use of the facility van for resident transportation. She stated she believed the current citation was unrelated to their previous POC. She additionally stated she believed this was a repeat deficiency because the area of accidents was so broad that a variety of items fell under this categorization. 7. F325 - Nutrition: Based on observation, staff interview, and record review, the facility failed to follow the physician's orders [REDACTED].#117) and failed to address weight loss (Resident #87) for 2 of 3 residents reviewed for nutrition. During the recertification survey of 2/4/16 the facility was cited F325 for failure to provide a nutritional supplement as ordered. On the current recertification survey of 3/3/17 the facility failed to follow the physician's orders [REDACTED]. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated she believed this was a repeat deficiency because the facility had not firmed up their process for Medication Administration Record [REDACTED]. 8. F329 - Unnecessary medications: [REDACTED]. During the recertification survey of 2/4/16 the facility was cited F329 for failure to administer antipsychotic medication as ordered by a physician, failure to monitor behaviors for residents receiving [MEDICAL CONDITION] medications, and failure to discontinue a medication as ordered. On the current recertification survey of 3/3/17 the facility failed to obtain laboratory values to monitor the use of statin medication. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She reported the facility received a monthly report from the pharmacy that included all residents who were on [MEDICAL CONDITION] medications and anticoagulant medications. She stated this list was utilized for monitoring purposes. She indicated she was unsure why it was a repeat deficiency. 9. F514: Complete and Accurate Clinical Records: Based on record review and pharmacy and staff interview, the facility failed to maintain a complete and accurate medical records as evidenced by medications signed off from the narcotic count were not documented as administered on the resident's Medication Administration Record [REDACTED]. During the recertification survey of 2/4/16 the facility was cited F514 for failure to maintain complete physician progress notes [REDACTED]. On the current recertification survey of 3/3/17 the facility failed to maintain complete and accurate medical records as evidenced by medications signed off from the narcotic count were not documented as administered on the resident's MAR indicated [REDACTED] An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated she believed multiple changes with staff had contributed to this deficiency. She indicated that ultimately the Unit Managers were responsible for monitoring MARs.

Based on record review, observation and staff interview, the facility failed to provide catheter care and failed to secure the catheter tubing for 1 (Resident #4) of 1 sampled resident with an indwelling urinary catheter. Resident #4 had three hospitalization s with [DIAGNOSES REDACTED]. Findings included: Resident #4 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#4 had severe cognitive impairment and she was frequently incontinent of bladder. Resident #4 had a doctor's order dated 12/7/16 to insert an indwelling urinary catheter due to unstageable pressure ulcer on the left buttock. Resident #4's physician's orders [REDACTED]. Resident #4 did not have an order for [REDACTED]. Resident #4's care plan dated 12/8/16 was reviewed. One of the care plan problems was resident had an indwelling urinary catheter and she was at risk for increased UTI. The goal was the catheter would remain patent and the resident would not develop increased incidence of UTI over the next 90 days. The approaches included to change catheter tubing and bag per doctor's order, monitor urine for odor, sediments and amount of urine and report abnormal to the doctor, encourage fluid intake within dietary limits, keep tubing and bag below the bladder, do not kink tubing and catheter care per doctor's order. The care plan also indicated that Resident #4 had pulled out her urinary catheter on 12/22/16 and 2/27/17. The medical records of Resident #4 revealed that she was discharged to the hospital on [DATE], 1/12/17 and 2/10/17. The hospital records of Resident #4 were reviewed. The hospital discharge summary with admitted ,[DATE] through 12/20/16 revealed a [DIAGNOSES REDACTED]. The hospital discharge summary with admitted ,[DATE]/ through 1/16/17 revealed a [DIAGNOSES REDACTED]. The hospital discharge summary with admitted ,[DATE] through 2/17/17 revealed a [DIAGNOSES REDACTED]. On 2/28/17 at 4:10 PM, Resident #4 was observed in bed with an indwelling urinary catheter in place. The urinary catheter tubing was not secured during the observation. On 3/1/17 at 9:05 AM, Resident #4 was observed in bed with an indwelling urinary catheter in place. The urinary catheter tubing was not secured during the observation. On 3/1/17 at 9:06 AM, Nurse #3 was interviewed. Nurse #3 stated that she was the nurse assigned to Resident #4. She stated that the Treatment Nurse was responsible for providing catheter care and for ensuring the catheter tubing was secured. She also indicated that Resident #4 had history of pulling her catheter out and the last time she pulled it out was on 2/27/17. On 3/1/17 at 9:08 AM, NA #6 was interviewed. NA #6 stated that the nurses were responsible for catheter care but she had cleaned the urinary catheter during incontinent care when the resident had a bowel movement. On 3/1/17 at 9:12 AM, the Treatment Nurse was interviewed. She stated that the nurses working on the floor were responsible for providing catheter care and for securing the urinary catheter tubing. The Treatment Nurse indicated that she was only responsible for providing care to suprapubic catheter and not indwelling urinary catheter. At 10:40 AM, the Treatment Nurse indicated that Resident #4 had pulled out her catheter on 2/27/17 and the nurse, who reinserted the urinary catheter, forgot to secure the catheter tubing. On 3/2/17 at 10:45 AM, the Director of Nursing (DON) was interviewed. The DON stated that she expected the catheter tubing to be secured at all times and catheter care to be provided to residents with a urinary catheter. She also indicated that the nursing aides were responsible for providing catheter care every shift but she could not find documentation that catheter care was provided to Resident #4.

Based on record review, observations, physician, pharmacy, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 2/4/16 recertification survey and the 9/23/16 complaint investigation for 3 recited deficiencies in the areas of services provided as care planned (F282), well-being (F309), and accidents (F323); following the 2/4/16 recertification survey for 5 recited deficiencies in the areas of assessment accuracy (F278), comprehensive care plans (F279), nutrition (F325), unnecessary medications (F329), and complete and accurate clinical records (F514); and following the 11/23/16 complaint investigation for 1 recited deficiency in area of urinary catheter care (F315). These 9 deficiencies were cited again on the current recertification survey of 3/3/17. The continued failure of the facility during 2 or more federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. The findings included: This tag is cross referenced to: 1. F278: Assessment Accuracy - Based on record review, observation, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of pressure ulcer for 1 (Resident #4) of 4 sampled residents reviewed for pressure ulcer and in the area of hospice for 2 (Residents #86 and #81) of 2 sampled residents reviewed for hospice. During the recertification survey of 2/4/16 the facility was cited F278 for failure to accurately code the MDS assessment for medications. On the current recertification survey of 3/3/17 the facility failed to accurately code the MDS assessment in the areas of pressure ulcer and hospice. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their Plan of Correction (POC) included. She stated as of 2/20/17 a new MDS Coordinator was hired to replace the previous MDS Coordinator. She indicated there were issues with the previous MDS Coordinator's evaluation of residents that effected MDS coding and care plans. 2. F279 - Comprehensive Care Plan: Based on record review, resident and staff interview, the facility failed to develop a care plan for the use of antipsychotic and hypnotic medication for two of five residents reviewed for unnecessary medication use (Residents #39 and #44). During the recertification survey of 2/4/16 the facility was cited F279 for failure to develop a care plan for falls. On the current recertification survey of 3/3/17 the facility failed to develop care plans for the use of antipsychotic medication and hypnotic medication. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated as of 2/20/17 a new MDS Coordinator was hired to replace the previous MDS Coordinator. She indicated there were issues with the previous MDS Coordinator's evaluation of residents that effected MDS coding and care plans. 3. F282 - Services Provided as Care Planned: Based on observation, staff interview, and record review, the facility failed to follow the care planned interventions for anticoagulant medication (Resident #81), dietary supplements (Resident #117), and restorative nursing services (Resident #42) for 3 of 17 care plans reviewed. During the recertification survey of 2/4/16 the facility was cited F282 for failure to follow the care plan interventions for obtaining a psychiatric consultation and monitoring behaviors for residents on [MEDICAL CONDITION] medications. During the complaint investigation survey of 9/23/16 the facility was again cited F282 for failure to follow the care plan for wound care. On the current recertification survey of 3/3/17 the facility failed to follow the care planned interventions for anticoagulant medication, dietary supplements, and restorative nursing services. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated their POC from the 9/23/16 complaint investigation included daily Treatment Administration Record (TAR) audits completed by Administrative staff, they hired a new treatment nurse, and implemented a Standards of Care (SOC) Meeting once weekly to review residents based on their needs. She stated this meeting included herself, the Director of Nursing (DON), Social Worker, Treatment Nurse, Dietary Manager, MDS, and Staff Development Coordinator. She additionally stated the floor nurses were responsible for monitoring care plan interventions. 4. F309 - Well-Being: Based on record review, physician interview, and staff interviews, the facility failed to administer a [MEDICATION NAME] (pain medication) for a resident which resulted in increased pain and increased need and request for an as needed [MEDICATION NAME] (pain medication) for 1 of 2 residents (Resident #40). During the 2/4/16 recertification survey the failed was cited F309 for failure to provide psychological interventions for residents with behavioral issues. During the complaint investigation survey of 9/23/16 the facility was again cited F309 for the failure to have the resident assessed/examined by a qualified person for possible injuries before moving a resident after the fall and the failure to treat wounds as ordered. On the current recertification survey of 3/3/17 the facility failed to administer a [MEDICATION NAME] to resident. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated the POC from the 9/23/16 complaint investigation included daily TAR audits completed by Administrative staff, they hired a new treatment nurse, and implemented a SOC Meeting once weekly to review residents based on their needs. She indicated they provided education to staff about their policy and procedure related to accidents/incidents. She stated she believed the current citation was unrelated the previous POC. She additionally stated she believed the previous deficiencies had been corrected. 5. F315 - Urinary Catheters: Based on record review, observation, and staff interview, the facility failed to provide catheter care and failed to secure the catheter tubing for 1 (Resident #4) of 1 sampled resident with an indwelling urinary catheter. Resident #4 had three hospitalization s with [DIAGNOSES REDACTED]. During the complaint investigation of 11/23/16 the facility was cited F315 for the failure to obtain Urinalysis (UA) with Culture and Sensitivity (C&S) as ordered by the physician and the failure to initiate treatment for [REDACTED]. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated the POC from the 11/23/16 complaint investigation included a new logging and monitoring system for all laboratory tests ordered by the physician as well as daily follow up with the laboratory. She stated the DON was responsible for this monitoring system. She indicated she was unsure why it was a repeat deficiency. 6. F323 - Accidents: Based on observation, staff and resident interviews, and record review, the facility failed to investigate the root cause of 2 falls and failed to monitor for delayed complications related to a fall for 1 of 2 residents (Resident #42) reviewed for accidents. During the recertification survey of 2/4/16 the facility was cited F323 for failure to properly secure a resident and the wheelchair in the transportation van according, failed to notify the Administrator about the incident, and failed to complete a root cause analysis of the incident. During the 9/23/16 complaint investigation the facility was again cited F323 for failure to raise the lift gate up before pushing a resident who was sitting in a wheelchair out of the transportation van causing the resident to fall backward. On the current recertification survey of 3/3/17 the facility failed to investigate the root cause analysis of falls and failed to monitor for delayed complications related to a fall. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She reported their POC for the 9/23/16 complaint investigation included discontinuing the use of the facility van for resident transportation. She stated she believed the current citation was unrelated to their previous POC. She additionally stated she believed this was a repeat deficiency because the area of accidents was so broad that a variety of items fell under this categorization. 7. F325 - Nutrition: Based on observation, staff interview, and record review, the facility failed to follow the physician's orders [REDACTED].#117) and failed to address weight loss (Resident #87) for 2 of 3 residents reviewed for nutrition. During the recertification survey of 2/4/16 the facility was cited F325 for failure to provide a nutritional supplement as ordered. On the current recertification survey of 3/3/17 the facility failed to follow the physician's orders [REDACTED]. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated she believed this was a repeat deficiency because the facility had not firmed up their process for Medication Administration Record [REDACTED]. 8. F329 - Unnecessary medications: [REDACTED]. During the recertification survey of 2/4/16 the facility was cited F329 for failure to administer antipsychotic medication as ordered by a physician, failure to monitor behaviors for residents receiving [MEDICAL CONDITION] medications, and failure to discontinue a medication as ordered. On the current recertification survey of 3/3/17 the facility failed to obtain laboratory values to monitor the use of statin medication. An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She reported the facility received a monthly report from the pharmacy that included all residents who were on [MEDICAL CONDITION] medications and anticoagulant medications. She stated this list was utilized for monitoring purposes. She indicated she was unsure why it was a repeat deficiency. 9. F514: Complete and Accurate Clinical Records: Based on record review and pharmacy and staff interview, the facility failed to maintain a complete and accurate medical records as evidenced by medications signed off from the narcotic count were not documented as administered on the resident's Medication Administration Record [REDACTED]. During the recertification survey of 2/4/16 the facility was cited F514 for failure to maintain complete physician progress notes [REDACTED]. On the current recertification survey of 3/3/17 the facility failed to maintain complete and accurate medical records as evidenced by medications signed off from the narcotic count were not documented as administered on the resident's MAR indicated [REDACTED] An interview was conducted with the Administrator on 3/3/17 at 11:45 AM. She indicated she had not worked at the facility during the time of previous recertification survey of 2/4/16 when this deficiency was cited and she was unaware what their POC included. She stated she believed multiple changes with staff had contributed to this deficiency. She indicated that ultimately the Unit Managers were responsible for monitoring MARs.

Based on observation, record review, family interview, physician interview, and staff interview, the facility's administration failed to establish an effective system to ensure the needs of the residents were met. The facility also failed to manage and have an effective system in place to consistently maintain compliance with F323 as evidenced by repeated citations at F323 with immediate jeopardy deficiencies cited on the recertification surveys of 3/26/15 and 2/4/16 and the complaint investigation survey of 9/23/16. The facility was also cited F323 at scope and severity level D on the recertification survey of 3/9/17 and the follow up recertification survey of 5/4/17. Immediate Jeopardy began on 4/12/17 when Resident #99 exited the facility unsupervised and was found outside by facility staff after an undetermined amount of time. The Immediate Jeopardy was lifted on 6/2/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: This tag is cross referenced to: F323: Based on observation, record review, family interview, staff interview, and physician interview, the facility failed to supervise a cognitively impaired resident with known exit seeking behaviors to prevent an elopement from the facility for 1 (Resident #99) of 3 residents reviewed for accidents. On 4/12/17 Resident #99, unsupervised by staff, exited the facility through the front door by wheelchair and traveled approximately 228 feet (76 yards) across the parking lot within 2 feet of a well-traveled roadway. Resident #99 was located by staff with no injuries after an undetermined amount of time outside of the facility. The facility was cited F323 during the recertification survey of 3/26/15 at immediate jeopardy level for not maintaining the water temperatures at or less than 116 degrees Fahrenheit. The facility was cited F323 during the recertification survey of 2/4/16 at immediate jeopardy level for not securing the resident and the wheelchair in the transportation van during transport causing the resident to have a fall. The facility was cited F323 during the complaint investigation survey of 9/23/16 at immediate jeopardy level for failing to raise the lift gate up before pushing the resident who was sitting in a wheelchair out of the transport van causing the resident to fall backward resulting in a head injury and cervical strain from the fall. The facility was cited F323 during the recertification survey of 3/9/17 at D level for failing to investigate the root cause of falls and failing to monitor for delayed complications related to a fall. The facility was cited F323 during the follow recertification survey of 5/4/17 at D level for failing to investigate the root cause of a fall and failing to provide supervision to prevent falls by failing to follow the physician's orders [REDACTED]. An interview was conducted with the Administrator on 6/2/17 at 2:07 PM. She indicated a Corporate Administrator Consultant, Corporate Nurse Consultant, and Corporate MDS Consultant were working with the facility to sustain and maintain compliance. She reported that accidents was a broad category and she felt this deficiency was different than the previous deficiencies cited at F323. The Administrator, Assistant Director of Nursing, Corporate Nurse Consultant, Corporate Administrator Consultant, and Corporate MDS Consultant were notified of Immediate Jeopardy on 6/1/17 at 9:41 AM. On 6/2/17 at 5:30 PM the facility provided the following credible allegation of compliance: This allegation of compliance constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Allegation of Compliance (AoC) is not an admission that a deficiency exists or that one was cited correctly. This AoC is submitted to meet requirements established by state and federal law. On 4/12/17, resident #99 was noted in parking lot at 7:50 pm by the Dietary Manager as she was leaving. Resident was sitting at the beginning of the drive way. He was just looking around. The Dietary Manager called into the facility by mobile phone. She parked her car and approached resident. Eight staff members responded to the call and they assisted resident back into the building. Resident #99 did not resist. Facility nursing staff met them and returned him to the nursing unit. Upon re-entry into the building, Nurse #3 completed an assessment of the resident and he was placed on the secured unit. Nurse #3, assessed him and determined he had no injuries or adverse effects related to being outside. Resident exited front entrance door and the amount of time outside was unable to be determined. An Incident Report was completed on 4/12/17 by Nurse #3. Resident's Responsible Party (RP) was notified by phone at 8:15pm by the previous Director of Nursing (DON). His physician was notified by phone on 4/12/17 at 8:30pm by Nurse #3. The Administrator was in the facility at the time of occurrence and was notified immediately by the Assistant Director of Nursing (ADON). The ADON completed a Wandering Assessment on 4/12/17. The assessment indicated resident is a Definite Risk for elopement. The Administrator, DON and ADON made the decision that resident should be moved to the secured unit. The Administrator completed the initial 24 hour report for the state and faxed it in on 4/12/17 at 9:18pm. The Administrator met with Resident #99's RP on 4/13/17 at 2:00pm to discuss interventions. Resident #99's RP agreed for resident to be placed in secured unit at night and remain in unsecured nursing unit during the day. Resident #99's RP refused for him to be in the secured unit at all times as recommended by the Administrator. Resident #99's RP was upset that resident was continuing to stay on the secured unit at night. She felt resident was being confused by the movement between the front and the back of the building. During the daytime hours, resident ' s whereabouts was monitored by staff. Resident #99's RP, the Administrator and attending physician met on 4/26/17 to discuss his case. His physician and Resident #99's RP felt resident's behavior should be managed by medication since she was so adamant that she did not want him in the secured unit. Resident #99's RP and physician agreed to let him stay on the secured unit for two weeks to give the medication time to work. [MEDICATION NAME] 0.25 milligrams was ordered at 6 pm on 4/26/17 for signs and symptoms of sun downing. Due to nursing observation of resident becoming more anxious, roaming in and out of residents' rooms and restlessness from 2pm to 6pm in the afternoons, the physician increased the [MEDICATION NAME] on 5/24/17 to 0.5 mg and the administration time to 4 pm to manage his sun downing symptoms. The resident's anxiety and restlessness was improved with the increase in the [MEDICATION NAME]. 1. A physician's orders [REDACTED].#99 to the secured dementia unit. He was moved to the unit on 6/1/2017. 2. New wandering assessments were completed on all residents on 6/1/17 to identify all residents at risk of elopement. The Assistant Director of Nursing (ADON) and licensed nurses completed the assessments. Three residents residing in the unsecured part of the facility were identified. Alarms were installed on 4 exit doors that did not have alarms. The CNA's and Nurses were educated on the three newly identified residents at risk for elopement on 6/2/17 before 1:00pm. The Kardex was updated for those residents to show potential for elopement on 6/2/17 before 1:00pm. On 6/2/17, before 1:00pm, care plans for potential for elopement were developed for all identified resident's, including those in the secured unit. The elopement book was updated on 6/2/17 before 1:00pm by the Medical Records Clerk. 3. The wandering/elopement notebook will be reviewed/updated with all residents identified at risk for elopement as the assessments are completed. A picture will be placed with each resident's profile. This was done by the Medical Records Clerk and on 6/2/17 by 1:00 pm. The wandering/elopement notebook will be kept at the nurse's station. 4. Door alarms will be installed on the four exit doors that currently do not have alarms. The four doors are the exit door in the dining room, inside door to the service hall, the activity room and the front entrance door. The alarms were installed on 6/1/17 by the Administrator. These alarms will sound when the door is opened. The staff, to include weekend, prn, and part time licensed and unlicensed, were educated by 6/2/17 at 1:00pm on alarms being placed on all exit doors, how to respond when an alarm is heard, including verifying who is opening the door and if no one is seen, then making sure to assess the outside area for a resident. 5. Care plans for resident's identified at risk will be reviewed and updated if indicated by the Nurse Assessment Coordinator (NAC) on 6/2/17 by 1:00pm. 6. The wandering and elopement policy was revised on 6/1/17 by the Corporate Clinical Nurse Consultant. Revisions included: assessment of residents at risk of elopement, reporting practices, correctible risk factors, care planning, documentation of unsafe actions of residents, reporting responsibilities, nursing service duties, what to do upon return of a resident who was observed leaving the facility, and discovery of a missing resident. Staff, to include weekend, prn and part time licensed and unlicensed, will be in-serviced on the facility's wandering and elopement policy by 6/2/17 at 1:00 pm. Any staff member not receiving the education will be educated before their next shift worked. Education will address the prevention of and response to a resident elopement as well as what should be done when a resident is newly identified as an elopement risk. Education will be provided by the Administrator and ADON. Education will be placed in orientation for new employees. Any staff not in-serviced by this date and time will be required to complete the education prior to next shift worked. 7. The regional director will visit the facility every other week to provide oversight of the Administrator in regards to regulatory compliance to ensure Plan of Corrections (POCs) are followed. Oversight will also include the Quality Assurance and Performance Improvement (QAPI) program. The QAPI committee has assigned teams to each deficiency cited. These teams meet a minimum of monthly prior to the monthly QAPI meeting, to review the action plans and ensure POC is being followed. Action plans are updated as indicated by the team assigned to that plan. The action plans along with the corresponding audits are then reviewed by the committee in the monthly QAPI meeting. The QAPI committee either approves the action plans or advises if revisions are needed based on audit results. The credible allegation was validated on 6/2/17 at 5:30 PM. The survey team confirmed Resident #99 had a physician's orders [REDACTED]. The completion of wandering assessments, the updated Kardex for residents with potential for elopement, the updated care plans for residents with potential for elopement, and the updated wandering/elopement notebook was verified. The installation of alarms on the four exit doors was confirmed and observed to be working properly. Staff interviews verified education on the door alarms and the wandering and elopement policy that was revised on 6/1/17.

Based on observation, record review, and staff interview, the facility neglected to provide effective monitoring of a cognitively impaired resident with known exit seeking behaviors to prevent an elopement from the facility for 1 (Resident #99) of 3 residents reviewed for accidents. On 4/12/17 Resident #99, unsupervised by staff, exited the facility through the front door by wheelchair and traveled approximately 228 feet (76 yards) across the parking lot within 2 feet of a well-traveled roadway. Resident #99 was located by staff with no injuries after an undetermined amount of time outside of the facility. Immediate Jeopardy began on 4/12/17 when Resident #99 exited the facility unsupervised and was found outside by facility staff after an undetermined amount of time. The Immediate Jeopardy was lifted on 6/2/17 when the facility's acceptable credible allegation of compliance was verified. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: Resident #99 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #99's cognition was significantly impaired. He had physical behaviors, other behavioral symptoms, and wandering behaviors 1 to 3 days during the review period. Resident #99 was assessed as dependent on 1 staff for assistance with bed mobility and the extensive assistance of 1 staff for transfers. Resident #99 required supervision/set up help only for locomotion on and off the unit. Resident #99 utilized a wheelchair. The comprehensive plan of care for Resident #99, most recently reviewed on 3/15/17, had not addressed the problem of exit seeking behavior. A review of Resident #99's Nursing Assistant (NA) Kardex, undated, had not indicated he had exit seeking behavior. A nursing note dated 4/12/17 at 8:00 PM written by Nurse #3 indicated Resident #99 was found in the parking lot by the road in his wheelchair. Resident #99 was brought back into the building by staff and placed in the secured unit for the night. Resident #99's Responsible Party (RP), his physician, the Director of Nursing (DON) and the Administrator were notified. An Accident/Incident Report dated 4/12/17 at 8:00 PM written by Nurse #3 indicated an elopement for Resident #99. Resident #99 was noted to have been found in the parking lot of the facility. Resident #99 was assessed as memory impaired, decision making impaired, physically impaired, and hearing impaired. He was noted to be confused and disoriented. Resident #99 was seen outside of the facility in the parking lot by the road. The recommended steps to prevent reoccurrence indicated Resident #99 was moved to the secured unit for the night. A review of the facility's wandering book, a book that contained a color photo of all residents who had wandering behaviors, was conducted on 5/31/17 at 9:30 AM. The wandering book included a photo of Resident #99 dated March 2017. An interview was conducted with Nurse #1 on 5/31/17 at 9:55 AM. She reported she was unaware of any residents who were high risk for elopement. An interview was conducted with the Administrator on 5/31/17 at 10:15 AM. The incident report dated 4/12/17 that indicated Resident #99 eloped from the facility and was found in the parking lot was reviewed with the Administrator. She revealed she had not known how Resident #99 was able to exit the facility unsupervised by staff. The Administrator stated the previous Director of Nursing (DON) completed the investigation into this incident, but she was unable to locate any of the documentation from the investigation. She indicated the previous DON was no longer working at the facility. The Administrator reported she was responsible for maintaining the documentation related to all investigations of incidents. An interview was conducted with Assistant Director of Nursing (ADON) on 5/31/17 at 1:24 PM. She stated Resident #99 was alert and oriented to self, he was able to self-propel in his wheelchair, and he wandered daily. She reported she was working at the time of Resident #99's elopement on 4/12/17. She stated she was in the conference room with several other Administrative staff at the time of the elopement. The ADON reported that several staff were seen coming down the hallway of the facility toward the front door and one of them stated that Resident #99 had gone out the front door. She stated that she was unsure of all of the staff members who were present, but she was aware NA #1 brought Resident #99 back into the facility. The ADON indicated the former Dietary Manager (DM) had initially found Resident #99 in the parking lot when she was leaving work. She called into the facility by mobile phone to alert staff. She reported Resident #99 was initially found outside around 8:00 PM. The ADON revealed it was unknown how long Resident #99 was outside. She additionally revealed she had not known how Resident #99 was able to exit the facility unsupervised by staff. This interview with the ADON continued on 5/31/17 at 1:30 PM. She reported Resident #99's RP and physician were notified by phone of the incident. Resident #99 was placed in the secured unit for the night and a meeting was scheduled for the following day with his RP. The ADON indicated the facility had wanted to move Resident #99 to the locked unit permanently as he met the criteria: Alzheimer's/dementia, able to propel self/ambulate, and an elopement risk. She revealed she had felt Resident #99 required placement in the secured unit since she began working at the facility (September 2016), but she indicated his RP had refused placement in the secured unit. The ADON additionally revealed she felt Resident #99's safety was not able to be guaranteed on the unsecured unit as he was at high risk for elopement. She stated that without Resident #99 being moved to the secured unit, the staff had done their best to observe and monitor Resident #99's whereabouts to ensure his safety. She explained the staff observed and monitored Resident #99's whereabouts throughout their shift (no specific timeframe for the monitoring) and if he was noted wandering toward the lobby area he was redirected toward the nurse's station so he was more easily observed. She indicated there was normally at least one staff member near the nurse's station which allowed Resident #99 to be observed more frequently. She stated there were occasions when staff members were occupied with other residents and there was no staff present at the nurse's station to monitor Resident #99. The ADON revealed it was this monitoring and observation that was in place at the time of Resident #99's elopement and she noted it had not been effective. A phone interview was conducted with the former DM on 5/31/17 at 2:00 PM. She stated she found Resident #99 outside of the facility on 4/12/17 sometime during the second shift (3:00 PM to 11:00 PM). She reported she was in her car leaving work for the day and as she drove up toward the exit of the parking lot she saw Resident #99 in his wheelchair approximately one to two feet from the roadway. She indicated she quickly got out of her car and moved Resident #99 away from the roadway as he was at risk of being hit by a car. The former DM reported Resident #99 was confused. She stated she called into the facility by mobile phone to alert staff that Resident #99 was found outside. She indicated several staff members came out of the facility to check on Resident #99. She stated that she was unsure of all of the staff members that were present, but she recalled NA #1 brought Resident #99 back into the facility. A review of the NA schedule indicated NA #1 or NA #2 was assigned to Resident #2 on 4/12/17. An interview was conducted with NA #1 on 5/31/17 at 3:22 PM. He stated he was familiar with Resident #99. He indicated Resident #99 was pleasantly confused, he was able to self-propel his wheelchair, and he wandered all the time all throughout the facility. NA #1 reported sometimes Resident #99 self-propelled into the lobby area of the facility. He indicated when that occurred, the staff had to redirect Resident #99 toward the nurse's station so he was more easily observed. He reported he tried to monitor Resident #99's whereabouts throughout his shift to make sure he had not wandered toward the lobby area, but he revealed there were occasions when he was working with another resident and he was unable to monitor Resident #99. NA #2 stated he was working on Resident #99's hall (200 hall) on 4/12/17 at the time of the elopement, but he did not think he was assigned to him. He indicated the former DM had phoned the facility from the parking lot to alert staff Resident #99 was found in the parking lot. NA #1 reported that he and several other staff members (he was unable to recall the other staff present) ran out of the building to attend to Resident #99. He stated when he got outside the former DM had moved Resident #99 toward the middle of the parking lot and he assisted her by transporting Resident #99 the remainder of the way inside of the building. He reported that Resident #99 was disoriented as evidenced by him singing and appearing unaware that he should not have been outside of the building unsupervised. Resident #99 was not injured. NA #1 indicated it was dangerous for Resident #99 to be outside on his own. He added that the roadway was well traveled and the speed limit was 45 miles per hour. NA #1 revealed he was unable to say for sure how long Resident #99 was outside of the building. He stated he was unable to recall what NA was assigned to Resident #99 on 4/12/17 at the time of the elopement. The interview with NA #1 continued on 5/31/17 at 3:30 PM. NA #1 revealed he had not known how Resident #99 had exited the building without being noticed by staff. He indicated that following the elopement the staff continued the same method of monitoring which included observing Resident #99's whereabouts throughout their shifts (no timeframe for the monitoring) and if he was noted traveling toward the lobby area of the facility he was redirected toward the nurse's station so he was more easily observed. An interview was conducted with NA #2 on 5/31/17 at 3:52 PM. She stated she was familiar with Resident #99. She indicated Resident #99 was alert and confused, he was able to self-propel his wheelchair, and he wandered all the time all throughout the halls of the facility, into other resident's rooms, and into the lobby area. NA #2 reported the staff observed Resident #99 throughout their shifts (no specified timeframe for the observations) and if he was noted to wander toward the lobby area he was redirected toward the nurse's station so he was more easily observed. She stated she had done her best to observe Resident #99's whereabouts, but revealed she was not able to watch him at all times as there were instances when she was assisting other residents. NA #2 stated she was working on Resident #9 s hall (200 hall) on 4/12/17 when Resident #99 had eloped. She indicated she may have been assigned to Resident #99, but she was unable to recall for certain. She reported that she was in another resident's room when one staff member (she was unable to recall the staff member) came into the room and said Resident #99 was outside. NA #2 indicated she and several other staff ran out to the parking lot as Resident #99 was not supposed to be outside unsupervised. She stated that she and NA #1 spoke with Resident #99 when he was brought back inside and he was very confused. Resident #99 was not injured. NA #2 revealed she was unable to say for sure how long Resident #99 was outside of the building. She stated she had last observed Resident #99 at the nurse's station, but she was unable to estimate the time of when she last saw him prior to time of the elopement. The interview with NA #2 continued on 5/31/17 at 4:00 PM. NA #2 revealed she had not known how Resident #99 had exited the building without being noticed by staff. She indicated that following the elopement the staff continued the same method of monitoring which included observing Resident #99's whereabouts throughout their shifts (no timeframe for the monitoring) and if he was noted traveling toward the lobby area of the facility he was brought back to the nurse's station so he was more easily observed. An interview was conducted with the Nurse Unit Manager (UM) on 5/31/17 at 4:29 PM. She indicated Resident #99 was alert with confusion, he was able to self-propel his wheelchair, and he wandered daily throughout the halls, into other resident's rooms, and sometimes he wandered toward the lobby area. She reported that she was the Nurse UM on 4/12/17 at the time of Resident #99's elopement, but that she had not been involved in any of the events during or after the elopement. An interview was conducted with Nurse #3 on 5/31/17 at 4:35 PM. She stated she was familiar with Resident #99. She indicated he was very confused, he was able to self-propel his wheelchair, and he wandered daily. She stated the wandering was up and down the hall ways and occasionally she saw him wandering up toward the lobby area and she had to go get Resident #99 and return him to the area around the nurse's station so he was able to be observed easily. Nurse #3 indicated she was assigned to Resident #99 on 4/12/17 at the time of his elopement. She reported that she had heard a staff member (she was unable to recall the staff member) say Resident #99 was outside. She indicated she had not observed Resident #99 when he was outside. Nurse #3 stated she was unable to recall where or when she had last seen Resident #99 prior to the elopement. She revealed she had not known how Resident #99 had exited the building without being noticed by staff. She indicated it was a safety risk for Resident #99 to have been outside alone. She reported she had completed the nursing note and the incident report related to the 4/12/17 elopement. Resident #99 was not injured. A second interview was conducted with the ADON on 5/31/17 at 5:35 PM. The NA schedule for 4/12/17 at the time of the elopement that indicated NA #1 or NA #2 was assigned to Resident #99 was reviewed with the ADON. The interviews with NA #1 and NA #2 that indicated they had not recalled who was assigned to Resident #99 on 4/12/17 was reviewed with the ADON. She stated that there was no record of who was actually assigned, but she confirmed it was either NA #1 or NA #2. Resident #99 was observed on 5/31/17 at 6:18 PM in his wheelchair near the nurse's station. He was alert with confusion. An interview was unable to be completed as Resident #99 was unable to respond intelligibly to questions. An interview was conducted with the Administrator on 5/31/17 at 6:46 PM. The 4/12/17 elopement incident for Resident #99 was reviewed with the Administrator. She confirmed the statements made by staff members related to the 4/12/17 elopement of Resident #99. The Administrator revealed the monitoring that was in place for Resident #99's wandering and exit seeking behaviors had not been effective as evidenced by his elopement on 4/12/17. An observation of the building on 6/1/17 at 10:00 AM revealed the front entrance doors had to be pushed open. The roadway was approximately 230 feet from the front entrance door. The speed limit on this road was 45 miles per hour. The temperature on 4/12/17 at 8:00 PM was 69 degrees (wunderground.com). An interview was conducted with the Assistant Director of Maintenance on 6/1/17 at 2:56 PM. She indicated she measured the distance from the front door of the facility to the roadway as 230 feet. The Administrator, ADON, Corporate Nurse Consultant, Corporate Administrator Consultant, and Corporate MDS Consultant were notified of Immediate Jeopardy on 6/1/17 at 9:41 AM. On 6/2/17 at 5:30 PM the facility provided the following credible allegation of compliance: This allegation of compliance constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Allegation of Compliance (AoC) is not an admission that a deficiency exists or that one was cited correctly. This AoC is submitted to meet requirements established by state and federal law. On 4/12/17, resident #99 was noted in parking lot at 7:50 pm by the Dietary Manager as she was leaving. Resident was sitting at the beginning of the drive way. He was just looking around. The Dietary Manager called into the facility by mobile phone. She parked her car and approached resident. Eight staff members responded to the call and they assisted resident back into the building. Resident #99 did not resist. Facility nursing staff met them and returned him to the nursing unit. Upon re-entry into the building, Nurse #3 completed an assessment of the resident and he was placed on the secured unit. Nurse #3, assessed him and determined he had no injuries or adverse effects related to being outside. Resident exited front entrance door and the amount of time outside was unable to be determined. An Incident Report was completed on 4/12/17 by Nurse #3. Resident's Responsible Party (RP) was notified by phone at 8:15pm by the previous Director of Nursing (DON). His physician was notified by phone on 4/12/17 at 8:30pm by Nurse #3. The Administrator was in the facility at the time of occurrence and was notified immediately by the Assistant Director of Nursing (ADON). The ADON completed a Wandering Assessment on 4/12/17. The assessment indicated resident is a Definite Risk for elopement. The Administrator, DON and ADON made the decision that resident should be moved to the secured unit. The Administrator completed the initial 24 hour report for the state and faxed it in on 4/12/17 at 9:18pm. The Administrator met with Resident #99's RP on 4/13/17 at 2:00pm to discuss interventions. Resident #99's RP agreed for resident to be placed in secured unit at night and remain in unsecured nursing unit during the day. Resident #99's RP refused for him to be in the secured unit at all times as recommended by the Administrator. Resident #99's RP was upset that resident was continuing to stay on the secured unit at night. She felt resident was being confused by the movement between the front and the back of the building. During the daytime hours, resident's whereabouts was monitored by staff. Resident #99's RP, the Administrator and attending physician met on 4/26/17 to discuss his case. His physician and Resident #99's RP felt resident's behavior should be managed by medication since she was so adamant that she did not want him in the secured unit. Resident #99's RP and physician agreed to let him stay on the secured unit for two weeks to give the medication time to work. [MEDICATION NAME] 0.25 milligrams was ordered at 6 pm on 4/26/17 for signs and symptoms of sun downing. Due to nursing observation of resident becoming more anxious, roaming in and out of residents' rooms and restlessness from 2pm to 6pm in the afternoons, the physician increased the [MEDICATION NAME] on 5/24/17 to 0.5 mg and the administration time to 4 pm to manage his sun downing symptoms. The resident's anxiety and restlessness was improved with the increase in the [MEDICATION NAME]. 1. A physician's orders [REDACTED].#99 to the secured dementia unit. He was moved to the unit on 6/1/2017. 2. New wandering assessments were completed on all residents on 6/1/17 to identify all residents at risk of elopement. The Assistant Director of Nursing (ADON) and licensed nurses completed the assessments. Three residents residing in the unsecured part of the facility were identified. Alarms were installed on 4 exit doors that did not have alarms. The CNA's and Nurses were educated on the three newly identified residents at risk for elopement on 6/2/17 before 1:00pm. The Kardex was updated for those residents to show potential for elopement on 6/2/17 before 1:00pm. On 6/2/17, before 1:00pm, care plans for potential for elopement were developed for all identified resident's, including those in the secured unit. The elopement book was updated on 6/2/17 before 1:00pm by the Medical Records Clerk. 3. The wandering/elopement notebook will be reviewed/updated with all residents identified at risk for elopement as the assessments are completed. A picture will be placed with each resident's profile. This was done by the Medical Records Clerk and on 6/2/17 by 1:00 pm. The wandering/elopement notebook will be kept at the nurse's station. 4. Door alarms will be installed on the four exit doors that currently do not have alarms. The four doors are the exit door in the dining room, inside door to the service hall, the activity room and the front entrance door. The alarms were installed on 6/1/17 by the Administrator. These alarms will sound when the door is opened. The staff, to include weekend, prn and part time licensed and unlicensed, was educated by 6/2/17 at 1:00pm on alarms being placed on all exit doors, how to respond when an alarm is heard, including verifying who is opening the door and if no one is seen, then making sure to assess the outside area for a resident. 5. Care plans for resident's identified at risk will be reviewed and updated if indicated by the Nurse Assessment Coordinator (NAC) on 6/2/17 by 1:00pm. 6. The wandering and elopement policy was revised on 6/1/17 by the Corporate Clinical Nurse Consultant. Revisions to the policy included: assessment of residents at risk of elopement, reporting practices, correctible risk factors, care planning, documentation of unsafe actions of residents, reporting responsibilities, nursing service duties, what to do upon return of a resident who was observed leaving the facility, and discovery of a missing resident. Staff, to include weekend, prn and part time licensed and unlicensed, will be in-serviced on the facility's wandering and elopement policy by 6/2/17 at 1:00 pm. Education will address the following: The prevention of and response to a resident elopement as well as what should be done when a resident is newly identified as an elopement risk to prevent neglect. The staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or DON as directed in the facility policy; If an employee observes a resident attempting to leave the premises, he/she should attempt to prevent the departure, get help from other staff members in the immediate vicinity, if necessary and instruct another staff member to inform the charge nurse or DON that a resident has left the premises; what to do upon return of resident who was observed leaving the facility; and nursing services duties upon return of a missing resident. Education will be provided by the Administrator and ADON. Education will be placed in orientation for new employees. Any staff not in-serviced by this date and time will be required to complete the education prior to next shift worked. The credible allegation was validated on 6/2/17 at 5:30 PM. The survey team confirmed Resident #99 had a physician's orders [REDACTED]. The completion of wandering assessments, the updated Kardex for residents with potential for elopement, the updated care plans for residents with potential for elopement, and the updated wandering/elopement notebook was verified. The installation of alarms on the four exit doors was confirmed and observed to be working properly. Staff interviews verified education on the door alarms and the wandering and elopement policy that was revised on 6/1/17.

Based on observation, staff and resident interviews and record review, the facility failed to investigate the root cause of 2 falls and failed to monitor for delayed complications related to a fall for 1 of 2 sampled residents reviewed for accidents. Findings included: Resident #42 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #42's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment with no behaviors. He was coded as independent with transfers, bed mobility and ambulating in his room. Resident #42 was coded for supervision with ambulating in the halls, toileting, hygiene and bathing. He was coded as continent of bladder and bowel and not coded for any falls. Resident #42's Fall Risk Assessment was last updated 11/22/16 and it indicated moderate risk for falls. Resident #42 was care planned on 9/14/16 for a moderate risk for falls. This care plan was last reviewed on 11/29/16. Resident #42's care plan was updated on 1/25/17 to include actual falls with interventions to include frequent rounds, non-skid socks, re-education to call for assistance and a therapy referral. The most recent care plan revision dated 2/10/17 indicated Resident #42 was receiving physical therapy for muscle weakness and unsteady gait. A review of the facility policy titled Assessing Falls and Their Causes last revised October 2010 read nursing staff were to observe a resident after a fall for a delayed complication for approximately 48 hours after an observed or suspected fall. The policy also read that nursing staff were to identify the possible cause of the fall. A review of the incidents logs revealed Resident #42 sustained falls on 1/23/17, 1/25/17, and 2/6/17 and again on 2/22/17. The incident reports indicated the following: -1/23/17 at 5:10 PM, Resident #42 was found on the floor in front of his recliner. He stated he was getting up from the recliner to get into his wheelchair when he slipped onto the floor. There were no injuries. The root cause was indicated as poor safety awareness and unassisted transfer. It noted increased swelling to bilateral feet. Interventions included a therapy consult, neurological checks and he was encouraged to call for assistance with transfers. A review of the paper medical record revealed the nursing staff obtained neurological checks and monitored Resident #42 as ordered for the fall that occurred on 1/23/17 from his personal recliner. There was no mention of an assessment of how he transfers from his personal recliner as a potential fall hazard. -1/25/17 at 7:45 AM. Resident #42 was observed sitting on the floor in front of the toilet. He stated the wheelchair folded up behind him with the wheelchair brakes on. There were no injuries. He was barefooted. The root cause was listed as improper footwear and poor safety awareness. Interventions included a therapy consult, neurological check and non-skid socks. Resident #42 was also re-educated to call for assistance. A review of the paper medical record revealed the nursing staff failed to obtain neurological checks or document any monitoring after the fall that occurred on 1/25/17 while toileting. A therapy screen was completed and he was referred to restorative nursing for ambulation on 2/3/17. A review of the Restorative Care Flow Record for February 2017 in the paper medical record listed ambulation and active range of motion 6 days a week starting on 2/6/17 and indicated Resident #42 was discharged from restorative on 2/15/17. There were no minutes listed and no restorative aide (RA) initials indicating Resident #42 received services. -2/6/17 at 4:30 PM Resident #42 was observed sitting on the floor with his back against the wall next to the bathroom. He stated he was getting something in the closet and his legs became weak. He stated he leaned against the closet door and slid to the floor. There were no injuries. The root cause was identified as unsteady gait and lower extremity weakness. Resident #42 was encouraged to call for assistance with getting his clothes out of the closet, a therapy consult and neurological checks. A review of the paper medical record revealed the nursing staff obtained neurological checks and monitored Resident #42 as ordered for the fall that occurred on 2/6/17 while trying to retrieve clothes from his closet. -2/21/17 at 10:05 PM, Resident #42 was observed sitting upright in front of his recliner. He stated he was transferring from the recliner to the wheelchair to go to bed. The root cause was unsteady gait, unassisted transfers and poor safety awareness. Interventions included therapy consult, neurological check and re-education to call for assistance. The form indicated Resident #42 was already receiving physical therapy. A review of the paper medical record revealed the nursing staff obtained neurological checks and monitored Resident #42 as ordered for the fall that occurred on 2/21/17 from his personal recliner. There was no mention of an assessment of how he transfers from his personal recliner as a potential fall hazard. A review of the physical therapy discharge summary indicated Resident #42 was on caseload from 2/10/17 until 2/24/17 when he reached his maximum potential. A restorative referral was completed on 2/24/17. In an interview on 2/27/17 at 9:17 AM, Resident #42 cautioned the surveyor against sitting in his personal recliner because it would tip forward and it was easy to slide out onto the floor. He stated he had fallen twice trying to get up from the recliner. In an interview on 3/1/17 at 10:10 AM, RA #1 and RA #2 stated they did not recall doing restorative with Resident #42. RA #1 stated if he was on their caseload, they would have documented their minutes on the Restorative Care Flow Record. RA #1 and RA #2 stated they normally got their assignments from either the MDS nurse or the Staff Development Coordinator (SDC). In an interview on 3/1/17 at 3:00 PM, the rehabilitation director stated the facility met and reviewed falls weekly to find the root cause. She stated she did not realize until 3/1/17 that two of Resident #42 ' s occurred from his personal recliner. The rehabilitation director stated Resident #42 ' s family brought the recliner from home but it should have been assessed for safety and it should have been evaluated after he fell from it on 1/23/17. In an interview on 3/1/17 at 3:40 PM, the SDC stated he did not realize the fall on 1/23/17 and 2/21/17 were from Resident #42 ' s personal recliner. He stated the recliner should have been assessed for safety and if it needed some non-skid material in the seat or maybe needed to be removed, it should have been addressed before 3/1/17. The SDC stated it was the facility practice to do neurological checks and monitor residents who fall for 48 hours after the fall but was unable to explain why no follow up monitoring or assessment was done after the fall on 1/25/17. In an interview on 3/2/17 at 9:30 AM, the Director of Nursing stated it was her expectation that Resident #42's personal recliner would have been assessed for a possible fall hazard. She further stated it was her expectation that Resident #42 would have been monitored for 48 hours after his fall on 1/25/17.

Based on record review, observation and staff interview, the facility failed to provide catheter care and failed to secure the catheter tubing for 1 (Resident #4) of 1 sampled resident with an indwelling urinary catheter. Resident #4 had three hospitalization s with [DIAGNOSES REDACTED]. Findings included: Resident #4 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#4 had severe cognitive impairment and she was frequently incontinent of bladder. Resident #4 had a doctor's order dated 12/7/16 to insert an indwelling urinary catheter due to unstageable pressure ulcer on the left buttock. Resident #4's physician's orders [REDACTED]. Resident #4 did not have an order for [REDACTED]. Resident #4's care plan dated 12/8/16 was reviewed. One of the care plan problems was resident had an indwelling urinary catheter and she was at risk for increased UTI. The goal was the catheter would remain patent and the resident would not develop increased incidence of UTI over the next 90 days. The approaches included to change catheter tubing and bag per doctor's order, monitor urine for odor, sediments and amount of urine and report abnormal to the doctor, encourage fluid intake within dietary limits, keep tubing and bag below the bladder, do not kink tubing and catheter care per doctor's order. The care plan also indicated that Resident #4 had pulled out her urinary catheter on 12/22/16 and 2/27/17. The medical records of Resident #4 revealed that she was discharged to the hospital on [DATE], 1/12/17 and 2/10/17. The hospital records of Resident #4 were reviewed. The hospital discharge summary with admitted ,[DATE] through 12/20/16 revealed a [DIAGNOSES REDACTED]. The hospital discharge summary with admitted ,[DATE]/ through 1/16/17 revealed a [DIAGNOSES REDACTED]. The hospital discharge summary with admitted ,[DATE] through 2/17/17 revealed a [DIAGNOSES REDACTED]. On 2/28/17 at 4:10 PM, Resident #4 was observed in bed with an indwelling urinary catheter in place. The urinary catheter tubing was not secured during the observation. On 3/1/17 at 9:05 AM, Resident #4 was observed in bed with an indwelling urinary catheter in place. The urinary catheter tubing was not secured during the observation. On 3/1/17 at 9:06 AM, Nurse #3 was interviewed. Nurse #3 stated that she was the nurse assigned to Resident #4. She stated that the Treatment Nurse was responsible for providing catheter care and for ensuring the catheter tubing was secured. She also indicated that Resident #4 had history of pulling her catheter out and the last time she pulled it out was on 2/27/17. On 3/1/17 at 9:08 AM, NA #6 was interviewed. NA #6 stated that the nurses were responsible for catheter care but she had cleaned the urinary catheter during incontinent care when the resident had a bowel movement. On 3/1/17 at 9:12 AM, the Treatment Nurse was interviewed. She stated that the nurses working on the floor were responsible for providing catheter care and for securing the urinary catheter tubing. The Treatment Nurse indicated that she was only responsible for providing care to suprapubic catheter and not indwelling urinary catheter. At 10:40 AM, the Treatment Nurse indicated that Resident #4 had pulled out her catheter on 2/27/17 and the nurse, who reinserted the urinary catheter, forgot to secure the catheter tubing. On 3/2/17 at 10:45 AM, the Director of Nursing (DON) was interviewed. The DON stated that she expected the catheter tubing to be secured at all times and catheter care to be provided to residents with a urinary catheter. She also indicated that the nursing aides were responsible for providing catheter care every shift but she could not find documentation that catheter care was provided to Resident #4.

Based on observations, staff, resident and physician interviews and record review, the facility failed to obtain Urinalysis (UA) with Culture and Sensitivity (C&S) as ordered by the physician for 2 (Resident #3 and Resident #1) 4 residents reviewed for Urinary Tract Infection (UTI ' s) resulting [MEDICAL CONDITION] (harmful bacteria and their toxins in the blood) for Resident #3. The facility also failed to initiate treatment for [REDACTED].#2) of 4 residents reviewed for UTI ' s. Findings included: 1. Resident #3 was admitted [DATE] and readmitted [DATE] with cumulative [DIAGNOSES REDACTED]. His admission Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment, total assistance with toileting and hygiene. He was coded for a urinary catheter. A review of the comprehensive care plan dated 9/21/16 indicated Resident #3 had a urinary catheter and at an increased risk for UTIs. The staff were to monitor the urine for odor, color, sediments and amount and report abnormal evidence to the physician. A physician order [REDACTED]. A UA is a test to detect microorganism in the urine. The UA results dated 10/27/16 indicated Resident #3 ' s urine was cloudy, positive for White Blood cells, Red blood cells, and blood, protein and trace bacteria. There was no evidence the facility obtained the C&S results (test used to determine what antibiotic would be effective against the identified microorganism) or followed up on the results of the UA. A nursing note dated 11/6/16 indicated Resident #3 was sent to the hospital on [DATE] for increased lethargy. The hospital discharge summary dated 11/11/16 indicated Resident #3 was diagnosed with [REDACTED]. In an observation on 11/23/16 at 11:25 AM, Resident #3 was asleep in bed. The urinary drainage bag was attached to bed frame lower than the bladder. A privacy bag was in place. Urine in the tubing appeared cloudy and pale in color. The treatment nurse stated Resident #3 was readmitted with orders Hospice. In an interview on 11/23/16 at 11:40 AM, the Administrator and the Director of Nursing stated it was their expectation Resident #3 ' s ordered 10/26/16 UA with C&S would have been completed as ordered. In an interview on 11/23/16 at 11:50 AM, the Staff Development Coordinator (SDC) provided the facility copy of the completed lab requisition form dated 10/27/16. The requisition was coded as requesting a urinalysis with microscopic testing. Urine C&S was not circled as ordered on the sample. The SDC stated normally Nurse #1 took off the physician orders [REDACTED]. He stated it appeared the lab requisition form was completed by Nurse #4 and it was not completed properly to include the C&S and it was not added to the Lab Tracking Sheet for follow up. He stated he contacted the lab today and there was no record that a C&S was ordered for completed on the urine sample tested on [DATE]. In an interview on 11/23/16 at 12:05 PM, Nurse #4 stated she was not aware that the UA with a microscopic test was not the same as a C&S. Nurse #4 stated normally Nurse #1 completed all the lab requisition forms but on 10/26/16, she completed her own to help out or because Nurse #1 was not working. In an interview on 11/23/16 at 12:10 PM, Nurse #1 stated she had recently been out of work and usually in her absence, the SDC or the floor nurses took off their own orders. Nurse #1 stated if she was not working the nurses knew to complete their own lab requisition forms and review their own returned lab work and contact the physician with the lab results. In an interview on 11/23/16 at 12:30 PM, Physician #3 stated when he ordered the UA C&S on Resident #3, he expected the facility to have obtained the ordered test and to have followed up on the results and contacted him in order to initiate needed treatment if indicated. 2. Resident #2 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was cognitively intact with no behaviors. She was coded as requiring total assistance with assistance with transfers, limited assistance with hygiene and always incontinent of bladder and bowel. She was not coded as being on a toileting program. Resident #2 was coded as having a UTI in the last 30 days. She was care planned on 11/7/16 for UTI risk with an intervention to monitor for signs or symptoms of a UTI and report to the physician. On review of Resident #2 ' s medical record, it was noted Physician #1 ordered a Urinalysis with a Culture and Sensitivity (UA C&S) on 10/3/16. A review of the Lab Tracking Sheet dated 10/4/16 indicated Resident #2 had a UA C&S completed as ordered. A review of Resident #2 nursing note dated 10/5/16 dated she was experiencing nausea. Physician #1 was notified and orders were given for an antiemetic (medication to reduce nausea) and increase oral fluids. A nursing note dated 10/8/16 read there was a strong odor of urine around Resident #2. She was encouraged to increase her fluids and Resident #2 denied any symptoms of a UTI. The note was written by the previous Director of Nursing who was no longer employed at the facility. A nursing note 10/9/16 read noted aroma of strong urine in room around Resident #2. Education was provided on increasing fluids to manage concentrated urine. Resident #2 denied symptoms of a UTI. The note was written by the previous Director of Nursing who was no longer employed at the facility. A review of the UA C&S lab results print date at the laboratory 10/12/16 indicated greater than 100,000 colonies of [MEDICATION NAME] faecalis (a bacteria known to cause abdominal pain, urgency, nausea and vomiting). The C&S was not called and faxed to Physician #1 until 10/13/16 and orders were given to start an antibiotic on 10/14/16. During an interview and observation on 11/22/16 at 10:40 AM, Resident #2 stated early in her admission to the facility, she recalled having pain in her lower abdomen and being nauseous. She stated once she got started on an antibiotic, the pain started to subside. She stated the staff commented on how strong her urine smelled during that time too. Incontinence care observed at this time with Nursing Assistant (NA) #1 stated she was taught to clean a female resident from front to back and use a clean part of a cloth for each wash. There was no observed concerns. In an interview on 11/22/16 at 4:34 PM, the Staff Development Coordinator (SDC) stated he or Nurse #1 reviewed the lab work daily. Nurse #1 stated she recently been out of work recently and if she was not working the SDC would have sent the UA C&S results to the physician. Nurse #1 stated it took 72 hours to get a final C&S result to be sure the proper antibiotic was used to treat the UTI. Nurse #1 confirmed Resident #2 ' s C&S would have been available no later than 10/7/16 for Physician #1 to have initiated the proper treatment. The SDC stated nobody was assigned to follow up on outstanding lab work to ensure all lab results were obtained timely. In an interview on 11/22/16 at 4:40 PM, Nurse #2 she was working with Resident #2 on 10/5/16 and recalled speaking with Physician #1 about Resident #2 complaints of nausea. Physician #1 ordered something for her nausea and told the staff to encourage fluids. Nurse #2 stated she was not aware Physician #1 had ordered a UA C&S and did not think to check to see if the results were ready for Physician #1 to review. She stated Nurse #1 normally did all the lab review and follow up. Nurse #2 stated Physician #1 was in the facility several times each week and had she been aware of the UA C&S results, she would have treated it timely. In a telephone interview on 11/22/16 at 5:10 PM, Nurse #3 stated she was assigned Resident #2 on 10/13/16. She stated when UA C&S results came in, she called Physician #1 and also sent the results to the Physician #1 ' s office. In a telephone interview on 11/23/16 at 8:55 AM, Physician #1 stated since Resident #2 was exhibiting symptoms associated with an UTI and had a history of [REDACTED]. In an interview on 11/23/16 at 11:40 AM, the Administrator and the Director or Nursing stated it was their expectation the nursing staff who cared for Resident #2 would have followed up timely on the obtaining the C&S results and notified Physician #1 prior to 10/13/16 since she was having symptoms of a UTI. 3. Resident #1 was admitted [DATE] with a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment with verbal and physical behaviors. She was coded as total assistance with hygiene and as having a suprapubic catheter (urinary catheter inserted into the bladder through a hole in the abdomen) and always incontinent of bowel. She was care planned for the suprapubic catheter on 4/14/16 and last revised on 10/8/16. Interventions included monitoring for any changes such as blood in her urine, sediment, fever of foul smelling urine and notifying the physician. A review of Resident #1 Urine testing indicated the following: -On 6/27/16 an order for [REDACTED]. There was no evidence of a Culture and Sensitivity (C&S) in the medical record. - On 7/13/16 an order for [REDACTED]. In an observation on 11/22/16 at 10:10 AM, Resident #1 was lying in bed. Her urinary drainage bag was attached low to the bed frame and covered to ensure privacy. The urine in the catheter tubing appeared clear and pale yellow in color. There was no observed sediment or blood. Resident #1 appeared cooperative but uncertain of circumstances or surrounding. In an interview on 11/23/16 at 10:00 AM, the SDC stated at the time these test were ordered, there was nobody tracking the lab work and the nurses were taking off their own orders and completing the lab requisition forms. The SDC stated he was unable to locate the C&S results or the lab requisition form for 6/27/16. The SDC stated it was likely the UA with C&S ordered 7/13/16 was not done at all since the lab had no record of receiving or testing Resident #1 ' s urine in July 2016. In an interview on 11/23/16 at 11:40 AM, the Administrator and the Director of Nursing stated it was their expectation Resident #1 ' s ordered June and July UA with C&S would have been completed as ordered. In a telephone interview on 11/23/16 at 12:20 PM, Physician #2 stated if he ordered the UA C&S on the dates in question, he would have expected the testing to have been completed for Resident #1.

Based on record review and physician and staff interview, the facility failed to have the resident assessed/examined by a qualified person for possible injuries before moving a resident after the fall for 1 (Resident #5) of 1 sampled resident with a van accident. Resident #5 sustained a head injury and cervical strain from the fall. The facility also failed to treat wounds as ordered for 3 (Residents # 10, #11 and #13) of 3 sampled residents reviewed for wounds. Immediate Jeopardy began on 9/10/16 when Resident #5 was moved prior to have a qualified person assessed/examined her for possible injuries after the fall and was removed on 9/23/16 at 4:14 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for Residents #10, #11 & #13 and for Resident #5 to ensure all staff were in-serviced on facility's accident and incident policy and procedure. The findings included: The facility's policy and procedure for accident and incidents dated 3/11/04 was reviewed. The policy read in part Regardless of how minor an accident or incident may be, it must be reported to the department supervisor. Employees witnessing an accident or incident involving a resident must report the occurrence to his or her immediate supervisor as soon as possible. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance. The charge nurse must be informed of all accidents or incidents so that medical attention can be provided. Should you witness an accident or find it necessary to aid an accident victim, you should render immediate assistance. Do not move the victim until he/she has been examined for possible injuries. 1. Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #5's cognition was moderately impaired. The assessment also indicated that the resident was independent with transfers and needed limited assistance with ambulation. On 9/20/16 at 9:25 AM and on 9/21/16 at 9:25 AM, Resident #5 was interviewed. She stated that it was negligence on the part of the driver for not paying attention on what she was doing. Resident #5 stated the Van Driver was pushing her backward in wheelchair and the driver was facing the back door. The resident stated that the driver should have noticed that the lift was not up but the driver did not and she ended up falling. She indicated that she had bruises on her thigh, back and elbow from the fall. She revealed that she hit her head on something and was hurting bad. The resident indicated that she asked the driver to take her to the hospital because she was scared she might have broken bones. The resident stated that the driver should have called emergency medical services (EMS) and not picked her up and placed her back in wheelchair because she might have some broken bones but she did. The incident report dated 9/10/16 at 10:00 AM revealed that while removing Resident #5 from the van at the [MEDICAL TREATMENT] center, the resident who was sitting in a wheelchair fell from the van. The resident was taken to the emergency room immediately for evaluation. The written statement from Van Driver #1 dated 9/10/16 was reviewed. The written statement read I was at the [MEDICAL TREATMENT] office at 10:10 AM unloading residents. I unloaded the first patient. I thought I lifted the lift back up to prepare for the next resident to come off. By me thinking I already put the lift back up I got on the van through the side door. Unhooked her straps from the front and back and unfastened her seatbelt. I proceeded to push the resident back to the lift. When I realized I didn't have the lift part up I tried to pull her back but was unsuccessful and we both fell . I jumped up asked the resident if she was okay. I ran into the [MEDICAL TREATMENT] to get help. No one was in the front part. So I knocked on the side door, no one came. So I went back to the resident. Sat her up looked over her body real good. I ran back in to the [MEDICAL TREATMENT] to get help with putting her in the chair, no one came to the door again. So I went back to the resident asked her if she was feeling any pain anywhere. She said only her head and elbow. Once I found out what was wrong I went back in to [MEDICAL TREATMENT], knocked on door again, no one came. So I went back outside to the resident, picked her up and put her back in the wheelchair. She complained of her head hurting bad and said that she wanted to go to the hospital. So I went in to the [MEDICAL TREATMENT] so I could use the phone to call emergency medical service (EMS) and the facility, but no one came out again. So I went and told the resident I could not get nobody so I could the phone. She said once again that I wanna go to the hospital . So I loaded the resident in the van, strapped her down with all the necessary straps, buckled her seatbelt and proceeded to take her to the emergency room . At 10:38 AM, when I got to the emergency room . I unloaded the resident and took her inside the hospital. I told the hospital that we fell off the van and she hit her head and wanted to make sure she was okay. I used the security guard's phone to call the facility. I called the facility and got instructions to stay there with the resident. I spoke with the supervisor in charge. The emergency room (ER) discharge instruction dated 9/10/16 revealed [DIAGNOSES REDACTED]. On 9/20/16 at 10:20 AM, Van Driver #2 was interviewed. She stated that she was the transportation coordinator, worked Monday through Friday and at times on weekends. She indicated that she was trained not to move the resident after the fall. She stated that she would call the facility first and inform the nurse about the accident. Then she would follow the advice from the nurse to either call EMS or wait for the staff to come assess the resident. On 9/20/16 at 11:35 AM, the Director of Nursing (DON) was interviewed. The DON stated that she was informed on 9/10/16 that there was an accident involving the van. She stated that she expected the driver not to move the resident after the fall but the driver had tried to get some help but she could not find anybody. So the driver had to move the resident and took her to the ER. The DON further indicated that Van Driver #1 was not allowed to drive the van anymore and the rest of the drivers were reeducated on 9/10/16. On 9/20/16 at 2:52 PM, the Administrator and the DON were interviewed. The Administrator stated that she started working at the facility as an administrator 2 weeks ago. The DON stated that the department heads had been reviewing the incident reports on a daily basis and there were no other residents with the same incident happened in the past. The DON revealed that they had not been monitoring the van drivers before or after the 9/10/16 incident. On 9/20/16 at 3:10 PM, Van Driver #1 was interviewed. She stated that she was trained 2-3 months ago, on the proper use of the securement system in the facility van and on the proper use of the lift gate to load and unload residents safely. She stated that she had been driving the transport van for almost 2 months now. At the [MEDICAL TREATMENT] parking lot, she unloaded the first resident and took her to the [MEDICAL TREATMENT] clinic. She proceeded to unload the second resident, Resident #5. After she unstrapped and unbuckled her, she pushed her wheelchair backward to unload her from the van. She did not realize the lift gate was not up so she and the resident fell off the van. She revealed that she left the resident lying on the ground to get help from the [MEDICAL TREATMENT] clinic but she could not get any help. After several attempts of getting help, she picked the resident up and placed her in the wheelchair by herself. After Resident #5 was placed in the wheelchair, she unloaded the third resident and brought her to the [MEDICAL TREATMENT] clinic. Then she loaded Resident #5 into the van and took her to the emergency room . Van Driver #1 stated that Resident #5 was complaining that her head was hurting and she wanted to go to the ER. She stated that the facility's transport van had no cell phone and her personal phone was left at the facility for charging. She stated that she had no way to call EMS or the facility and she could not get any help, so she had to do something, which Van Driver #1 stated was to, pick the resident up and take her to the ER. The training records for Van Driver #1 were reviewed. The in-service sheet dated 7/14/16 indicated that Van Driver #1 was trained on the proper use of the securement system in the facility transport van to safely transport residents and on how to properly use the lift gate on the facility transport van to load and unload residents safely and all related safety procedures. There was no record that Van Driver #1 was trained on the facility's accident/incident policy and procedure on reporting and assessing the resident prior to driving the van. On 9/22/16 at 9:00 AM, Resident #5's attending physician was interviewed. She indicated that her expectation was for the Van Driver to call the facility staff or EMS to transport the resident to the ER after the fall. She added that she was told that the driver had tried to get help but was unable to get any help so she moved the resident by herself, placed her in wheelchair and took her to the ER. On 9/20/16 at 5:00 PM, the Administrator and the DON were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 9/23/16 at 4:14 PM. The credible allegation indicated: On September 10, 2016, Resident #5 was being transported to the [MEDICAL TREATMENT] center. Upon arrival, the transportation aide had unloaded another resident. When she returned, she came back in the van through the side door. She proceeded to unlock/unhook the resident in question and proceeded to unload the resident. At which time the lift was on ground level and was not level with the exit of the van. The transportation aide realized this when the audible alarm sounded to indicate something was wrong. She tried to stop the resident from exiting. The momentum pulled them both off the van, landing on the ground. This occurred at 10:10am. The transportation aide went inside the [MEDICAL TREATMENT] center three separate times and knocked on the treatment room door to try to get assistance. When she did not get anyone to come to the door and did not have a cell phone available (she left the cell phone at the facility to charge), she looked the resident over for any apparent injuries and asked the resident if she was in pain. Resident stated her head and elbow hurt and wanted to go to the emergency room . The transportation aide lifted the wheelchair with the resident in it to an upright position. She loaded the resident in the facility van to go to the emergency room for evaluation at 10:35 am. The resident was evaluated for injury in the emergency room due to complaints of headache and elbow hurting. On September 10, 2016, the transportation aide was removed from providing transportation services now and in the future. The transportation aide stated the incident was due to her human error. The facility reviewed residents that were potentially affected by the alleged deficient practice. It is determined that any resident who would require transportation on the facility van would be at risk. The Administrator and or Director of Nursing will in-service all staff on facility ' s accident/incident policy and procedure to include reporting and assessing residents. In-servicing began on September 20, 2016. Any one not in-serviced will be educated prior to the start of their next shift. Staff will seek appropriate medical assessment prior to moving residents who may be at risk for or have an injury, after an incident and or accident. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor. Employee witnessing an accident or incident involving a resident must report the occurrence to his or her immediate supervisor as soon as possible. Staff will be in-serviced upon new hire orientation regarding incidents and accident policy as well as the process for assessment by medical staff prior to moving resident after an accident or incident or possible injury by Staff Development Coordinator or assigned administrative nurse. The credible allegation was verified on 9/23/16 at 5:04 PM by interviewing the staff including the van drivers that they have received in-service on the facility's accident/incident policy and procedure. The in-service records were reviewed and the in-service on accident/incident policy and procedure was started on 9/20/16. Interview with the van drivers revealed that the in house transport was terminated and a third party transportation company would transport all residents for appointments. The transport van was observed parked out of service and the key was locked at the administrator's office. 2. Resident #10 was admitted to the facility on [DATE]. The annual Minimum Data Set ((MDS) dated [DATE] revealed he had moderate cognitive impairment and an indwelling catheter. His current [DIAGNOSES REDACTED]. Review of the care plan initiated 7/19/16 and updated on 7/21/16 revealed in part, for the nursing staff to provide suprapubic catheter care every shift and as needed. Review of the physician order [REDACTED]. Review of the physician order [REDACTED]. Review of the August 2016 treatment administration record (TAR) revealed suprapubic catheter documentation revealed the suprapubic catheter was not cleaned and changed on 8/6 ( Saturday), 8/7 (Sunday), 8/13 (Saturday), 8/14 (Sunday), 8/15 (Monday), 8/20 (Saturday) or 8/21 (Sunday). Additionally, suprapubic catheter documentation revealed the suprapubic catheter was not cleaned and changed on 8/20 (Saturday) and 8/21 (Sunday), with Santyl and Mipirocin 2% ointment. Review of the September 2016 TAR revealed the suprapubic catheter dressing change was documented as not done on 9/10 (Saturday) or 9/11 (Sunday). During interview on 9/20/16 at 2:33pm, Nurse #1, the wound care nurse, indicated the weekend nurse supervisor changed the dressings on the weekend. When the nursing supervisor worked on a hall passing medications, all nurses were responsible to do the treatments of their assigned residents. During an interview on 9/21/16 at 5:15pm, a family member of Resident #10 indicated his suprapubic catheter dressing changes were not done every weekend. During an interview on 9/22/16 at 8:10am, Nurse #1 indicated treatment were not done when she was off during the week or on the weekends. On 9/22/16 at 8:43pm, Nurse #1 was observed during the suprapubic dressing change. The suprapubic site was observed to have a scant amount of dried exudate and pink tissue from around the incision site. There was no foul odor. The site was cleaned with normal saline and covered with a split gauze and paper tape. During an interview via telephone on 9/22/16 at 10:00am, Nurse #4 indicated she had not done any dressing changes until after 8/20/16. The schedule revealed she was assigned to do the treatment on 8/15/16 (Monday). During an interview via telephone on 9/22/16 at 2:22pm, Nurse #9 (weekend supervisor), revealed she was responsible to complete the weekend treatments. When she worked on the hall with a resident assignment the treatments were delegated to the nurses who had the assigned residents. She indicated she had elected to do the treatments scheduled for twice a day and not to do the suprapubic dressing changes. The schedule revealed she was assigned to do Resident #10 suprapubic treatment on 8/6/16 (Saturday). During an interview via telephone on 9/22 at 4:48pm, Nurse # 12 revealed she was not hired to do treatments. She was hired to pass medication. She had not done any treatments. She was assigned to do the suprapubic dressing changes on 8/7 (Sunday), 8/14 (Sunday), 8/20 (Saturday) and 8/21 (Sunday). Nurse #15 was not available for interview. She was assigned to do the dressing change on 8/13 (Saturday). During interview on 9/22/16 at 5:30pm, the Director of Nursing indicated that nurses were expected to do the treatments of the residents they were assigned and to document after each shift. 3. Resident # 11 was admitted to the facility on [DATE]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that she had severe cognitive impairment and a wound. The most recent [DIAGNOSES REDACTED]. Review of the most recent wound care plan dated 1/8/16, revealed in part, wound care was to be done as ordered to the lesion on the medial back. Review of the physician order [REDACTED]. Review of the physician order [REDACTED]. Clarification order was added on 8/26/16, to apply the [MEDICATION NAME] for a total of 1 month. Review of the July 2016 treatment administration record (TAR) revealed that treatment to the wound of Resident #10 was not documented as done on 7/2 (Saturday), 7/3 (Sunday) and on 7/24 (Sunday). Review of the August 2016 TAR revealed the wound treatment was documented as not done on 8/5 (Friday), 8/7 (Sunday), 8/13 (Saturday), 8/14 (Sunday), 8/15 (Monday) or on 8/21 (Sunday). The [MEDICATION NAME] was not administered to the wound on 8/20 (Saturday) and 8/21 (Sunday). Review of the September 2016 TAR revealed wound treatment was documented as not done and the [MEDICATION NAME] was documented as not administered on 9/10 (Saturday). During an interview on 9/20/16 at 2:33pm, Nurse #1, the wound care nurse, indicated the weekend nurse supervisor changed the dressings on the weekend. When the nursing supervisor worked on a hall passing medications, all nurses were responsible to do the treatments of their assigned residents. During interview on 9/21/16 at 8:35am, Nurse #1 indicated the wound was changed daily due to the tissue necrotization. A crushed 500 mg [MEDICATION NAME] tablet was used in the wound bed. The management of the wound was dressing changes. During the dressing change observation on 9/22/16 at 8:10am, revealed a large clean pink wound with dark rolled edges and no odor. The wound was cleaned with normal saline and dressed with Clebetasol, calcium alginate and [MEDICATION NAME] and dressed. During interview on 9/22/16 at 8:10am, with Nurse #1, she indicated this wound was not always being changed while she was out on vacation and on the weekends. She produced the medication card of [MEDICATION NAME] and indicated the pills were still in the card when she returned from the weekend. During an interview on 9/22/16 at 9:20am, the Physician indicated Resident #11 dressing changes were required for the wounds to be clean and the dressing to be changed daily with [MEDICATION NAME] to promote the healing of the wound. During an interview via telephone on 9/22/16 at 11:15 am, Nurse #6 indicated she had not worked any weekends. She indicated she worked with Resident # 11 and changed the dressing on her left shoulder that had a cause an ulcer to her back. She was unable to recall the treatment. Nurse # 6 was assigned to do wound care to Resident #11's back on 8/5/16 (Friday). During an interview via telephone on 9/22/16 at 1:43pm, Nurse # 8 indicated the wound care nurse or the weekend supervisor completed the dressings and the treatments. The supervisor delegated the nurses when to do treatments and dressings. The TAR was kept on the wound cart. She wasn't aware of any treatment she had missed. Review of the schedule revealed Nurse #8 was scheduled to do the treatment on 7/2(Saturday) and 7/3 (Sunday). During an interview via telephone on 9/22 at 4:48pm. Nurse # 12 revealed she was not hired to do treatments. She was hired to pass medication. She had not done any treatments. She was assigned to do the dressing changes on Resident #11 on 7/24 (Sunday), 8/7 (Sunday), 8/14 (Sunday) and 8/21(Sunday). Nurse # 14 the assigned nurse for the hall on 9/10/16 (Saturday) was not available for interview. During interview on 9/22/16 at 5:30pm, the Director of Nursing indicated that nurses were expected to do the treatments of the residents they were assigned and to document after each shift. 4. Resident # 13 was admitted on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was cognitively intact and with gangrene to her left foot and right toes. Her [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the September 2016 treatment administration record (TAR) revealed the treatment was documented as not done on 9/10/16 (Saturday) and 9/11/16 (Sunday). During an interview on 9/20/16 at 2:27pm, Nurse # 1, the wound care nurse, revealed it was important to keep the heel painted with [MEDICATION NAME] to prevent the spread of gangrene. During interview on 9/20/16 at 2:47pm, Resident #13 indicated the [MEDICATION NAME] was applied to her feet most days. During a wound observation on 9/21/16 at 7:00am, of the left and right feet, revealed a darkened toes and amputation of the small toes on the right foot and partially amputated 1st toe and total amputation of the 2nd toe. Mild [MEDICAL CONDITION] was noted to both feet. Nurse #1 painted the foot and heel with [MEDICATION NAME] bilaterally and let it dry and reapplied the heel protector. During an interview on 9/22/16 at 8:10am, Nurse #1, the wound care nurse, indicated treatment were not done when she was off during the week or on the weekends. During an interview via telephone on 9/22/16 at 2:22pm, Nurse #9 (weekend supervisor), revealed she was responsible to complete the weekend treatments. When she worked on the hall with a resident assignment the treatments were delegated to the nurses who had the assigned residents. She indicated she changed the stage 3 and 4 pressure ulcers dressings and dressings that were scheduled for twice a day, the remaining treatments were omitted. Nurse #9 was scheduled to provide treatments on 9/10 and 9/11/16. Nurse # 14 the assigned nurse for the hall on 9/10 and 9/11 was not available for interview. During interview on 9/22/16 at 5:30pm, the Director of Nursing indicated that nurses were expected to do the treatments of the residents they were assigned and to document after each shift.

Based on record review, observation and resident, physician and staff interview, the facility's administration failed to effectively manage and to have an effective system in place to maintain compliance with F323 as evidenced by repeated immediate jeopardy citations at F323 during the recertification survey of 2/4/16 and 3/26/15 and complaint investigation survey of 9/23/16 and failed to provide a communication device in the transportation van for use in case of emergency for 1 (Resident #5) of 1 sampled resident with a van accident. The facility failed to have a resident assessed/examined by a qualified person for possible injuries before moving a resident after the fall for 1 (Resident #5) of 1 sampled resident with a van accident (F309). The facility failed to provide adequate staff to provide wound care per physician orders [REDACTED].#9, # 10, #13 and #11) of 6 residents reviewed for wound care (F224, F309, F314, F353). Immediate Jeopardy (IJ) began on 9/10/16 when Resident #5 fell off the transportation van and was moved before a qualified person assessed/examined her for possible injuries and the IJ was removed on 9/23/16 at 4:14 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff were in-serviced on facility's accident/incident policy and procedure and to correct deficient practice for residents #9, #10, #11 and #13 which was cited at a scope and severity of an E. Findings included: This tag is cross referred to: 1. F323 - Based on record review and staff interview, the facility failed to raise the lift gate up before pushing the resident who was sitting in a wheelchair out of the transport van causing the resident to fall backward for 1 (Resident #5) of 1 sampled resident with a van accident. Resident #5 sustained a head injury and cervical strain from the fall. The facility was cited F323 during the recertification survey of 2/4/16 at immediate jeopardy level for not securing the resident and the wheelchair in the transportation van during transport causing the resident to have a fall. The facility was cited F323 during the recertification survey of 3/26/15 at immediate jeopardy level for not maintaining the water temperatures at or less than 116 degrees Fahrenheit. 2. F309 - Based on record review and physician and staff interview, the facility failed to have the resident assessed/examined by a qualified person for possible injuries before moving a resident after the fall for 1 (Resident #5) of 1 sampled resident with a van accident. Resident #5 sustained a head injury and cervical strain from the fall. The facility also failed to treat wounds as ordered for 3 (Residents # 10, #11 and #13) of 3 sampled residents reviewed for wounds. On 9/20/16 at 2:52 PM, the administrator and the Director of Nursing (DON) were interviewed. The administrator stated that she started working at the facility as an administrator 2 weeks ago. She stated that she could call her Regional Vice President for any questions. She indicated that a cell phone will be placed in the van permanently for the staff to use in case of emergency. The DON stated that the accident was a human error. On 9/20/16 at 5:00 PM, the Administrator and the DON were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 9/23/16 at 4:14 PM. The credible allegation indicated: On September 10, 2016, resident was being transported to the [MEDICAL TREATMENT] center. Upon arrival, the transportation aide was unloading the resident and the resident fell off the back of the 10:10 am. The transportation aide tried to get assistance from the [MEDICAL TREATMENT] center to no avail. The transportation aide ensured the resident was safe and transported her to the emergency room for evaluation 10:35 am. The facility transportation aide was suspended on September 10, 2016 at 12:12 pm permanently from driving the van. Facility transportation was suspended on September 10, 2016 and any resident that still required transportation services was routed to a third party transport company. The full time transportation aide called the third party transport company to set up appointments. The vehicle was inspected on September 12, 2016 for proper working order of the by the servicing agent. The lift on the van was found to be in proper working order. Transportation services were resumed by facility transportation aides on September 13, 2016. The Administrator and or Director of Nursing will in-service all staff on facility's accident/incident policy and procedure to include reporting and assessing residents. In-servicing began on September 20, 2016. Any one not in-serviced will be educated prior to the start of their next shift. Staff will seek appropriate medical assessment prior to moving residents who may be at risk for or have an injury, after an incident and or accident. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor. Employee witnessing an accident or incident involving a resident must report the occurrence to his or her immediate supervisor as soon as possible. Currently, the facility (nursing administration and department heads) meet daily Monday through Friday in stand up meeting and reviews incidents and accident reports. The facility meets monthly to review in QA meeting any accident and or incidents to monitor trends and compliance of current practices. As of September 22, 2016 at 5:00pm, it has been determined to ensure 100% safety for all residents, in-house transportation has been terminated. All resident transport will be provided by a third party transportation company. The van has been parked and locked up in the facility parking lot. In-servicing began on September 22, 2016. Any one not in-serviced will be educated prior to the start of their next shift. The keys for the van are locked up in the Administrator's office in a locked box. During the QA meeting, areas of identified concern will be addressed by the committee. And in turn the staff will be educated during the staff meetings held by the administrative staff. Education will consist of on one to two policies identified per meeting to educate and set expectations to adhere to these policies. If these policies and procedures are not adhered to, disciplinary action will take place up to and including termination. The Administrator will oversee the adherence to the education schedule and policy adherence. The Regional Vice President will oversee the Administrator for overall compliance of facility policy and procedures. The credible allegation was verified on 9/23/16 at 5:04 PM by interviewing the staff including the van drivers that they have received in-service on the facility's accident/incident policy and procedure. The in-service records were reviewed and it was started on 9/20/16. Interview with the van drivers revealed that the in house transport was terminated and a third party transportation company would transport all residents for appointments. The transport van was observed parked out of service and the key was locked at the administrator's office. 2. F224 - Based on record review, observation and physician, resident and staff interview, the facility neglected to provide wound treatment as ordered by the physician for 4 (Residents #9, # 10, #11 and #13) of 6 sampled residents reviewed for wound treatment. During an interview on 9/22/16 at 3:06 pm, the Director of Nursing (DON) indicated she was not told that the treatments were not being completed on the weekends. She indicated she had heard murmurs that the nurses had no time to get treatments done. She indicated she felt the nurses were refusing to do the treatments because they had been swamped with staffing issues. 3. F314 - Based on record review, observation, resident and staff interview, the facility failed to treat the pressure ulcers as ordered on weekends for 2 of 3 sampled residents with pressure ulcers (Resident#9 and #13). During an interview on 9/22/16 at 3:06 pm, the Director of Nursing (DON) indicated she was not told that the treatments were not being completed on the weekends. She indicated she had heard murmurs that the nurses had no time to get treatments done. She indicated she felt the nurses were refusing to do the treatments because they had been swamped with staffing issues. 4. F353 - Based on record review, observation, and physician, resident and staff interview, the facility failed to have adequate staff to ensure treatments to pressure ulcers and wounds were provided as ordered for 4 (Residents #9, # 10, #11 and #13) of 6 sampled residents reviewed for pressure ulcers and wounds. During an interview on 9/22/16 at 2:22 PM, Nurse #9, the weekend supervisor, indicated she had reported to the Director of Nursing that the treatments had not been done because of shortage of staff on the weekends. She indicated there wasn't always a nurse to call in for work and she had to take a resident assignment. On 9/22/16 at 3:06 PM, the Director of Nursing (DON) was interviewed. The DON stated that the facility had a full time treatment nurse who was scheduled to provide the treatments Monday through Friday. The weekend supervisor was responsible to provide the treatment on the weekends. She added that she had heard murmurs that the nurses had no time to get wounds done. She indicated she felt the nurses were refusing to do the treatments because the facility had been swamped with staffing issues, three months ago when there were aides and nurses that quit.

Based on record review, observation and physician, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedure and failed to monitor the interventions put into place following the 2/4/16 recertification survey. The facility has repeated deficiencies on accidents (F323), and care and services (F309) on the recertification survey of 2/4/16 and on the complaint survey of 9/25/16. The facility had systemic failure to treat pressure sores as ordered by the physician (F314). The continued failure of the facility during the two federal surveys of record and the systemic failure to treat pressure sores as ordered showed a pattern of the facility's inability to sustain an effective QAA program. Immediate Jeopardy (IJ) began on 9/10/16 when Resident #5 fell off the transportation van and the IJ was removed on 9/23/16 at 4:14 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) for Residents' # 9, #10, #11 and #13) and to ensure all staff were in-serviced on the facility's accident/incident policy and procedure. Findings included: This tag is cross referred to: 1. F323 - Based on record review and staff interview, the facility failed to raise the lift gate up before pushing the resident who was sitting in a wheelchair out of the transport van causing the resident to fall backward for 1 (Resident #5) of 1 sampled resident with a van accident. Resident #5 sustained head injury and cervical strain from the fall During the recertification survey of 2/4/16, the facility was cited F323 for not properly securing the resident and the wheelchair in the transport van, failed to notify the administrator about the incident and failed to complete a root cause analysis of the incident. On 9/20/16 at 2:52 PM, the administrator and the DON were interviewed. The administrator stated that she started working at the facility as an administrator 2 weeks ago. The DON stated that the department heads had been reviewing the incident reports on a daily basis and there were no other residents with the same incident happened in the past. The DON revealed that they had not been monitoring the van drivers before or after the 9/10/16 incident. The Administrator stated that the previous administrator might have done the monitoring for the duration stated on the plan of correction from the last survey. 2. F309 - Based on record review and physician and staff interview, the facility failed to have the resident assessed/examined by a qualified person for possible injuries before moving a resident after the fall for 1 (Resident #5) of 1 sampled resident with a van accident. Resident #5 sustained a head injury and cervical strain from the fall. The facility also failed to treat the wounds as ordered for 3 (Residents # 10, #11 & #13) of 3 sampled residents reviewed for wounds. During the recertification survey of 2/4/16, the facility was cited F309 for not providing psychological interventions for 2 of 2 sampled residents. On 9/20/16 at 2:52 PM, the administrator and the DON were interviewed. The administrator stated that she started working at the facility as an administrator 2 weeks ago. The DON revealed that they had not been monitoring the van drivers before or after the 9/10/16 incident. The Administrator stated that the previous administrator might have done the monitoring for the duration stated on the plan of correction from the last survey. On 9/20/16 at 5:00 PM, the Administrator and the DON were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 9/23/16 at 4:14 PM. The credible allegation indicated: The QA committee meets every month and discusses all incidents and accidents. The monitoring tools were in place as per the plan of correction from the prior incident in February 2016. There were no issues regarding transportation. However, in this incident, the accident stemmed from human error. Currently, the facility (nursing administration and department heads) meet daily Monday through Friday in stand up meeting and reviews incidents and accident reports. The QA committee (Administrator, Director of Nursing, Staff Development Coordinator, Social Worker, Dietary Manager, Environmental Services Manager, Medical Director, Activities Supervisor, Maintenance Director, Medical Records and MDS Coordinator) meets monthly to review in QA meeting any accident and or incidents to monitor trends and compliance of current practices. The facility had an emergency QA meeting on 9/20/16 to discuss the four IJ tags listed above to implement measures to ensure the continued safety and well- being of all the residents in the facility. Our current policy and procedures in place were adequate for the safety of residents during transportation. This incident was a result of human error. There is an audible alarm signal in place in the van when improper use of the lift is occurring. This system was operating properly when this incident occurred. Every month the QA meeting minutes will be sent to corporate office for review to provide collaboration on any identified issues. Consultants will provide assistance with these issues identified. Every week the incident and accident log will be sent to corporate office for review for six months and monthly thereafter. The corporate office and consultants will review and provide assistance to ensure the processes are being followed according to policy. A member of the corporate staff will be on-site during the quarterly QA meetings to ensure the facility is following policies. The credible allegation was verified on 9/23/16 at 5:04 PM by interviewing the staff including the van drivers that they have received in-service on the facility ' s accident/incident policy and procedure. The in-service records were reviewed and it was started on 9/20/16. Interview with the van drivers revealed that the in house transport was terminated and a third party transportation company would transport all residents for appointments. The transport van was observed parked out of service and the key was locked at the administrator's office. 3. F314- Based on record review, observation, resident and staff interview, the facility failed to treat the pressure ulcers as ordered on weekends for 2 of 3 sampled residents with pressure ulcers (Resident#9 and #13).

Based on record review, observation and staff interview, the facility failed to raise the lift gate up before pushing the resident who was sitting in a wheelchair out of the transport van causing the resident to fall backward for 1 (Resident #5) of 1 sampled resident with a van accident. Resident #5 sustained a head injury and cervical strain from the fall. Immediate Jeopardy began on 9/10/16 when Resident #5 fell off the transpiration van and was removed on 9/23/16 at 4:14 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff were in-serviced on the facility's accident/incident policy and procedure. The findings included: Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #5's cognition was moderately impaired with the Brief Interview for Mental Status (BIMS) score of 11, independent with transfers and needed limited assistance with ambulation. On 9/20/16 at 9:25 AM and on 9/21/16 at 9:25 AM, Resident #5 was interviewed. She stated that it was negligence on the part of the driver for not paying attention on what she was doing. The Van Driver was pushing her backward in wheelchair and the driver was facing the back door. The driver should have noticed that the lift was not up but the driver did not and she ended up falling. She had bruises on her thigh, back and elbow from the fall. She hit her head on something and was hurting bad. She asked the driver to take her to the hospital because she was scared she might have broken bones. The incident report dated 9/10/16 at 10:00 AM revealed that while removing Resident #5 from the van at the dialysis center, the resident who was sitting in a wheelchair fell from the van. The resident was taken to the emergency room immediately for evaluation. The written statement from Van Driver #1 (driver of the van during the accident) dated 9/10/16 was reviewed. The written statement read I was at the dialysis office at 10:10 AM unloading residents. I unloaded the first patient. I thought I lifted the lift back up to prepare for the next resident to come off. By me thinking I already put the lift back up I got on the van through the side door. Unhooked her straps from the front and back and unfastened her seatbelt. I proceeded to push the resident back to the lift. When I realized I didn't have the lift part up. I tried to pull her back but was unsuccessful and we both fell . I jumped up asked the resident if she was okay. I ran into the dialysis to get help. No one was in the front part. So I knocked on the side door, no one came. So I went back to the resident. Sat her up, looked over her body real good. I ran back in to the dialysis to get help with putting her in the chair, no one came to the door again. So I went back to the resident asked her if she was feeling any pain anywhere. She said only her head and elbow. Once I found out what was wrong I went back in to dialysis, knocked on door again, no one came. So I went back outside to the resident, picked her up and put her back in the wheelchair. She complained of her head hurting bad and said that she wanted to go to the hospital. So I went in to the dialysis so I could use the phone to call emergency medical service (EMS) and the facility, but no one came out again. So I went and told the resident I could not get nobody so I could the phone. She said once again that I wanna go to the hospital . So I loaded the resident in the van, strapped her down with all the necessary straps, buckled her seatbelt and proceeded to take her to the emergency room . At 10:38 AM, when I got to the emergency room . I unloaded the resident and took her inside the hospital. I told the hospital that we fell off the van and she hit her head and wanted to make sure she was okay. I used the security guard's phone to call the facility. I called the facility and got instructions to stay there with the resident. I spoke with the supervisor in charge. The emergency room discharge instruction dated 9/10/16 revealed [DIAGNOSES REDACTED]. On 9/20/16 at 10:20 AM, Van Driver #2 was interviewed. She stated that she was the transportation coordinator, worked Monday through Friday and at times on weekends. She indicated that she was trained not to move the resident after the fall. She stated that she would call the facility first and inform the nurse about the accident. Then she would follow the advice from the nurse to either call EMS or wait for the staff to come assess the resident. On 9/20/16 at 11:20 AM, the transport van was observed. The lift gate was observed at the back of the van. The lift gate can go up or down using a switch. The lift gate was used to load and unload the resident from the van. The lift was observed to be working properly at this time. On 9/20/16 at 11:35 AM, the DON was interviewed. She stated that she was informed on 9/10/16 that there was an accident involving the van. She was told that the Van Driver was in the process of unloading Resident #5 from the van at the dialysis parking lot. Apparently, the lift was not up and the resident fell backwards and the driver fell on top of the resident. She added that it was a human error on the part of the driver. On 9/20/16 at 2:52 PM, the administrator and the DON were interviewed. The administrator stated that she started working at the facility as an administrator 2 weeks ago. The DON stated that the department heads had been reviewing the incident reports on a daily basis and there were no other residents with the same incident happened in the past. She revealed that they had not been monitoring the van drivers on proper use of lift gate before or after the 9/10/16 incident. She further indicated that they figured out that the root cause of the accident was the driver exited the van via the lift gate and entered the van via the side door instead of using the lift gate. On 9/20/16 at 3:10 PM, Van Driver #1 was interviewed. She stated that she was trained on the proper use of the securement system in the facility van and on the proper use of the lift gate to load and unload residents safely last 2-3 months ago. She stated that she had been driving the transport van for almost 2 months now. She stated that she was transporting 3 residents to the dialysis center that Saturday of 9/10/16. She was already late because 1 resident was not ready yet that morning so she was rushing. At the dialysis parking lot, she unloaded the first resident and took her to the dialysis clinic. She proceeded to unload the second resident, Resident #5. After she unstrapped and unbuckled her, she pushed her backward in wheelchair to unload her from the van. She did not realize the lift gate was not up so she and the resident fell off the van. She revealed that she left the resident lying on the ground to get help from the dialysis clinic but she could not get any help. After several attempts of getting help, she picked the resident up and placed her in the wheelchair by herself. After Resident #5 was placed in the wheelchair, she unloaded the third resident and brought her to the dialysis clinic. Then she loaded Resident #5 into the van and took her to the emergency room . Van Driver #1 stated that Resident #5 was complaining that her head was hurting and she wanted to go to the ER. She stated that the facility's transport van had no cell phone and her personal phone was left at the facility for charging. She stated that she had no way to call EMS or the facility and she could not get any help, so she had to do something, picked the resident up and took her to the ER. The training records for Van Driver #1 were reviewed. The in-service sheet dated 7/14/16 indicated that Van Driver #1 was trained on the proper use of the securement system in the facility transport van to safely transport residents and on how to properly use the lift gate on the facility transport van to load and unload residents safely and all related safety procedures. On 9/22/16 at 5:00 PM, the administrator was interviewed. She stated that the decision was made to terminate the use of the in house transportation and a third party transportation company would transport all residents to and from appointments. On 9/20/16 at 5:00 PM, the Administrator and the DON were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 9/23/16 at 4:14 PM. The credible allegation indicated: On September 10, 2016, Resident #5, was being transported to the dialysis center. Upon arrival, the transportation aide had unloaded another resident. When she returned, she came back in the van through the side door. She proceeded to unlock/unhook the resident in question and proceeded to unload the resident. At which time the lift was on ground level and was not level with the exit of the van. The transportation aide realized this when the audible alarm sounded to indicate something was wrong. The transportation aide was pushing the resident and tried to stop the resident from exiting. The momentum pulled them both off the van, landing on the ground. This occurred at 10:10am. The transportation aide tried to get assistance from the dialysis center on three occasions to no avail. (The facility's transportation policy does not dictate cell phone necessity.) The transportation aide looked the resident over for any apparent injuries and asked the resident if she was in pain. Resident stated her head and elbow hurt and wanted to go to the emergency room . The transportation aide placed the resident back in her wheelchair and transported her via facility van to the emergency room for evaluation at 10:35 am. The resident was evaluated for injury in the emergency room due to complaints of headache and elbow hurting. The Emergency department performed a Head Computed Tomography (CT) scan and there were no skull fractures or anomalies. The resident was released from the hospital and was prescribed to take a pain medication every four to six hours as needed and follow up with attending physician as needed. Resident was transported back to the facility at 6:00 pm via the transport company with pain medication and an abrasion to elbow. The transportation aide contacted the facility as soon as she had access to a telephone on September 10, 2016 at 10:40am. The transportation aide left her cell phone at the facility due to needing to be charged. The Weekend supervisor was updated, the Director of Nursing was contacted at 11:42 am and an incident/occurrence sheet and investigation was started to ensure safe practices were in place. Administrator was updated at 11:46 am and made aware of incident and plan of investigation. The Regional Vice President was made aware at 11:56 am. The Physician was notified on September 10, 2016 at 4:03 pm and the responsible party was notified on September 10, 2016 at 1:00 pm. The facility transportation aide was suspended on September 10, 2016 at 12:12 pm and any resident that still required transportation services was routed to transport company. The facility reviewed residents that were potentially affected by the alleged deficient practice. It is determined that any resident who would require transportation on the facility van would be at risk. On September 20, 2016, a 100% audit was completed for current residents with or without transports with no injuries. The transportation aide involved was interviewed for details of fall by Director of Nursing and root cause analysis was established on September 10, 2016. On September 10, 2016, the transportation aide was removed from providing transportation services now and in the future. The transportation aide stated the incident was due to her human error. The Director or Nursing called in the current transportation aides on September 10, 2016 to be in-serviced with new process for the exiting and reentering of the van during transports. We have three active transportation aides, training began on September 10, 2016 through September 11, 2016. On September 12, 2016, the lift on the van was inspected for proper working order by servicing agent. The lift for the van is in proper working order per the servicing agent. The suspension of transportation services was discontinued on September 13, 2016 after in-service of process and new safety measures was implemented. The in-service entailed exiting and entering the van in the same manner as to assure the lift is in the proper position for loading and unloading of residents. Added to the pre-trip daily inspection report for transport driver form was the additional check for access to cell phone for emergencies with a charging system in place on September 20, 2016. All transportation aides were in-serviced on this on September 20, 2016 through September 21, 2016 by Administrator and or Director of Nursing. As of September 22, 2016 at 5:00pm, it has been determined to ensure 100% safety for all residents, in-house transportation has been terminated. All resident transport will be provided by a third party transportation company and any future transport companies identified. The van has been parked and locked up in the facility parking lot. The transportation aides, department heads and administrative nurses were notified of the termination of in house transports for residents on September 22, 2016 at 5:00 pm. The keys for the van are locked up in the Administrator's office. The credible allegation was verified on 9/23/16 at 5:04 PM by interviewing the staff including the van drivers that they have received in-service on the facility's accident/incident policy and procedure. The in-service records were reviewed and it was started on 9/20/16. Interview with the van drivers revealed that the in house transport was terminated and a third party transportation company would transport all residents for appointments. The transport van was observed parked out of service and the key was locked at the administrator's office.

Based on observations, record reviews, resident and staff interviews, the facility's Quality Assessment and Assurance committee (QAA) failed to maintain implemented procedures and monitor these interventions that the committee put into place in March of 2015. This was for five (5) recited deficiencies which were originally cited on 3/26/15 during the recertification survey and on the current recertification/complaint investigation survey (F278, F279, F323, F329 and F490). The continued failure of the facility during the two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: Immediate jeopardy began on 1/8/16 for F323 at scope/ severity (s/s) J, F490 s/s J and F520 s/s J and was removed on 2/4/16 at 6:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems have been put into place and are effective, the facility van has the appropriate securement system installed and all staff have been in-serviced. F278 is cited at s/s D, F279--s/s D and F329-s/s D. This tag is cross referred to: 1. F323: Accidents: Based on observation, record review, resident and staff interviews, the facility failed to properly secure one of one sampled residents reviewed for accidents (Resident #97) and the wheelchair in the transportation van according to manufacturer's instructions resulting in Resident #97 tipping over in the wheelchair and hitting her right stump on the floor of the van, failed to immediately notify administration about the accident and failed to complete a root cause analysis of the incident. During the recertification survey of 3/26/15, the facility was cited F323 for failure to maintain water temperatures at or less than 116 degrees Fahrenheit (F) in eight (8) of eleven (11) resident's rooms (room [ROOM NUMBER],#103,#114,#201,#202,#203,#215,#302) and two (2) of two (2) central bathrooms (100 and 400 hall). Immediate jeopardy began on 1/8/16 and was removed on 2/4/16 at 6:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems have been put into place and are effective, the facility van has the appropriate securement system installed and all staff have been in-serviced. On 2/4/16 at 3:48 PM, an interview was conducted with the Director of Nursing and the staff development coordinator. The staff development coordinator stated they were still monitoring for the hot water which was the F323 in 2015 but did not monitor for accidents in the transportation van because there had been no incidents prior to the accident on 1/8/16. 2. F490: Effective Administration: Based on observation, record review and staff interviews, the facility implemented the use of a new van without ensuring the seat belting was for adults and that lap and shoulder belts were in place, failed to provide training for the transportation driver prior to use of the new van, failed to possess manufacturer ' s instructions and manual for proper securement devices and how to accurately apply the devices, failed to impose expectations that all incidents would be reported to administration immediately and failed to complete a root cause analysis after a serious incident. During the recertification survey of 3/26/15, the facility was cited F490 for failure to utilize the manufacturer ' s instructions to maintain and monitor the hot water system, failure to have a policy and procedure to address notification of administration when the hot water problem was not promptly resolved and failure to monitor and train the maintenance supervisor on the mixing valve. The administrator was not aware that the maintenance supervisor was not providing preventative maintenance on the mixing valve and was not aware that the maintenance supervisor was not monitoring the water temperatures in the shower rooms. Immediate jeopardy began on 1/8/16 when the facility started to use the new van to transport residents to and from appointments. The transportation driver had not received training prior to using the new van in how to accurately apply the securement devices for the wheelchair resulting in an accident. The incident was not immediately reported to administration and a root cause analysis was not completed following the accident. On 2/2/16 at 4:43 PM, the Administrator was informed of the Immediate Jeopardy for F490. The Immediate Jeopardy was removed on 2/4/16 at 6:20 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems have been put into place and are effective, the facility van has the appropriate securement system installed and all staff have been in-serviced. On 2/2/16 at 3:49 PM, the Administrator and Director of Nursing were informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 2/4/16 at 6:00PM. The allegation of compliance indicated: Credible Allegation of Compliance: An emergency meeting was convened on 2/3/2016 with all Administrative Staff and members of the QA committee, excluding the Pharmacist, to review the recent accident on the facility transport van and to review the facility policy on incident/accident reporting that was reported to the Administrator and Director of Nursing on 2/2/2016. Effective 2/3/2016 and every weekday (Monday-Friday) thereafter, morning meetings will be conducted with all department heads to discuss daily issues and to include incident reporting. QA meetings will be held monthly instead of quarterly to be conducted with members of the QA Committee to discuss all issues occurring during the month with emphasis on resident safety, safe transportation, and all safety concerns. Responsibilities contiguous to the F-520 tag for the areas of concern were delegated to designated individuals, i.e. delegation of Administrator to follow up with the transport driver to review the transport driver ' s pre-trip inspection reports weekly x4 weeks, DON, and SDC to lead mandatory in-services on notification of incidents and accident reporting. The incident/accident education will be added to the orientation process for ALL new hires from 2/4/2016, not just nursing staff. The credible allegation was verified 2/4/16 at 6:20 PM as evidenced by staff interviews on the policy and procedure for reporting incidents/accidents, what to do if any type of incident/accident occurred no matter how minor, whom to report to, when to write the incident report and whom to notify in case of an incident/accident. The Transportation driver verified that the van had been out of service since 2/2/16 and the facility was currently using an outside transportation company for all transports. A review of the in-service for the policy and procedure for incidents/ accidents revealed 94 staff members had been in-serviced as of 2/4/16 at 6:20 PM. On 2/4/16 at 3:48 PM, an interview was conducted with the Director of Nursing and the staff development coordinator. The staff development coordinator stated there had been four (4) Director of Nursing personnel since the last survey on 3/26/15 and three (3) Administrators over the past year. He also stated the Administrator had been here five (5) months and the Director of Nursing just under three months. Turnover of administrative staff was a factor in the repeat deficiencies. 3. F278: Assessment accuracy: Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for medications for one of five residents (Resident#34) reviewed for unnecessary medications. During the recertification survey of 3/26/15, the facility was cited F278 for failure to accurately code Preadmission Screening Resident Review (PASRR) on the Minimum Data Set (MDS) for three of three residents admitted with a PASRR level 2 (Resident #37, #83 and #92). On the current recertification/ complaint investigation survey of 2/4/16, the facility failed to accurately code the MDS assessment for medications for one of five residents (Resident #34). On 2/4/16 at 3:48 PM, an interview was conducted with the Director of Nursing and the staff development coordinator. The Director of Nursing stated the corporate nurse consultant made her aware of the previous survey and the deficiencies cited. The staff development coordinator stated there had been new staff hired for the MDS position to assist the current MDS nurse. As the MDS coordinator was training new staff, the new staff were inputting data in the computer. Therefore, errors might have occurred. The staff development coordinator also stated they had hired three people to help with the MDS process and all three were no longer employed at the facility. Turnover was also a factor. 4. F279: Develop a comprehensive care plan: Based on record review and staff interviews, the facility failed to develop a care plan for one of one residents (Resident #97) whose Care Area Assessment (CAA) indicated that falls would be addressed in the care plan. During the recertification survey of 3/26/15, the facility was cited F279 for failure to develop a care plan to address the limitation in range of motion for one (Resident#10) of one sampled residents with a left hand contracture. On the current recertification/complaint investigation survey of 2/4/16, the facility failed to develop a care plan for falls as noted on the CAA for falls for one of one residents (Resident #97). On 2/4/16 at 3:48 PM, an interview was conducted with the Director of Nursing and the staff development coordinator. The staff development coordinator stated there had been a lot of turnover in the MDS department which could have contributed to the omission of the falls care plan. 5. F329: Drug regime free from unnecessary medications: [REDACTED]#6, #34), and failed to discontinue a medication as ordered for one of five residents (Resident #109) reviewed for unnecessary medications. During the recertification survey of 3/26/15, the facility was cited F329 for failure to obtain laboratory tests as ordered by the physician for one (1) of five (5) sampled residents (Resident #91) reviewed for unnecessary medications. On 2/4/16 at 3:48 PM, an interview was conducted with the Director of Nursing and the staff development coordinator. Both stated the process of checking the physician's order [REDACTED]. They stated the process of double checking the physician orders [REDACTED].

Based on observation, record review and staff interviews, the facility implemented the use of a new van without ensuring the seat belting was for adults and that lap and shoulder belts were in place, failed to provide training for the transportation driver prior to use of the new van, failed to possess manufacturer's instructions and manual for proper securement devices and how to accurately apply the devices, failed to impose expectations that all incidents would be reported to administration immediately and failed to complete a root cause analysis after a serious incident. The findings included: Immediate jeopardy began on 1/8/16 when the facility started to use the new van to transport residents to and from appointments. The transportation driver had not received training prior to using the new van in how to accurately apply the securement devices for the wheelchair resulting in an accident. The incident was not immediately reported to administration and a root cause analysis was not completed following the accident. On 2/2/16 at 4:43 PM, the Administrator was informed of the Immediate Jeopardy for F 490. The Immediate Jeopardy was removed on 2/4/16 at 6:20 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems have been put into place and are effective, the facility van has the appropriate securement system installed and all staff have been in-serviced. This tag is cross-referred to F323. Based on observation, record review, resident and staff interviews, the facility failed to properly secure one of one sampled residents reviewed for accidents (Resident #97) and the wheelchair in the transportation van according to manufacturer ' s instructions resulting in Resident #97 tipping over in the wheelchair and hitting her right stump on the floor of the van, failed to immediately notify administration about the accident and failed to complete a root cause analysis of the incident. On 2/2/16 at 4:43 PM, the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 2/4/16 at 6:00PM. The allegation of compliance indicated: Credible Allegation of Compliance: An emergency meeting was convened on 2/3/2016 with all Administrative Staff and members of the QA committee, excluding the Pharmacist, to review the current transport accident that happened on 1/8/2016 and was reported to the Administrator and Director of Nursing on 2/2/2016. Effective 2/3/2016 and every weekday (Monday-Friday) thereafter, morning meetings will be conducted with all department heads to discuss daily issues and to include incident/accident reporting. QA meetings will be held monthly instead of quarterly to be conducted with members of the QA Committee to discuss all issues occurring during the month with emphasis on resident safety, safe transportation, and all safety concerns. The Kingswood Nursing Facility Transport Van was taken out of service on 2/2/16. This transport van will not be in service until an authorized wheel chair tie down system technician can correctly install the tie downs correctly with the correct shoulder harness and all relevant documentation will be provided to the state surveyors. The facility will continue to use an outside transport agency to transport all residents to and from appointments until the proper securement system is installed by an authorized agent. From 2/3/2016 moving forward, the Administration of the facility will use resources for prevention of accidents/ incidents, effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This will be mandated by everyone attending the QA meeting. The Administrator will adjudicate this process to ensure full compliance with all facility policies and processes followed by the facility and decide if any additional processes need to be modified. The QA committee will have an emphasis on safety, and incident reporting. The director of operations has been in touch with the facility Administrator each day but is not familiar with the van wheelchair tie down system as we just bought the transport van in January. The director of operations will continue to monitor the administration of the facility on a monthly basis with an onsite visit to ensure all issues at the facility are being addressed properly. The credible allegation was verified 2/4/16 at 6:20 PM when the transportation driver verified that the transportation van had been out of service since 2/2/16 and the facility was currently sing an outside transportation company for all transports.

Based on observation, record review, resident and staff interviews, the facility failed to properly secure one of one sampled resident reviewed for accidents (Resident #97) and the wheelchair in the transportation van according to manufacturer's instructions resulting in Resident #97 tipping over in the wheelchair and hitting her right stump on the floor of the van, failed to immediately notify administration about the accident and failed to complete a root cause analysis of the incident. Immediate jeopardy began on 1/8/16 and was removed on 2/4/16 at 6:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems have been put into place and are effective, the facility van has the appropriate securement system installed and all staff have been in-serviced. The findings included: Resident #97 was admitted to the facility on [DATE] and last readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. An Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #97 was cognitively intact. She required limited assistance with bed mobility and transfers. Ambulation did not occur. Balance was noted as impaired. Resident #97 was only able to stabilize with staff assistance for moving from seated to standing position, moving on and off the toilet and surface to surface transfer. No impairment was noted with upper extremity and impairment of range of motion was noted for both lower extremities. Resident #97 had not sustained any falls prior to admission to the facility and no falls since admission to the facility. The Care Area Assessment (CAA) for falls indicated limitation included difficulty in maintaining standing balance and impaired balance during transitions. On 02/01/2016 at 5:35PM, an interview was conducted with Resident #97. She stated she was riding in the facility van that was a new van and the driver hit the brakes. Resident #97 stated the wheelchair tipped over and she hit her right stump on the floor of the van causing her stump to begin bleeding. Resident #97 stated the van driver took her back to the wound doctor who checked her out and said it was ok because the doctor had tried to remove the scab from the stump and Resident #97 had scraped the scab off when her stump hit the floor of the van. On 2/3/16 at 11:45AM, Resident #97 was re-interviewed. She stated when she got on the van at the wound clinic, the maintenance man was the person who placed the back straps on her wheelchair and she felt he placed them too low and that was why they loosened and her wheelchair tipped up. She also again stated she hit her right stump on the floor of the van. A review of the medical record revealed a nursing note dated 1/12/16 at 12:00AM written by Nurse #2 for late entry for 1/9/16 stated Resident #97 said she was riding on the van and when the van came to a stop, resident and her wheelchair fell forward and she became wedged between the wall. Resident #97 stated an ambulance nearby came to assist the driver to get her up. Resident #97 was in a lot of pain and requested pain medication stating she was literally standing on her right stump which started to bleed and she said she was taken to the wound clinic and a large pressure dressing was placed on the stump which had several staples that were wedged into her skin and could not be removed. Her pressure dressing was not removed and Resident #97 was given PRN (as needed) medication for pain. On 2/2/16 at 9:21 AM, an interview was conducted with the transportation driver. She stated she had been the transportation driver since January of last year. The transportation driver said the facility had gotten the new van and they had been using that van since January 2016 as well as using an outside transportation company. The transportation driver stated she had not received training in using the new van or in using the securement system that was in the new van because she had been previously trained by former transportation staff in 2004 and both vans had the same securement system. The transportation driver stated she was the only staff member who transported residents in the facility van. She said she was the one transporting Resident#97 back from the wound center when incident happened. The transportation driver stated she thought the incident happened on 1/6/16 because it was a day when Resident didn't have dialysis and Resident #97 received dialysis on Tuesday, Thursday and Saturday. The transportation driver stated she picked up Resident #97 from the wound center around 10:40 AM. She stated she had called the maintenance director to come to the wound care center parking lot to help her because she had problems with the van lift. She said she had fixed the lift by the time the maintenance director got to the wound care center and the maintenance director helped her strap down Resident #97's wheelchair in the van. She stated the maintenance director strapped down the back part of the wheelchair and she strapped down the front of the wheelchair. The maintenance director left and she started to leave the wound care center. When she got in the turn lane leaving the wound care center parking lot, the transportation driver said she heard Resident #97 say Whoa . She looked back and the wheelchair had tilted forward with Resident #97 still in the wheelchair. She stated the wheelchair was halfway flipped. The back securement strap was still on the chair but it was loose. The driver pulled over and there was an ambulance following the van. The ambulance stopped and ambulance personnel helped her lift the resident back into the chair. The transportation driver stated she saw a little bit of blood on the right stump dressing and felt that Resident #97 hit her right knee on the pole that was on the right side of Resident #97. She said they returned back to the wound clinic and the wound care staff checked Resident #97's stump and placed another bandage on the right stump. She indicated she informed the staff development coordinator (SDC), the Administrator and Nurse #1 about the incident when she returned to the facility. She told them they had an accident with the van, Resident #97 did not fall all the way out of the wheelchair and she had taken Resident #97 back to the wound center. The maintenance director was unable to be interviewed as he no longer worked at the facility. On 2/2/16 at 9:43 AM, Nurse #1 was interviewed and stated she had worked at the facility since August 2015. She stated she didn't remember anything about the incident except the transportation driver told her Resident #97 had an accident in the van. She was not sure of the day of the incident. Nurse #1 stated she saw Resident #97 after the incident and her dressing on her right knee was fine since she had been at the wound clinic. The right stump was wrapped so she did not remove the dressing. On 2/2/16 at 10:15 AM, a return demonstration of securing a resident in a wheelchair in the van was conducted with the transportation driver. The van was capable of holding two residents in wheelchairs. There was also seating available on the right side of the van. A pole was noted to be situated on the right side of the van near the right seat. Anyone in a wheelchair would not be located near the pole. The transportation driver placed the wheelchair in the center of the van, secured the front of the wheelchair by placing the securement straps around the crossbar that was located under the wheelchair seat at the center of the wheelchair and tightened up the straps using buttons on either side of the strap. She placed the back straps around the crossbar of the wheelchair and tightened up the straps in the same manner. The resident was then strapped in with a seatbelt that was placed across the waist. A shoulder strap was not visualized. The transportation driver stated that was how she secured the wheelchair in the van and the straps could be hooked anywhere on the wheelchair as long as it held the wheelchair in place. The transportation driver stated Resident #97 was in the front wheelchair position in the van at the time of the incident. On 2/2/16 at 10:34 AM, an interview was conducted with Administrator and Director of Nursing. The Director of Nursing stated she was not aware of the incident until 2/2/16 but she would have to look at her notes. The Administrator stated he was not sure of the date and when he was made aware of the incident. Administrator stated he was notified that Resident #97 had slipped while she was in the van. He stated he does not have any documentation personally about the incident. The Administrator stated the transportation driver had been educated on how to properly strap down residents before the incident and he personally educated her. He stated, to his understanding, that the resident slipped and there was no injury. He was under the impression that Resident #97 started to slip off the edge of the seat and she did not fall. He said the people involved were in stand-up (morning meeting) and they were asked about the incident but no statements were done at that time. When asked if he had trained any other individuals in securement of the wheelchairs in the transportation van, he stated he had only trained the transportation driver. On 2/2/16 at 1:15 PM, the Administrator stated he used educational material from the department of transportation web site for securement of a wheelchair in a transportation van. He in-serviced the transportation driver 9/2/15. He stated the current van was a 2009 E250 transportation van and it replaced an older van but the securement devices in the van were the same type. He was not sure if there was a manufacturer's manual for the van as they bought it secondhand. The Administrator checked in the van and stated there was not a manual for the care of the van or proper procedure for securement of the wheelchair. On 2/2/16 at 1:35PM, a telephone interview was conducted with clinical manager for the wound clinic. She stated she remembered the phone call that Resident #97 had an accident after leaving the clinic in the van and she advised them to bring the resident back so her stump could be rechecked. She stated the incident occurred on 1/8/16. Resident #97 was taken back to the clinic and was seen by the physician again. There was a small amount of bleeding and Resident #97 was checked and the area was re-bandaged. On 2/2/16 at 1:44 PM, the Administrator stated the incident happened on 1/8/16 after the stand-up meeting. On Monday, 1/11/16, during the stand-up meeting, the transportation driver informed all present at the meeting (which included the Administrator) that, during the transport of Resident #97 on 1/8/16, she looked back and saw that the back straps on the wheelchair of Resident #97 were loose. The transportation driver pulled over and tightened the straps. She stated there was no injury and the resident was fine. The Administrator stated that was all the information given at that time so he did not investigate any further. He stated he did not know until today (2/2/16) that EMS (Emergency Medical Services) assisted the transportation driver to put Resident #97 back to the chair. The Administrator stated his expectation was that the transportation driver should have notified him immediately of the incident so a full investigation could have been done at the time of the incident. On 2/2/16 at 2:10 PM, the Administrator provided a copy of the in-service given to the transportation driver on 9/2/15. The material used for the in-service was titled Ride Safe from the (name of university) Health System dated 2005. Information included in the brochure stated, in part, 1. It is best if you have wheelchair that has been designed and tested for use as a seat in motor vehicles, often referred to as a WC19 wheelchair or transit wheelchair (has four, crash tested securement points where tiedown straps and hooks can be easily attached. These points are clearly marked with a hook symbol). If a WC19 wheelchair is not available, the next best choice is a wheelchair with an accessible metal frame where tiedown straps and hooks can be attached at frame junctions. It is important to use a complete WTORS (Wheelchair Tiedown and Occupant Restraint System) to secure the wheelchair and provide the wheelchair occupant with a properly designed and tested seatbelt system The most common type of wheelchair tiedown uses four straps to secure the wheelchair to the vehicle. Although it requires someone other than the wheelchair rider to secure and release the wheelchair, this tiedown can secure a wide range of WC19 and non-WC19 wheelchairs. To protect the rider during a crash or sudden braking, and to minimize the likelihood of injury caused by contact with the vehicle, a seatbelt system with both pelvic and upper torso belts must be used On 2/3/16 at 7:42 AM, an interview was conducted with Nurse #2 who stated she went into Resident #97 ' s room Monday night (1/11/16) and Resident #97 stated she wanted to talk to her. Resident #97 started to tell her about the episode that happened on the van. Resident #97 said they were riding in the van, came to a sudden stop and she toppled over. She said there was an ambulance behind them and they helped them because the lady on the van was trying to get her upright. She said somehow they bumped her stump and said the scab came off and it bled a little bit. Resident #97 told her they went to the wound clinic and that is where they put on the dressing. Nurse #2 stated she had not heard about the incident during report change. She stated she checked the 24 hour reports from Saturday day shift and also checked the nursing notes and did not see anything written/ recorded about the incident. Nurse #2 stated she called the staff development coordinator and asked him about the incident with Resident #97 in the van. Nurse #2 stated the staff development coordinator said he was aware of the incident. On 2/3/16 at 3:00PM, the Administrator provided a copy of the investigation report that had been completed on 2/2/16 for Resident #97. The investigation report stated that an investigation was conducted on 2/2/16 concerning the incident involving Resident #97 on 1/8/16. The transportation driver did transport Resident #97 to the wound clinic for a follow up visit. After the follow up visit was completed, Resident #97 was paced back on the transport van by the transportation driver. The transportation driver did secure the safety straps. The transportation driver proceeded to leave the wound clinic and she started driving down the road. She noticed that the wheelchair tilted forward slightly but the seat belt prevented Resident #97 from sliding out of the wheelchair. The transportation driver immediately stopped safely to retighten the safety straps. An EMS (Emergency Medical Services) technician and the maintenance director had stopped behind the transport van. Resident #97 did lean forward and slightly slid downward but never touched the floor. The transportation driver, the EMS technician and the maintenance director did loosen the safety strap and help Resident #97 to the floor of the van. The EMS technician did assist the transportation driver with helping Resident #97 back safely in her wheelchair and safely retightened the straps. The transportation driver then proceeded to return back to the wound clinic to make sure there was no injury to Resident #97. Resident #97 did have some drainage due to some of her staples being removed a few days before 1/8/16. The transportation driver did mention this situation briefly in the standup meeting the following Monday which was on 1/11/16 but only stated that the wheelchair straps had slightly loosened when she left the wound clinic with Resident #97 and approximately two miles from the clinic, she stopped and retightened the safety straps. The Administrator questioned her about the incident on 1/8/16 but all this information was not disclosed at that time. During the investigation on 2/2/16, the transportation driver did state that she reported the incident to the RN supervisor (Nurse #1) on 1/8/16. Nurse #1 made a late entry to the nursing notes on 2/2/16. A witness statement signed by the transportation driver was provided by the Administrator on 2/2/16 and had been attached to the investigation. The statement stated the transportation driver provided transportation for Resident #97 to and from the wound clinic on 1/8/16. As she was leaving the wound clinic and was moving over into the turn lane, the transportation driver looked back and Resident #97 was tilted slightly forward and her seat belt was holding her in the wheelchair. She came to a safe stop with the emergency flashers on and then tried to help Resident #97 back in her wheelchair where she had slid forward. An EMS technician had stopped behind the transportation van to ask if she needed any help. The maintenance director from the facility had also stopped to help. Resident #97 was helped completely back in her wheelchair and strapped back in safely (it was not mentioned who strapped Resident #97 back in her wheelchair). There was some yellow drainage that had soaked through to the outside of her dressing. The transportation driver took Resident #97 back to the wound clinic to have the doctor check her out to make sure she had not hurt herself. The wound clinic staff rewrapped her wound and they returned back to the facility. The transportation driver stated she reported the incident to the nurse on the hall (no name mentioned). On 2/4/16 around 10:30 AM, a demonstration of proper wheelchair and safety belt securement was conducted with the Administrator and transportation driver. The transportation driver secured the wheelchair using the floor tiedowns and attached them to the frame of the wheelchair with the tiedowns attached just above the wheels of the wheelchair. She then placed the safety belt under the arms of the surveyor and tightened the safety belt straps. The Administrator stated the manufacturer ' s instructions that he had found in the transportation van indicated the postural belt should be placed around the person under the arms and buckled up around the wheelchair. The Administrator stated there were two different securement systems that could have been on the transportation van and the new van that had been purchased only had the postural seat belt for the wheelchair residents but did have lap and shoulder belts for those who rode in the seats of the van. On 2/4/16 around 10:30 AM, the Administrator provided a copy of the (name of the system) securement system manufacturer's directions last revised 11/14/08. The instructions for the use of the (name) securement system manufactured by (name) was reviewed and indicated the tiedown securement straps for the wheelchair should be attached on the frame of the wheelchair just above each wheel and not on the crossbars of the wheelchair. The instructions also included the use of the pap/ shoulder belt and stated the belt should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger's hip. Adjust the belts as firmly as possible consistent with use comfort. Place the postural belt around the person below the arms. Buckle up around the wheelchair. Make sure the padding is located at the chest height. Note: postural belts are not crash tested . On 2/4/16 around 5:00PM, the Administrator stated he called the (name) manufacturer for the securement system in Florida and they referred him to the local manufacturer in Raleigh who told him that the seat belt system that was currently in the transportation van was to be used only for a child or small person (postural seat belt). The Administrator stated he would take the transportation van to Raleigh on 2/5/16 to have the proper securement system installed. He also indicated the first use of the transportation van was on 1/8/16 when Resident #97 was taken to the wound care center. On 2/2/16 at 3:49 PM, the Administrator and Director of Nursing were informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 2/4/16 at 6:00PM. The allegation of compliance indicated: Credible Allegation of Compliance: On 2/2/16, a full investigation was conducted by the Administrator and Director of Nursing (DON) concerning the alleged accident involving Resident #97 during transport from the wound clinic on 1/8/16. The result of the investigation was that Resident #97 claims when her wheel chair leaned forward, her stump touched the floor. The wheel chair leaned slightly forward because the rear safety tie down straps attached to the wheel chair had slightly loosened just after leaving the wound clinic approximately 2 miles from the clinic. At that time the rear tie downs were securely tightened and Resident #97 was lifted back into her wheel chair. The transport driver then transported Resident #97 back to the wound clinic to ensure there was no injury to her. While the resident was at the doctor's office, the dressing on the right stump was changed. After ensuring there was no injury, the transport driver returned Resident #97 safely back to the facility. The transport driver received a written disciplinary action for poor work performance for failing to properly tighten the rear wheel chair tie down straps. The RN (Registered Nurse) supervisor received a written disciplinary action for failing to enter the incident on the facility's incident report. Also, the staff development coordinator received a written disciplinary action for failing to report the incident on the facility incident report. The Kingswood Nursing Facility Transport Van was taken out of service on 2/2/16. This transport van will not be in service until an authorized wheel chair tie down system technician can correctly install the tie downs correctly with the correct shoulder harness and all relevant documentation will be provided to the state surveyors. The facility will continue to use an outside transport agency to transport all residents to and from appointments until the proper securement system is installed by an authorized agent. An audit was completed on 2/3/16 by the Administrator during the emergency QA (Quality Assurance) meeting to discuss the possibility of any other patients being affected by any deficient practices. The finding was that no one else was affected by any other accident/incident on the transport van as evidenced by interviewing the transport driver and based on incident/accident reports reviewed by the SDC (Staff Development Coordinator). The facility's staff development coordinator has educated/in-serviced all staff members actively working in the facility on the facility ' s incident/accident policy which included completing an incident report, reporting incidents to the DON and administrator, as of 2/3/2016. Seventy nine employees have been in-serviced. PRN (as needed) staff will be educated on the incident/accident policy before working their next shift. All staff that is not currently working will be educated/in-serviced on incident/accident policy of the facility before their next shift. Incident/accident education will be added for all new hires from 2/4/16 moving forward. Previously, just the nursing staff was receiving this education. The credible allegation was verified 2/4/16 at 6:20 PM as evidenced by staff interviews on the policy and procedure for reporting incidents/accidents, what to do if any type of incident/accident occurred no matter how minor, whom to report to, when to write the incident report and whom to notify in case of an incident/accident. The Transportation driver verified that the van had been out of service since 2/2/16 and the facility was currently using an outside transportation company for all transports. A review of the in-service for the policy and procedure for incidents/ accidents revealed 94 staff members had been in-serviced as of 2/4/16 at 6:20 PM.

Based on observations, interview with the staff, residents and the plumber and record review, the facility failed to maintain water temperatures at or less than 116 degrees Fahrenheit (F) in 8 of 11 resident's rooms (#102, #103, #114, #201, #202, #203, #215, #302) and 2 of 2 central bathrooms (100 and 400 hall). Immediate Jeopardy began on 3/17/15 at 9:30 AM when elevated hot water temperatures were identified in room #102 at 138 degrees F and in room #114 at 130 degrees F. The administrator was notified of immediate jeopardy on 3/17/15 at 3:14 PM. Immediate jeopardy was removed on 3/19/15 at 4:45 PM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective and all staff were in serviced. Findings Include: Observation on 3/17/15 starting at 9:20 AM, revealed the hot water temperature coming from the sink in room #201 was 122 degrees F, and in room #202 was 120 degrees F. The temperatures were obtained by the surveyor after the thermometer was calibrated in ice water. Observation on 3/17/15 starting at 9:30 AM using a calibrated thermometer, of the hot water temperatures in various residents ' rooms and in the central bath room revealed: Room #s Location Water Temperature 201 sink 120 degrees F 202 sink 120 degrees F 203 sink 120 degrees F 215 sink 118 degrees F 102 sink 138 degrees F 114 sink 130 degrees F 302 sink 120 degrees F Central Bath-sink (100 hall) 124 degrees F Interview on 3/17/15 at 10:00 AM with NA #1 on 100 hall was conducted. NA #1 reported the water temperatures were real hot in the sink when you run the water for 10 minutes. The water was hot at times but, not every day. He indicated that he always made sure to mix the hot water with the cold water before bathing a resident. NA #1 indicated that he informed the Maintenance Supervisor 2 weeks ago. Interview on 3/17/15 at 10:15 AM with NA #2 (shower aide) was conducted. NA #2 revealed the water in the shower room was sparkling hot that you could see the steam. After 5 minutes it would cool down a little bit and it fluctuated from very hot to cold. The fluctuation of the water temperature did not happen every day, however, it happened about 2-3 times a week. She indicated that she always checked the water temperature before the shower. Today (3/17/15) the water was hot. NA #2 indicated that she had informed the Maintenance Supervisor 2 weeks ago. Interview on 3/17/15 at 10:16 AM with NA #4 on 200 hall was conducted. NA #4 reported the water was too hot in the shower room. She had to mix it with cold water to give a shower. The hot water was real hot some days. NA #4 didn't inform the maintenance supervisor because the shower team had already informed him. NA #4 worked on floor but had to give showers when the shower team was not available. She added that the water in the shower in room #211 was hot yesterday (3/16/15 Interview on 3/17/15 at 10:17 AM with Resident #47 (resided in room 211) was conducted. Resident #47 stated that the water in the shower was hot but the aides mixed it with cold water during shower. On 3/17/15 at 10:19 AM, water temperatures were checked with administrative staff #1. The temperature of the water in the sink in room 102 fluctuated from 130 degrees F down to 111 degrees F. In the central bath tub in 100 hall, a button was pushed to turn on the water in the bath tub to check the water temperature. The water ran for few seconds, but automatically shut off before the water temperature could be checked. At the time the water shut off, a display of water temperature of 115 F showed on a lighted panel on the tub. After pushing the tub water button to turn the water on several times, the temperature was 120 degrees F, then it dropped to 116 degrees F. Observation on 3/17/15 starting at 10:50 AM with the Maintenance Supervisor and Administrative staff #1 of water temperatures, using the facility ' s calibrated thermometer, in various residents ' rooms revealed the following: Room #s Locations Water Temperature 302 sink 127 degrees 114 sink 127 degrees 202 sink 127 degrees In the Central Bath on 400 hall, the water temperature from the sink was 117 degrees F. A button was pushed to turn on the water in the bath tub to check the water temperature. The water ran for few seconds, but automatically shut off before the water temperature could be checked. At the time the water shut off, a display of water temperature of 115 F showed on a lighted panel on the tub. After pushing the tub water button to turn the water on the water temperature was 120 degrees F, then dropped to 118 degrees F. Interview on 3/17/15 at 11:35 AM with the Maintenance Supervisor revealed that the water system for this facility had two main water lines, one line for the kitchen and laundry and one line for the rest of the facility. It ran off of 2 hot water heaters that were tied in together. It was a circulatory system that had a mixing valve which had a knob that can be adjusted to control the mixing of hot and cold water. There were also two temperature gauges, one temperature gauge which indicated the temperature of the water going out of the mixer to the facility and another temperature gauge which indicated the temperature of the water coming back in. The temperature gauge to the water going out of the mixer normally read 120 degrees F and the temperature gauge for the water coming in was normally at 110 degrees F. The water was heated by propane and the facility used city water. The cartridge which fits inside of the mixing valve was replaced on 10/16/13. He reported that the shower team had complained that the water was too cold but, it had been a while and that he fixed problems by adjusting the mixing valve as soon as any issues were reported to him. He checked the water temperature in the resident room sink every Wednesday and maintained a water temperature log. He calibrated his thermometer monthly. He notified the administrator of any issues and neither were previously aware of the temperature fluctuation problem or high water temperatures. He reported that on 3/17/15 at 11:30 AM the mixing valve outgoing temperature gauge was 140 degrees F, however, he adjusted the valve on the mixer so the water temperature gauge read 120 degrees F and noticed there was a leak around the mixing valve knob. Observation on 3/17/15 at 11:45 AM of the mixing valve with the Maintenance Supervisor revealed he demonstrated how he adjusted the mixing valve by turning the knob ½ of a turn. The outgoing temperature on the mixing valve temperature gauge read 120 degrees F and the incoming temperature read 110 degrees F. There was no leaking water coming from the mixing valve knob during this observation. There was a sheet of paper, attached to the wall beside the mixing valve, on which it was written that on 10/16/13 a new cartridge had been installed and on 3/17/15 the knob had been turned ½ of a turn to adjust the cold water coming in. Review of maintenance receipts from 10/4/13 to present revealed there were no receipts for the replacement of the mixing valve cartridge. Review of facility's water temperature logs for the months of January 2015, February 2015 and March 2015 revealed water temperature recordings ranged from 102 degrees F to 108 degrees F in residents ' rooms. There was no Central Bath water temperatures recorded on the logs. Interview on 3/17/15 at 12:25 PM with Administrative Staff #1 revealed the Maintenance Supervisor kept a log of the recorded water temperatures. He was not aware of any problems with the hot water and they were working on getting a plumber in on 3/17/15 to assess the problem. He reported that when or if there was a problem, staff reported it to their supervisor who relayed the information to the maintenance department either verbally or in writing. Interview on 3/17/15 at 12:35 PM with the Maintenance Supervisor revealed there were no manufacturer's instructions available for the mixing valve. He added that the cartridge had not had a routine maintenance since 2013 when it was installed. He reported that the last time he checked the mixing valve was last week (Thursday or Friday) by checking the temperature on the gauge. He reported that he adjusted the mixing valve according to what they needed the water temperature to be. He didn't have anything in writing indicating the recommended temperature setting. He normally adjusted the mixing valve so that the water temperature going out is at 120 degrees F and 110 degrees F for incoming based on knowledge. He reported that he turned the water temperature all the way down at 12:20 PM (3/17/15) because the water was not cooling and the mixing valve temperature gauge was up to 140 degrees F. Observation on 3/17/15 starting at 12:43 PM revealed the following: Room #102 sink 130 degrees F for 9 seconds dropped to 111 degrees F rose to 120 degrees F for 27 seconds rose to 122 degrees F for 13 seconds rose to 130 degrees for 15 seconds rose to 140 degrees for 60 seconds. Room #103 bath-sink 120 degrees F for 30 seconds. Interview on 3/17/15 at 1:00 PM with NA #3 (shower aide) was conducted. NA #3 revealed the water in the shower room was hot. She always checked the water temperature before the shower. NA #3 informed the Maintenance Supervisor 2 weeks ago. Interview on 3/17/15 at 3:05 PM with the plumber revealed the mixing valve was brass and the cartridge/control stem (regulates the water temperature) was messed up. The cartridge/control stem which was inside the mixing valve was stuck and he was not able to take it out. The only way to fix it was to replace the mixing valve. He reported that the mixing valve was cut back off after working on it at 2:50 PM. He also reported that the mixing valve should be checked at least every 3 months. Interview on 3/17/15 at 3:14 PM with the Maintenance Supervisor revealed that he checked the mixing valve last Friday as a normal routine check and the outgoing temperature gauge was at 120 degrees F and the incoming temperature gauge was at 110 degrees F. He reported that he usually checks the temperature gauges 2-3 times per week. Interview on 3/17/15 at 3:15 PM with Administrative Staff #1 revealed he will put up signs to notify everyone that the hot water is currently off until 3/18/15 after repairs are done. It was discussed that the facility will be using bath wipes for activity of daily living (ADL) care. Interview on 3/18/15 at 8:20 AM with NA #2 revealed that she had been a shower aide for 8 months. NA #2 reported the water was hot then but, not as hot as it had gotten to be as of 2 weeks ago. It was so hot that you can see the steam. Interview on 3/18/15 at 8:25 AM with NA #3 revealed that the water had been hot but lately, as of 2 weeks ago, it was real hot in the shower room and in the resident's sink. It was too hot you could see the steam coming out and the water fluctuated from being too hot to cold. NA #3 was aware that she should have written it in the book (communication book for the maintenance supervisor) but because she saw the Maintenance Supervisor on the floor she just informed him verbally. The Maintenance Supervisor informed NA #3 that he already adjusted the water temperature. The previous director of nursing (DON) and unit managers were aware of the hot water and when the water temperature was too hot, she was told not to give shower. Interview on 3/18/15 at 8:30 AM with NA #4 revealed the water was hot in the sinks and in the shower rooms. It fluctuated from being too hot to cold, when it was hot you could see the steam. On 3/18/15 at 8:33 AM, Resident #22 was interviewed. She stated that she used the water in the bathroom sink. She indicated the water was real hot especially for her with tender skin but she knew how to mix it with cold water. Interview on 3/18/15 at 9:15 AM with the Maintenance Supervisor revealed that he did not check the temperature on Central Bathroom. He reported that he checked the water temperatures in the rooms and did not know that he needed to check the central bathrooms. Observation on 3/18/15 at 2:45 PM of Maintenance Supervisor calibrating his thermometer revealed that he used a cup of small cubed ice (with no water) and inserted the thermometer probe approximately 2 inches into the center of the cup of ice until the thermometer read 32 degrees, then removed the thermometer. He checked the water temperature by holding the thermometer probe directly in the center of the water flow so that the water actually fell on the middle of the stem of the probe and the tip of the probe was not in the stream of water. On 3/18/15 at 3:14 PM, the Administrator was informed of immediate jeopardy. The facility provided a credible allegation of compliance on 3/19/15 at 4:45 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Credible Allegation of Compliance: · 3/17/2015- Maintenance director immediately lowered water temperature valve to reduce hot water temperatures immediately there-after. · 3/17/2015- 2:50 pm - Plumber arrived to assess heating unit for repair and found that the mixing valve needed replacement. Valve had to be special ordered for over-night delivery and plumber would make repair on 3/18/2015. · 3/17/2015- 3 pm-Maintenance director informed administrator that hot water valve was turned off from residential areas to eliminate risk of hot water temperatures. · 3/17/2015- A memorandum was posted throughout the facility to notify all residents, family members, visitors, and staff of the hot water valve being shut down and its repair. · 3/18/2015- 4 pm- Administrator made several follow-up calls to the plumber regarding service repair starting around 10 am. The plumber did not make facility visit as scheduled but informed writer at 4 pm that the wrong valve was delivered and another mixing valve was reordered for 3/19 delivery. · 3/18/2015- The facility ' s corporate office provided policies on Water Temperature-Safety, Preventive Maintenance of Hot Water, and Elevated Hot Water Readings. · 3/18/2015-All staff on floor was in-serviced on policy and procedures regarding elevated hot water by staff development coordinator, and nurse supervisors. Staff not in-serviced will be in-serviced prior to working on floor. · 3/18/15-Revised memos were posted with new repair date of 3/19/2015. Once repairs are completed, the plumber has agreed to instruct maintenance director to complete monthly preventative maintenance as recommended by the mixing valve ' s operations manual. · 3/19/15-11:15 are- plumbers confirmed 11:30 am start of service repair for mixing valve. · 3/19/15- 1 pm- Plumber completed repair and provided operation and maintenance manual. · 3/19/15-1 pm- Maintenance director provided temperatures checks upon completion of the repairs and the readings indicated 113 degrees. · The owner and maintenance manual provide the following instruction for preventative maintenance: o The cartridge unit contains the entire valve control mechanism. For non-interrupted services, keep a spare cartridge at hand o Temp Control valve control mechanism must be kept clean and free from deposits and any foreign matter build-up that will be present in many water systems o Inspect within 30 days of initial installations or operation. o If inspection determines that your water system causes deposits and foreign matter build-up monthly, then valve should be cleaned monthly as follows § Remove cartridge (see page 11 for cartridge removal and replacement section). § Soak in any acceptable de-liming agent or regular household vinegar. § Wash off deposits § Be sure piston is moving freely in its sleeve § Replace cartridge § Clean more frequently if your system so demands § Do not completely remove piston from cartridge · A copy of the operation and maintenance manual will be kept next to the mixing valve and the maintenance director ' s office. · Facility will have a spare cartridge as recommend in operations manual. · Facility expects to be in compliance from the immediate jeopardy on 3/19/15. On 3/19/15, validation of the credible allegation was conducted. Review of the in-service records revealed that 58 employees were already in-serviced on the facility ' s policy on elevated hot water readings, preventative maintenance of hot water and safety of water temperatures on 3/18/15. Staff interviews were conducted with the staff (nursing and non-nursing) on reporting of hot water temperature and with the maintenance supervisor on the maintenance of the mixing valve per manufacturers ' instruction and monitoring of water temperature to include the central bath. The water temperature in the residents ' rooms and central bath were checked and it ranged from 104-114 degrees F.

Based on record review, observation and staff interview, the facility's quality assessment and assurance committee (QAA) failed to have systems in place to identify problems with water temperatures. The facility's QAA committee had no system in place to evaluate and monitor the performance of the maintenance supervisor. Immediate Jeopardy began on 3/17/15 at 9:30 AM when elevated hot water temperatures were identified in room [ROOM NUMBER] at 138 degrees F and in room [ROOM NUMBER] at 130 degrees F. The administrator was notified of immediate jeopardy on 3/26/15 at 11:30 AM. Immediate jeopardy was removed on 3/26/15 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective and all staff were in serviced. Findings included: Cross refer to F323. Based on observations, staff interviews and record review, the facility failed to maintain water temperatures at or less than 116 degrees Fahrenheit (F) in 8 of 11 resident's rooms (#102, #103, #114, #201, #202, #203, #215, #302) and 2 of 2 central bathrooms (100 and 400 hall). On 3/19/15 at 3:59 PM, the administrator was interviewed. He stated that he was the head of the QAA committee. He stated that the committee consisted of all the department heads including the medical director. The committee had met every third Wednesday of the month. The department heads identified issues in their department and brought the issues to QAA meeting. The committee implemented interventions if there were issues and the specific department (with issues) was responsible for the monitoring and evaluation if interventions were effective or not. The maintenance supervisor was responsible to identify issues in his department to include the hot water temperature. The maintenance supervisor had brought his temperature log to the meeting every month and there were no issues noted. The committee also had identified problems by their satisfaction surveys from the family members and by the reports from the sub committees like falls/wounds. On 3/26/15 at 9:25 AM, the maintenance supervisor was interviewed via phone. He stated that aside from checking the water temperature in the resident's rooms once a week, he also checked the gauge on the mixing valve to make sure it was set at 120 degrees F going out and 110 degrees F going in. On 3/26/15 at 10:06 AM, the administrator was interviewed via phone. He stated that he had no other system in place to identify problems with hot water aside from the checking of the water temperature by the maintenance supervisor on a weekly basis. He was not informed that the staff and the residents were experiencing hot water temperatures in the resident's room and shower rooms. He also stated that he had monitored the maintenance supervisor by checking his water temperature logs and repair logs. He revealed that he had not observed the maintenance supervisor in calibrating the thermometer. On 3/26/15 at 11:30 AM, the Administrator was informed of immediate jeopardy. The facility provided a credible allegation of compliance on 3/26/15 at 8:06 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Credible Allegation of Compliance: · 3/26/2015- The QAA Committee had met and addressed the identified concern regarding water temperatures; o Facility has established a Calibration Log for facility thermometers and revised the water temperature log to include the central shower rooms and committee will be reviewing completed logs on the monthly QA meetings o Weekly water temperature Logs for 3/19, 3/24 and 3/26- Temps were within 100-116 o Policy and Procedures were reviewed on hot temperatures and reporting to immediate supervisor as well. Committee established to have monthly water temperature checks by both Administrator and Maintenance Director. o United States Department of Agriculture guidelines on how to calibrate thermometer was reviewed during meeting o Committee discussed that Plumbing Technician would do semi-annual checks to monitor maintenance director's performance on water system and temperature checks · 3/26/2015- A quarterly maintenance performance checklist was completed today by this administrator which will be reviewed during the QA meetings. · 3/26/2015- facility alleged to be in compliance. On 3/27/15 at 3:09 PM - validation of the credible allegation was conducted. The maintenance supervisor was interviewed. He stated that he was a member of the QA committee. He indicated that the QA committee had met and discussed the hot water temperature issue. The committee had revised and created new forms for the monitoring of the hot water temperature. He indicated that these forms will be presented to the QA meetings monthly. He also stated that he was already instructed by the plumber on the preventative maintenance of the mixing valve and the manual was kept beside the mixing valve. The administrator was interviewed and revealed that the policy was revised as well as the monitoring tools. He further stated that he will be monitoring these tools monthly as well as in the QA meeting. The revised policy, revised water temperature log and new thermometer calibration logs were reviewed. The in-service records of the staff and the maintenance supervisor were also reviewed.

Based on record review, observation and staff interview, the facility's administration failed to utilize manufacturer's instructions to maintain and monitor hot water system, failed to have a policy and procedure to address notification of administration when the hot water problem was not promptly resolved and failed to monitor and train the maintenance supervisor on how to calibrate the thermometer, monitor the water temperature, and provide preventative maintenance on the mixing valve. The administrator was not aware of the hot water problem in the resident's rooms and shower rooms, not aware that the maintenance supervisor was not providing preventative maintenance on the mixing valve and was not aware that the maintenance supervisor was not monitoring the water temperature in the shower rooms. Findings included: Immediate Jeopardy began on 3/17/15 at 9:30 AM when elevated hot water temperatures were identified in room [ROOM NUMBER] at 138 degrees F and in room [ROOM NUMBER] at 130 degrees F. On 3/26/15 at 11:30 AM, the administrator was informed of the immediate jeopardy. Immediate jeopardy was removed on 3/26/15 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective and all staff were in serviced. This tag is cross referred to F323 Based on observations, staff interviews and record review, the facility failed to maintain water temperatures at or less than 116 degrees Fahrenheit (F) in 8 of 11 resident's rooms checked (#102, #103, #114, #201, #202, #203, #215, #302) and 2 of 2 central bathrooms (100 and 400 hall). On 3/26/15 at 9:25 AM, the maintenance supervisor was interviewed via phone. He stated that nobody from the facility had trained him and that he had learned his job especially on how to calibrate the thermometer and how to check the water temperature from his previous job as a maintenance person. He indicated that he didn't see manufacturer's instructions for the mixing valve when he started. When the cartridge was installed on 10/16/13, there was a manual that came with it but he didn't read the manual. During the survey (3/17/15), he was looking for the manual and could not find it. He revealed that he didn't know that he had to provide preventative maintenance such as cleaning the cartridge on a regular basis. He indicated that nobody had told him that he had to check the water temperature in the shower rooms. He added that if he had some questions regarding his job, he went to the administrator or the director of nursing. On 3/26/15 at 10:06 AM, the administrator was interviewed via phone. He stated that he was not aware that the facility had no manufacturer's instruction/manual for the mixing valve. He also revealed that the facility had no policy and procedure to address notification of the administration when hot water problem not promptly resolved. The administrator further indicated that the maintenance supervisor was already employed at the facility before he started as the administrator, so he didn't know who trained him and what training he had received. He also revealed that he was not aware that the maintenance supervisor was not providing preventative maintenance on the mixing valve like routine cleaning but he was aware that he was checking it for leaks or other problems. He also indicated that he was not aware of the hot water problems in the resident's rooms and shower rooms. He stated that he was aware that the maintenance supervisor was checking the water temperature in the resident's rooms but he was not aware that he was not checking the shower rooms. On 3/26/15 at 3:14 PM, the Administrator was informed of immediate jeopardy. The facility provided a credible allegation of compliance on 3/26/15 at 8:06 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Credible Allegation of Compliance: · 3/18/15- The facility ' s corporate office provided policies on Water Temperature-Safety, Preventive Maintenance of Hot Water, and Elevated Hot Water Readings. · 3/18/15- One policy refers employee to call their immediate supervisor if there is any concerns regarding hot water. Also, if hot water continues -residents, family and staff will be notified of the matter and completion of the repairs by administration. · 3/18/15-When water temps were high- a memo was posted to notify residents, families, visitors and staff with the time of repair completion. · 3/18/2015-All staff on floor was inserviced on policy and procedures regarding elevated hot water by staff development coordinator, and nurse supervisors. Staff not inserviced will be inserviced prior to working on floor. · 3/19/15- 1 pm- Plumber completed repair of Mixing Valve and provided operation and maintenance manual. He also instructed maintenance director on how to complete a preventative maintenance on the Mixing Valve. · 3/19/15-1 pm- Maintenance director provided temperature checks upon completion of the repairs and the readings indicated 113 degrees. · The owner and maintenance manual provide the following instruction for preventative maintenance: o The cartridge unit contains the entire valve control mechanism. For non-interrupted services, keep a spare cartridge at hand o Temp Control valve control mechanism must be kept clean and free from deposits and any foreign matter build-up that will e present in many water systems o Inspect within 30 days of initial installation or operation. o If inspection determines that your water system causes deposits and foreign matter build-up monthly, then valve should be cleaned monthly as follows § Remove cartridge (see page 11 for cartridge removal and replacement section). § Soak in any acceptable de-liming agent or regular household vinegar. § Wash off deposits § Be sure piston is moving freely in its sleeve § Replace cartridge § Clean more frequently if your system so demands § Do not completely remove piston from cartridge · 3/19/15- A copy of the operation and maintenance manual will be kept next to the mixing valve and the maintenance director ' s office. · 3/19/15- Facility will have a spare cartridge as recommend in operations manual. · 3/19/2015- Water temperature Log was modified to include both central shower rooms for water temperature checks. · 3/24/15- Water temperature readings averaged 112 degrees · 3/26/15- Water temperature checked and read an average of 105 degrees F · 3/26/15- Maintenance Director reviewed United States Department of Agricultures printed instructions on thermometer calibration and reviewed both process of thermometer calibration and water temperature checks . · 3/26/15- A revised thermometer calibration log was created for weekly checks prior to water temperature checks · 3/26/15- QAA committee reviewed water temperature monitoring tools, and discussed water temperature checks, the implementation of policy and procedure · 3/26/15 Maintenance director was in-serviced on monitoring of water temperatures and on the thermometer calibration using the new log weekly by administrator. These logs will be monitored by the administrator monthly and in QA meetings. · 3/26/15 - Facility alleged to be in compliance. On 3/27/15 at 3:09 PM - validation of the credible allegation was conducted. The maintenance supervisor was interviewed and revealed that he had been in-serviced by the administrator on how to calibrate the thermometer and on how to check the water temperatures. A new weekly thermometer calibration form was created and the water temperature form was revised to include the central shower rooms. These forms will be brought to QA monthly. He also stated that he was already instructed by the plumber on the preventative maintenance of the mixing valve and the manual was kept beside the mixing valve. The administrator was interviewed and revealed that the policy was revised as well as the monitoring tools. He further stated that he will be monitoring these tools monthly as well as in the QA meeting. The revised policy, revised water temperature log and new thermometer calibration logs were reviewed. The in-service records of the staff and the maintenance supervisor were also reviewed.