Every finding on record at Deer Park Health and Rehabilitation

Based on observation, record review, resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of flies in resident rooms that affected 5 of 5 residents (Residents #79, #103, #49, #50, #94) on the South Hallway. The findings included: a. Resident #79's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. On 8/3/26 at 11:19 AM observation was made on South Hall of Resident #79 in bed, and three to four flies were seen landing on his legs. In an interview during the observation, Resident #79 stated flies in the room had been a daily thing for weeks. He explained sometimes the flies landed on his face and bed and hadn't yet told anyone about it, but anyone could have seen them when they came in the room.An observation was made in Resident #79's room on 8/5/26 at 2:02 PM. Resident #79 was not in the room at the time, and three to four flies were flying around his empty bed, landing on bed linens, the bed frame, and the wall.An interview was conducted with Housekeeper #1 on 8/06/26 at 9:50 AM while she was standing at her cart on the South Hall. She stated she had worked there a few months and had noticed flies on South Hall for a while. Housekeeper #1 explained the flies weren't in every room but seemed to be worse in certain rooms such as Resident #79's room and she saw them in his room most days. During a follow up interview on 8/6/26 at 10:08 AM with Resident #79 in his room, he stated he saw flies in the room about every day for a month or so. He explained it was usually two or three at a time sometimes more and they would land on him, his clothes and skin and the bed and blankets but he hadn't seen them land on his food. Resident #79 further explained he had been in this room a long time and hadn't noticed this before and he hadn't spoken with anyone about it because he just figured that was how it was. He revealed they often left the window open a crack and had not seen the flies coming from the window but had seen them coming from the hall through the door. An observation was made on 8/6/26 at 10:25 AM of Resident #79 who was lying in bed, and there were two to three flies landing on the pad on his bed, the foot board and his urinal which was hanging on the footboard.An interview was conducted on 8/6/26 at 10:39 AM with Nurse Aide (NA) #3 who was going room to room on South Hall stocking supplies. NA #3 revealed she saw flies on this hall a lot and revealed she had just seen a fly land on Resident #79's bed. She stated she didn't see flies on the other side of the building and thought that was because South Hall was close to the smoking area door which was opened dozens of times a day and didn't have a screen. Nurse #10 was interviewed on 8/6/26 at 10:43 AM who stated she has been at the facility many years and worked 3 - 4 days a week, often on South Hall. Nurse #10 stated she saw flies most days the past few months on South Hall. She explained the flies were worse in certain rooms such as Resident #79's room. Nurse #10 continued to explain she thought the problem was the smoking area door which was at the beginning of South Hall which was opened and closed all day, between scheduled smoke breaks and the independent smokers going in and out. Nurse #10 revealed she had spoken with the Maintenance Director before and a few weeks ago she spoke with the Environmental Services Director about the fly problem. Nurse #10 concluded the interview by stating the facility didn't have flies in the fall or winter, but they would start when it got warm and it had happened other years in the past. She stated the blowers at the smoking area helped some, and in past years they had tried fly strips by the door, but the flies still got inside.An interview was conducted with NA #4 on 8/6/26 at 10:55 AM who stated she had worked there about a year, was on South Hall usually 3 times a week and saw flies about every day. She explained flies were in different rooms and the room that was Residents' #79 was especially bad. NA #4 further explained she thought they came through the smoking area door and had not seen them come through the window. She described flies in that room usually landing on the bed, the resident's clothes and skin. NA #4 thought they might be attracted to urine odors since Residents #79 used a urinal. NA #4 stated she changed sheets and wiped down the bed whenever she had that room to see if that helped but wasn't sure if it helped.The Housekeeping Director was interviewed on 8/6/26 at 12:21 PM who stated she had spoken with the Maintenance Director about seeing flies often in Residents #79's room on South Hall but didn't think she mentioned it to the Administrator.b. Resident #103's quarterly MDS assessment dated [DATE] indicated he was moderately cognitively impaired and able to understand others and make himself understood. On 8/3/26 at 11:25 AM an observation was made of Resident #103 who was sitting on the side of his bed and three to four flies were on his side of the room landing on his bed linens, bed frame and window ledge. The sliding window was opened about 1-inch, and the window screen was intact without tears or holes. During the observation an interview was conducted with Resident #103 who stated he saw flies in his room a lot. He further stated he had not told anyone from administration about the flies but talked with several nursing and housekeeping staff when they had noticed flies in his room. He did not recall the staff members' names or if they told him they would do anything about the flies.An observation on 8/04/26 at 3:00 PM in Resident #103's room revealed him to be sleeping in bed, with four to five flies hovering around him, landing on his shirt and the skin on his legs and ankles. An observation was made on 8/5/26 at 2:02 PM of Resident #103 who was sleeping in bed without a top sheet. Four flies were flying around him over the bed and repeatedly landed on his shirt, pajama bottoms, the bare skin on his ankles, bed linens and foot board. An observation was made on 8/6/26 at 10:25 AM of Resident #103 in his room who was asleep in bed and had three to four flies landing on his legs, pajama pants, bed covers and foot board. Nurse #10 was interviewed on 8/6/26 at 10:43 AM who stated she has been at the facility many years and worked 3 - 4 days a week, often on South Hall. Nurse #10 stated she saw flies most days the past few months on South Hall. She explained the flies were worse in certain rooms such as Resident #103's room. Nurse #10 continued to explain she thought the problem was the smoking area door which was at the beginning of South Hall which was opened and closed all day, between scheduled smoke breaks and the independent smokers going in and out. Nurse #10 revealed she had spoken with the Maintenance Director before and a few weeks ago she spoke with the Environmental Services Director about the fly problem. Nurse #10 concluded the interview by stating the facility didn't have flies in the fall or winter, but they would start when it got warm and it had happened other years in the past. She stated the blowers at the smoking area helped some, and in past years they had tried fly strips by the door, but the flies still got inside.An interview was conducted with NA #4 on 8/6/26 at 10:55 AM who stated she had worked there about a year, was on South Hall usually 3 times a week and saw flies about every day. She explained flies were in different rooms and the room that was Resident #103's was especially bad. NA #4 further explained she thought they came through the smoking area door and had not seen them come through the window. She described flies in that room usually landing on the bed, the resident's clothes and skin. NA #4 thought they might be attracted to urine odors since Residents #103 used a urinal and sometimes she had seen urine drips. NA #4 stated she changed sheets and wiped down the bed whenever she had that room to see if that helped but wasn't sure if it helped. c. The quarterly MDS assessment dated [DATE] for Resident #49 showed him to be cognitively intact. During an interview on 8/03/26 at 1:57 PM with Resident #49 in his room on South Hall, an observation was made of two flies walking on the jacket he was wearing, and that the window was closed. Resident #49 explained flies had been on the rise since June and mostly landed on his clothes and bed and once on his drink mug. Resident #49 stated he had told one of the staff that came in to help about the flies, but no one had come to ask him about it.During an observation of perineal care (care of groin area) provided in bed for Resident #49 on 8/4/26 at 2:12 PM, two flies were noted to be hovering over the bed and landed on the bedframe.During a follow up interview on 8/6/28 at 10:23 AM with Resident #49 in his room, he explained he had been in that room a few months and had seen flies since early summer. He stated he saw them almost hourly three or four at a time and they would land on him, especially his legs and pants and sometimes the furniture and wall. Resident #49 stated he and his roommate had talked about how distasteful it was having the files but figured it was just part of the reality that flies get inside in summer. He stated he hadn't reported the flies to administration but had spoken to one nurse aide about a month ago who said they would let someone know but couldn't remember who. Resident #49 explained the window was closed and flies came from the corridor and thought it was from when they opened the big door at the beginning of the hall for smoke breaks. He went on to explain their bathroom was connected with the room next door, and he had seen dozens of flies in there over the past months and wondered if they were also coming into his room from that room through the bathroom. During the interview, two flies were observed hovering on Resident #49's side of the room. Observation was also made of the adjoining bathroom room and no flies were seen.d. Resident #50's comprehensive MDS assessment dated [DATE] revealed him to be cognitively intact. An interview was conducted on 8/6/26 at 10:00 AM with Resident #50 in his room. He stated he had been in that room about four months and started seeing flies sometime in May when it got warm. He explained he saw flies daily, usually three or four at a time. Resident #50 further explained the flies landed on him, the bed, and window sill and he swatted at them to keep them away from his food when he ate in the room. Resident #50 revealed he hadn't personally let anyone know about the flies but had known that staff knew about the flies because he had heard staff mentioning them a few different times. During the interview two flies were observed flying near his bed frame.e. The quarterly MDS assessment dated [DATE] for Resident #94 indicated he was cognitively intact. An interview was conducted with Housekeeper #1 on 8/06/26 at 9:50 AM while she was standing at her cart on the South Hall. She stated she had worked here a few months and has noticed flies on South Hall for a while. Housekeeper #1 explained the flies weren't in every room but seemed to be worse in certain rooms such as room Resident #94's room.Nurse #5 was interviewed on 8/6/26 at 10:43 AM and stated flies were worse in the rooms that had more food spills like Resident #94's room which she described as one of the worst rooms for flies.An observation of Resident #94's room, was made in the presence of the Maintenance Director on 8/6/26 at 11:40 AM and no flies were seen. The door had been closed, and various types of food debris were seen scattered on the floor and bed linens. During the observation the resident said there had been several flies in his room earlier and flies were in his room a lot.The Housekeeping Director was interviewed on 8/6/26 at 12:21 PM who stated she had spoken with the Maintenance Director about seeing flies often in Residents #94's rooms on South Hall but didn't think she mentioned it to the Administrator. A review of the Pest Control Company invoice and service report dated 4/10/26 indicated treatment of target pests, cockroaches, and large flies with glue board in dining room and hallways and exterior bait stations. A review of the Pest Control Company invoice and service report dated 4/20/26 indicated treatment of target pests mice and cockroaches with insecticide and traps. A review of the Pest Control Company invoice and service report dated 5/26/26 indicated treatment of target pests mice and cockroaches with insecticide and traps. A review of the Pest Control Company invoice and service report dated 6/18/26 indicated treatment of target pests mice and cockroaches. A review of the Pest Control Company invoice and service report dated 7/16/26 indicated treatment of target pests cockroaches with pesticide application to cracks and crevices and mice traps and bait at kitchen door interior and exterior. During an interview with the Maintenance Director on 8/06/26 at 11:17 AM in the South Hall Day room, he stated the flies come every year, attracted by open fields with manure on area farms. He explained the facility contracted with a Pest Control Company and their Service Specialist came monthly to do different treatments for different pests. The Maintenance Director further explained in addition to what he put in the service report, the Service Specialist would verbally tell him if he done anything extra if he had seen areas of pest activity. He stated they did talk about flies when the Service Specialist was there for his regular monthly visit on 7/16/26 and had shown him there were all kinds of bugs including flies on the sticky strips in the fly lights that the Service Specialist changed monthly. The Maintenance Director stated he had asked the Service Specialist about getting more fly lights, but the Service Specialist had not had any with him that day. The Maintenance Director explained their main deterrent was fly curtains, which were strong blowers that blew air outward, over the four high-use doors; the front and back doors, two at the double doors to the side, and at the South Hall smoking area door. The Maintenance Director further explained the blowers were installed over five years ago and had been replaced six month ago with stronger models. He revealed he felt like they helped, but the South Hall smoking door was opened multiple times a day and held open for long periods for all the residents at smoke breaks. The Maintenance Director explained other strategies they used were a bug zapper light on the wall across from the South smoking door and fly lights on the walls throughout the building. The Maintenance Director said he hadn't gotten work orders about flies, but different nursing and housekeeping staff had told him they had seen flies in a couple of rooms on South Hall, mostly Residents #79 and #103's room and Residents #49 and #50's rooms but hadn't realized they were landing on residents on a regular basis. He stated he had been in Residents #79 and #103's room last week while the residents were out of the room and saw 4 or 5 flies in about 20 minutes. The Maintenance Director explained he killed a few of them with a fly swatter and sprayed a non-toxic direct contact spray the Pest Control Company had given him to try. He further explained the spray did work to kill them, but it wasn't meant to be applied to baseboards, and that swatting and direct spraying wasn't practical for multiple areas. During the interview, observation was made of a fly coming in from the South Hall corridor into the Day Room and a second fly hovered in the air above the couch were the interview was taking place. A follow-up interview and walking tour of South Hall locations and were done with the Maintenance Director on 8/6/26 at 11:36 AM. The Maintenance Director stated he had seen some flies in other areas of the building but thought things seemed worse in this area due to the proximity to the smoking area door and that if flies got in the building they were going to go to whatever attracted them. Observation was made of resident rooms including Resident #103's room with the Maintenance Director confirming the window screen was intact, and he stated the flies had to be coming in from the smoking door. While in the room, Resident #103 asked for his urinal and when the Maintenance Director reach for the urinal on the nightstand a fly was observed hovering near the nightstand next to the urinal. Resident #103 stated flies were around his room quite a bit, landed on him every day and it was annoying. On 8/6/26 at 11:40 AM the follow up interview and walking tour of South Hall locations with the Maintenance Director continued. Observation was made of room Resident #94's room which had the door closed. The Maintenance Director stated this was the other room staff had reported more fly activity and he hadn't seen any in this room when he had been in here the other day to check. No flies were seen, and various types of food debris were scattered on the bed and floor. Resident #94 stated there had been several flies in the room earlier and they were in his room a lot. On 8/6/26 at 11:45 AM the South Hall area observations and follow-up interview with the Maintenance Director concluded near the area of the smoking area door. A bug zapper light with the light on was seen on the wall across from the smoking area door. Fly lights were seen mounted on the wall in the South Day room, and in Hall Three adjacent to South Hall behind the nurses station. No fly light was observed on the South Hall walls. The Maintenance Director opened the Hall Three fly light and 15 - 20 dead insects were seen on the glue board. He stated there had been ten fly lights around the building but currently two were not working including the one that had been on South Hall. The Maintenance Director said the South Hall fly light hadn't been working for about a month and they hadn't replace the inoperable fly lights yet. He explained when the Pest Control Company Service Specialist had been there on 7/16/26 he had asked if the Service Specialize if he could give him any fly lights, but he did not have any but would bring fly lights on his next visit. Observation of the fly screen blower showed it kicked on with a strong breeze when the door was opened. A three to four-foot area of standing water was seen outside next to the wall on the right of the door, with water run off 1- foot wide that was observed across the pavement 6 - 8 feet in front of the door and went toward the smoking area patio about 10 - 12 feet. The Maintenance Director explained they had a lot rain recently and the Air Conditioner condenser unit was on the roof and putting off a lot of condensation. He revealed it was possible water coming down from the gutter and standing water could be a contributing factors for the flies. The Maintenance Director also stated the Pest Control Company had sprayed and treated multiple outside areas near docs and dumpsters and places that would attract mice, ant hills and other pests. He concluded the interview by stating maybe there were other treatments they could try for the flies.The Housekeeping Director was interviewed on 8/6/26 at 12:21 PM who explained she hadn't asked the housekeepers to swat flies but as the manager she tried to swat them herself but wasn't always successful and she hadn't used any sprays. The Housekeeping Director stated she wondered if there were more flies in some of the South Hall rooms because of food debris and urinals. She revealed she and the housekeepers tried to get into rooms they knew would have food debris after meals when they could to clean up.On 8/6/26 at 1:21 PM a phone interview was conducted with the Pest Control Company Service Specialist. He stated he came monthly for treatments and had seen flies outside the facility, had not seen any in the halls, and had seen some in resident rooms but didn't go in every resident room each month. He stated the facility had a contract for mice, rats, and German cockroaches but did not subscribe to the fly program. The Service Specialist explained the facility had several fly deterrents including fly dampeners (door curtain blowers), a bug zapper light at the smoking area door, and had their own fly lights on various interior locations, which all helped, but flies would still find ways to get in. He explained the fly program would include swapping out glue trap boards in the fly lights, spraying exterior doors and applying a product in specific rooms as well as add-on services if needed such as drain treatments. He also explained there were different types of flies with larger flies typically coming through doors, and smaller ones could possibly come from drains, and some flies could reproduce in drains. The Service Specialist stated he had not seen flies in facility drains, but in older facilities with multiple drain points it was possible that could be a factor. The Service Specialist revealed he had spoken with the Maintenance Director about flies and as a courtesy had swapped out adhesive strip glue boards in the fly lights and sprayed a repellant around the main exterior doors at times but had not sprayed the repellant last month on 7/16/26 because there were residents around. The Service Specialist continuing by explaining flies start getting active around May depending on the weather, and there seemed to be an increase in flying insect activity since the hurricane late 2024 and with all the recent rain.An interview was conducted with the Administrator on 8/06/26 11:51 AM who revealed the facility had on ongoing problem with flies that fluctuated on a seasonal basis when the weather got warmer. She explained there were farms in the area and flies were a problem in the whole region. She stated last year they were swarming outside the building, and it haven't been as bad this year, but she had seen some flies in the common areas this year. The Administrator explained she was just back from leave on 8/4/26, and no one had yet reported to her there had been flies landing on residents routinely. She described that it made her upset to hear that flies were this bad, landing on residents and their belongings which she was sure was annoying and residents shouldn't have to deal with that. She explained the problem was probably worse on South Hall because that's where the door to the smoking area was and it was opened multiple times every day and held open for the time it took residents to go through. She explained they had changed to new fly curtains with stronger blowers at the exit doors and had installed fly lights on the some of the hall and common area walls in the past year but certain deterrents like certain sprays and traps weren't appropriate for resident's rooms. The Administrator concluded the interview by stating her expectation was to control this problem the best they could and to continue to explore solutions.

Based on record review, and interviews with staff and Pharmacy Director, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 1 of 3 residents reviewed for misappropriation of resident property (Resident # 132).Findings included: The facility's Abuse, Neglect and Exploitation policy dated 9/1/24 read in part that it is the policy of this facility to provide protection 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. Resident #132 was admitted to the facility on [DATE]. A physician's order created by Nurse #3 dated 12/23/25 at 2:48 PM read in part Oxycodone (narcotic pain reliever) 5 milligrams (mg) two times a day. Attempts to reach Nurse #3 were unsuccessful. The Pharmacy delivery manifest dated 12/26/25 at 8:36 PM showed a delivered status for Resident #132 of Oxycodone 5 mg with a quantity of 14 tablets. The manifest had a facility staff signature and a typewritten staff name for Medication Aide (MA) #2. A telephone interview on 8/5/26 at 10:39 AM with MA #2 revealed she had been on duty at the facility on 12/26/25 and had received and signed for the pharmacy medication delivery. She stated she was very busy when the pharmacy delivery driver had delivered the facility medications and did not verify the medications she received but had signed for the medications and put them in the locked medication room. MA #2 stated she had not had time to go to the medication room to check the medications or secure them in the medication carts but had notified the oncoming nurse the medications were in the locked medication room. She stated she did not know what happened to the medications after she left the facility. An in-person interview on 8/5/26 at 10:49 AM with Nurse #2 revealed she had been on duty 12/27/25 and 12/28/25. On 12/27/25 when she discovered 3 unsecured narcotic medications in the locked medication room, she placed them in the correct medication carts. On 12/28/25, she was notified by Nurse #1 who had contacted the pharmacy about Resident #132's missing Oxycodone medication and she was notified the medication had been delivered to the facility on [DATE]. On 12/28/25, Nurse #2 initiated a search to locate Resident #132's Oxycodone narcotic medication card with the 14 medication tablets but the medication card and medication tablets were not found. Nurse #2 stated she contacted the Director of Nursing (DON) about the missing medication. An in-person interview on 8/5/26 at 11:29 AM with the Director of Nursing (DON) and the Regional Nurse Consultant revealed on 12/28/25 the DON had been notified by Nurse #2 of Resident #132's missing Oxycodone medication card. The DON stated she went to the facility and searched for the medication but was unable to locate it. The DON stated she contacted the Pharmacy Director and Resident #132's Oxycodone medication was replaced at facility expense. Staff who worked between 12/26/25 and 12/28/25 with key access to the medication room were contacted and interviewed. Those staff were drug tested except for 3 agency staff members who were unable to be contacted. Those 3 agency staff members were not permitted to return to the facility. All staff who were drug tested were negative. A telephone interview on 8/5/26 at 5:24 PM with the Pharmacy Director revealed the Oxycodone for Resident #132 was dispensed from the pharmacy and the facility staff signed to accept the medication. The Pharmacy Director stated the pharmacy completed an internal narcotic count in the pharmacy which matched their dispensed inventory. An in-person interview on 8/6/26 at 1:04 PM with the Administrator revealed the facility was unable to locate Resident #132's Oxycodone medication card and replaced it at facility expense.

Based on observations, record review, and staff interviews, the facility failed to ensure a resident with dysphagia (difficulty swallowing foods or liquids) and an order for no straws, was not provided thin liquid with a straw for 1 of 1 resident with physician orders for thickened liquids (Resident #4). The findings included: Resident #4 was admitted on [DATE] with diagnoses including dysphagia, hemiplegia (paralysis on one side) and hemiparesis (weakness and reduced strength on one side) following non-traumatic intracerebral hemorrhage (bleeding in the brain), unilateral primary osteoarthritis (arthritis on both sides), and dementia. Review of Resident #4's physician orders indicated an order dated 4/16/26 for regular diet with fortified foods (foods to increase calories and nutrients) and pureed texture (a blended, smooth consistency), honey/moderately thick consistency liquids, thin (regular) liquids by spoon or cup, and no straws. Resident #4's care plan revised 6/25/26 had focus areas including:Totally dependent for activities of daily living (ADL) care needs related to contractures to bilateral hands, hemiplegia and weakness with the goal of having ADL care needs met with assistance from staff.Resident is a dependent diner with intervention/task to have care need met with assistance of staff. The quarterly Minimum Data Set (MDS) assessment for Resident #4 dated 6/26/26 showed her to be severely cognitively impaired with no behaviors or rejections of care. She was coded for functional limitation of range of motion of one side for upper and both sides for lower extremities. Resident #4 was dependent for eating with helper completing the activity for the resident and was on a mechanically altered diet. Active diagnoses included cerebrovascular accident (CVA or stroke), hemiplegia or hemiparesis, non-Alzheimer's dementia, and dysphagia. Review of Resident #4's speech therapy notes showed she received Speech Therapy services from 7/3/26 to 7/29/26 for dysphagia. Resident #4's Speech Therapy Discharge summary dated [DATE] revealed her highest practical level had been achieved, and recommendations were to continue pureed diet and honey thick liquids. On 8/3/26 at 2:56 PM an observation was made of Resident #4's room while she was lying quietly in bed. A cooler with cups of honey thick liquids was seen against the wall under the window. A clear plastic cup with a straw was sitting on her overbed table within reach which was half-full of about 4 ounces of a thin dark liquid with bubbles that looked like cola. During the observation an interview was attempted with Resident #4 who was unable to state who had brought her the cup or if she had taken a drink from it. A continuous observation was made on 8/3/26 from 3:05 PM to 3:15 PM from the doorway of Resident #4's room of Housekeeper #1 cleaning Resident #4's room. While cleaning, Housekeeper #1 discarded the plastic cup with the cola and the straw and was overheard telling Resident #4 she would get her some fresh ice water. Housekeeper #1 returned to the room a short time later with a large cup with a straw and was seen holding the straw to Resident #4's mouth as the surveyor entered the room and before the surveyor was able to stop Housekeeper #1 from providing the thin water. Resident #4 did not cough or make any other sounds, and the surveyor stopped the Housekeeper. An interview was completed with Housekeeper #1 at that time, and she stated she got rid of the cup with the soda because she had seen a fly in the cup and it felt warm when she touched it. Housekeeper #1 explained Resident #4 had told her she wanted some ice water and knew she was supposed to ask a nurse or nurse aides about the water and usually did. Housekeeper #1 indicated she had not seen any nursing staff and thought it would be alright since she had seen the cup of soda with the straw on her table. Housekeeper #1 stated she was just trying to be helpful. Housekeeper #1 further stated she had pinched the straw while Resident #4 was sipping so she wouldn't get too much water at a time. An interview was conducted with Nurse Aide (NA) #1 on 8/3/26 at 3:07 PM while standing at Resident #4's doorway. She confirmed she was assigned to Resident #4. When asked about the cup of cola with the straw on the overbed table NA #1 stated she hadn't seen a cup of cola with a straw on Resident #4's table but wasn't surprised because her family had been there a while ago with pizza and a bottle of cola. NA #1 explained Resident #4 needed assistance with eating and drinking and she knew that Resident #4 was on honey thick liquids which she got from her meal tray or from the cooler in her room. NA #1 stated she sometimes gave her regular water with a spoon. NA #1 indicated housekeepers did sometimes bring residents water and usually checked with nursing staff if it was alright. During a follow-up interview with Housekeeper #1 on 8/3/26 at 3:59 PM she stated she had been told in orientation when she started a few months ago housekeepers could only bring food or water to residents if they knew it was alright for them to have it. Housekeeper #1 explained no one had trained her to provide sips to residents or to pinch the straw. Housekeeper #1 further explained she held the cup for Resident #4 to make sure she could get a sip and had pinched the straw so she wouldn't get too much at a time. Unit Manager #2 was interviewed on 8/3/26 at 3:25 PM during which she stated housekeepers were supposed to check with a nurse or nurse aide on the hall if a resident asks for water to make sure they can have it. She explained Housekeeper #1 was someone who tried to be helpful but should have told a nurse or nurse aide the resident said she wanted water. Unit Manager #2 revealed Resident #4's family didn't visit often, and she hadn't seen them that day, but staff had spoken with them in the past about her being on puree diet with thickened liquids. In an interview with the Housekeeping Supervisor on 8/3/26 at 3:32 PM she stated that housekeepers were not trained to give food or water to residents. She explained they could answer a call light and do minor things like hand them a remote or cover their feet with a blanket, but not any patient care. She further explained during housekeeper training they were taught not to give residents any food or drink because they don't know everyone's diet orders and were supposed to tell a nurse or nurse aide if the resident said they wanted something to eat or drink. An interview was conducted with the Speech Therapist (ST) on 8/5/26 at 11:48 AM during which she explained Resident #4 was not currently on her caseload but had treated the resident in July. The ST stated she had started at the facility in July and had done routine reviews of residents on mechanically altered diets. The ST explained Resident #4 had already been on pureed food and honey thick liquids with sips of water from a cup or spoon and had been generally doing well on those. The ST described that honey thick liquids were used to provided hydration for residents with swallowing problems, but residents sometimes missed having regular water and wanted to see if Resident #4 had could possibly be upgraded to a less thick liquid. The ST stated while Resident #4 was on her caseload from 7/3/26 to 7/29/26 she tried strategies such as supervised single straw sips of liquids while in a fully upright position and Resident #4 did not show signs of aspiration during these trials. The ST further explained she ultimately did not change Resident #4's current fluid orders from 4/16/26 because it was just safer to keep her with her current diet and fluid orders. The ST revealed that it wasn't unusual for residents on thickened liquids to have sips of regular water for comfort from a spoon or cup while sitting upright and supervised, but it would not have been safe for Resident #4 to have regular water with a straw because of her impaired cognition and limited strength and posture control which could have impacted how she could control the liquid in her mouth and create a risk for aspiration (something you swallow gets into your airway or lungs). The Director of Nursing (DON) was interviewed on 8/3/26 at 4:40 PM and confirmed Resident #4 had a history of swallowing problems, had been evaluated by Speech Therapy last month, and was on honey thick liquids with sips of regular liquids. The DON explained Resident #4 was only supposed to get regular water by sips from a cup or spoon not straws, and only by clinical staff. She explained with straws it was easy to pull too much liquid at once and with regular liquids there could have been a higher potential for aspiration. The DON revealed housekeepers could bring residents a specific drink only if they were told by nursing staff that it was OK and they should never give residents sips of liquids or bites of food.

Based on record review, Registered Dietitian (RD) and staff interviews, the facility failed to provide a liquid protein supplement for wound healing and malnutrition for 1 of 2 residents reviewed for nutrition (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses that included protein-calorie malnutrition and muscle wasting and atrophy (shrinking of body tissue, organ or muscle).Resident #3's care plan revised on 4/27/26 indicated Resident #3 was at risk for malnutrition related to advanced age, history of significant weight change, need for a therapeutic/mechanically altered diet, low body mass index and altered skin integrity. Interventions included to provide and serve supplements as ordered and for the Registered Dietitian to evaluate and make diet change recommendations as needed.The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact, had a weight loss and was not on a prescribed weight-loss regimen. Resident #3 had one stage 3 pressure ulcer (wound with full-thickness loss of skin).The Nutrition Evaluation completed by the facility's Registered Dietitian (RD) on 7/10/26 indicated Resident #3 was at risk for malnutrition and triggered for significant, unplanned, undesirable weight loss of 10.5% in 6 months. Diet order reviewed and appropriate. Oral intakes varied, on average around 50%. No clinical symptoms/signs or gastrointestinal issues at this time. No edema. Resident #3 had a new mid back stage 3 pressure injury. Suspected the resident was not meeting estimated energy needs, cause of weight loss. Will add 30 milliliters (ml) Prostat (liquid protein supplement) twice a day. RD to monitor nutritional status as needed.Resident #3's medical record indicated a physician's order dated 7/10/26 for 30 ml of Prostat two times a day for pressure injury/malnutrition. The order was created by the RD on 7/10/26 and revised by the MDS Nurse on 7/23/26.A review of Resident #3's Medication Administration Records (MAR) for July and August 2026 indicated no documentation of Prostat having been given to Resident #3.An interview with Medication Aide (MA) #1 on 8/6/26 at 9:40 AM revealed she had been regularly assigned to Resident #3 and had given him medications on day shift in July and August. MA #1 stated she had not been giving Resident #3 any Prostat, because it did not show up on his MAR.An interview with the Registered Dietitian (RD) on 8/6/26 at 9:48 AM revealed Resident #3 had increased nutrient needs because of the pressure injury. The RD stated that she added the Prostat on 7/10/26 because it was recommended for pressure injuries and weight loss, and it could help Resident #3's weight to increase because it had calories and protein. The RD stated that she entered the order for the Prostat on 7/10/26 and she was not sure why it did not show up on the MAR.An interview with the MDS Nurse on 8/6/26 at 10:09 AM revealed when he revised Resident #3's order for Prostat on 7/23/26, all he did was add the diagnoses for the order. The MDS Nurse confirmed that the Prostat order was created by the RD on 7/10/26, but he did not notice that it was entered as other in Resident #3's medical record. The MDS Nurse stated that he would need to ask the Director of Nursing to be sure, but he thought that the reason why the Prostat order did not show up on Resident #3's MAR was because it was entered as other. He added that the nursing staff would not know they were supposed to give Resident #3 Prostat if it did not show up on the MAR.An interview with the Director of Nursing (DON) on 8/6/26 at 10:28 AM revealed the RD created the order for Prostat for Resident #3 on 7/10/26, but she entered it under the order type of other orders - no documentation required which was why it did not get reflected on the MAR. The DON stated that the RD should have picked other orders - MAR under the order type in order for the Prostat to get reflected onto Resident #3's MAR. The DON explained that the nurses and medication aides were supposed to give Prostat and if it was not placed on the MAR, they would not have any way of knowing that they were supposed to administer it to Resident #3. The DON further stated that she had no idea that the Prostat was not being given to Resident #3 ever since it was ordered on 7/10/26.An interview with the Administrator on 8/6/26 at 1:40 PM revealed the RD normally put in her own orders for diet and supplements, and the Administrative nurses were notified of new orders whenever they ran an order listing. The Administrator stated that if the order was entered incorrectly and was not entered to be reflected to go on the MAR, it would not show up on the order listing or on the MAR and the nurses would not have known that they were supposed to administer the supplement order to the resident.

Based on record review, and interviews with staff, Pharmacy Director and Physician, the facility failed to have effective systems in place for storing, acquiring and administering narcotic pain medication which resulted in Resident # 132 missing 4 doses of Oxycodone (narcotic pain medication). The deficient practice occurred for 1 of 3 residents reviewed for misappropriation of property (Resident #132).Findings included: Resident #132 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following cerebral infarction. Resident #132 was discharged home on 1/20/26. A physician's order dated 12/23/25 at 2:48 PM read Oxycodone (narcotic pain reliever) 5 milligrams (mg) two times a day was entered by Nurse #3. Attempts to reach Nurse #3 were unsuccessful. Review of the pharmacy manifest dated 12/26/25 and signed by Medication Aide (MA) #2 at 8:36 PM revealed Oxycodone 5 mg 14 tablets was listed as received by the facility for Resident #132. A telephone interview on 8/5/26 at 10:39 AM with MA #2 revealed she had been on duty at the facility on 12/26/25 and had received and signed for the pharmacy medication delivery which included Resident #132's Oxycodone. She stated she was very busy when the pharmacy delivery driver had delivered the facility medications and did not verify the medication count she received but had signed for the medications and put them in the locked medication room on a counter. MA #2 stated she had not had time to go back to the medication room to check the medications or secure them in the medication carts later in the shift but had notified the oncoming nurse the medications were in the locked medication room. She stated she did not know what happened to the medications after she left the facility. MA #2 explained the process was to check and compare to the delivery sheet at the time of delivery before signing for the medications with the pharmacy driver. The interview further revealed the medications should be checked and placed directly in the locked medication cart. Review of Resident #132's December 2025 Medication Administration Record (MAR) revealed the Oxycodone 5 mg was scheduled to be administered twice a day at 6:00 AM and 6:00 PM but was not administered on 12/25/25 at 6:00 PM, 12/26/25 at 6:00 PM, 12/27/25 at 6:00 AM and 12/29/25 at 6:00 AM. Nurses initialed the MAR on these dates and times and entered a 9 which indicated See progress notes.Review of Resident #132's nursing progress notes revealed: No entry on 12/25/25. On 12/26/25 at 5:11 PM Nurse #9 documented the Oxycodone was on order. On 12/27/25 at 5:26 AM Nurse #6 documented the Oxycodone was on order. On 12/29/25 at 5:49 AM Nurse #8 documented the Oxycodone had been requested and was waiting for approval. Attempts to reach Nurse #6, Nurse #8, and Nurse #9 for interviews were unsuccessful. Review of Resident #132's nursing progress notes revealed Resident #132 had no complaints of pain between 12/25/25 and 12/29/25. Review of Physician's progress note with a date of service of 12/26/25 at 9:30 AM read in part that Resident #132 had chronic back pain with no current complaints of pain. An interview on 8/4/26 at 2:17 pm with Nurse #1 revealed she did not remember anything about Resident #132's missing doses of Oxycodone. She stated there was a backup medication cabinet which was accessed through a code provided by the pharmacy. An interview on 8/5/26 at 10:49 AM with Nurse #2 revealed she was on duty 12/28/25 when Nurse #1 informed her that she (Nurse #1) had contacted the pharmacy 12/28/25 regarding Resident #132's missing Oxycodone. Nurse #1 informed her the pharmacy had delivered the Oxycodone to the facility on [DATE]. Nurse #2 indicated she initiated a search to locate Resident #132's Oxycodone narcotic medication card but the card and tablets were not found. Pharmacy was contacted again by Nurse #1, and a code was provided to access the backup medication cabinet so Nurse #1 could give Resident #132 her scheduled dose of Oxycodone on 12/28/25 at 6:00 PM. Review of the undated facility investigation summary documented by the Director of Nursing (DON) read in part that Resident #132's missing card was discovered on 12/28/25 when the pharmacist telephoned Nurse #1 due to nursing continuing to pull medication from the backup medication cabinet requiring a verification code. The pharmacist reported to nursing that a card for this medication had been delivered to the facility on [DATE]. Nurse #1 checked the medication cart and notified Nurse #2. A telephone interview on 8/5/26 at 5:24 PM with the Pharmacy Director revealed Oxycodone for Resident #132 was dispensed from the pharmacy 12/26/25 and the facility staff signed for and accepted the delivery of Resident #132's 14 tablets of Oxycodone 5 mg 12/26/25. The Pharmacy Director could not determine the exact quantity of Oxycodone available in the back up medication cabinet between 12/26/25 and 12/29/25. An interview on 8/5/26 at 11:29 AM with the Director of Nursing (DON) revealed Resident #132 missed 4 doses of pain medication when the nursing staff did not follow the facility policy to obtain the medication from the backup medication cabinet. She stated there was a process in place to contact the pharmacy to get a verification code to access the backup medication cabinet and get prescribed pain medication. The DON confirmed Resident #132 had received 6 doses of her scheduled Oxycodone pain medication from the backup medication cabinet between 12/23/25 and 12/28/25. The DON indicated she interviewed Resident #132 on 12/28/25 and she had no complaints of pain. She stated the pharmacy was supposed to be available 24/7 to deliver emergency medications, but they had delivered Resident #132's Oxycodone on 12/26/25. The DON stated that MA #2 should have checked and compared the delivery sheet to the medications received at the time of delivery before signing for the medications with the pharmacy driver. MA #2 should also have checked the medications and placed them directly in the locked medication cart. The DON stated the pharmacy was contacted on 12/28/25 and replacement medication was sent to the facility on [DATE]. A telephone interview on 8/6/26 at 11:17 AM with the Physician revealed he was unaware Resident #132 had missed any doses of Oxycodone and did not recall if the facility notified him or not. He stated he expected the facility to notify him for missing medication doses in case he needed to order alternate pain medication. The Physician indicated the resident did not have any adverse outcomes from the missed doses. An interview on 8/6/26 at 1:04 PM with the Administrator revealed the facility was unable to locate Resident #132's Oxycodone medication card and tablets and she did miss 4 doses. She stated it was due to a communication breakdown during the holidays.

Based on record review, staff, Nurse Practitioner (NP), and Medical Director interviews, staff failed to consult with the on-call provider immediately to obtain treatment orders for hypoglycemia when Resident #1, who had diabetes, had a critically low blood glucose level of 31 (normal 80-100), was lethargic, mumbling, and unable to receive anything by mouth as assessed by Nurse #1. Staff failed to communicate other symptoms that indicated urgent medical attention including abnormal eye movements, and tightness in her hands as assessed by Nurse #2, and inability to receive sugar under her tongue due to a tight jaw, as assessed by Unit Manager #1. Resident #1 was transferred to the hospital on 7/17/25. An emergency medical services (EMS) report dated 7/17/25 indicated when EMS arrived on scene at the facility at 4:48 PM the patient was found lying in her bed, eyes open but only reactive to pain. The EMS report stated Resident #1 was noted to be comatose with seemingly left gaze with inability to follow any types of commands for more detailed assessment. The hospital Discharge summary dated [DATE] indicated Resident #1 did not have improvement in her mental status despite improvement in acute kidney injury and treatment for urinary tract infection. The hospital discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. Immediate jeopardy began on 7/17/25 when staff failed to consult the physician about Resident #1's critically low blood glucose level of 31, abnormal eye movements and tightness in her hands and jaw. Immediate jeopardy was removed on 8/12/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains 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 education and monitoring systems put into place are effective. Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included type-2 diabetes mellitus. Resident #1's July 2025 medication administration record (MAR) revealed an order dated 12/4/23, for glucometer checks before breakfast and at bedtime. The blood sugar goal was a range of 100 - 250. Interventions included to notify the Nurse Practitioner (NP) if the results were greater than 250 consistently. For blood sugar less than 70, offer oral glucose and recheck blood sugar in 1 hour. Notify Medical Doctor (MD), if blood sugar is not improved or patient symptomatic.Review of the medical record revealed the facility did not have standing orders. Review of Resident #1's medical record revealed there were no nursing note entries from Nurse #1 on 07/17/25. The only entry made by Nurse #1 on 7/17/25 was a blood glucose result of 61 entered at 7:35 AM under vital signs. An interview was conducted on 8/7/25 at 9:09 AM with Nurse #1. She was the night shift (11PM-7AM) nurse for Resident #1 on the morning of 7/17/25. Nurse #1 recalled Resident #1 and her low blood sugars on the morning of 7/17/25. Nurse #1 recalled around 5:00 AM she checked Resident #1's blood glucose when she started her morning medication pass. She stated Resident #1's blood sugar was very low. Nurse #1 said Resident #1's blood sugar reading was 31. She remembered Resident #1 was lethargic and in and out of it, she stated Resident #1 would open her eyes and look at her and mumble inaudibly but would then close her eyes and go back to sleep. Nurse #1 said she would not have felt comfortable giving Resident #1 anything by mouth, that she was not alert enough. Nurse #1 explained she had intramuscular (IM) glucagon (emergency medicine used to treat low blood sugar) in the medication cart and administered the IM glucagon to Resident #1 right after she got the blood glucose reading of 31. Nurse #1 said she did not open Resident #1's medication administration record (MAR) or look at her orders for instructions on how to treat her hypoglycemia. She explained a few months ago Resident #1 had an episode of low blood sugar and IM glucagon had been used to treat the low blood sugar. Nurse #1 stated she assumed after that episode Resident #1 had an as needed standing order for IM glucagon. She reported she thought it was standard and that all residents with diabetes had an as needed order for IM glucagon. Nurse #1 stated after she administered the IM glucagon to Resident #1, she rechecked her blood glucose every 15 minutes. She recalled at first Resident #1's blood glucose went up steadily but then started to drop back down. Nurse #1 said the highest she could get Resident #1's blood glucose up to was 61. She reported by the time the day shift Unit Manager (UM #1) came in, around 6:45 AM, Resident #1's blood glucose was back down to 61. Nurse #1 said when UM #1 arrived at the facility she gave over care of Resident #1 to UM #1 because she had worked on Resident #1 for an hour and a half and 61 was the highest, she could get her blood sugar. Nurse #1 reported she asked UM #1 to call the on-call provider to let them know Resident #1 had an episode of hypoglycemia and what had been done to treat it and that what had been done was not effective. Nurse #1 explained she did not call the on-call provider during her shift when Resident #1's blood glucose was 31. Nurse #1 stated she was going to call the on-call provider after she treated Resident #1's hypoglycemia and let them know if it was effective or not. She explained she wrote down Resident #1's blood sugar results and gave them to UM #1. Nurse #1 stated she asked UM #1 if she would call the on-call provider and ask them what to do and to call Resident #1's family member to update them. Nurse #1 stated UM #1 said she would document the blood glucose results, call the on-call provider, and call Resident #1's family. Nurse #1 reported she did not notice any seizure like activity or vomiting for Resident #1. A progress note by the day shift Unit Manager (UM) #1 dated 7/17/25 at 7:13 AM read, night nurse reported resident was experiencing hypoglycemia, blood sugars as follows: 5:30 AM-31, 5:45 AM- 52, 6:00 AM- 56, 6:15 AM-61, 6:30 AM- 66, 6:45 AM- 61. On call notified and was advised to put sugar under her tongue and recheck blood sugar in 30 minutes.An interview was conducted with UM #1 on 8/6/25 at 3:05 PM. UM #1 reported she arrived to work on 7/17/25 between 6:30 AM and 7:00 AM. She did not recall the exact time. She said Nurse #1 reported to her when she arrived that Resident #1 had low blood sugar during the night. UM #1 said Nurse #1 reported she had given Resident #1 IM glucagon. She stated Nurse #1 did not ask her to document Resident #1's blood glucose checks from the night shift. UM #1 reported she did document the blood glucose results reported to her by Nurse #1 because she thought it was prudent to do so. UM #1 also reported Nurse #1 did not ask her to call the on-call provider or Resident #1's family. UM #1 did remember calling the on-call provider about Resident #1's low blood sugar and recalled the on-call provider gave her instructions to put sugar under Resident #1's tongue and recheck her blood sugar in 30 minutes. UM #1 stated when she went to put the sugar under Resident #1's tongue her mouth and jaw were tight, and she could not open her mouth. UM #1 said she did not want to pry open and force Resident #1's mouth open to put the sugar under her tongue. She reported she tried to put the sugar into her cheek as best as she could. UM #1 said she did not recall telling anyone about Resident #1's jaw being tight. She did not recall Resident #1 having tight arms or abnormal eye movement when she was in the room with her. A progress note by Nurse #2 dated 7/17/25 at 7:45 AM read, On coming to shift during report resident was reported to have struggled with low blood sugars throughout the night. Last blood sugar check was 61 at on coming of shift 7:00 AM. I was told to recheck blood sugar at 7:30 AM and call provider back. I rechecked blood sugar at 7:30 AM blood sugar dropped down to 59. I called provider to inform her of blood sugar level. Provider stated to just hold short acting and long-acting insulin for the morning and to recheck in an hour and give her a call back. Resident in bed. Eyes rolling side to side. Moaning. hands tight. Informed unit manager to recheck in an hour and call provider back.An interview was conducted with Nurse #2 on 8/6/25 at 2:53 PM. Nurse #2 was the day shift (7-3) and evening shift (3-11) nurse for Resident #1 on 7/17/25. Nurse #2 stated when she arrived on shift, the night shift (11PM-7AM) nurse (Nurse #1) reported to her Resident #1's blood sugars were extremely low in the 30's. Nurse #1 reported, she said 33 to be exact. Nurse #2 stated Nurse #1 reported to her the on-call provider was aware of Resident #1's low blood sugar and had said to recheck Resident #1's blood sugar around 7:30 AM and call the on-call provider back with what Resident #1's blood sugar was. Nurse #2 said she rechecked Resident #1's blood sugar at 7:30 AM and it was in the 50's, she did not recall the exact number. She reported she called the on-call provider back after checking Resident #1's blood sugar at 7:30 AM and was told by the on-call provider to hold Resident #1's insulin. She stated the provider instructed her to try to give her something to eat to increase her blood sugar and to recheck her blood sugar in an hour. Nurse #2 stated she told the provider she did not have time to do that or keep rechecking Resident #1's blood sugar because she had to pass medications and check blood sugars for her other residents with diabetes, so they sent a Registered Nurse (Nurse #3) to help with Resident #1. Nurse #2 said she did not remember Resident #1 having abnormal eye movements and tight hands during the morning or reporting it to anyone. Nurse #2 said she remembered that more from the evening right before Resident #1 went out. She stated Resident #1's eyes were moving left and right slowly like her head was turning side to side but her head was not moving, and her arms were tight and hard to move. Nurse #2 stated Resident #1 was transferred to the hospital between 4:30 PM and 5:00 PM on 7/17/25. An interview was conducted on 8/6/25 at 4:33 PM with Nurse #3. Nurse #3 said she communicated with the NP about Resident #1 and received orders from the NP throughout the day. Nurse #1 stated she had not noticed seizure symptoms, abnormal eye movements, tightness of hands, arms, or mouth, or foaming at the mouth when she was in Resident #1's room. She said staff had not mentioned those symptoms to her. Nurse #3 explained she left the facility in the afternoon after lunch before 3 PM- 11 PM shift change but was not sure of the exact time. Nurse #3 stated Resident #1's blood sugar had increased to 74 that afternoon before she left but Resident #1 had not had any improvement in her mental status. Review of an EMS report dated 7/17/25, revealed EMS received the emergency call from the facility at 4:33 PM and arrived on scene at the facility at 4:48 PM. The EMS report stated when they arrived the patient was found lying in her bed, eyes open but only reactive pain. Patient is noted to be comatose with seemingly left gaze with inability to follow any types of commands for more detained assessment. Her baseline is reported to be normal with some memory problems however, otherwise able to answer questions and hold conversation. The EMS report stated her blood sugar was 94 and then 84 with direct blood drawn from midline. She was given 125 milliliters (ml) of D10 (10% dextrose (glucose) in water) to see if it improved her mental status. The report stated no improvement in mental status was noted and D10 was stopped after 125 ml. The EMS report said they departed the scene at 5:09 PM. A hospital Discharge summary dated [DATE] indicated Resident #1 arrived to the hospital on 7/17/25 at 5:32 PM. The hospital course said Resident #1 presented to the hospital from the facility secondary to increasing lethargy, somnolence, with concern for acute metabolic encephalopathy. The discharge summary included the hospital workup was remarkable for acute kidney injury (AKI) and likely urinary tract infection (UTI). The hospital course stated Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged hypoglycemia and possible seizure which led to comatose state. The Discharge summary included that goals of care were discussed with family, and the decision was made to transitions to comfort care with inpatient hospice. A death certificate for Resident #1 documented she passed away on 7/30/25. Acute metabolic encephalopathy was listed as the cause of death.An interview was conducted on 8/7/25 at 12:15 PM with the NP. The NP reported Nurse #1 should have called the on-call provider when to report Resident #1's hypoglycemia and to get an order for how to treat the low blood glucose prior to giving Resident #1 glucagon. The NP said it had not been reported to her that Resident #1 had abnormal eye movements or tightness of her hands, arms, or mouth. She stated those were seizure symptoms and she was not made aware of that. NP #1 said she would have been worried about seizures if those symptoms had been reported to her and would have sent Resident #1 out that morning if she was concerned about seizures. An interview was conducted with the Medical Director on 8/7/25 at 11:15 AM. He stated the best thing in acute scenarios was to call the provider. He stated a medical provider should have been notified when Resident #1 had a critical blood sugar level of 31 at 5:30 AM on 7/17/25. He said the facility had a physician call service in place to manage hypoglycemia and that was better than paper standing orders. He explained the call service was 24 hours and if the on-call provider did not answer, the call would roll over to a backup on-call provider, and if the backup on-call provider did not answer, then the call would roll over to a second back up on call provider. He said he did not like standing orders because then you had someone with less knowledge making medical decisions. An interview was conducted with the interim Director of Nursing (DON) on 8/7/25 at 11:25 AM. The DON said Nurse #1 should have called the provider to report Resident #1's blood glucose level of 31 and to get an order for the IM glucagon. The DON stated the facility did not have standing orders and nurses needed to call the provider for everything. She reported Nurse #1 should have checked the MAR and called the provider before giving Resident #1 IM glucagon to get orders for how to treat her hypoglycemia. An interview was conducted with the Administrator on 8/7/25 at 3:50 PM. The Administrator said as a nurse she would have done what needed to be done to protect the resident at the time but would expect the nurse to call the provider timely to let them know what was going on. The facility's Administrator was informed of the immediate jeopardy on 8/7/25 at 4:03 PM. The facility submitted the following credible allegation of immediate jeopardy removal. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 7/17/25 at 5:30 AM Resident #1's blood glucose level was 31. Nurse #1 stated she administered intramuscular glucagon to Resident #1 to treat her low blood glucose. Nurse #1 said she did not call the physician or check Resident #1's medical record for hypoglycemia treatment orders before administering the glucagon. Nurse #1 reported when Unit Manager (UM #1) arrived to the facility around 6:45 AM she asked UM #1 to call the physician to notify them about Resident #1's low blood glucose and what had been done to treat her low blood glucose. UM #1 documented she contacted the Provider at 7:13 AM. Unit Manager #1 did recognize that she was unable to place sugar under resident #1's tongue due to her clinched jaw however she failed to notify the MD of resident #1's emergent situation. Nurse #2 failed to notify the MD of abnormal eye movement, and tight hands which were signs of an emergent situations. Failure to notify the physician about Resident #1's critically low blood glucose level could likely result in serious injury, harm, impairment, or death.All residents with diabetes or those taking antidiabetic medications are at risk. On August 8, 2025, the Director of Nursing and the Unit Manager reviewed medical records related to diabetes diagnoses and physician orders for diabetic medications and insulin. This was done to identify residents at risk of hypoglycemic episodes and to ensure that their physician orders were updated according to facility protocol.1. Notify the physician for blood glucose levels below 60 and above 500 or identified as Hi on the glucometer.For blood glucose levels 50 and below: (1) Verify blood glucose level using a finger on the opposite hand, if the blood glucose level remains the same or below 50, then (2) give 1milligram (mg) of Glucagon intramuscularly. (The Glucagon is located in the medication cart of each resident and in the pharmacy e-kit located in the medication room at the nursing units) and (3) notify the physician for additional orders and continue to monitor and evaluate the resident's status, (4) notify the physician of any changes. All licensed nurses, including agency nurses, were educated on 8/11/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event and feel as if the on call/ extended practice provider does not respond to a call or does not address an identified emergent situation as emergent the facility is to contact the Medical Director/Designee. All residents who were transferred to the hospital within the past 30 days were reviewed for life threatening events which included initiation of symptoms, time reported to the physician and time transferred to the hospital by the Director of Nursing on 8/8/25 to ensure proper notification of the physician and management of symptom/changes. No further deficient practices were identified. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.All licensed nurses, including agency nurses, were educated on 8/7/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event. This education included once you identify a change in a resident's baseline (usual) status, the physician must be notified for further direction; and the nurse must document in the resident's medical record the change in condition and physician notification. All staff education began on 8/7/2025 to notify the nurse if a resident emergent situation is identified or suspected and the importance of reporting resident emergent situations. Staff who have not received education by 8/8/2025 will not be allowed to work until education is completed. The Director of Nursing is responsible for ensuring all staff are educated prior to working. Nurse #1 has been suspended pending the completion of this investigation on 8/7/2025Nurse #1 was terminated on 8/8/2025 for deficient practice, failure to identify emergent resident situation, failure to notify MD of emergent situation in status, providing medications without MD order. On 8/8/2025, UM#1 and Nurse #2 received disciplinary action for not identifying an emergent resident situation and failing to notify the MD of emergent situation, by the Director of Nursing.Immediate Jeopardy Removal Date: 8/12/2025 On 8/14/25 the facility's credible allegation of immediate jeopardy removal was validated by the following: Review of facility audits revealed the facility completed an audit of all diabetic residents residing in the building. Review of physician orders for diabetic residents, including non-insulin dependent diabetic residents revealed as needed (PRN) glucagon orders had been added for all residents. Medication cart observations were completed. Each medication cart was overserved to have emergency glucagon kits for individual residents. Review of in-service education logs revealed licensed nurses including UM #1 and Nurse #2 were educated on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician for change in a residents condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. Additional in-service logs were reviewed and revealed all staff (including UM #1 and Nurse #2) were educated on the signs/ symptoms of hypoglycemia, emergent situations, including when to call 911, and notifying the nurse of change in condition. Interviews were conducted with licensed nurses, including agency nurses. The nurses confirmed they had received education on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician when there is a change in resident condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. The licensed nurses were able to accurately verbalize the education they received. Interviews were conducted with licensed nurses, nurse aides, dietary staff, housekeeping, maintenance, office, administration/management, therapy, and agency staff. Interviews were conducted with staff from different shifts. The staff interviews revealed they had received education on the symptoms of hypoglycemia/ hyperglycemia, emergent situations including when to call 911, and notifying the nurse for change of condition. Staff were able to accurately verbalize the education they had received. Review of provider in-service logs revealed on 8/8/25 providers were educated by the Medical Director on the importance of notifying the medical Director when a resident is identified as having a critically low blood sugar and is showing symptoms that require emergency care. Education included: identification of emergent situation versus nonemergent situation, what is within the capabilities of the facility to properly care for residents with critically low blood sugar, and when to get the resident emergency medical attention. Education included acknowledgement of the devastation this type of scenario could bring if not treated properly. It was verified Nurse #1 no longer worked at the facility. An interview with the Administrator confirmed the involved NP was removed from facility services beginning on 8/7/25. The Administrator stated the facility had contacted the board of nursing and reported the involved NP but had not heard back from the board of nursing. Immediate Jeopardy Removal Date of 8/12/25 was validated.

Based on observation, record review, staff, resident, family, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's (Resident #1) right to be free from neglect when the facility failed to ensure Resident #1 received emergent care extending beyond the capabilities of the facility when she had critically low blood sugar and was symptomatic. Symptoms included lack of responsiveness, eyes moving left to right, obtunded, jaw tightness, inability to swallow, tightness of hands, moaning, foaming at the mouth. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brains function is impaired due to metabolic distubance), prolonged hypoglycemia, acute kidney injury (AKI), and urinary tract infection (UTI). The hospital Discharge summary dated [DATE] said, Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. This deficient practice occurred for 1 of 1 resident reviewed for neglect. Immediate jeopardy began on 7/17/25 when the facility failed to recognize Resident #1 who had critically low blood sugar and was symptomatic, needed emergency medical services extending beyond the capabilities of the facility. Immediate jeopardy was removed on 8/13/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains 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 education and monitoring systems put into place are effective. Findings included: This tag is cross referred to:F 684- Based on observations, record review, staff, family, Nurse Practitioner (NP), Physician Assistant and Medical Director interviews the facility failed to recognize that a diabetic resident (Resident #1) with critically low blood sugar (normal 80-100) needed emergency medical care that required transfer to a higher level of care. On 7/17/25 at 5:30 AM Resident #1's blood sugar was 31(a serious life-threatening medical condition) and Resident #1 was lethargic (sluggish), in and out of it, mumbling, and not alert enough to eat or drink. After an intramuscular (IM) injection of glucagon (medication to treat low blood sugar) the resident remained symptomatic and was still lethargic, in and out of it, and not alert enough to eat or drink. Symptoms Resident #1 experienced from the initial low blood sugar of 31 at 5:30 AM on 07/17/25 until her discharge at 5:09 PM on 07/17/25 included lack of responsiveness, eyes moving left to right, obtunded (reduced level of alertness), jaw tightness, inability to swallow, tightness of hands, moaning, and foaming at the mouth. Resident #1's blood glucose level remained less than 70 until 1:08 PM when it was documented her blood glucose level was 77, however she remained obtunded with no verbal response. Resident #1's blood glucose decreased again to 59 at 2:30 PM. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brain dysfunction), prolonged hypoglycemia (low blood sugar), acute kidney injury (AKI), and urinary tract infection (UTI). The hospital Discharge summary dated [DATE] said, Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. This deficient practice affected 1 of 3 residents reviewed for quality of care. F 580- Based on record review, staff, Nurse Practitioner (NP), and Medical Director interviews, staff failed to consult with the on-call provider immediately to obtain treatment orders for hypoglycemia when Resident #1, who had diabetes, had a critically low blood glucose level of 31, was lethargic, mumbling, and unable to receive anything by mouth as assessed by Nurse #1. Staff failed to communicate other symptoms that indicated urgent medical attention including abnormal eye movements, and tightness in her hands as assessed by Nurse #2, and inability to receive sugar under her tongue due to a tight jaw, as assessed by Unit Manager #1. Resident #1 was transferred to the hospital on 7/17/25. An emergency medical services (EMS) report dated 7/17/25 indicated when EMS arrived on scene at the facility at 4:48 PM the patient was found lying in her bed, eyes open but only reactive to pain. The EMS report stated Resident #1 was noted to be comatose with seemingly left gaze with inability to follow any types of commands for more detailed assessment. The hospital Discharge summary dated [DATE] indicated Resident #1 did not have improvement in her mental status despite improvement in acute kidney injury and treatment for urinary tract infection. The hospital discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. The Administrator was notified of immediate jeopardy on 8/11/25 at 3:30 PM. The facility submitted the following credible allegation of immediate jeopardy removal 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.The facility's failure to ensure Resident #1 received emergent care extending beyond the capabilities of the facility had the high likelihood of resulting in serious injury, serious harm, serious impairment or death. Failure to notify the physician about Resident #1's critically low blood glucose level could likely result in serious injury, harm, impairment, or death.On 7/17/25 at 5:30 AM Resident #1's blood glucose level was 31. Nurse #1 stated she administered intramuscular glucagon to Resident #1 to treat her low blood glucose. Nurse #1 said she did not call the physician or check Resident #1's medical record for hypoglycemia treatment orders before administering the glucagon. Nurse #1 reported when Unit Manager (UM #1) arrived to the facility around 6:45 AM she asked UM #1 to call the physician to notify them about Resident #1's low blood glucose and what had been done to treat her low blood glucose. UM #1 documented she contacted the Provider at 7:13 AM. Unit Manager #1 did recognize that she was unable to place sugar under resident #1's tongue due to her clinched jaw however she failed to notify the MD of resident #1's emergent situation. Nurse #2 failed to notify the MD of abnormal eye movement, and tight hands which were signs of an emergent situations. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:06 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. The hospital course stated, suspect she had prolonged blood glucose and seizure which led to comatose state. Her hospital diagnoses included acute metabolic encephalopathy, prolonged hypoglycemia, acute kidney injury, and urinary tract infection. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. All residents in the facility have the potential to be affected by this deficient practice. All residents with diabetes or those taking antidiabetic medications are at risk. On August 8, 2025, the Director of Nursing and the Unit Manager reviewed medical records related to diabetes diagnoses and physician orders for diabetic medications and insulin. This was done to identify residents at risk of hypoglycemic episodes and to ensure that their physician orders were updated according to facility protocol. Notify the physician for blood glucose levels below 60 and above 500 or identified as Hi on the glucometer.For blood glucose levels 50 and below: (1) Verify blood glucose level using a finger on the opposite hand, if the blood glucose level remains the same or below 50, then (2) give 1mg of Glucagon intramuscularly. (The Glucagon is located in the medication cart of each resident and in the pharmacy e-kit located in the medication room at the nursing units) and (3) notify the physician for additional orders and continue to monitor and evaluate the resident's status, (4) notify the physician of any changes. All licensed nurses, including agency nurses, were educated on 8/11/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event and feel as if the on call/ extended practice provider does not respond to a call or does not address an identified emergent situation as emergent the facility is to contact the Medical Director/Designee. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On August 8, 2025, the Medical Director conducted a training session for all primary care physician extenders. The purpose was to emphasize the importance of notifying the Medical Director when a resident is identified as having critically low blood sugar and is showing symptoms that require emergency care. Education included identification of emergent situation versus nonemergent situation and within the capabilities of the facility to properly care for the resident with critically low blood sugar and when to get the resident emergency medical attention. Additionally, on August 8, 2025, the Director of Nursing, Minimum Data System (MDS) RN, and Weekend RN Unit Manager provided education for all staff. This education covered the signs and symptoms of hypoglycemia and provided guidance on when to notify the nurse, the medical doctor, and when to call 911 if a resident appears to be in an emergency situation. Education included if blood sugar levels fall outside the parameters specified in the physician's orders and the patient exhibits symptoms of hypoglycemia-such as shakiness, chills, nausea, a rapid heartbeat, or hunger-but remains responsive, this is considered a non-emergent situation. Education was provided regarding emergent events, such as non-responsiveness or seizure activity, which would require immediate notification of a physician and a call to 911. The training included the importance of treating hypoglycemia as it can lead to devastation including up to death if left untreated. A100% audit was conducted of all identified diabetic resident's medication orders was completed by the Director of Nursing, and/or Unit Manager on 8/8/25 to identify residents without parameters for when to contact the MD for abnormal glucose blood level. For those residents identified, orders were updated to include the parameters of when to notify the physician. New protocol established:1. Notify the physician for blood glucose levels below 60 and above 500 or identified as Hi on the glucometer.2. For blood glucose levels 50 and below: (1) Verify blood glucose level using a finger on the opposite hand, if the blood glucose level remains the same or below 50, then (2) give 1mg Glucagon intramuscularly. Glucagon is stored in the medication cart for all residents with a diabetic diagnosis, including those on diet control, insulin-dependent residents, and residents taking antidiabetic medications who are at risk for hypoglycemic episodes. Glucagon was added to each resident's medication drawer on 8/8/2025, who was identified as a diabetic. Additionally, it can be found in the pharmacy emergency kit located in the medication room at the nursing station. The following additional actions should be taken: (1) notify the physician for additional orders, (2) continue to monitor the resident, (3) evaluate their condition, and (4) inform the physician of any changes. All licensed nurses, including agency nurses, were educated on 8/7/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event. This education included once you identify a change in a resident's baseline (usual) status, the physician must be notified for further direction; and the nurse must document in the resident's medical record the change in condition and physician notification. All staff education began on 8/7/2025 to notify the nurse if a resident emergent situation is identified or suspected and the importance of reporting resident emergent situations. Staff who have not received education by 8/8/2025 will not be allowed to work until education is completed. The Director of Nursing is responsible for ensuring all staff are educated prior to working. Nurse #1 has been suspended pending the completion of this investigation on 8/7/2025Nurse #1 was terminated on 8/8/2025 for deficient practice, failure to identify emergent resident situation, failure to notify MD of emergent situation in status, providing medications without MD order. On 8/8/2025, UM#1 and Nurse #2 received disciplinary action for not identifying an emergent resident situation and failing to notify the MD of emergent situation, by the Director of Nursing.Nurse Practitioner involved was removed from facility services effective 8/7/2025 by the Facility Director of Operations and the Extended Provider Practice. All staff education began on 8/11/2025 by the Director of Nursing and the Human Resource Director on Abuse, Neglect and Exploitation policy with the emphasis on neglect, such as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Staff who have not received education by 8/11/2025 will not be allowed to work until education is completed. The Director of Nursing is responsible for ensuring all staff are educated prior to working. On 8/12/2025 The Facility Administrator filed a report to the North Carolina Board of Nursing regarding Nurse Practitioner involved. Immediate Jeopardy Removal Date: 8/13/2025On 8/14/25 the facility's credible allegation of immediate jeopardy removal was validated by the following: An onsite facility revisit was conducted on 8/14/25. Review of facility audits revealed the facility completed an audit of all diabetic residents residing in the building. Review of physician orders for diabetic residents, including non-insulin dependent diabetic residents revealed as needed (PRN) glucagon orders had been added for all residents. Medication cart observations were completed. Each medication cart was overserved to have emergency glucagon kits for individual residents. Review of in-service education logs revealed licensed nurses including UM #1 and Nurse #2 were educated on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician for change in a residents condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. Additional in-service logs were reviewed and revealed all staff (including UM #1 and Nurse #2) were educated on abuse/ neglect including the facility abuse/ neglect policy, the signs/ symptoms of hypoglycemia, emergent situations, including when to call 911, and notifying the nurse of change in condition. Interviews were conducted with licensed nurses, including agency nurses. The nurses confirmed they had received education on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician when there is a change in resident condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. The licensed nurses were able to accurately verbalize the education they received. Interviews were conducted with licensed nurses, nurse aides, dietary staff, housekeeping, maintenance, office, administration/management, therapy, and agency staff. Interviews were conducted with staff from different shifts. The staff interviews revealed they had received education abuse/ neglect, on the symptoms of hypoglycemia/ hyperglycemia, emergent situations including when to call 911, and notifying the nurse for change of condition. Staff were able to accurately verbalize the education they had received. Review of provider in-service logs revealed on 8/8/25 providers were educated by the Medical Director on the importance of notifying the medical Director when a resident is identified as having a critically low blood sugar and is showing symptoms that require emergency care. Education included: identification of emergent situation versus nonemergent situation, what is within the capabilities of the facility to properly care for residents with critically low blood sugar, and when to get the resident emergency medical attention. Education included acknowledgement of the devastation this type of scenario could bring if not treated properly. It was verified Nurse #1 no longer worked at the facility. An interview with the Administrator confirmed the involved NP was removed from facility services beginning on 8/7/25. The Administrator stated the facility had contacted the board of nursing and reported the involved NP but had not heard back from the board of nursing. Immediate Jeopardy Removal Date of 8/13/25 was validated.

Based on observations, record review, staff, family, Nurse Practitioner (NP), Physician Assistant and Medical Director interviews the facility failed to recognize that a diabetic resident (Resident #1) with critically low blood sugar (normal 80-100) needed emergency medical care that required transfer to a higher level of care. On 7/17/25 at 5:30 AM Resident #1's blood sugar was 31 (a serious life-threatening medical condition) and Resident #1 was lethargic (sluggish), in and out of it, mumbling, and not alert enough to eat or drink. After an intramuscular (IM) injection of glucagon (medication to treat low blood sugar) the resident remained symptomatic and was still lethargic, in and out of it, and not alert enough to eat or drink. Symptoms Resident #1 experienced from the initial low blood sugar of 31 at 5:30 AM on 07/17/25 until her discharge at 5:09 PM on 07/17/25 included lack of responsiveness, eyes moving left to right, obtunded (reduced level of alertness), jaw tightness, inability to swallow, tightness of hands, moaning, and foaming at the mouth. Resident #1's blood glucose level remained less than 70 until 1:08 PM when it was documented her blood glucose level was 77, however she remained obtunded with no verbal response. Resident #1's blood glucose decreased again to 59 at 2:30 PM. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brain dysfunction), prolonged hypoglycemia (low blood sugar), acute kidney injury (AKI), and urinary tract infection (UTI). The hospital Discharge summary dated [DATE] said, Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. This deficient practice affected 1 of 3 residents reviewed for quality of care. Immediate jeopardy began on 7/17/25 when the facility failed to recognize that Resident #1 had a critically low blood sugar and was symptomatic and needed emergency care extending beyond the capabilities of the facility. Immediate jeopardy was removed on 8/9/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains 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 education and monitoring systems put into place were effective. Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included type-2 diabetes mellitus. She was discharged from the facility on 7/17/25 to an acute care hospital. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS documented revealed that she received insulin injections and hypoglycemic medication.A care plan revised on 06/13/25 read, Resident #1 has diabetes mellitus and has fluctuations in blood sugars, sliding scale insulin and capillary blood glucose (CBG) per orders. Resident #1 often refuses meals at times. The care plan goal last revised on 6/13/25 was for Resident #1 to not have any complications related to diabetes through the review date. The care plan interventions included:-monitor/ document/ report as needed any signs or symptoms of hyperglycemia (high blood sugar) (increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (a deep and labored breathing pattern), acetone breath (smells fruity), stupor, coma. -Monitor/document/report as needed any signs or symptoms of hypoglycemia (low blood sugar) (sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait). -The care plan interventions additionally included, diabetes medications as ordered by the doctor, monitor/ document for side effects and effectiveness. Fasting serum blood sugar as ordered by the doctor. Review of Resident #1's July 2025 medication administration record (MAR) revealed the following orders:- An order dated 11/22/22 read, Jardiance (diabetic medication) tablet 25 milligrams (mg) give one tablet by mouth in the morning. The medication was documented by Nurse #2 as not administered on 7/17/25 at 8:00 AM due to drug refused. The MAR documented the medication was also not received on 7/11/25 due to drug refused. Resident #1 received all other doses as ordered for the month of July 2025. -An order dated 12/4/23 read, glucometer (blood sugar) checks before breakfast and at bedtime blood sugar goal-100-250 range. Notify Nurse Practitioner (NP) if greater than 250 consistently. For blood sugar less than 70 offer oral glucose and recheck blood sugar in 1 hour- notify Medical Doctor (MD) if blood sugar is not improved or patient symptomatic. Review of the medical record revealed Resident #1 had blood sugar results that ranged from 30-439 during the month of July 2025. -An ordered dated 2/27/25 read, Humalog (short acting insulin/diabetic medication) Kwik Pen subcutaneous solution pen injector 100 unit/ ml inject as per sliding scale:if 0 - 150 = 0151 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units401 - 450 = 12 units451 - 999 = call Medical Doctor (MD)Subcutaneously before meals and at bedtime for diabetes. The order was discontinued on 7/17/25 at 1:39 PM. The MAR documented the medication was last administered on 7/15/25 at 8:00 PM. - An order dated 2/28/25 read, Tresiba (long-acting insulin/diabetic medication) FlexTouch subcutaneous solution pen injector 100 unit/ milliliter (ml) inject 45 units subcutaneously in the morning. The MAR documented the medication was last administered on 7/16/25 at 9:00 AM All of Resident #1's morning (8:00 AM and 9:00 AM) and evening (2:00 PM and 5:00 PM) scheduled medications on 7/17/25 were documented as not administered by Nurse #2 due to drug refused. Additional review of Resident #1's medical record revealed that there was no standing order for the administration of IM glucagon. Review of Resident #1's medical record revealed there were no nursing note entries from Nurse #1 on 07/17/25. An interview was conducted on 8/7/25 at 9:09 AM with Nurse #1. She was the night shift (11pm-7am) nurse for Resident #1 on the morning of 7/17/25. Nurse #1 recalled Resident #1 and her low blood sugars on the morning of 7/17/25. Nurse #1 recalled around 5:30AM she checked Resident #1's blood sugar when she started her morning medication pass. Nurse #1 said Resident #1's blood sugar reading was very low and was 31. She remembered Resident #1 was lethargic and in and out of it, she stated Resident #1 would open her eyes and look at her and mumble inaudibly but would then close her eyes and go back to sleep. Nurse #1 said she would not have felt comfortable giving Resident #1 anything by mouth, that she was not alert enough. Nurse #1 explained she had IM glucagon in the medication cart and administered the IM glucagon to Resident #1 right after she got the blood glucose reading of 31. Nurse #1 said she did not open Resident #1's MAR or look at her orders for instructions on how to treat her hypoglycemia. She explained a few months ago Resident #1 had an episode of low blood sugar and IM glucagon had been used to treat the low blood sugar. Nurse #1 stated she assumed after that episode Resident #1 had an as needed standing order for IM glucagon. She reported she thought it was pretty standard and that all diabetic residents had an as needed order for IM glucagon. Nurse #1 stated after she administered the IM glucagon to Resident #1, she rechecked her blood sugar every 15 minutes. She recalled at first Resident #1's blood sugar went up steadily but then it started to drop back down. Nurse #1 said the highest she could get Resident #1's blood sugar up to was 66. She stated by the time the day shift Unit Manger (UM #1) came in around 6:45 AM her blood sugar was back down to 61. Nurse #1 said when UM #1 arrived at the facility she turned over care of Resident #1 to UM #1 because she had worked on Resident #1 for an hour and a half and 61 was the highest, she could get her blood sugar. Nurse #1 reported she asked UM #1 to call the on-call provider to let them know Resident #1 had an episode of hypoglycemia and what had been done to treat it and that what had been done was not being effective. Nurse #1 explained she did not call the on-call provider during her shift when Resident #1's blood glucose was 31. Nurse #1 stated she was going to call the on-call provider after she treated Resident #1's hypoglycemia and let them know if it was effective or not but she did not. She explained she did not document the every 15 minute blood sugar check results in Resident #1's medical record but she did write them down and gave them to UM #1. Nurse #1 stated she had asked UM #1 if she would call the on-call provider and ask them what to do and call Resident #1's family member to update them. Nurse #1 stated UM #1 said she would document the blood sugar results, call the on-call provider, and call Resident #1's family. Nurse #1 reported she did not notice any seizure like activity or vomiting for Resident #1. A progress note by UM#1 dated 7/17/25 at 7:13 AM read, night nurse reported resident was experiencing hypoglycemia, blood sugars as follows: 5:30 AM-31, 5:45 AM- 52, 6:00 AM- 56, 6:15 AM-61, 6:30 AM- 66, 6:45 AM- 61. On call notified and was advised to put sugar under her tongue and recheck blood sugar in 30 minutes. An additional progress note dated 7/17/25 at 8:33 AM by UM #1 read, blood sugar is 61 and resident is still not responding, called provider and left message for NP, as to resident's condition.An order dated 7/17/25 entered at 1:00 PM on the MAR read, please have midline catheter (IV access) placed one time only for 2 days. A progress note dated 7/17/25 at 2:11 PM by UM #1 read, [mobile X-ray vascular company] called to come and start PICC (peripherally inserted central catheter) line, informed they will be here around 3:15 PM. Rocephin (antibiotic) 1 gram, administered IM 1 gram in left hip and 1 gram in right hip, resident obtunded and made no response. [NP] notified. An interview was conducted with UM #1 on 8/6/25 at 3:05 PM. UM #1 reported she arrived at work on 7/17/25 between 6:30 AM and 7:00 AM, but she did not recall the exact time. She said Nurse #1 reported to her when she arrived that Resident #1 had low blood sugar during the night. UM #1 said Nurse #1 reported she had given Resident #1 IM glucagon. UM #1 reported she documented the blood glucose results reported to her by Nurse #1 because she thought it was prudent to do so. UM #1 stated Nurse #1 did not ask her to call the on-call provider or Resident #1's family. UM #1 remembered calling the on-call provider about Resident #1's low blood sugar at the start of her shift but did not recall the exact time. She recalled the on-call provider gave her instructions to put sugar under Resident #1's tongue and recheck her blood sugar in 30 minutes. UM #1 stated when she went to put the sugar under Resident #1's tongue her mouth and jaw were tight, and she could not open her mouth. UM #1 said she did not want to pry open and force Resident #1's mouth open to put the sugar under her tongue. She reported she tried to put the sugar into her cheek as best as she could. She did not recall Resident #1 having tight arms or abnormal eye movement when she was in the room with her and no one had reported that to her. UM #1 said she did not recall Resident #1 having any seizure like activity. UM #1 stated Resident #1 was given another dose of glucagon at some point, but she was not entirely sure when. UM #1 explained she thought there was no more glucagon in the building but that when she looked, she was able to find another dose of glucagon on the other side of the building. She was not sure if it was in the morning or the afternoon when she found the second dose. UM #1 stated she did not administer any glucagon to Resident #1 on 07/17/25. She reported when she found the glucagon she gave it to Nurse #2 to administer. She stated she was not sure if Resident #1 had an order for glucagon but thought it was a standing order for diabetic residents. UM #1 said Resident #1's blood sugar hoovered between 50 and 60 throughout the day, she stated Resident #1's blood sugar never came up above 61. She explained that a Registered Nurse (RN) who worked for the NP provider group (Nurse #3) was at the facility and was in and out of Resident #1's room all day. She said when Nurse #3 arrived at the facility she took over care of Resident #1 and communicated with the NP directly. UM #1 recalled that Nurse #3 attempted several times to start an intravenous (IV) access site on Resident #1 but was unsuccessful. She recalled 5% dextrose in water (D5W) was administered to Resident #1 by hypodermoclysis (clysis) (fluids administered subcutaneous) by Nurse #3. UM #1 recalled talking to the NP about vascular access for Resident #1 and setting that up with the mobile vascular company to come to the facility and place a midline (vascular access) for Resident #1. She stated she called the mobile vascular access company and set up for them to come to the facility to place the midline with an estimated time of arrival at 3:15 PM that day. UM #1 said she was in and out of Resident #1's room during the day and Resident #1 was not awake, not alert, and was not responsive at all the entire time. When asked if Resident #1 was able to eat or drink anything that day, UM #1 stated [NAME] no she was not eating she was somnolent [sleepy/drowsy]. UM #1 did not recall if she asked the NP about sending Resident #1 to emergency room (ER) when she spoke to her on the phone. UM #1 stated if it had been the facility's Medical Director provider group they would have sent Resident #1 out. UM #1 stated if she was the provider she would have sent Resident #1 out to the ER but that that was not a nurse's call to make. UM #1 stated she had no idea why the NP did not send Resident #1 out earlier. UM #1 reported Nurse #2 called Resident #1's family to update them on what was going on but was not sure what time she called. UM #1 explained Resident #1 was sent out the ER that afternoon after Nurse #2 called the family. UM #1 stated she did not see Resident #1 when she went out. A progress note dated 7/17/25 and timed 5:10 PM by Nurse #3 read, Seen today at the request of the nurse for low blood glucose levels. Nurse reports that member with noted blood glucose levels this morning 31-61. It was reported that she received 1 mg glucagon injection prior to my arrival. She is seen lying in bed, eyes open but she appears obtunded. [Capillary Blood Glucose] CBG at that time was 43. Glucagon 1 mg was repeated. NP aware with new order to obtain IV and administer D5 [5% dextrose (sugar) in water]. IV attempted x 3 unsuccessful. Clysis [fluids given subcutaneously] was initiated at that time at 60cc [cubic centimeters]/hr. Blood glucose levels checked periodically after initiation of clysis and slowly increased to 74, however she remained obtunded with no verbal responses. Underlying infection suspected- UA [urinalysis] C&S [culture & sensitivity] ordered, Rocephin [antibiotic] 2 gm IM x 1 dose. Tresiba decreased to 38 units daily- hold for CBG less than 150, SSI [sliding scale insulin] discontinued. Also order to have midline [vascular access] placed for continuous fluid with initial 500 cc bolus of NS [normal saline] and then resume D5 at 125cc/hr for remainder of current liter. She has had no po [by mouth] intake today and NA caring for member reports very little po intake for the previous day. UM updated on orders and reports that call has been placed for midline and approximate ETA [estimated time of arrival] is 3:15 pm. VS [vital signs] ordered every 4 hours x 3 days and CBG every 3 hours x 24 hours. NP left message for son to return call. Administrator also updated. Staff to notify provider group with any concerns or needs. An order dated 7/17/25 entered at 1:30 PM read, ceftriaxone (Rocephin) (antibiotic) injection solution, inject 2 grams (gm) intramuscularly one time only for urinary tract infection (UTI) for 1 day. An order dated 7/17/25 entered at 2:30 PM read, normal saline flush intravenous solution 0.9 %, use 500 ml intravenously one time only for dehydration for 1 day bolus 999 ml /hour (hr.) once midline placed. An order dated 7/17/25 entered at 1:45 PM read, dextrose (glucose) intravenous solution 5 %, use 1 liter intravenously one time only for Dehydration for 1 Day, 60 ml/hr. clysis. Call NP once midline placed. An interview was conducted on 8/6/25 at 4:33 PM with Nurse #3. Nurse #3 worked for the NP's provider group and with the NP which was a separate provider group from the Medical Director provider group. She explained she went to the facility several days a week to check on their patients. She reported she arrived at the facility around 9:00 AM on 7/17/25. She stated the NP called her that morning before she arrived at the facility and updated her that Resident #1 was having problems with low blood sugar. Nurse #3 reported when she arrived at the facility, she went to see Resident #1 first. Nurse #3 explained she checked Resident #1's blood sugar when she arrived and it was 43. Nurse #3 said it was reported to her Resident #1 had been given glucagon before she arrived, she was not sure what time it was given. She explained it was told to her there was no other glucagon available in the building at that time. Nurse #3 said when she arrived, Resident #1 was not her normal self and was not verbally responsive. She said Resident #1 was not able to take fluids, she explained she was not able to swallow the fluids and would just hold the fluids in her mouth. Nurse #3 explained she spoke with the NP and communicated with her throughout the day about Resident #1. She said the NP had wanted her to try to start an IV on Resident #1 to administer fluids. She further explained they had wanted to administer IV fluids because they were worried Resident #1 would aspirate because she was not swallowing and was holding fluids in her mouth. Nurse #3 stated she assumed Resident #1 usually did not have any trouble swallowing because she normally ate and drank. Nurse #3 said she tried three times to place an IV access site unsuccessfully. Nurse #3 reported then the facility found more glucagon and they gave it to Resident #1. She did not see them administer the glucagon and was not sure who administered it to Resident #1, but she thought it was UM #1. She thought it had been sometime between 9:00-10:00 AM but was not sure of the exact time. Nurse #3 was not sure what Resident #1's blood sugar came up to after the second dose of glucagon was administered. Nurse #3 said around 10:00 AM she started D5W administered by hypodermoclysis on Resident #1. She reported Resident #1's eyes were open, but she was not verbally responsive. Nurse #3 said she did not stay at Resident #1's bedside the entire time, she explained she had other patients to see at the facility. She reported she was in and out of Resident #1's room every 15-20 minutes to check on her and recheck her blood sugar. Nurse #3 said Resident #1's blood sugar was 55 at 12:06 PM. She explained she had checked Resident #1's blood sugar before that but did not remember what the blood sugar results were. She further explained she had rechecked her blood sugars to make sure they were going up and not falling, she recalled they had been going up but did not remember the results. Nurse #3 said after the hypodermoclysis was started she spoke to the NP again and the NP thought it would be best to get a mid-line (vascular access) placed for Resident #1. She did not remember what time she talked to the NP but said it was sometime between 10:00 AM- 12:00 PM. She said UM #1 called the mobile vascular access company and they were able to come to the facility at 3:15 PM that day to place the midline. Nurse #3 reported Resident #1 stayed in bed the entire day. She said she had arrived at the facility after breakfast, but the staff reported to her Resident #1 did not eat breakfast. Nurse #3 said Resident #1 did not eat lunch or anything because she was not alert enough to eat. She reported Resident #1's mentation was the same and unchanged the entire time she was there. Nurse #3 said she did not stay at the facility the entire day. She explained she left the facility sometime after lunch before the 3-11 shift change but was not sure of the exact time. She said Resident #1's last blood sugar before she left was 74 and she still had no improvement in her mental status. She explained she spoke with the NP, and they thought maybe there was another issue other than Resident #1's low blood sugar causing her decreased mental status. She explained that was why the NP ordered the intramuscular Rocephin (antibiotic) and a urinalysis (UA) for Resident #1. Nurse #3 said she was not in the room when the Rocephin was administered to Resident #1, but it was reported it had been given to her. Nurse #3 said she had not called the family but that the NP told her she had tried to call and update Resident #1's family. When Nurse #3 was asked if she and the NP discussed transferring Resident #1 to the ER, Nurse #3 said the NP had asked her what her thoughts were. Nurse #3 reported she told the NP she was at the facility and would hang around and see how Resident #1 did. Nurse #3 explained they were doing the fluids with hypodermoclysis and were going to be able to get the midline placed and would be able to get some hydration in her. She further explained the initial concern was her low blood sugar and treating her hypoglycemia. She reported that if Resident #1 had not stabilized after the midline was placed then she would have needed to go the ER. Nurse #3 stated she had not witnessed Resident #1 having any seizure activity. Nurse #3 stated she had not noticed any tightness in Resident #1's hands, arms, or jaw, abnormal eye movements, or foaming at the mouth. A progress note by Nurse #2 dated 7/17/25 at 7:45 AM read: On coming to shift during report resident was reported to have struggled with low blood sugars throughout the night. Last blood sugar check was 61 at on coming of shift 7:00 AM. I was told to recheck blood sugar at 7:30 AM and call provider back. I rechecked blood sugar at 7:30 AM blood sugar dropped down to 59. I called provider to inform her of blood sugar level. Provider stated to just hold short acting and long-acting insulin for the morning and to recheck in an hour and give her a call back. Resident in bed. Eyes rolling side to side. Moaning. hands tight. Informed unit manager to recheck in an hour and call provider back. A progress note dated 7/17/25 at 1:08 PM by Nurse #2 read, [Nurse #3] nurse reported resident's blood sugar increased to 77. Resident does have hypodermoclysis in right low abdominal. Resident is looking around. [Nurse #3] with resident. An interview was conducted with Nurse #2 on 8/6/25 at 2:53 PM. Nurse #2 was the day shift (7-3) and evening shift (3-11) nurse for Resident #1 on 7/17/25. Nurse #2 stated when she arrived on shift, the night shift nurse (Nurse #1) reported to her Resident #1's blood sugars were extremely low in the 30's. Nurse #2 reported, she said 33 to be exact. Nurse #2 stated Nurse #1 reported to her the on-call provider was aware of Resident #1's low blood sugar and had said to recheck Resident #1's blood sugar around 7:30 AM and call the on-call provider back with what Resident #1's blood sugar was. Nurse #2 said she rechecked Resident #1's blood sugar at 7:30 AM and it was in the 50's, she did not recall the exact number. She reported she called the on-call provider back after checking Resident #1's blood sugar at 7:30 AM and was told by the on-call provider to hold Resident #1's insulin. She stated the provider instructed her to try to give her something to eat to increase her blood sugar and to recheck her blood sugar in an hour. Nurse #2 stated she told the provider she did not have time to do that or keep rechecking Resident #1's blood sugar because she had to pass medications and check blood sugars for her other diabetic residents, so the NP's provider group sent a Nurse (Nurse #3) who worked for the NP provider group to help with Resident #1. She explained Nurse #3 was with Resident #1 during her day shift while she worked with the other residents, she was assigned to take care of. She reported UM #1 was also helping with Resident #1 throughout the day. Nurse #2 did not recall Resident #1 having abnormal eye movements and tight hands during the morning or reporting it to anyone. Nurse #2 said she remembered that more from the evening right before Resident #1 went out. She stated Resident #1's eyes were moving left and right slowly like her head was turning side to side but her head was not moving, and her arms were tight and hard to move. She said Resident #1 was not talking or responding. Nurse #2 said Nurse #3 checked Resident #1's blood sugars while she was at the facility and had communicated with the NP. She did not know what the blood sugar results were but reported Nurse #3 told her Resident #1's blood sugar would go up and then drop back down. Nurse #2 stated she did not administer any glucagon to Resident #1. She reported glucagon had not been mentioned to her to administer. Nurse #2 said it was the providers' call for how low someone's blood sugar needed to be before they sent them out to the hospital. Nurse #2 stated Nurse #3 left sometime around the 3-11 shift change. Nurse #2 said she needed someone there to help with Resident #1 because she had other residents to take care of. When she noticed no one was going to be there to watch Resident #1 she spoke to UM #1 and recalled UM #1 had to do something else. Nurse #2 reported she went and checked Resident #1's blood sugar herself and it was low, she said she could not remember the exact number but remembered it was in the 50's once again. Nurse #2 said she asked UM #1 if anyone had called Resident #1's family to let them know what was going on and UM #1 told her she had not. Nurse #2 said she looked in the nursing notes to see if anyone had reached out to the family and saw no one had called, so she called the family to let them know what was going on. She did not recall the exact time she called Resident #1's family. Nurse #2 stated Resident #1's family member arrived at the facility not long after she called them. She said when Resident #1's family member saw Resident #1 they were concerned about the way she looked and requested for her to be sent out to the hospital. Nurse #2 stated she called the provider and let them know Resident #1's family was requesting for her to go out to the hospital. She reported she called the on-call provider and the on-call provider initially said they were going to call the NP, Nurse #2 reported she told the provider her family wanted her to go to the hospital as soon as possible (ASAP) and the provider then said okay. Nurse #2 said she thought Resident #1 needed to go to the hospital that morning and that was why she had called the provider. She explained when someone's blood sugar was that low, she felt it was above the capabilities of the facility and that they could only do so much at the facility. She further explained they had been trying to increase her blood sugar, and it was going up and then dropping back down, she said there was only so much that could be done at the facility. Nurse #2 stated she called Resident #1's family herself because she knew Resident #1's family was usually there for her and had not been there that day, she thought Resident #1's family would want her to be sent out and what the family wanted went above the NP. She reported that Emergency Medical Services (EMS) arrived at the facility quickly after she called them. Nurse #2 stated she thought Resident #1 went out around 4:40 PM.An interview was conducted with Nurse Aide (NA) #1 on 8/6/25 at 5:00 PM. NA #1 recalled she had worked 1st shift (7am-3pm) and 2nd shift (3pm-11pm) on 7/17/25, she did not recall if Resident #1 was assigned to her that day but said she remembered going into her room to provide care to her on 7/17/25. She remembered 7/17/25 was the day she was transferred to the hospital. She recalled she was doing rounds when a nurse was trying to put an IV site in Resident #1, and she could not get to her for rounds. She recalled it had been between 10:00-11:00 AM and Resident #1 had been foaming at the mouth. She said in the afternoon right before Resident #1 went out to the hospital she was foaming at the mouth again, she said it had been around the 3-11 shift change. NA #1 recalled she had asked the nurse why Resident #1 was having foaming at the mouth. She reported the nurse told her they were handling it., She thought the nurse she spoke to was UM #1. An order dated 7/17/25 entered at 1:15 PM read, Glucagon Emergency Injection Kit 1mg, inject subcutaneously as needed for low capillary blood glucose (CBG), recheck CBG in 15 minutes. The glucagon was not documented as administered on the MAR. There were no other orders for glucagon present on the MAR. The order was entered by Nurse #4. An interview was conducted with Nurse #4 on 8/14/25 at 4:15 PM. Nurse #4 said she was not Resident #1's nurse on 7/17/25 but had worked day shift (7am-3pm) that day. She explained she had been an extra nurse and had been trying to help where needed that day. Nurse #4 reported she entered the order for IM glucagon into the electronic medical record for Resident #1 because UM #1 had asked her to. Nurse #4 said she did not know when the glucagon was administered or who had administered it. She remembered seeing Resident #1 during the morning on 7/17/25, she said Resident #1 was not well. Nurse #4 explained Resident #1 had a decreased level of consciousness and her eyes looked weird. She said Resident #1's eyes were set like they were stuck, and she showed no response when you spoke or talked to her. She stated Resident #1's eyes were open, but she was not alert or responsive. Nurse #4 recalled Resident #1's eyes would move but not like she was following or focusing on anything. She further recalled her eyes rocking back and forth moving left and right very slowly but she was not moving her head. Nurse #4 said her eyes were not always like that, that sometimes they would just stare straight off and then other times they would move slowly back and forth. Nurse #4 remembered being in Resident #1's room at mealtime, she did not say what meal but said the NA attempting to assist Resident #1 with her meal stated he could not feed Resident #1 because she would not open her mouth. Nurse #4 reported she told the NA Resident #1 did not look safe to eat. Nurse #4 said as far as she knew Resident #1 did not eat anything that day, she said she was not safe to eat because she was not alert enough. She did not remember the name of the NA. Nurse #4 reported she was in and out of Resident #1's room during her shift just checking on her because she was concerned and curious about what was going on. Nurse #4 stated she saw Resident #1 multiple times during her shift, she said she was trying to be helpful and available if she was needed. Nurse #4 stated she remembered Resident #1's blood sugar was in the 30's multiple times during the day. She was not sure about Resident #1's blood sugars from the night shift but remembered during the day shift her blood sugars were in the 30's and 50's multiple times. Nurse #4 stated she thought one time they were able to get Resident #1's blood sugar up to the 70's but then it dropped again. Nurse #4 said her shift ended at 3:00 PM and she left sometime between 3:00 PM and 4:00 PM that day. She recalled hearing Nurse #2 talking to Resident #1's family on the phone right before she left. Nurse #4 stated Resident #1 did not wake up and was non-responsive the entire time. Nurse #4 said Resident #1 was pretty much the same from the time she got there in the morning until she left at the end of her shift that day. She reported she did not remember seeing anything that lo

2. Resident #15 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included: displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, muscle wasting/atrophy multiple sites, and primary osteoarthritis. Resident #15's care plan was last updated on 11/08/24 as being at risk for falls related to confusion, gait/balance problems, psychoactive drug use, unaware of safety needs, wandering and history of falls and used a reclining chair, with interventions that included fall mat at bedside, anticipate resident's needs, and bed in lowest position while resident is in bed. Resident #15 was also care planned for pain related to arthritis and hepatic (liver) mass with interventions that included administer analgesics as ordered, monitor/document for signs and symptoms of nonverbal pain, monitor/report/record resident complaints of pain to the nurse. Resident #15 had an active physician's order dated 11/11/2024 for oxycodone-acetaminophen (pain medication) oral tablet 7.5-325 milligrams (mg) give one tablet by mouth two times a day for pain management. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Review of a discharge MDS assessment dated [DATE] indicated Resident #15 had a fall with major injury. Review of the progress note dated 12/28/2024 at 4:41pm, written by the Director of Nursing (DON) revealed the DON heard Resident #15 yelling and as the DON arrived at Resident #15's doorway the DON observed Resident #15 as she attempted to get out of bed. The DON was unable to reach Resident #15 before she fell onto her right side onto the fall mat. Resident #15 did not strike head but yelled out my hip is broken. The DON assessed Resident #15, leg length could not be assessed due to mild contraction. Resident #15 expressed pain when area to right hip was touched. Facility Physician Assistant (PA) was contacted and orders received to obtain right hip x-ray and to give a one-time dose of oxycodone 2.5 mg related to acute right hip pain. The progress note indicates Resident #15 was assisted back to bed by staff x 3 and x-ray was pending. Review of Resident #15's orders revealed on 12/28/2024 at 4:25 PM the PA ordered oxycodone HCL 5mg tab- give 0.5 (half) tablet by mouth one time only for right hip pain x 1day. Review of Resident #15's orders revealed on 12/28/2024 at 4:32 PM the PA ordered an x-ray of Resident #15's right hip one time only for pain x 1 day. Review of the x-ray completed on 12/29/2024 with results reported to the facility on [DATE] at 2:09 PM revealed Resident #15 sustained an acute right femoral intertrochanteric fracture. An interview with the DON on 6/20/2025 at 11:04 AM revealed she cared for Resident #15 on 12/28/2024 3:00 PM to 11:00 PM. The DON stated on 12/28/2024 she heard Resident #15 yelling for help and when she came to the door, Resident #15 was attempting to get out of bed and the DON was unable to reach Resident #15 in time, Resident #15 fell out of her bed, onto her right side. The DON stated Resident #15's bed was in the lowest position and Resident #15 had fallen onto her fall mat next to the bed. The DON stated Resident #15 yelled that her hip was broken. The DON stated she immediately assessed Resident #15. The DON stated due to Resident #15's legs being contracted it was difficult to assess the length of Resident #15's legs. The DON stated she called the facility PA to report the fall and received orders for a right hip x-ray and oxycodone 2.5 mg for pain. The DON stated after she received the orders from the PA, she and two staff members transferred Resident #15 back to her bed with a mechanical lift. The DON stated after being transferred back to bed and pain medication was administered, Resident #15 attempted to crawl out of the bed multiple times. The DON stated Resident #15 was then transferred using the mechanical lift into her reclining chair and placed next to the nurse's station. The DON verified when Resident #15 was placed in the reclining chair she was sitting up, unsure of the exact position, but stated it was probably 90 degrees because the reclining chair was not reclined. The DON stated that sitting at a 90 degree angle was not a good position to be in for a resident experiencing hip pain after a fall, but since Resident #15 was continuing to attempt to get up the DON felt it was the best option at that time. The DON verified she instructed the staff to get Resident #15 up into the reclining chair to prevent further falls. The DON stated Resident #15 had a history of yelling out and with her continued movement she did not think Resident #15 had sustained a fracture. The DON stated the PA had only given an order for the x-ray to be obtained, and did not specify it should be a stat (now) order. The DON stated that when Resident #15 was in her chair at the nurse ' s desk, Resident #15 responded she was not in pain when asked. The DON stated she called in the order for the right hip x-ray to the mobile x-ray service. The DON stated the x-ray was not called in stat. The DON stated a mobile x-ray order placed in the evening or on a weekend had the potential to not be completed until the next day. The DON stated she reported to the oncoming shift, Nurse #1, that an x-ray was ordered and was waiting to be completed for Resident #15. The DON stated that typically the mobile x-ray reports were automatically uploaded into the resident electronic medical record and any nurse with access to the medical record could review x-ray reports. If there was positive fracture results the mobile x-ray company would call and alert the facility. Once the facility was notified, she would expect the staff to immediately notify the provider for further orders. The DON added that she believed there was a delay in the facility receiving the x-ray report which also delayed Resident #15 in being transferred to emergency room (ER) for evaluation. During a telephone interview on 6/20/2025 at 12:12 PM Nurse #4, who was scheduled 11:00 PM to 7:00 AM on 12/28/2024 and 12/29/2025, stated he did not recall Resident #15 specifically or any information related to a fall. He stated he may have been scheduled to take care of Resident #15 but did not remember back that far. Review of Resident #15's Medication Administration Record (MAR) dated December 2024 revealed the following documentation: On 12/28/2024 at 6:55 PM oxycodone 2.5 mg was documented as administered by the DON for a pain level of 8 out of 10. On 12/28/2024 at 9:00 PM scheduled oxycodone-acetaminophen 7.5-325 mg was documented as administered by the DON. Pain assessments on 12/29/2024 revealed a documented pain level of 0 out of 10 on all 3 assessments. Pain assessment on 12/30/2024 revealed a documented pain level of 0 out of 10, for the shift 11:00 PM to 7:00 AM. Review of Resident #15's electronic medical record revealed no documentation regarding Resident # 15's right hip or x-ray in the progress notes that were dated 12/29/2024. Review of the 24-hour report sheets from 12/29/2024 indicated Resident #15 was status post fall day 1 and mobile x-ray company was coming 12/29/2024 in AM for right hip x-ray. Review of the x-ray results completed on 12/29/2024 at 1:19 PM revealed Resident #15 sustained an acute right femoral intertrochanteric fracture. Multiple attempts to reach Nurse #17, who worked with Resident #15 on 12/29/2024 from 7:00 AM to 3:00 PM were unsuccessful. Multiple attempts to reach Nurse #18 who worked with Resident #15 on 12/29/2024 from 3:00 PM to 11:00 PM were unsuccessful. During a telephone interview on 6/20/2025 at 4:35 PM Nurse #5 stated she was not at work when Resident #15 fell on [DATE] but worked on 12/30/24 and received the x-ray results. Nurse #5 stated she answered a call from the mobile x-ray company, who called to verify the facility had received the x-ray results for Resident #15. Nurse #5 stated after she received the call, she checked the electronic medical record for radiology results, saw that it indicated a fracture, printed the report and immediately brought it to the facility PA who reviewed the x-ray report and gave orders to send Resident #15 to the emergency room. Nurse #5 stated once she received the order from the PA she immediately called 911 for transport and started the process to send Resident #15 to the hospital. Review of Resident #15's electronic medical record revealed a Physician progress note dated 12/30/2024 at 1:16 PM written by a Nurse Practitioner (NP) that indicated Resident #15 had reported pain at a 10 out of 10 when she was assessed, but in no apparent distress, and no tenderness to palpation of bilateral upper and lower extremities, unable to test range of motion in the right lower extremity due to increased pain, and nursing reports she is being sent to the hospital for right hip fracture. During a telephone interview on 6/20/2025 at 12:56 PM the facility NP stated she had seen Resident #15 on the morning of 12/30/2024 as part of her rounds. Resident #15 complained repeatedly that her pain was 10 out of 10. The NP stated she was not aware of the hip fracture before she saw Resident #15 on 12/30/24. The NP stated after she saw Resident #15, she went to the nursing staff to report the resident's pain and was told Resident #15 was being sent to the hospital. The NP stated she would normally inform the facility PA but since she was informed the Resident was being sent out, she did not talk to the facility PA. Review of progress notes revealed a note dated 12/30/2024 at 9:29 AM written by Nurse #2 revealed x-ray results were received and reported to the facility PA and orders to send Resident #15 to the emergency room for further evaluation and treatment of right hip were received. Report was called to the hospital and Resident #15 was transferred to the hospital. Review of Resident #15's hospital records dated 12/30/24 revealed Resident #15 presented to the hospital on [DATE] with a right intertrochanteric femoral fracture and underwent closed reduction and cephalomedullary (hardware used to fix broken bones) nail fixation. Documentation from hospital physician revealed Resident #15 was confused, voiced right hip pain, no painful response noted when right hip was palpated, and resident had active range of motion in bilateral lower extremities while in bed. During an interview on 6/20/2025 at 8:52 AM the Physician Assistant (PA) stated he had received a call from the DON regarding Resident #15 and a fall on 12/28/24. The PA stated he did not recall the DON reporting that Resident #15 yelled my hip is broken, but that wound not have changed his mind regarding the order for the x-ray and not sending Resident #15 to the hospital on [DATE]. The PA stated Resident #15 was not a reliable historian. The PA stated he had received report Resident #15 did not have leg shortness. The PA stated normally an x-ray would take about 4 hours to be completed, but on evenings and weekends it sometimes took longer. The PA stated he was not aware that Resident #15 had been placed in the reclining chair prior to the x-ray being completed. The PA stated he would expect a resident to stay in bed until the x-ray had been done. The PA stated when he arrived at the facility on 12/30/2024 he was informed of Resident #15's x-ray results and immediately gave orders for Resident #15 to be sent to the hospital for an orthopedic evaluation. The PA stated they have on call providers on the weekend and ideally the x-ray results would have been received on 12/29/2024 and reported to him or the on-call provider and Resident #15 would have been sent to the hospital on [DATE]. During a telephone interview on 6/26/2025 at 11:23 AM the facility Physician stated x-ray reports were faxed to the facility and available in the resident ' s electronic medical record. The Physician stated all nurses would have access to review the x-ray results in the medical record and the fax would come in on the copy machine in the hallway. The Physician stated agency nurses may know to check the copy machine, but she would expect the nurses to answer the phone as soon as they were able and review the chart for results if an x-ray was pending. During a joint interview on 6/20/2025 at 4:35 PM with the Interim DON and Administrator, Interim DON stated she was not going to provide an answer to questions regarding the fall because she thought a loaded question had been asked and did not want to comment on an event she did not have all the details for. The Administrator stated she felt Resident #15 had received appropriate care after her fall on 12/28/2024. The Administrator stated after a fall she expected a nurse to assess the resident, notify the provider and report the findings from the assessment. The Administrator stated she felt the DON did what was appropriate to keep Resident #15 safe. The Administrator stated she would expect a resident with a fracture to be sent to the hospital once they were notified of the fracture. Based on record review, and resident, staff, Nurse Practitioner (NP), Physician Assistant (PA), Physician, and Contract Transport Company Owner interviews, the facility failed to complete a clinical assessment of injury after a fall. Resident #101 was being transported back from a medical appointment in a contract transport van in her specialized wheelchair. Resident #101 was not secured in wheelchair according to the manufacturer's instructions. Driver #1 hit a bump pulling into the facility entrance which caused Resident #101 to fall forward, landing partially out of her wheelchair with her legs under the chair. Driver #1 notified staff at the facility Resident #101 had fallen. Nursing Assistant (NA) #1 and NA #2 entered the van and lifted Resident #101 back into her chair without having the resident assessed for injuries by a nurse or medical provider. NA #2 returned Resident #101 to her room and notified Nurse #1 (agency nurse) who then completed an assessment of Resident #101. NA #1 and NA #2 were not qualified to provide a comprehensive physical assessment to determine if Resident #101 sustained any acute injury. In addition, the facility also failed review a resident's electronic medical record for x-ray results after Resident #15's fall on12/28/24 which resulted in a delay in medical treatment. The x-ray was completed on 12/29/24 and the report was sent to the facility that same day that indicated Resident #15 had an acute right femoral intertrochanteric fracture. The x-ray results were reported to the Nurse Practioner (NP) on 12/30/24 and when assessed by the NP Resident #15 reported a pain level of 10 (based on a scale of 1 to 10 with 10 being the worst pain). Resident #15 was sent to the emergency department on 12/30/24 and underwent a closed reduction and cephalomedullary (hardware used to fix broken bones) nail fixation and returned to the facility on [DATE]. This deficient practice affected 2 of 5 residents reviewed for quality of care (Resident #101 and Resident #15). Immediate Jeopardy began on 03/26/25 when Resident #101 was not assessed for injuries by a nurse or medical provider before being moved from the floor of the transportation van after a fall. The immediate jeopardy was removed on 06/20/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity of G. The findings included: 1. Resident #101 was initially admitted to the facility on [DATE] and was readmitted to facility on 05/13/25. Resident #101's diagnoses include end-stage kidney disease, cerebral infarction (stroke), muscle weakness, and limited mobility. A review of orders revealed an order dated 11/04/24 for apixaban (blood thinner) 5 milligrams by mouth twice daily. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was severely cognitively impaired. Resident #101 utilized a wheelchair for mobility, a mechanical lift for all transfers, and had impairments to both upper and lower extremities with contractures. The MDS also noted Resident #101 received an anticoagulant. The care plan originally initiated 02/20/24 for Resident #101 revealed Resident #101 was at risk for falls due to deconditioning. The stated goal was Resident would be free from falls. Interventions included anticipating Resident's needs, staff would ensure call device was in place, and staff would provide reminders for Resident in fall prevention. The mobility care plan stated goal was Resident #101 would have activities of daily living (ADL) care needs met with assistance from staff. Interventions included assistance for all ADL, and Resident #101 was a 2-person transfer using the mechanical lift. A review of Nurse Aide (NA) #2's written statement dated 03/26/25 revealed front-desk staff had asked her to assist getting Resident #101 out of the transport van when Driver #1 notified staff Resident #101 fell on the transport van. NA #2 saw NA #1 and asked for her help and they both went to the transport van without notifying a nurse. NA #2 wrote she observed Resident #101 out of her chair, legs folded up under her, leaning to the right side. NA #2 reported she asked Resident #101 if she was ok or if anything hurt, and Resident #101 responded no. NA #2 further reported she and NA #1 arm and armed Resident #101 back to her wheelchair. NA #2 then brought Resident #101 back to her hall and notified the nurse. An interview with NA #2 (agency staff) on 06/19/25 at 3:35 PM revealed she had walked by the main entrance when Driver #1 told the front desk staff Resident #101 fell on the transport van and needed help. NA #2 stated she could not recall what staff reported fall to her. NA #2 observed Resident #101 on the van with the buckled seatbelt around her breast and had slid down under the seatbelt. NA #2 stated Resident #101 was seated on the wheelchair footrest with both legs positioned under the chair footrest. NA #2 stated she and NA #1 lifted Resident #101 back into the wheelchair by getting her upper and lower body. They removed Resident #101 from the van via the wheelchair lift and brought Resident inside the facility. NA #2 indicated when Resident #101 was returned to her room, she reported the fall to Nurse #1. NA #2 confirmed Resident #101 was not assessed by the nurse prior to being moved from the floor of the van. She stated Resident #101 was returned to her bed for an assessment by Nurse #1. A review of NA #1's undated written statement revealed at 4:45 PM, NA #2 asked for assistance getting Resident #101 out of the transport van after a fall. NA #1 revealed Driver #1 explained Resident #101 was adjusting herself during car ride and while pulling into the parking lot, she slid out into van floor. NA #1 observed Resident #101 lying on the floor of the van on right side with her legs bent against the back of the driver's seat and back was on the footrest of the wheelchair. It was noted the seatbelt was around wheelchair. NA #1 and NA #2 lifted Resident #101 back into her wheelchair. An interview with NA #1 (agency staff) on 06/19/25 at 3:23 PM revealed she recalled NA #2 requested her help on the transport van because Resident #101 had fallen. NA #1 stated, she observed Resident #101 on the floor of the van when she arrived to assist. NA #1 indicated Driver #1 stated Resident #101 had been fidgeting and he pulled into the facility driveway, hit a bump, and Resident #101 slid out of her chair. She reported Resident #101's back rested on the wheelchair footrest, which was extended out, and both of Resident #101's legs were on the floor under the footrest of her wheelchair. NA #1 reported the seat belt was fastened and was sitting on the back seat area of the wheelchair. NA #1 stated it appeared Resident #101 had slid under the seatbelt. NA #1 revealed she and NA #2 lifted Resident #101 back into the wheelchair. NA #1 reported she grabbed Resident #101's upper body and NA #2 grabbed Resident #101's lower body and they transferred Resident #101 from the floor to the wheelchair. She stated no nurse was notified of the fall or had been present for assessment prior to Resident #101 being lifted back into the wheelchair. NA #1 stated Resident #101 denied pain and asked to get up. Once Resident #101 was back in the wheelchair, NA #1 indicated she left and returned to her assigned hall. Review of facility incident report dated 03/26/25 completed by Nurse #1 stated the NA reported Resident #101 was on the floor of the transport van. Driver #1 reported Resident #101 slid from chair in a curve. No injuries were noted upon nurse assessment by Nurse #1. The physician and responsible party were notified. Resident #101 was transferred to the Emergency Department for evaluation after the incident. Review of nursing progress notes written by Nurse #1 dated 03/26/25 revealed a progress note which stated a NA reported to Nurse #1 Resident #101 was on the floor of the transport van. The note stated Resident #101 was placed back in the wheelchair using a sling. Resident #101 was then transferred to the Emergency Department for evaluation per responsible party's request. A second progress note also written by Nurse #1 dated 03/26/25 stated Resident #101's responsible party called facility and reported Resident #101 had been evaluated at the hospital, had no injury, and would return to the facility. A telephone interview with Nurse #1 (agency nurse) on 06/19/25 at 9:02 AM revealed Nurse #1 was assigned to Resident #101 on 03/26/25 during the shift when Resident #101 slid out of her wheelchair while on transport van. Nurse #1 stated she could not recall specifics but thought Resident #101 used a special chair that reclined and not a regular wheelchair. Nurse #1 stated she could not remember if she went to the van to assess Resident #101. Nurse #1 stated if so, she would have directed staff to get the Resident up with a blanket or sheet because Resident #101 used a total lift for transfers. Nurse #1 did not know where Resident #101 had fallen out of the chair during the drive, but believed it was not far from the facility. Nurse #1 stated Resident #101 was placed in Resident's room after the incident and Nurse #1 assessed her. The interview further revealed Nurse #1 was an agency nurse and had not worked at facility for months and could not recall the name of the staff member who reported to her that Resident #101 had fallen, but knew it was an NA. Review of the hospital Discharge summary dated [DATE] revealed Resident #101 was evaluated on 03/26/25 after fall at the Emergency Department. It was noted in the discharge summary that Resident #101 received an anticoagulant. The hospital record stated Resident #101 had no signs of acute injury upon assessment and had no complaints of pain during visit. A computed tomography (CT) of Resident #101's head, thoracic (middle) spine, and lumbar (lower) spine were completed and results indicated no acute injury was noted on the CT. A review of the Transport Company and facility contract dated 08/24/12 revealed the Transport Company would provide safe transit which was defined as transporting patients to required destinations without scare or endangerment. A review of Driver #1's undated statement revealed Driver #1 picked up Resident #101 after her dialysis treatment and secured Resident #101 into the wheelchair inside the transport van using the 4-point anchor system. Driver #1 stated he also secured Resident #101's seatbelt under her arms and snug around her midsection. Driver #1's statement further revealed when he pulled into the facility entrance, Resident #101 had slid out from under her seatbelt and was sliding out of her chair. Driver #1 contacted the facility staff for assistance and observed both NAs lift Resident #101 back into her wheelchair. Driver #1 reported one of the NAs stated Resident #101 needed a belt to better keep her in her chair as Resident #101 cannot sit up properly. Driver #1 left after Resident #101 was taken back into the facility. A phone interview was attempted with Driver #1 but was unable to be reached. Telephone interviews with the Transport Company Owner on 06/19/25 at 12:53 PM and 2:44 PM revealed he did recall the incident on 03/26/25 but could not recall who the driver was but would check his records. Transport Company Owner stated he had no written records of the incident but remembered what the driver told him. The Transport Company owner stated Driver #1 told him Resident #101 had not fallen out of the chair, but her buttocks had come out a little forward in her wheelchair when Driver #1 hit a bump pulling into the facility driveway. He reported the Driver #1 parked the transport van, and Resident #101 was on the edge of her wheelchair seat and her seatbelt still held her in the wheelchair. Driver #1 unfastened the seatbelt and lowered Resident #101 to the floor of the van. Driver #1 then entered the facility and notified the staff who helped get Resident #101 up. The Transport Company Owner stated the Driver #1 resigned from the company 6 weeks ago. The Transport Company Owner explained all drivers were trained to stop the van during any adverse event when safe to do so and tend to the residents' needs which Driver #1 did immediately after Resident #101 fell when he pulled into the facility entrance. An interview with the facility PA on 06/20/25 at 10:08 AM revealed Resident #101 was totally dependent on staff for all activities of daily living. The PA stated Resident #101 was severely cognitively impaired, and Resident had very limited mobility due to upper and lower body contractures. He reported Resident #101 was unable to do anything to brace herself or prevent a fall. The PA stated Resident #101 received an anticoagulant (blood thinner) and thus would be at risk for bleeding with any fall or accident. Due to the use of an anticoagulant, bleeding could occur anywhere in the body. With an anticoagulant, the PA indicated he would be most concerned about the possibility of a head injury with bleeding on or around the brain which would be life threatening. The interview further revealed anytime a Resident fell, they would need to be assessed by a nurse before being moved, who would then notify the provider of the fall or any injury. An interview with the Director of Nursing (DON) on 06/19/25 at 1:11 PM stated NA #1 and NA #2 were agency staff but had fall protocol training prior to starting at facility. The DON stated the NAs should have notified a nurse for a comprehensive assessment prior to Resident #101 being moved. The interview with the Administrator on 06/19/25 at 4:15 PM revealed after the incident, she had interviewed Driver #1 who stated when he had hit a bump pulling into the facility driveway Resident #101 had slid out of the wheelchair. NA #1 and NA #2 stated the driver reported Resident #101 slid out of chair. The two NAs went out to the van, but did not notify a nurse prior to moving Resident #101 for assessment. The Administrator was aware the nurse had not completed an assessment before staff moved Resident #101. From the Administrator's recollection, Resident #101 had been evaluated at the Emergency Department, and had no injury from the fall. The Administrator indicated she would have expected NAs to notify a nurse to assess Resident #101 for injury prior to moving the resident. The facility was notified of immediate jeopardy on 06/19/25 at 7:35 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 03/26/25, Resident #101 was picked up by a contract transportation company to transport the resident round trip to a dialysis appointment. While on the return route back to the facility the contract driver hit a bump when turning into the facility parking lot, causing Resident #101 to slide forward from the chair. The contract driver notified an employee of the facility Resident #101 had fallen out of chair. Two nursing assistants responded to the contract driver's request for assistance. The nursing assistants went to the transportation vehicle, lifted Resident #101 from the floor of the transportation vehicle, placed Resident #101 back into the wheelchair, then brought the resident into the facility. The nursing assistants notified Nurse #1 of the fall in the transportation vehicle. Resident #101 was assessed by Nurse #1, once the resident arrived at the facility and found no injuries. The physician was notified of the incident with Resident #101 by Nurse #1. The physician gave a verbal order to Nurse #1 to send the resident to the hospital for further evaluation as a precautionary measure. All residents in the facility, who are transported for appointments via contracted transportation company and by the facility transport vehicle have the potential to be at risk of being moved by nurse aides after a fall without having an assessment by qualified personnel. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. As of 06/19/25, the facility will provide transportation services with our facility van unless the residents require stretcher service, then they are transported by EMS (ambulance service). The facility will continue with its current process of determining the appropriateness of wheelchair or stretcher transportation for residents. All residents who lack upper body strength and are unable to sit up in a wheelchair will be transported to appointment via stretcher. All appointments are discussed in the morning meeting daily for the next week with the Director of Nursing, Director of Rehabilitation and Administrator. Any resident identified at time requiring special accommodation for transport will have the change made for transportation. The care plan will be updated when the resident is identified as requiring stretcher transportation, for future reference. The facility van drivers, which included 2 alternate drivers (Maintenance Director and admission Coordinator), were educated by the Director of Facility Services on 06/20/25, to notify a nurse or medical provider if a resident falls while being transported or calling 911 immediately via their personal cell phones. A reminder notice was placed in the transportation vehicle stating to call 911 in case of an emergency. The education also included a nurse or medical provider must conduct a head-to-toe assessment of the resident prior to being moved. On 06/19/25, the Administrator in-serviced all department heads (Director of Rehabilitation, Food Service Manager, Environment Service Manager, Activities Director, Human Resources Director, Social Services, Director of Nursing, Business Office Manager, Staff Development Coordinator, MDS Coordinator and admission Director) on notifying a nurse or medical provider immediately, if notified by the driver of a fall on the van. On 06/19/25 the Staff Development Coordinator, Director of Nursing, Activities Director and Human Resources Director conducted an in-service for all employees in person and via phone including agency personnel, on what to do if they witness a resident fall. Employees, including agency personnel, will not be allowed to complete a shift before completion of this training by the Director of Nursing, Staff Development Coordinator or designee. The Staff Development Coordinator, Director of Nursing and Administrator are responsible for ensuring all employees including agency personnel have completed the training.<br[TRUNCATED]

Based on record reviews, resident, observation, staff, Physician Assistant (PA), Transport Company's Owner, and Driver #1 (Transport Company's Driver) interviews, the facility failed to ensure a resident was safely secured in the transport company's van during the return trip from an appointment back to the facility. On 3/26/25 Driver #1 failed to secure Resident #101 in a specialized wheelchair in the Transport Company's van per manufacturer's instructions and according to Driver #1 when the van hit a bump pulling into facility entrance, Resident #101 fell forward, landing partially out of her wheelchair with her legs under the chair. Resident #101 was assisted back into the wheelchair by facility staff at the facility and was wheeled inside the facility. After being assessed by the nurse, Resident #101 was transported to the Emergency Department (ED) on 03/26/25, evaluated for injury, and then returned to the facility on [DATE] with no injury noted upon assessment at the ED. There was a high likelihood of serious injury, or death, to Resident #101 due to the resident being an unsecured passenger in a specialized wheelchair which was not designed for transportation as she was transported back to the facility from an appointment. The facility also failed to provide effective supervision to prevent a resident-to-resident altercation when Resident #76 hit Resident #58 in the lip when Resident #76 attempted to grab the television remote from Resident #58. When Resident #58 grabbed the remote back, Resident #76 hit Resident #58 on the lip. Resident #58 had a small bruise on top of his left hand, but no visible injury to lip or face. This deficient practice affected 2 of 7 residents reviewed for abuse (Resident #101 and Resident #58). Example #2 was cited at a scope and severity of D. Immediate Jeopardy began on 03/26/25 when Resident #101 was improperly secured in the wheelchair van and slid out of her wheelchair on the transportation company's van while being transported back to the facility from a scheduled appointment. The immediate jeopardy was removed on 06/20/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: 1. A review of the Transport Company's van vehicle anchorage and accessory manufacturer instructions indicated wheelchairs would be anchored to the van using a retractable 4-point anchor tie-down system. Two anchors would be applied to the front base of the wheelchair and two would be attached to the back base of the wheelchair. A detachable lap belt would fasten to the floor anchor system, and chest belt would then be anchored to the side and behind the resident and applied for all wheelchair-bound residents during transport. A review of the Transport Company and facility contract dated 08/24/12 revealed the Transport Company would provide safe transit which was defined as transporting patients to required destinations without scare or endangerment. Resident #101 was initially admitted to the facility on [DATE] and was readmitted to facility on 05/13/25. Resident #101's diagnoses include end-stage kidney disease, encephalopathy (brain disease which caused confusion), cerebral infarction (stroke), muscle weakness, and limited mobility. A review of Resident #101's physician orders revealed an order dated 11/04/24 for apixaban (blood thinner) 5 milligrams by mouth twice daily; and an order dated 12/11/24 for hemodialysis every Monday, Wednesday, and Friday at 11:30 AM at the local dialysis center. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was severely cognitively impaired. Resident #101 utilized a specialized wheelchair for mobility, a mechanical lift for all transfers, and had impairments to both upper and lower extremities with contractures. The MDS also noted Resident #101 received an anticoagulant (blood thinner) and dialysis. The care plan originally initiated 02/20/24 included the problem for Resident #101 of the resident being at risk for falls due to deconditioning. The stated goal was the resident would be free from falls. The listed interventions included anticipating the resident's needs, staff would ensure the call device was in place, and staff would provide reminders for the resident in fall prevention. A review of Driver #1's undated statement revealed he picked up Resident #101 after her dialysis treatment and secured Resident #101 into her specialized wheelchair inside the transport van using the 4-point anchor system. Driver #1 indicated he also secured Resident #101's seatbelt Under her arms and snug around her midsection. Driver #1's statement further revealed when he pulled into the facility entrance, he noticed Resident #101 had slid out from under her seatbelt and was sliding out of her chair. Driver #1 entered the facility and requested staff assistance. The statement revealed Driver #1 observed [name redacted (NA#1)] and [name redacted (NA #2)] lift Resident #101 back into her wheelchair. Driver #1 reported one of the NA's stated Resident #101 needed a belt to better keep her in her chair as Resident #101 cannot sit up. Driver #1 left after Resident #101 was taken back into the facility. A phone interview was attempted with Driver #1, but he was unable to be reached. A review of nursing progress note dated 03/26/25 written by Nurse #1 revealed the NA reported to Nurse #1 Resident #101 was on the floor of the transport van. Review of a facility incident report dated 03/26/25 completed by Nurse #1 documented the Nursing Assistant (NA) reported Resident #101 was on the floor of the transport van. Driver #1 reported Resident #101 slid from chair in a curve. No injuries were noted upon nurse assessment by Nurse #1. The physician and responsible party were notified. Resident #101 was transferred to the ED for evaluation after the incident on 03/26/25. A review of NA #1's undated written statement revealed at 4:45 PM, NA #2 asked NA #1 to assist Resident #101 in the transport van after a fall. The statement revealed Driver #1 explained to them (NA #1 and NA #2) Resident #101 was adjusting herself during car ride and while pulling into the parking lot, she slid out into van floor. The statement revealed NA #1 observed Resident #101 lying on the floor of the van on her right side with her legs bent against the back of driver's seat and her back was on the footrest of the wheelchair. It was noted the seatbelt was around Resident #101's wheelchair. An interview with NA #1 on 06/19/25 at 3:23 PM revealed she recalled NA #2 had requested her help on the transport van because Resident #101 had fallen. NA#1 stated, she observed Resident #101 on the floor of the van when she arrived to assist. NA #1 indicated Driver #1 told them Resident #101 had been fidgeting and when he pulled into the facility driveway, he hit a bump and Resident #101 slid out of her chair. NA #1 reported Resident #101's back rested on the wheelchair footrest, which was extended out, and both of Resident #101's legs were on the floor under the footrest of her wheelchair. NA #1 reported the seat belt was fastened and rested on the back seat area of the wheelchair. NA #1 stated it appeared Resident #101 had slid under the seatbelt. NA #1 also stated Resident #101 had asked to get up off the van floor and denied any pain. NA #1 revealed once Resident #101 was back into her wheelchair, NA #1 left and returned to her assigned hall. A review of NA #2's written statement dated 03/26/25 revealed staff had asked her to assist getting Resident #101 off of the transport van when Driver #1 notified staff Resident #101 fell. NA #2 saw NA #1 and asked for her help and they both went to the transport van. NA #2 wrote she observed Resident #101 out of her chair, legs folded up under her, leaning to the right side. She reported she asked Resident #101 if she was ok or if anything hurt, and Resident #101 responded no. An interview with NA #2 on 06/19/25 at 3:35 PM revealed NA #2 had walked by the main entrance when Driver #1 told the front desk staff Resident #101 fell on the transport van and needed help. NA #2 observed Resident #101 on the van with the buckled seatbelt around her breasts and she had slid down under the seatbelt. NA #2 stated Resident #101 was seated on the wheelchair footrest with both of her legs positioned under the chair footrest. Review of the hospital Discharge summary dated [DATE] revealed Resident #101 was transferred via Emergency Medical Services (EMS) to be evaluated after fall. It was noted in the hospital discharge summary Resident #101 received an anticoagulant. The hospital record stated Resident #101 had no signs of acute injury upon assessment and had no complaints of pain during examination. A computed tomography (CT) of Resident #101's head, thoracic (middle) spine, and lumbar (lower) spine were completed and results indicated no acute injury was noted on the CT. No acute injuries were reported. No new orders were received and Resident #101 returned to facility on 03/26/25 via EMS. A review of the facility transport van vehicle anchorage and accessory manufacturer instructions, which were a different system than what was used in the transport company van, indicated wheelchairs would be anchored to the van using retractable 4-point anchor tie-down system. Two anchors would be applied to the front base of the wheelchair and two would be attached to the back base of the wheelchair. A detachable lap belt would fasten to the floor anchor system, and chest belt would then be anchored to the side and behind the resident and applied for all wheelchair-bound residents during transport. An interview with Driver #2, who was employed by the facility, on 06/19/25 at 10:50 AM revealed Resident #101 was transferred to her dialysis appointments on Monday, Wednesday, and Friday. Driver #2 reported Resident #101 used a specialized reclining wheelchair during transport. Driver #2 indicated Resident #101 was placed in a high-reclined position, while still upright during transport for resident comfort. The facility transport van had 4 detachable floor anchors that hooked to the wheelchair base which secured the wheelchair to the van. Driver #2 reported the seatbelt was placed over Resident #101's wheelchair armrest because there were no open areas on the armrest of the wheelchair to loop the lap belt through. Driver #2 indicated there was a shoulder strap attached to the lap belt, but since Resident #101 was in the reclined wheelchair, it was often not tight. Driver #2 reported Resident #101 preferred the seat belt loose around her abdomen for comfort. An observation was conducted on 06/19/25 at 1:18 PM of Driver #2 loading Resident #101 into facility transport van, not the transport company van, for a medical appointment. The observation revealed a detachable 4-point wheelchair securement system on transport van in place. Resident #101's specialized wheelchair wheels were locked, and the wheelchair was anchored using a 4-point wheelchair securement system and appeared secure. Observation of application of the lap belt revealed a removable pelvic belt which attached to the floor anchor. The pelvic belt was applied over Resident #101's lap on top of the arm rest of her wheelchair. Resident #101 was reclined slightly in the wheelchair. The detachable shoulder strap was then applied but did not contact Resident #101's body and did not cross her shoulder and chest. During observation, Driver #2 stated Resident #101's wheelchair only allowed the lap belt to go over the wheelchair armrests due to no opening on the side of the armrests. She stated the detachable shoulder strap was positioned loosely due to the type of wheelchair Resident #101 had, but Driver #2 stated she felt Resident was secured. She asked Resident #101 if the belt bothered her to which Resident #101 responded no. An observation and interview with Resident #101 on 06/16/25 revealed she was alert sitting in her specialized wheelchair after her dialysis appointment but was not able to be interviewed due to cognitive loss. An observation of the driveway was performed on 06/19/25 which revealed two entrances to the facility's main entry from the road the facility was on. The first entrance had an inclined curve that led into the parking lot. The second entrance had a short, steeper hill which turned sharply to the left into the parking lot. No discernable speed humps, holes, or bumpy areas were noted. It could not be determined which entrance Driver #1 entered the facility through on 03/26/25. Telephone interviews with the Transport Company Owner on 06/19/25 at 12:53 PM and 2:44 PM revealed he did recall the incident on 03/26/25 but could not recall who the driver was during the first interview but would check his records. He stated he had no written records of the incident but remembered what the driver told him. He stated Driver #1 told him Resident #101 had not fallen out of her chair, but her buttocks had come out a little forward in her wheelchair when Driver #1 hit a bump pulling into the facility driveway. The Transport Company owner reported Driver #1 parked the transport van, and Resident #101 was on the edge of her wheelchair seat and her seatbelt still held her in place in the wheelchair. Driver #1 reported to Transport Company Owner Driver #1 unlatched Resident #101's seatbelt and lowered the resident to the floor. Driver #1 entered the facility and told the staff who helped get Resident #101 up. During the second interview, the Transport Company Owner stated Driver #1 resigned from the company 6 weeks ago and no longer worked for them. The Transport Company Owner stated he voiced concerns to the facility about the chair for Resident #101 and felt it was unsafe. The Owner stated he had not documented this on an incident report, but he spoke with Driver #2 about his concerns. He stated he had recommended a stretcher chair which he had available for use, but the facility would not use it. He reported there were several incidents where Resident #101 would slide down in her wheelchair, and he notified the facility when that occurred, but he stated there was no record of that. He reported after that episode on 03/26/25, he refused to transport Resident #101 due to his safety concerns. He indicated he believed there was no way to place the belt on her wheelchair according to the manufacturer's instructions, thus his company could not transport her safely. An interview with the facility PA on 06/20/25 at 10:08 AM revealed Resident #101 was totally dependent on staff for all activities of daily living. The PA stated Resident #101 was severely cognitively impaired. PA indicated Resident #101 had very limited mobility due to upper and lower body contractures. PA reported Resident #101 was unable to do anything to brace herself or prevent a fall. Resident #101 received an anticoagulant (blood thinner) and thus would be at risk of bleeding with any fall or accident. Due to the use of an anticoagulant, bleeding could occur anywhere in the body. Regarding a fall when Resident #101 was on an anticoagulant, the PA would be most concerned about the possibility of a head injury with bleeding on or around the brain which would be life threatening. The interview with the Administrator on 06/19/25 at 4:15 PM revealed after the incident, she had interviewed Driver #1 who stated he had hit a bump pulling into the facility driveway and Resident #101 had slid out of her wheelchair. The Administrator indicated the transport company owner would not cooperate with the investigation and would not initially provide a statement or records of training the company provided Driver #1, but did eventually provide a written statement to the facility from Driver #1. The Administrator indicated the transport company owner never spoke to her prior to this incident about any concerns related to the safety of Resident #101's wheelchair. After the incident, the transport company owner sent an email dated 04/03/25 to the Administrator that the company had a stretcher chair available for use beginning 04/01/25. Information on the stretcher chair was included in the email. The Administrator reported the stretcher chair the transport company owner recommended had built in restraints that they were not allowed to use. The Administrator recalled at that time; the decision was made to transport Resident #101 by facility van only and no longer use the Transportation Company for Resident #101. The Administrator indicated Resident #101 had never been evaluated by therapy for transport chair needs, but a non-skid mat was added to wheelchair after the incident. The Administrator further stated Resident #101 continued to be transported by the same specialized wheelchair that was used during the 03/26/25 fall. The facility was notified of immediate jeopardy on 06/19/25 at 7:35 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 03/26/25, Resident #101 was picked up by contract transportation Contracted Driver from a scheduled dialysis appointment for transport back to the facility. Prior to leaving the appointment, Driver #1 secured Resident #101's specialized wheelchair to the vehicle but failed to secure Resident #101 to the vehicle. The construction of the specialized chair prevented a snug restraint around Resident #101 and did not stop Resident #101 from falling forward in the chair. Resident #101 had a high likelihood of suffering an adverse outcome related to not being secured to the vehicle to prevent them from falling out of the chair onto the footrest and using a chair not designed for transport in a vehicle. All residents in any type of wheelchair are at risk of an adverse outcome while being transported if the wheelchair used is not secured to the vehicle in compliance with the restraint manufacturer and if they are not in a wheelchair designed for transport. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. All staff and agency staff were in-serviced on 06/20/2025 by the Director of Nursing, Staff Development Coordinator and Human Resources on identifying safe wheelchairs to be used during transportation. This education included that any patient in a specialized wheelchair will be transported by non-emergent ambulance services or in a facility designated transport wheelchair that is designed for vehicle transportation. This education also included the removal of additional objects from the wheelchair that might be placed inappropriately and interfere with the ability to apply the restraint as designed. The contract was cancelled on 06/19/2025 for the outside transportation company used during the adverse incident. We will only use our in-house transportation vehicle except for stretcher services. All residents requiring a specialized chair for transport will be transported by EMS stretcher service until a chair designed for vehicle transportation has been obtained. The in-house transportation driver and all designated back up drivers were in-serviced on 06/20/2025 by the Regional Maintenance Director. This in-service included how to secure residents according to manufacturer's instructions during wheelchair transportation. The manufacturer's manual and restraint system manual were referenced for this training. A return demonstration by all individuals trained was performed as well. Alleged Date of IJ Removal: 06/21/25. The facility's IJ removal plan was validated on 06/21/25 by the following: Interviews with the facility transporters revealed they had received education on restraint system in van and how to secure a resident in the van per manufacturer's instructions, as well as the transport securement form that was to be completed prior to leaving facility with residents. The facility transporters also stated they had to verbalize their understanding of the education they had received and complete a demonstration showing they were capable of securing residents per manufacturer's instructions inside the van for transport. The facility transporters revealed they would only transport residents in standard wheelchairs inside the facility vans at this time and any resident that required a different type of chair for transport would have to be transported by non-emergent EMS transport. The facility cancelled their contract with the Transport Company on 06/19/25. Review of facility orientation education for new hire transport drivers verified the education included the transport securement form and educational material on van restraint system and securing residents per manufacturer's instructions into van prior to transport. Review of the audit tools and the transport securement form was completed with no issues noted. An observation was made on 06/20/25 of the facility transport driver securing a resident into their wheelchair inside the van in accordance with the manufacturer's instructions prior to being transported. Interviews were also conducted with alert and oriented residents who had been transported since 06/20/25 with no concerns and no additional transportation incidents were identified. Interviews with all staff revealed they had been educated on the correct chair to use for resident transport and if a resident required a specialized chair they could only be transported by non-emergent transport via Emergency Medical Services (EMS), making sure all residents are restrained per manufacturer's instructions in their transport chairs, remove any items from transport chairs that might interfere with the residents ability to be restrained per manufacturer's instructions, and notify administration immediately if there are any issues or concerns with a resident's transport chair. An interview with the Administrator revealed she had educated the facility transport drivers on securing residents per manufacturer's instructions into the vans, completing the transport securement form, hands-on observations of drivers securing residents into vans prior to transport, and completed audits with no issues. The Administrator also stated the facility had ordered an approved transport wheelchair but until that chair was delivered, they would only transport residents with standard wheelchairs in their facility vans and residents who required a transport wheelchair would be transported by non-emergent EMS transport. The facility's immediate jeopardy removal date was validated as 06/21/25 and the IJ removal plan completion date was validated as 06/21/25. 2. Resident #76 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, cerebrovascular disease, and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #76 was severely cognitively impaired, had no impairment of range of motion to upper or lower extremities, and used a wheelchair for mobility. Resident #76 required moderate assistance with transfers and could propel himself in a wheelchair. A review of Resident #76's care plan noted a plan in place for behavior problems due to resistance to care, yelled at staff, verbally aggressed to roommates, and refused medications at times. The stated goal for the care plan was Resident #76 would have fewer episodes of behavior. Interventions included administering medications, explaining procedures to Resident #76 prior to care, discussing appropriateness of behaviors, and intervening to prevent injury to others. A second care plan in place noted Resident #76 had a mood problem. The stated goal was Resident #76 would demonstrate improved mood state. Interventions included administering medications as ordered. A third care plan is in place for impaired cognition related to dementia. The stated goal for the care plan is Resident #76 would be able to communicate his needs. Interventions include staff to have appropriate communication with Resident #76. Resident #58 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, generalized anxiety disorder, unspecified osteoarthritis, and major depressive disorder. The annual MDS dated [DATE] revealed Resident #58 was cognitively intact. No behaviors were noted on lookback period. Resident #58 used a wheelchair for mobility and both legs were amputated above the knee. MDS noted Resident #58 had no impairment of range of motion to his upper extremities. The care plan for Resident #58 dated 02/22/25 included a care plan for assistance with activities of daily living (ADL) due to amputation of both legs above the knee, and weakness. The stated goal was Resident #58 would be free from a decline in ADL. Interventions included assist Resident #58 with ADL as needed, allow rest, break up tasks into smaller steps, encourage self-care, and observe for changes in ADL and notify the nurse. A review of the initial allegation report completed by the Director of Nursing (DON) for an incident which occurred on 05/27/25 at 1:30 PM. Resident #58 was hit in the face near the lip area by Resident #76. Resident #58 was noted to have a small bruise on the top of his left hand, but no visible injury to lip or face. Resident #76 was noted to have a skin tear to the inside of his left forearm. Resident #76 and Resident #58 were separated by staff immediately and assessed for injuries. Resident #76 agreed to a room change, and his room was changed that day. The DON notified local law enforcement and the Department of Adult Protective Services. The report was signed by the DON on 05/27/25. The completed initial allegation report was faxed to the Division of Health Service Regulation on 05/27/25 at 3:11 PM. A review of the investigation report completed by the DON about the incident which occurred on 05/27/25 at 1:30 PM. Resident #58 was hit in the face near the lip area by Resident #76. Resident #58 was noted to have a small bruise on the top of his left hand, but no visible injury to lip or face. Resident #76 was noted to have a skin tear to the inside of his left forearm. Resident #76 and Resident #58 were separated by staff immediately and assessed for injuries. Resident #76 agreed to a room change, and he was moved that day. The DON notified local law enforcement and the Department of Adult Protective Services on 05/27/25. Corrective actions included Resident #76 room change and corporate maintenance were contacted to provide 2 televisions per room to prevent future altercations. The investigation end date was signed by the DON as 06/02/25. The completed investigation report was faxed to the Division of Health Service Regulation on 06/02/25 at 7:51 PM. An interview with Therapy Staff #1 on 06/19/25 at 1:38 PM revealed she had walked down the hallway towards another resident's room when she heard Resident #58 and Resident #76 yelling at each other from their shared room. She entered the room and observed Resident #76 sitting in his wheelchair beside his bed and Resident #58 was also seated in his wheelchair facing Resident #76 who held the remote. Resident #58 reported to Therapy Staff #1 he had been watching television when Resident #76 grabbed the remote from him and changed the channel. Therapy Staff #1 reported she immediately separated the Residents. Therapy Staff #1 indicated after Residents were separated, she notified the nurse on the hall but could not recall the name of the nurse who was notified. Therapy Staff #1 indicated she did not observe any obvious injury on either Resident. An interview with the Infection Preventionist on 06/19/25 at 1:47 PM revealed she was notified of altercation between Resident #58 and Resident #76 by Therapy Staff #1. Therapy Staff #1 reported to Infection Preventionist Resident #58 and Resident #76 were heard fighting in their shared room. Therapy Staff #1 indicated to the Infection Preventionist that she had immediately separated the Residents. The Infection Preventionist stated she went to Resident #58 and Resident #76's room to assess both residents. Resident #58 stated to Infection Preventionist that Resident #76 took the television remote and changed the channel while Resident #58 was watching the television. Resident #58 further explained when he tried to grab the remote back from Resident #76, Resident #76 hit him (Resident #58) in the face. Upon assessment, Resident #58 had no injury noted to his lip or face, but a small bruise was noted on his left hand. The Infection Preventionist indicated Resident #76 could be confused and had changed rooms prior to this incident for not getting along with his roommates. The Infection Preventionist stated she was not aware of any other incidents of Resident #76 assaulting others. A progress note for Resident #58 dated 05/27/25 at 2:50 PM completed by Infection Preventionist stated Therapy Staff #1 observed Resident #58 and Resident #76 fighting over the television remote. Therapy Staff #1 was able to separate them, and Resident #58 explained he was watching television when Resident #76 came in and took the remote and changed the channel. Resident #58 reported to staff Resident #76 hit him in the face. No injury for Resident #58 noted upon physical assessment. The facility provider was notified of the incident. An additional progress note for Resident #76 dated 05/27/25 at 3:07 PM also completed by the Infection Preventionist stated Resident #58 and Resident #76 were fighting over the television remote. The residents were able to be separated by Therapy Staff #1. The note indicated Resident #58 accused Resident #76 of stealing the remote and changing the channel. Resident #58 also reported to staff Resident #76 hit him in the face. Resident #58 denied hitting Resident #76 back. Resident #58 and Resident #76 were separated. An observation and interview with Resident #58 on 06/16/25 at 11:38 AM revealed him to be alert, sitting upright in his wheelchair in his room watching television. He verbalized he recalled the altercation which occurred on 05/27/25 and reported Resident #76 grabbed the television remote when he was watching something and changed the channel. When Resident #58 attempted to grab the remote back from Resident #76, Resident #76 struck him on the lip. Resident #58 stated he had no injury from the altercation and denied physical pain. He reported he felt safe after Resident #76 was moved to another room, but he tried to avoid him when out of room. An observation and interview with Resident #76 on 06/17/25 at 11:15 AM noted he was alert, sitting upright in his wheelchair in his room. Resident #76 stated he recalled the altercation which occurred with Resident #58 on 05/27/25. He reported Resident #58 would not let him watch what he wanted so he grabbed the remote and hit Resident #58. Resident #76 further stated he did not get hurt and he agreed to move the same day. Resident #76 indicated he had no problems with his current roommate or sharing the television. An interview with the Director of Nursing (DON) on 06/19/25 at 1:55 PM, who reported the Infection Preventionist notified her Resident #58 and Resident #76 were fighting over the television remote. The DON reported she completed an assessment of both Residents on 05/27/25 after the altercation. She indicated Resident #76 had reopened a skin tear on his left forearm which required no treatment; and Resident #58 did not sustain any visible injury to his lip or face but had a small bruise on his left hand. The DON stated Resident #76 agreed to a room change the same day. An interview with the Administrator and Corporate Nurse on 06/20/[TRUNCATED]

Based on record review, and staff, mobile x-ray company representative, and Physician Assistant and Physician interviews, the facility failed to notify the provider of x-ray results when they were reported to the facility on [DATE], which resulted in Resident #15's right hip fracture not being reported to a provider until 12/30/24 which delayed Resident #15's transfer to the hospital until 12/30/24 for an evaluation and treatment for a right hip fracture that required surgical intervention for 1 of 4 residents reviewed for falls (Resident #15). The findings included: Review of the progress note dated 12/28/2024 written by the Director of Nursing (DON) revealed the DON heard Resident #15 yelling and as the DON arrived at Resident #15's doorway the DON observed Resident #15 as she attempted to get out of bed. The DON was unable to reach Resident #15 before she fell onto her right side onto the floor mat. Resident #15 did not strike her head but yelled out my hip is broken. The DON assessed Resident #15, leg heights could not be assessed due to mild contraction. Resident #15 expressed pain when area was touched. Facility Physician Assistant (PA) was notified and orders were received to obtain right hip x-ray and to give one time dose of oxycodone 2.5 milligrams (mg) related to acute right hip pain. The progress note indicated Resident #15 was assisted back to bed by staff x 3 and x-ray was pending. Review of Resident #15's orders revealed on 12/28/2024 the PA ordered an x-ray of Resident #15's right hip. An interview with the DON on 6/20/2025 at 11:04 AM revealed she cared for Resident #15 on 12/28/2024 3:00 PM to 11:00 PM. The DON stated on 12/28/2024 she heard Resident #15 yelling for help and when she came to the door Resident #15 was attempting to get out of bed and the DON was unable to reach Resident #15 in time, Resident #15 fell out of her bed, onto her right side. The DON stated Resident #15's bed was in the low position and Resident #15 had fallen onto her fall mat next to the bed. The DON stated Resident #15 yelled that her hip was broken. The DON stated she immediately assessed Resident #15. The DON stated due to Resident #15's legs being contracted it was difficult to assess the length of Resident #15's legs. The DON stated she called the facility PA to report the fall and received orders for a right hip x-ray and oxycodone 2.5mg for pain. The DON stated she called in the order for the right hip x-ray to the mobile x-ray service. The DON stated the x-ray was not called in stat. The DON stated when a mobile x-ray was ordered on the evening or weekend the x-ray was sometimes not completed until the next day. The DON stated she reported to 3rd shift that an x-ray was to be completed for Resident #15. The DON stated that typically the mobile x-ray reports were automatically uploaded into the resident electronic medical record. If there was positive fracture results the mobile x-ray company would call and alert the facility. Once the facility was notified, she would expect the staff to immediately notify the provider for further orders. The DON added that she believed there was a delay in the facility receiving the x-ray report which also delayed Resident #15 in being transferred to Emergency Room( ER) for evaluation. During an interview on 6/20/2025 at 8:52 AM the Physician Assistant (PA) stated he had received a call from the DON regarding Resident #15 and a fall. The PA stated he did not recall the DON reporting that Resident #15 yelled my hip is broken, but he did recall the DON reported Resident #15 had voiced pain. The PA stated Resident #15 was not a reliable historian. The PA stated he had received report Resident #15 did not have leg shortness. The PA stated he ordered for a hip x-ray to be completed and a one time extra dose of oxycodone 2.5mg. The PA stated normally it would take the mobile x-ray about company around four hours to arrive and perform an x-ray, but on evenings and weekends it sometimes took longer. Review of Resident #15's electronic medical record (EMR) revealed no documentation regarding Resident # 15's right hip or x-ray in the progress notes that were dated 12/29/2024. During a telephone interview on 6/20/2025 at 12:12 PM Nurse #4, who was scheduled on Resident #15's hall on 12/28/2024 and 12/29/2024 from 11:00 PM until 7:00 AM, stated he did not recall Resident #15 specifically or any information related to a fall. He stated he may have been scheduled to take care of Resident #15 but did not remember back that far. Review of Resident #15's electronic medical record revealed no documentation regarding Resident # 15's right hip or x-ray in the progress notes that were dated 12/29/2024. Review of the x-ray completed on 12/29/2024 with results reported to the facility on [DATE] at 2:09 PM revealed Resident #15 sustained an acute right femoral intertrochanteric fracture. Multiple attempts to reach Nurse #17, who worked with Resident #15 on 12/29/2024 from 7:00 AM to 3:00 PM were unsuccessful. Multiple attempts to reach Nurse #18 who worked with Resident #15 on 12/29/2024 from 3:00 PM to 11:00 PM were unsuccessful. Review of a progress note dated 12/30/2024 written by Nurse #5 revealed x-ray results were received and reported to the facility PA and orders to send Resident #15 to the emergency room for further evaluation and treatment of right hip were received. Report was called to the hospital and Resident #15 was transferred to the hospital. During a telephone interview on 6/20/2025 at 4:35 PM Nurse #5 stated she was not at work when Resident #15 fell but worked on 12/30/24 and received the x-ray results. Nurse #5 she answered a call from the mobile x-ray company, who called to verify the facility had received the x-ray results for Resident #15. Nurse #5 stated after she received the call, she checked Resident #15's Electronic Medical Record (EMR) and was able to view the radiology results. Nurse #5 stated she saw that the report indicated a fracture, she printed the report and immediately brought it to the facility PA who reviewed the x-ray report and gave orders to send Resident #15 to the emergency room. Nurse #5 stated once she received the order from the PA she immediately called 911 for transport and started the process to send Resident #15 to the hospital. Nurse #5 stated nurses can view results or reports from x-rays in the residents EMR, and stated when you are in the residents EMR the radiology and lab section will have an alert that results are available. Review of Resident #15's electronic medical record revealed a progress note dated 12/30/2025 at 1:16 PM written by a Nurse Practitioner (NP) that indicated Resident #15 had reported pain at a 10 out of 10 when she was assessed, but in no apparent distress, and no tenderness to palpation of bilateral upper and lower extremities, unable to test range of motion in the right lower extremity due to increased pain, and nursing reports she is being sent to the hospital for right hip fracture. During a telephone interview on 6/20/2025 at 1:06 PM with the mobile x-ray company Representative , the Representative stated they were notified on 12/28/2024 at 4:32 PM that the facility needed mobile x-ray for a resident, and stated it was not ordered stat, and that stat orders were completed the same day. The Representative stated the x-ray was done on 12/29/24 at 12:52 PM and the images were released at 1:19 PM. The Representative revealed the x-ray report was faxed to the facility at 2:09 PM, which meant the x-ray results would be available in the resident's electronic medical record for the facility to view. The Representative further stated they attempted to call report to the facility five times on 12/29/2024 with no answer by the facility. The Representative reported on 12/29/24 they made the first call at 3:47 PM, and calls were made every 30 minutes four additional times with no answer at the facility. The Representative indicated on 12/30/2024 the mobile x-ray company reached someone at the facility at 8:59 AM and spoke with Nurse #5 and gave her the report findings of positive fracture. During an interview on 6/20/2025 at 2:58 PM the Unit Manager #1 stated an x-ray order called in to the mobile company in the evening could possibly be completed that night if called in as a stat order, but if not called in as a stat order on an evening or weekend it would normally not be completed until the next day. The Unit Manager #1 stated when there is a result of a positive fracture on an x-ray the mobile x-ray company would call the facility to report the results and get the name of the person that received the report. The Unit Manager #1 stated when the mobile x-ray called the facility, the call would ring at the nurses desk and the call would transfer to the other nurses station if not answered. The Unit Manager #1 stated that on the weekend during second shift the phone could have gone unanswered, but the nurses should do their best to answer the phone when it rings especially when an x-ray report was pending. During an interview on 6/20/2025 at 11:51 AM The PA stated when he arrived to the facility on [DATE] he was informed of Resident #15's x-ray results and immediately gave orders for her to be sent to the hospital for an orthopedic evaluation. The PA stated they have on call providers on the weekend and ideally the x-ray results should have been reported to him or the on-call provider when received on 12/29/2024. During a telephone interview on 6/25/2025 at 11:23 AM the facility's Physician stated when x-ray results were released by the mobile x-ray company, and nurse would have access to the reports in a residents EMR. The Physician stated the mobile x-ray company also faxed a report to the facility when x-ray results were released. The Physician stated faxes were received on the copy machine located in the front hallway of the facility and all nurses would have had access to the machine, but not all agency nurses may have known about the fax being received. During an interview on 6/20/2025 at 4:35 PM the Administrator stated she would expect a resident to be sent to the hospital once they were notified of a fracture. The Administrator was unaware the mobile x-ray company had attempted and failed to reach the facility multiple times on 12/29/2024. The Administrator stated she would have wanted to receive the x-ray report as soon as it was available so it could be reported to the provider.

Based on observation, record review, resident, staff and provider interviews, the facility failed to administer medications as ordered by the physician for 1 of 2 residents reviewed for pain medications (Resident # 106). The findings included: Resident #106 was admitted to the facility on [DATE] with diagnosis that included nontraumatic subarachnoid hemorrhage from unspecified intracranial artery (a type of stroke where bleeding occurs in the space between the brain and the skull and the source of the bleeding is not due to trauma or a known cause), chronic respiratory failure with hypoxia, pressure ulcer sacral region stage four, chronic pain and persistent vegetative state. The quarterly minimum data set (MDS) dated [DATE] revealed Resident #106 was in a persistent vegetative state and indicated Resident #106 received opioid medication. Review of Resident #106's care plan revealed Resident #106 was care planned for minimal consciousness secondary to subarachnoid hemorrhage and persistent vegetative state with interventions that included monitor the patients neurological state. Resident #106 was care planned for alteration in neurological status related to non traumatic subarachnoid hemorrhage from unspecified intracranial artery with interventions that included pain management as needed. Resident #106 was care planned for potential/actual pain with interventions that included administer analgesia as per orders and monitor/record/report to nurse any signs or symptoms of nonverbal pain. Resident #106 was care planned for pressure ulcer related to immobility, admitted with stage 4 sacral ulcer present on admission with interventions that included administer medications as order. Review of Resident #106's physicians' orders revealed the following: A physician's order dated 7/4/2024 that read: fentanyl transdermal patch 72 hour 25 micrograms (MCG) per hour apply 1 patch transdermally every 72 hours for pain and remove old patch per schedule. A physician's order dated 8/27/2024 that read: oxycodone HCL oral tablet 5 milligrams (mg) give one tablet via PEG (a feeding tube inserted through the abdominal wall into the stomach) tube three times a day for sacral wound pain. Review of the Medication Administration Record (MAR) for July 2024 revealed documentation on 7/25/2024 by Nurse #6 that Resident #106's fentanyl patch was not applied as ordered due to not being available. Review of progress notes revealed an electronic Medication Administration Record (eMAR) administration note dated 7/25/2024 at 5:26 PM written by Nurse #6 that revealed fentanyl transdermal patch 25 MCG was awaiting order. Nurse #6 was unable to be reached for interview, the facility was unable to obtain a working number. Review of the MAR for September 2024 revealed documentation on 9/11/2024 by Nurse #12 that Resident #106's fentanyl patch was not applied as ordered due to not being available. Review of progress notes revealed an eMAR administration note dated 9/11/2024 by Nurse #12 that revealed fentanyl transdermal patch was awaiting arrival from pharmacy. Provider aware. During an interview on 6/19/2025 at 9:51 AM Nurse #12 stated she was familiar with Resident #106. Nurse #12 did not recall a specific instance when Resident #106 did not have her fentanyl patch available. Nurse #12 stated when a resident needs a controlled medication refilled, the prescription must be printed for the provider to sign and then faxed to the pharmacy. Nurse #12 stated if a resident does not have scheduled medication available, she would notify the provider, and make sure the medication had been reordered from the Pharmacy. Review of the MAR for October 2024 revealed documentation on 10/14/2024 by Nurse #12 that Resident #106 ' s fentanyl patch was not applied as ordered due to not being available. Review of progress notes revealed an eMAR administration note dated 10/14/2024 by Nurse #12 that revealed fentanyl transdermal patch new patch is on order. During an interview on 6/19/2025 at 9:51 AM Nurse #12 stated she normally notified the provider when a medication was not available. Nurse #12 stated she may have forgot to document notification but if she documented it was on order, she had ordered it from the pharmacy and that meant the provider had signed a script. Review of the MAR for April 2025 revealed documentation on 4/12/2025 by Nurse #8 that Resident #106's fentanyl patch was not applied as ordered due to not being available. Review of Progress notes revealed an eMAR administration note dated 4/12/2025 8:47 PM written by Nurse #8 that revealed Resident #106's fentanyl patch was unavailable. During a telephone interview on 6/20/2025 at 3:33 PM Nurse #8 stated she was an agency nurse at the facility and there were times when controlled medications were not available at the facility. Nurse #8 verified she had worked with Resident #106 on 4/12/2025. Nurse #8 stated that when she reordered controlled medications, she clicked the reorder button located on the eMAR, and stated she did not call the provider. Nurse #8 stated she did not know a prescription had to be printed, signed by the provider and faxed to the pharmacy. Nurse #8 stated since she was agency and did not always work the same hall she normally did not reorder controlled medication. Nurse #8 stated recently the unit managers rounded on the carts and reordered controlled medications that were low on supply. Review of the MAR for April 2025 revealed documentation on 4/15/2025 by Nurse #9 that Resident #106's fentanyl patch was not removed or applied as ordered. Review of progress notes revealed an eMAR administration note dated 4/15/2025 at 6:16 PM written by Nurse #9 that read left old patch on until new script is signed for medication to be sent. During a telephone interview on 6/19/2025 at 10:26 AM Nurse #9 verified she worked with Resident #106 on 4/15/2025 from 3:00 PM to 11:00 PM. Nurse #9 stated Resident #106 did not have a fentanyl patch available. Nurse #9 stated she did not leave an old patch on that old patches were removed and wasted so no patch was available to be removed. Nurse #9 stated when a resident did not have a scheduled medication she would check the back up medication, and if the medication was not available she would print off a prescription to be signed by the provider and faxed to the pharmacy. Review of the MAR for May 2025 revealed documentation on 5/12/2025 by Nurse #10 that Resident #106's fentanyl patch was not removed or applied as ordered. Review of progress notes revealed eMAR administration note dated 5/12/2025 at 9:53 PM written by Nurse #10 that read : fentanyl patch not available. Also revealed an eMAR administration note dated 5/12/2025 at 9:54 PM written by Nurse #10 that read: fentanyl patch not removed. Nurse #10 was unable to be reached for interview, the facility was unable to obtain a working number. Review of the MAR for May 2025 revealed documentation on 5/15/2025 by Nurse #11 that Resident #106's fentanyl patch was not available. Review of progress notes revealed eMAR administration note dated 5/15/2025 at 10:46 PM written by Nurse #11 that read: none available. Called on call, and he was unable to order a script but said to take old patch off and get a script tomorrow on day shift. Nurse #11 was unable to be reached for interview, the facility was unable to obtain a working number. An observation of Resident #106 was conducted on 6/16/2025 at 1:45 PM. Resident #106 was lying in her bed. Resident #106 was not able to respond or answer any questions. Resident #106 was observed to have regular breathing and appeared comfortable and in no distress. Resident was noted to have a fentanyl transdermal patch to her left upper chest. During an interview on 6/19/2025 at 11:07 AM Nurse #12 stated she goes through her narcotic drawer every day that she works to see what medications are low, then she prints the scripts for medications that are needed and Nurse #12 or the unit managers deliver the scripts to the provider to be signed and then the scripts are faxed to the pharmacy. Nurse #12 stated she sometimes forgot to look at the patches when she checked the cassettes but when patches were ordered the pharmacy sent them as soon as possible. During an interview on 6/19/2025 at 11:21 AM the Physicians Assistant (PA) stated he did not think it was significant that Resident #106 had missed 1 or 2 applications of her scheduled fentanyl patch because Resident #106 also received scheduled oxycodone and if the staff had been concerned Resident #106 was having increased pain they would have asked for a PRN to be ordered. The PA stated he had signed refill requests for the fentanyl patch but did not recall specific dates. The PA stated he knew they had been out at one point but was not concerned due to Resident #106's scheduled pain medication. During an interview on 6/19/2025 at 1:21 PM the Physician stated Resident #106 is in a vegetative state and non-verbal, and due to her severe brain damage pain response or reaction is hard to judge. The Physician stated she ordered the fentanyl patch for Resident #106 to make sure she was not in pain, but missing one dose would probably not cause significant discomfort, but missing two doses may cause some discomfort. The Physician stated since Resident #106 also had scheduled oxycodone it would help with any withdrawal symptoms. The Physician stated Resident #106 had sweating at her baseline so the only way to know if she had effects from missing her fentanyl doses would be vomiting or diarrhea. The Physician stated a resident who could vocalize might say they felt bad from missing two doses of a fentanyl patch. The Physician stated she was not aware of missed applications of Resident #106's fentanyl patch. During an interview on 6/19/2025 at 5:13 PM the Director of Nursing (DON) stated that she had started to transition to the Unit Managers reordering the narcotics. The DON stated the unit managers would go through the carts at least once a week to print scripts for the narcotics that needed to be reordered, then take the scripts to the provider to be signed then unit managers would fax the scripts to the pharmacy. The DON stated it had only been about a month since she had started this new process. The DON stated she expected the residents to have ordered medications available at the facility to be administered as scheduled. The DON expected narcotics to be reordered when needed and for the nurse to notify the provider of medications that were unavailable. During an interview on 6/20/2025 at 7:55 AM the Administrator stated she expected residents ordered medication to be available from the pharmacy, reordered when the supply is low. The Administrator would expect the provider to be notified if medication was not available.

Based on observations, record review and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 13 of 36 residents reviewed for respiratory care (Resident #78, #90, #45, #32, #4,#10, #27, #61, #3, #36, #26, #57, #67). The findings included: a. Resident #78 was admitted to the facility on [DATE]. A review of Resident #78's physician orders revealed an order dated 5/5/25 for oxygen to be administered continuously via nasal cannula at 4 liters per minute (l/min). A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident # 78 was coded for receiving oxygen during the assessment period. An observation on 6/18/25 at 2:03 PM revealed Resident #78 was lying in bed wearing a nasal cannula with oxygen being administered at 4 l/min. There was no cautionary or safety signage posted at the entrance to Resident #78's room to indicate oxygen was in use. An observation of Resident #78 conducted on 6/19/25 at 11:00 AM revealed he was sitting on the side of his bed with oxygen being administered via nasal cannula at 4 l/min. There was no safety signage posted at the entrance to Resident #1's room to indicate oxygen was in use. b. Resident #90 was admitted to the facility on [DATE]. A review of Resident #90's physician orders revealed an order dated 6/24/24 for oxygen to be administered via nasal cannula at 2 l/min as needed. A review of the quarterly MDS dated [DATE] indicated Resident #90 was coded for receiving oxygen therapy during the assessment period. An observation on 6/18/25 at 2:05 PM revealed Resident #90 was sitting in bed wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #90's room to indicate oxygen was in use. An observation on 6/19/25 at 9:45 AM revealed Resident #90 was lying in bed and wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #90's room to indicate oxygen was in use. c. Resident #45 was admitted to the facility on [DATE]. A review of Resident #45's physician orders revealed an order dated 10/22/24 for oxygen to be administered via nasal cannula at 2 l/min as needed. A review of the admission MDS dated [DATE] indicated Resident #45 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:21 PM revealed Resident #45 was lying in bed wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #8's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 9:30 AM revealed Resident #45 was lying in bed wearing a nasal cannula with oxygen being administered at 2 l/min. There was no safety signage posted at the entrance to Resident #45's room to indicate oxygen was in use. d. Resident #32 was admitted to the facility 8/9/18. A review of Resident #32's physician orders indicated an order dated 7/16/24 for oxygen to be administered via nasal cannula at 2 l/min continuously. A review of the quarterly MDS dated [DATE] revealed Resident #32 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:25 PM revealed Resident #32 was lying in bed wearing a nasal cannula with oxygen being delivered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #42's room to indicate oxygen was in use. An observation of Resident #32 was conducted on 6/19/25 at 11:30 AM. Resident #32 was lying in bed wearing a nasal cannula with oxygen being delivered at 2 l/min. There was no safety signage posted at the entrance to Resident #32's room to indicate oxygen was in use. e. Resident #4 was admitted to the facility on [DATE]. A review of Resident #4's physician orders indicated an order dated 5/16/24 for oxygen to be administered via nasal cannula at 2l/min as needed for shortness of breath. A review of the quarterly MDS dated [DATE] revealed Resident #4 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:28 PM revealed Resident #4 sitting in her room without her oxygen on, concentrator was in room but not running. There was no cautionary or safety signage posted at the entrance to Resident #4's room to indicate oxygen was in use. An observation on 6/19/25 at 11:10 AM revealed Resident #4 sitting in her without her oxygen on, concentrator was in room but not running. There was no cautionary or safety signage posted at the entrance to Resident #4's room to indicate oxygen was in use. f. Resident #10 was admitted to the facility 1/25/17. A review of Resident #10's physician orders indicated an order dated 5/8/24 for oxygen to be administered via nasal cannula at 2L/min at night. A review of the quarterly MDS dated [DATE] revealed Resident #10 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:30 PM revealed Resident #10 in his room not wearing oxygen, concentrator was in the room but not running, oxygen tubing was draped across the bed. There was no cautionary or safety signage posted at the entrance to Resident #10's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 8:30 AM revealed Resident #10 in his room not wearing oxygen, concentrator was in room but not running, oxygen tubing was draped across the bed. There was no cautionary or safety signage posted at the entrance to Resident #10's room to indicate oxygen was in use. g. Resident #27 was admitted to the facility on [DATE]. A review of Resident #27's physician orders indicated an order dated 4/17/25 for oxygen to be administered continuously via nasal cannula 2l/min. A review of the quarterly MDS dated [DATE] revealed Resident #27 was coded for receiving oxygen therapy during the assessment period. An observation of Resident #27 conducted on 6/18/25 at 2:33 PM revealed Resident #27 in his room wearing a nasal cannula with oxygen being delivered at 2L/min There was no cautionary or safety signage posted at the entrance to Resident #27's room to indicate oxygen was in use. An observation of Resident #27 conducted on 6/19/25 at 10:20 AM revealed Resident #27 in his room wearing a nasal cannula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #27's room to indicate oxygen was in use. h. Resident #61 was admitted to the facility on [DATE]. A review of Resident #61's physician orders indicated an order dated 4/13/24 for oxygen to be administered continuously via nasal canula at 2L/min. A review of quarterly MDS dated [DATE] revealed Resident #61 was coded for receiving oxygen therapy during the assessment period. An observation of Resident #61 conducted on 6/18/25 at 2:38 PM revealed Resident #61 in his room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #61's room to indicate oxygen was in use. An observation of Resident #61 conducted on 6/19/25 at 11:05 AM revealed Resident #61 in his room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #61's room to indicate oxygen was in use. I. Resident #31 was admitted to the facility on [DATE]. A review of Resident #31's physician orders indicated an order dated 1/16/24 for oxygen to be administered continuously via nasal canula at 2L/min. A review of quarterly MDS dated [DATE] revealed Resident #31 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:40 PM revealed Resident #31 in his room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #31's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 12:30 PM revealed Resident #31 in his room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #31's room to indicate oxygen was in use. i. Resident #36 was admitted to the facility on [DATE]. A review of Resident #36's physician orders indicated an order dated 3/12/25 for oxygen to be administered continuously via nasal canula at 2L/min. A review of the quarterly MDS dated [DATE] indicated Resident #36 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:44 PM revealed Resident #36 in his room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident ##36's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 12:35 PM revealed Resident #31 in his room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #36's room to indicate oxygen was in use. j. Resident #26 was admitted to the facility on [DATE]. A review of Resident #26's physician orders indicated an order dated 11/26/24 for oxygen to be administered continuously via nasal canula at 2L/min. A review of quarterly MDS dated [DATE] indicated Resident #26 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:48 PM revealed Resident #26 in her room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #26's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 12:40 PM revealed Resident #31 in her room wearing a nasal canula with oxygen being delivered at 2L/min. There was no cautionary or safety signage posted at the entrance to Resident #26's room to indicate oxygen was in use. k. Resident #57 was admitted to the facility on [DATE]. A review of Resident #57's physician orders indicated an order dated 5/7/25 for oxygen to be administered continuously via nasal canula at 2L/min as needed for shortness of breath. A review of the quarterly MDS dated [DATE] indicated Resident #57 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:50 PM revealed Resident #57 in his room not wearing a nasal canula, the concentrator was in the room but not in use at the time of observation. There was no cautionary or safety signage posted at the entrance to Resident #57's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 12:20 PM revealed Resident #57 in his room not wearing a nasal canula, the concentrator was in the room but not in use at the time of observation. There was no cautionary or safety signage posted at the entrance to Resident #57's room to indicate oxygen was in use. l. Resident #67 was admitted to the facility on [DATE]. A review of Resident #67's physician orders indicated an order dated 5/22/25 for oxygen to be administered continuously via nasal canula at 3L/min. A review of the quarterly MDS dated [DATE] indicated Resident #67 was coded for receiving oxygen therapy during the assessment period. An observation conducted on 6/18/25 at 2:55 PM revealed Resident #67 in her room wearing a nasal canula with oxygen being delivered at 3L/min. There was no cautionary or safety signage posted at the entrance to Resident #67's room to indicate oxygen was in use. An observation conducted on 6/19/25 at 10:43 AM revealed Resident #67 in her room wearing a nasal canula with oxygen being delivered at 3L/min. There was no cautionary or safety signage posted at the entrance to Resident #67's room to indicate oxygen was in use. m. Resident #31 was initially admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia (low oxygen levels). Resident #31's physician orders revealed an order dated 01/16/24 for oxygen via nasal cannula continuously at 2 liters per minute. A review of Resident #31's care plan revised on 03/24/25 revealed a plan for oxygen therapy to relieve hypoxia due to COPD. The stated goal was that Resident #31 would have no signs of poor oxygen absorption. Interventions included oxygen via nasal cannula as ordered, monitor for signs of respiratory distress and notify provider if indicated, administer medications as ordered. Resident #31's significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #31 was severely cognitively impaired, dependent on staff for all activities of daily living, and coded for COPD, respiratory failure, and continuous oxygen use. An observation of Resident #31 on 06/16/25 at 12:18 PM revealed oxygen via nasal cannula in place and oxygen concentrator was in use at 2 liters per minute. No cautionary oxygen in use signage was noted outside of Resident #31's room indicating oxygen in use. A second observation of Resident #31 on 06/1/25 at 2:40 PM revealed the oxygen concentrator administering oxygen to the resident at 2 liters per minute via the oxygen cannula in place. There was no cautionary oxygen in use signage outside of Resident #31's room indicating oxygen in use. During an interview with Nurse #12 on 06/18/25 at 8:14 AM stated Resident #31 received oxygen continuously. Nurse #12 stated that she did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms. Nurse #12 indicated that she had not noticed that Resident #31 did not have a sign on his door. An interview was conducted with the Director of Nursing on 6/18/25 at 3:05 PM indicated safety signage for the use of oxygen should be posted outside the doors of residents' rooms that were using oxygen. The DON explained the staff member who brought the concentrator into the resident's room were responsible to hang the oxygen in use signs but it was ultimately all staff members' responsibility to make sure the oxygen in use signs were in place. An interview was conducted with the Administrator on 6/20/25 at 3:15 PM indicated she had not noticed there were no oxygen in use safety signage posted on the doors of the residents' rooms who were prescribed oxygen. The Administrator stated oxygen in use signs should be posted on all doors of rooms where oxygen was being used, and she felt staff should know this.

Based on record review, staff, and Consulting Pharmacist, Psychiatric Nurse Practitioner, and Physician interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnosis that included late onset Alzheimer's disease with behavior disturbance, dementia with mood disturbances, recurrent major depressive disorder, major neurocognitive disorder due to dementia, generalized anxiety disorder, primary insomnia. A review of Resident #15's Physician's orders revealed an order dated 2/6/2024 for Zyprexa (an atypical antipsychotic) 2.5 milligrams (mg) give one tablet by mouth two times a day for mood disorders. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and indicated Resident #15 received an antipsychotic on a routine basis during the 7-day look back period and that a Gradual Dose Reduction (GDR) clinically contraindicated on 4/2/2025. The MDS also indicated Resident #15 exhibited verbal behaviors symptoms directed toward others. A review of Resident #15's electronic medical record revealed an AIMS test was completed on 5/31/2024. Review of the Consulting Pharmacist recommendations dated 4/18/2025 revealed a recommendation for nursing that read: This resident is taking medications that can cause extrapyramidal side effects. An AIMS test should be done at baseline and every 6 months thereafter. The recommendation indicated the date of Resident #15's last AIMS test was 5/31/2024. Review of the progress notes revealed a note dated 5/15/2025 at 11:24 PM written by the Consulting Pharmacist that read: Medication Regimen Review completed. No Recommendation. A telephone interview was conducted with the Consultant Pharmacist on 6/19/2025 at 1:48 PM. The Consulting Pharmacist stated that it was recommended that residents taking Zyprexa have an AIMS test completed every 6 months. The Consulting Pharmacist verified during the Monthly Regimen Review (MRR) dated 4/18/2025 he recommended that Resident #15 needed an AIMS baseline then every six months, and that the last AIMs documented for resident #15 was 5/31/2024. The Consulting Pharmacist stated an AIMS assessment every 6 months was the recommended best care practice, and he could have recommended the assessment be completed before April of 2025, but the facility had completed one on 5/31/2024. The Consulting Pharmacist stated if they had not completed any monitoring he may have made the recommendation sooner. The Consulting Pharmacist stated when his recommendations were submitted the facility had 30 days to complete the recommendations. During a telephone interview on 6/25/2025 at 10:03 AM the Psychiatric Nurse Practitioner (Psych NP) stated AIMS tests were recommended every 6 months when taking Zyprexa, but Resident #15 was taking a very low dose of Zyprexa. During an interview on 6/18/2025 at 10:27 AM the Weekend Supervisor stated if an assessment was due for a resident, the electronic medical record (EMR) would show an alert or flag in the residents EMR that an assessment was due under a section labeled UDA (Un-done Assessments). The Weekend Supervisor stated nurses were responsible for checking the EMR for assessments that are due, and unit managers also monitored residents electronic medical record to make sure assessments were completed. The Weekend Supervisor stated she helped monitor assessments and would assist the nurses to make sure they were completed when needed, but did not know who entered them into the EMR. During a telephone interview on 6/26/2025 at 11:23 AM the Physician stated residents who received Zyprexa should have an AIMS assessment completed every 6 months per recommendations. During an interview with the Director of Nursing (DON) on 6/19/2025 at 5:20 PM the DON stated the Consulting Pharmacist emailed recommendations to the provider and DON. The DON stated she was responsible for completing nursing recommendations received from the Consulting Pharmacist. The DON stated she had received the April 2025 recommendation which indicated Resident #15 needed an AIMS assessment completed. The DON stated the AIMs assessment should have been completed when the recommendation was received, since the Consulting pharmacist had recommended it be completed every six months. The DON stated the AIMs assessment would be completed in the electronic record under assessments, and she was responsible for completing the recommended assessment. The DON was unsure if the AIMs assessment had been entered into Resident #15 ' s EMR to be completed every 6 months. The DON stated she normally completed the recommendations from the Consulting Pharmacist but did delegate to others at times. The DON stated when the pharmacy recommendation was requested by the surveyor, the DON realized the recommended AIMS assessment for Resident #15 had not been completed. The DON stated she would normally go out and complete the assessment as soon as a recommendation was received, but she must have forgotten to complete the one for Resident #15. During an interview with the Administrator on 6/20/2025 at 7:50 AM the Administrator stated she expected AIMS to be completed per pharmacy recommendations. The Administrator stated it was possible the assessment was completed on paper and had not been uploaded into the electronic chart. No further AIMS assessments for Resident #15 were provided by the Administrator.

Based on record review, and resident and staff interviews, the facility failed to follow their planned menus for 3 of 3 residents reviewed for preferences (Residents #96, #3, #111). The deficient practice had the potential to affect other residents who received food from the kitchen. The findings included: An interview with nursing assistant (NA) #3 on 6/18/25 at 3:15 PM revealed he had noticed residents not getting their dinner meal. He reported the kitchen had ran out of the prepared food items on the menu for the dinner meal. He stated when this happened the residents that had not received the food items on the menu got sandwiches. NA #3 reported it had happened several times although he could not remember an exact number or the exact days it happened on. He did remember it was always the dinner meal. He reported the residents would report to him they did not like getting cold sandwiches and would have preferred a hot meal. He reported the second time it happened he did make the Director of Nursing (DON) aware. An interview with a 1:1 sitter on 6/18/25 at 3:26 PM revealed she had had two occasions where the resident she was responsible for did not get the listed menu items at the dinner meal. She reported they got a sandwich instead. She stated she could not remember the specific resident this happened to, and she had seen other times where residents she was not responsible for also not get the listed menu items for dinner. She was unsure what those residents were given. She reported she did make the nurse on duty aware but she could not remember which nurse it was. An interview with the Dietary Manager (DM) on 6/18/2025 at 3:50 PM revealed [NAME] #1 had been replaced recently due to him frequently not preparing enough of the food items on the menu despite the training he had received. She reported she was unsure if [NAME] #1 was not cooking enough food or if he was serving too much food, but he would frequently run out of food on the dinner meal. DM reported she had tried several times to retrain him by working with him personally during meal times, explaining how to use the recipes and census to determine how much food to cook. She reported she reviewed the serving spoons to determine how much to serve on a plate. She reported her relief cook also worked with him, but the training was not successful. DM stated she also felt [NAME] #1's choices in what to use to replace the menu items were not adequate, however he would not call her with questions or concerns even though she had told him to always call if he was unsure. DM reported there was always adequate food in the kitchen to prepare for the meals on the menu as well as adequate choices for substitutes. a. Resident #96 was admitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #96 was cognitively intact and required only set up assistance from staff for eating. Interview with Resident #96 on 6/19/25 at 3:23 PM indicated there have been times when we didn't get what was on the menu because the kitchen ran out of food. He stated it always happened at the dinner meal. Resident #96 reported when the kitchen ran out of food for that meal they substituted with a sandwich. Resident #96 reported he had not been served the dinner meal on the menu at least three times. b. Resident #111 was admitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #111 was cognitively intact and required only set up assistance from staff for eating. Interview with Resident #111 on 6/19/25 at 3:35 PM revealed she had not received the dinner meal listed on the menu on at least three different evenings. The last time being 6/16/25. She indicated she was told by staff that the kitchen had ran out of the food items on the menu and she got a sandwich instead. She reported she was not given an option to choose what kind of sandwich she preferred but also revealed she was okay with what the facility staff gave her and did not ask for anything different but would have preferred to been asked. She reported she really liked to have a hot meal for dinner. c. Resident #3 was admitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and required only set up assistance from staff for eating. An interview with Resident #3 on 6/19/25 at 3:45 PM revealed the kitchen had ran out of the food items listed on the menu at the dinner meals three times. She reported she only got a sandwich for these meals instead of what was listed on the menu. Resident #3 indicated the most recent time the kitchen ran out of food was Monday 6/16/25. She reported she was not given a choice of what she wanted since the listed menu items were not available. She reported she would have liked to have had a hot meal instead of a cold sandwich. An interview with [NAME] #1 on 6/20/25 at 10:30 AM revealed he had been a dietary aide at the facility for several months and was moved into the cook position about two months ago. He stated he was thrown into the position without adequate training. [NAME] #1 indicated he was not aware of any formulas or tools that assisted him in determining how much food to cook. He reported he was told to do something quick in the instance he ran out of food. He reported he ran out of food several times usually during the dinner meal, although, he could not remember how many times. He stated he made the residents a sandwich to replace the menu items they did not receive. [NAME] #1 reported he stepped down from this position on 6/2/25. Record Review of personnel file for [NAME] #1 on 6/20/25 at 11:00 AM revealed he was written up for not following the menu on 5/7/25. An interview with [NAME] #2 revealed he had been hired as a cook on 6/2/25. [NAME] #2 reported his training was mostly on the job and he had learned about diets, food temps, hygiene, and looking at census to prepare meals. He reported there is no formula/recipe, and he uses his judgement on how much to cook. He stated if food items on the menu ran out he would use his own judgement of what to make for the residents who didn't get a meal. He reported he was aware residents should have a protein. He stated a meat and cheese sandwich or Peanut Butter & Jelly sandwich would be an adequate replacement meal if we run out of the listed food items on the menu. [NAME] #2 denied running out of listed menu items during the dinner meal on 6/19/25. An interview with Director of Nursing (DON) on 6/20/25 at 1:32 PM indicated residents get three meals a day always but did not know if the food the residents received was actually the food items listed on the menu. There were a few times that it was reported to her that the kitchen had run out of food and some residents did not get the listed menu items but were served a sandwich. She reported she knew the facility had an issue with a cook serving too much or not cooking enough food. She indicated on those days the residents did not get served what was on the menu and she was not sure what they were fed. An interview with the Administrator on 6/20/25 at 1:50 PM revealed she was aware of complaints about running out of the listed menu items during the dinner meal. She reported it was her understanding [NAME] #1 was either serving too big of portions or was not cooking enough. She stated she talked to [NAME] #1 and he let me know he did not feel comfortable in the position because he did not feel he had adequate understanding of how to prepare the food for the facility. She reported the DM and a relief cook provided one on one training with [NAME] #1. She reported he did well for a short time but then began to have problems with having enough food again. She reported at that time, she and the DM began looking for a new cook to fill the position and one was hired on 6/3/25. She indicated that cooks get on the job training with a senior cook. She reported there is no skills check off for this position, that the senior cook or dietary manager determines if the new employee was ready to be independent by observation of their work performance.

Based on observations, and resident and staff interviews, the facility failed to provide evening snacks to residents when requested for 6 of 6 residents reviewed for frequency of snacks (Residents #3, #37, #44, #96, #105 and #111). This deficient practice had the potential to affect other residents who requested evening snacks. The findings included: a. Resident #3 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #3 was cognitively intact. An interview with Resident #3 on 6/17/25 at 11:15 AM revealed over the past six months she had been offered or received an evening snack once or twice but not on a consistent basis. She stated she believed dietary staff were supposed to restock the snack rooms at least twice a day but there were never any snacks available during the evening shifts or anytime during the weekends. Resident #3 revealed when she would ask staff about receiving an evening snack, they would tell her there were no snacks available in the snack rooms for them to give to her and she was not aware if staff were able to get snacks from the kitchen after hours or not. b. Resident #37 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes and malnutrition. A quarterly MDS dated [DATE] indicated Resident #37 was cognitively intact. An interview with Resident #37 on 6/17/25 at 11:17 AM revealed for the past several months she had been offered or received an evening snack on a handful of occasions but not on a consistent basis. She stated she would have her family bring her snacks to keep in her room or buy them herself. Resident #37 revealed when she or other residents would ask staff about receiving an evening snack, they would tell her there were no snacks available for them to give to her. She stated the snack rooms were typically only stocked once a day during first shift and were empty during the evening shift and weekends. c. Resident #44 was admitted to the facility on [DATE]. An annual MDS dated [DATE] indicated Resident #44 was cognitively intact. An interview with Resident #44 on 6/17/25 at 11:20 AM revealed during her stay at the facility she had never received an evening snack on a consistent basis. She stated when she had requested an evening snack from nursing staff, they had told her there were no snacks available, all the snacks had been passed out, they had run out of snacks for the evening, or nursing staff did not have access to the kitchen to refill their snacks. d. Resident #96 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes. An admission MDS dated [DATE] indicated Resident #96 was cognitively intact. An interview with Resident#96 on 6/17/25 at 11:21 AM revealed since he had been at the facility he had never received an evening snack or been offered an evening snack consistently. He stated sometimes nursing staff would offer a snack and other times you would have to request a snack, and staff would usually come back and say they couldn't find any snacks in the snack room, or they were not able to access the kitchen for more snacks. e. Resident #105 was admitted to the facility on [DATE]. A quarterly MDS dated [DATE] indicated Resident #105 was cognitively intact. An interview with Resident #105 on 6/17/25 at 11:25 AM revealed since he had been at the facility he had been offered or received an evening snack on a handful of occasions but not consistently. He stated that sometimes nursing staff would offer a snack and other times you would have to request a snack, and then staff would usually come back and say they couldn't find any snacks in the snack room, or they were not able to access the kitchen for more snacks. f. Resident #111 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes. A quarterly MDS dated [DATE] indicated Resident #111 was cognitively intact. An interview with Resident #111 on 6/17/25 at 11:27 AM revealed for the past several months she had been offered or received an evening snack on a handful of occasions but not on a consistent basis. She revealed when she or other residents would ask staff about receiving an evening snack, they would tell her there were no snacks available for them to give to her. She stated the snack rooms were typically only stocked once a day during first shift and were empty during the evening shift and weekends. An observation of nourishment rooms on 6/18/25 at 9:50 AM with Dietary Manager #1 revealed the dietary staff had stocked the refrigerator the previous day with pre-made sandwiches, drinks and juice, crackers, snack cakes and soups available for residents. An interview with Nursing Assistant (NA) #6 on 6/18/25 at 10:17 AM revealed she had worked at the facility for the past two years on both first and second shift and was familiar with resident complaints of not receiving their evening snacks. She stated there had been times when she had gone to the nourishment rooms during evening and weekend shifts and there were no snacks available, no sandwiches, no drinks and dietary staff were informed of the issue. NA #6 revealed dietary staff were responsible for replenishing the nourishment rooms and she was not aware of nursing staff having access to the kitchen after hours to be able to get snacks or drinks for residents. An interview with Dietary Manager (DM) #1 on 6/18/25 at 2:50 PM revealed she had been at the facility since April 2025. DM #1 stated she was not aware of issues with no snacks being available in the nourishment rooms for residents and nursing staff not having access to snacks from the kitchen. DM #1 revealed she was not aware of dietary staff not stocking the nourishment rooms during first and second shift and on the weekends. DM #1 indicated personally stocked the nourishment room herself yesterday and informed nursing staff that it had been stocked and was available for residents. She also stated she had educated dietary staff on making sure the nourishment rooms were stocked with snacks, sandwiches, and drinks to be available for residents and staff. An interview with the Administrator on 6/20/25 at 5:45 PM revealed she expected there to always be snacks available for residents. The Administrator further revealed she was not aware of residents not having snacks available to them upon request and dietary staff should be stocking the nourishment rooms twice a day with enough snacks, sandwiches, and drinks for residents. She stated nursing staff should have notified dietary staff, nursing supervisors, or herself if there was an issue with not having evening snacks available for residents. The Administrator revealed that she orders an overabundance of snacks each month to make sure residents have a variety of options for their snacks and there was no reason why residents should not be receiving their evening snacks.

Based on observations and staff interviews, the facility failed to remove expired food and failed to date perishable food stored for use in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents. The findings included: During the initial tour of the kitchen, with the Dietary Manager, on 6/16/25 from 9:45 AM to 10:15 am, an observation of the walk-in cooler revealed the following: a. a plastic container with cranberry thickener was opened and no date was written on the container b. a plastic container with lemon thickener was opened and no date was written on the container c. a box of blueberry muffins, resealed with plastic wrap had no date written on the container d. an opened bottle of orange flavored juice was opened and no date written on the container. An interview with the Dietary Manager on 6/18/25 at 11:30 AM revealed all food items should be sealed, labeled, and dated when stored. She stated all dietary aides should be checking food items on a regular basis and discard any items that are were not sealed, labeled, dated, or have expired immediately. An interview with the Administrator on 6/20/25 at 3:40 PM revealed all dietary staff had been educated on food storage. She stated all food should be labeled, sealed, dated, and expired foods should be discarded immediately.

Based on observations, record review, and staff interviews, the facility staff failed to implement infection control policy and procedures when Nurse #12 did not don personal protective equipment (PPE) for enhanced barrier precautions (EPB) when providing high-contact resident care activities for Resident #106 who had a gastrostomy tube (g-tube-a tube that goes into stomach), an indwelling urinary catheter, and a tracheostomy tube (a tube in the throat for breathing). The facility also failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 3 residents whose blood sugar levels were checked (Resident #96, Resident #10). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were 3 residents with bloodborne pathogens in the facility at the time of the investigation. This deficient practice was identified for 3 of 6 staff members observed for infection control practices (Nurse #12, Nurse #14, Nurse #15). The findings included: 1. A review of facility EBP policy dated 09/01/24 revealed EBP should be applied to include gown, gloves, and mask for high contact care activities such as dressing, bathing, transfers, changing linens, toileting, device care (urinary catheters, feeding tubes, tracheostomy), and wound care. A continuous observation of Nurse #12 on 06/18/25 at 8:13 AM during medication administration revealed Nurse #12 entered Resident #106's room to administer medications and perform tracheostomy care. Nurse #12 failed to don PPE prior to care of Resident #106. Nurse #12 also failed to perform hand hygiene when gloves were removed after administering medications via g-tube for Resident #106. Nurse #12 then donned new gloves and performed tracheostomy care. An interview with Nurse #12 on 06/18/25 at 8:41 AM stated due to nervousness, she forgot to apply PPE during medication administration and tracheostomy care of Resident #106. Nurse #12 stated she also forgot to perform hand hygiene between administration of medication via g-tube and performing tracheostomy care for Resident #106. An interview with the Infection Preventionist on 06/18/25 at 11:51 AM revealed that Nurse #12 should have donned PPE during medication administration and tracheostomy care for Resident #106 who was on EBP. The Infection Preventionist indicated that PPE would include a gown, gloves, and a mask. PPE hangs on door and is stocked regularly by the Infection Preventionist. An interview with the Director of Nursing (DON) on 06/19/25 at 1:11 PM revealed Nurses were to apply PPE for high contact interactions with residents who had urinary catheters, tracheostomy, or g-tubes when medication was administered, or other care was provided. Hand hygiene should also be performed by staff before moving from one body part to another. An interview with the Administrator on 06/19/25 at 4:15 PM revealed Nurses were to apply PPE for high contact interactions with residents with catheters, tracheostomy, or g-tubes. Hand hygiene should be performed by all staff before, during, and after care. 2. A review of the glucometer manufacturer's cleaning and disinfection procedure guide revealed the glucometer should be cleaned with an Environmental Protection Act (EPA) approved germicidal wipe after use on each patient. Manufacturer instructions stated use one germicidal wipe to clean and a second wipe to disinfect. The glucometer manufacturer procedure guide indicated the germicidal disposable wipes that the facility had available on medication cart, were listed as an approved disinfectant on the manufacturer's cleaning instructions. A review of facility policy titled Glucometer Disinfection dated 10/01/24 revealed glucometers will be cleaned and disinfected after each use and according to manufacturer instructions regardless of whether intended for single resident or multiple resident use. The procedure for glucometer disinfection stated retrieve 2 disinfection wipes from the container. Use the first wipe to clean first to remove heavy soil, blood, or other contaminants left on the surface of the glucometer. After cleaning with the first wipe, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe. Allow the glucometer to air dry. An observation on 06/18/25 at 12:00 PM of Nurse #14 performing a blood glucose test for Resident #96 with a shared glucometer stored in the medication cart. Nurse #14 gathered supplies (alcohol pad, disposable lancet, and test strips) for blood glucose check. Nurse #14 did not clean the glucometer prior to blood glucose check. Nurse #14 entered Resident #96's room. While wearing gloves, Nurse #14 wiped Resident #96's finger with the alcohol pad, used disposable lancet to obtain a drop of blood from her finger and applied the blood to the test strip inserted into the glucometer. Once the blood glucose results were obtained, Nurse #14 discarded the trash and placed the disposable lancet in the sharps container. Nurse #14 obtained EPA approved germicidal wipes from the medication cart and used 1 wipe to clean the shared glucometer. Nurse #14 failed to use the second germicidal wipe to disinfect the glucometer. An interview with Nurse #14 06/18/25 at 12:05 revealed Nurse #14 only cleaned the glucometer after performing blood glucose checks. Nurse #14 stated to his knowledge, the facility policy stated to clean the shared glucometer after use. Nurse #14 stated glucometer was considered clean prior to use because it had been cleaned after the last glucometer check. An interview with the Infection Preventionist on 06/18/25 at 11:51 AM revealed that glucometers are shared and stored in medication carts. The Infection Preventionist stated glucometers should be disinfected after use with germicidal wipes should be visibly wet for at least 2 minutes. An interview with the Director of Nursing (DON) on 06/19/25 at 1:11 PM revealed Nurses were to disinfect shared glucometers according to facility policy and manufacturer directions. An interview with the Administrator on 06/19/25 at 4:15 PM revealed glucometers needed to be disinfected to prevent blood borne pathogen transmission. Nurses used shared glucometers and had germicidal wipes available to cleanse and disinfect the shared glucometers after each use. 3. An observation on 06/18/25 at 3:31 PM of Nurse #15 performing a blood glucose test for Resident #10 with a shared glucometer stored in the medication cart. Germicidal wipes were observed on the medication cart. Nurse #15 gathered supplies (alcohol pad, disposable lancet, and test strips) for blood glucose check. Nurse #15 did not clean the glucometer prior to blood glucose check. Nurse #15 entered Resident #10's room. Nurse #15 wore gloves, and wiped Resident #10's finger with the alcohol pad, used disposable lancet to obtain a drop of blood from Resident #10's finger and applied the blood to the test strip inserted into the glucometer. Once the blood glucose results were obtained, Nurse #15 discarded the trash and placed the disposable lancet in the sharps container. Nurse #15 obtained EPA approved germicidal wipes from the medication cart and used 1 wipe to clean the shared glucometer. Nurse #15 scrubbed glucometer for 2 minutes using 1 germicidal wipe. Nurse #15 failed to use the second germicidal wipe. Nurse #15 then placed the glucometer on a tissue to dry. An interview on 06/18/25 at 3:36 PM Nurse #15 (agency staff) stated the glucometer was shared between residents. Nurse #15 reported the glucometer should be cleaned after blood glucose checks were performed. Nurse #15 indicated he does not clean the glucometer before use but does use the disinfectant wipes on the glucometer after each use, then placed the glucometer on a tissue to dry before stored back in medication cart. An interview with the Infection Preventionist on 06/18/25 at 11:51 AM revealed that glucometers are shared and stored in medication carts. The Infection Preventionist stated glucometers should be disinfected after use with germicidal wipes and glucometer should be visibly wet for at least 2 minutes. An interview with the Director of Nursing (DON) on 06/19/25 at 1:11 PM revealed Nurses were to disinfect shared glucometers according to facility policy and manufacturer directions. An interview with the Administrator on 06/19/25 at 4:15 PM revealed glucometers needed to be disinfected to prevent blood borne pathogen transmission. Nurses used shared glucometers and had germicidal wipes available to cleanse and disinfect the shared glucometers after each use.

Based on record reviews, and resident, staff, Physician Assistant (PA), and Physician interviews, the facility failed to protect resident's right to be free of misappropriation of controlled substances for 1 of 3 residents reviewed for misappropriation of resident property (Resident #117). The findings included: The facility's Abuse, Neglect, Exploitation, and Misappropriation policy, last revised on 09/01/2024, revealed in part the facility would ensure all residents were free from misappropriation of property. Resident #117 was admitted to the facility on [DATE] with diagnoses of left clavicle fracture, multiple fractures of the pelvis, left hip fracture, left leg fracture, and chronic pain. A review of the physician's order dated 11/25/2024 revealed Resident #117 had an order for 10 milligrams (mg) of Methadone (an opioid that acts on the central nervous system to relieve pain); give 35 mg/3.5 tablets twice a day for pain (9:00 AM and 9:00 PM). A review of Resident #117's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had moderately impaired cognition. The MDS also revealed Resident #117 received scheduled opioid pain medications during the 7-day look back period. Review of Resident #117's April 2025 Medication Administration Record (MAR) revealed Methadone 35 mg scheduled for 9:00 AM on 04/16/2025 was not administered and was sign off as not available. Review of the Pharmacy Consolidated Delivery Sheet revealed 210 tablets of Methadone 10 mg for Resident #117 was delivered to the facility on [DATE] at 4:00 PM. Review of Resident #117's April 2025 MAR revealed Methadone 35 mg scheduled for 9:00 PM on 04/16/2025 was documented as administered by Nurse #3. Review of Resident #117's declining inventory sheet for Methadone 10 mg tablets; give 35mg/3.5 tablets twice a day for pain revealed one dose of Methadone was signed out by Nurse #3 on 04/16/2025 with no indication of what time the medication was signed out or administered. On 04/17/2025 one dose of Methadone was signed out by Nurse #3 on 04/17/2025 at 10:00 PM. Review of the nursing assignment sheets dated 04/16/2026 revealed Nurse #3 was assigned to Resident #117 from 3:00 PM on 04/16/2025 through 04/17/2025 at 7:00 AM. Nurse #3 was not working on 4/17/25 at 10:00 PM. The initial allegation report dated 04/17/2025 revealed the Director of Nursing (DON) became aware of the misappropriation of resident's property on 04/17/2025 at 12:00 PM when Nurse #2 reported the declining inventory sheet revealed a discrepancy with Resident #117's pain medication on 04/16/2025. On 04/17/2025, an internal investigation was initiated regarding the allegation of misappropriation of property for Resident #117. Nurse #3's agency was contacted, and Nurse #3 was placed on the do not return list. An interview on 06/18/2025 at 1:15 PM with Nurse #2 revealed on 04/17/2025 at approximately 7:15 AM during the medication count, Nurse #2 observed Resident #117's declining inventory sheet for Methadone 35 mg. Resident #117's Methadone was signed out twice between second and third shift on 04/16/2025. Nurse #2 revealed that Nurse #3 stated that she did not write the time down that she gave a dose but that she did give the medication to Resident #117 two times during her shifts. Nurse #2 stated that Nurse #3 did not fill in the time she gave the medication before leaving the facility. Nurse #2 stated Resident #117's medications should have been given every 12 hours at 9:00 AM and 9:00 PM. Nurse #2 also stated that Resident #117 stated he was only given one dose of his Methadone. Nurse #2 stated that she notified the DON at approximately 11:15 AM on 04/17/2025. Review of Nurse #3's telephone statement taken by the DON on 04/18/2025 revealed Nurse #3 stated that Resident #117's medication came in from the pharmacy on her shift around 4:00 PM and she thought it was okay to administer the medication at approximately 6:00 PM in place of the missed morning dose which had not arrived from the pharmacy. Nurse #3 also stated that she did not contact the physician about the missed dose and did not receive a one-time order from the physician to administer the medication early on 04/16/2025. Nurse #3 stated she administered Resident #117's Methadone 35 mg at 6:00 PM and again at 10:00 PM on 04/16/2025. Multiple unsuccessful attempts were made to contact Nurse #3. The investigation report (5-day) dated 04/22/2025 revealed the Director of Nursing (DON) was alerted by Nurse #2 on 04/17/2025 at 12:00 PM that Resident #117's declining inventory sheet revealed Methadone 35 mg was signed out on 04/16/2025 by Nurse #3 with no indication of what time the medication was administered. Nurse #3 signed out a second dose of Methadone with the date and time reading 04/17/2025 at 10:00 PM. Nurse #3 started her shift on 04/16/2025 at 3:00 PM and her shift ended on 04/17/2025 at 7:00 AM. Nurse #3 was not on duty on 04/17/2025 at 10:00 PM. The investigation report revealed statements had been obtained from Nurse #2 and Nurse #3. Nurse #3 was instructed by the DON to contact her agency in regard to submitting a statement and a drug screen. Nurse #3 submitted to drug testing on 04/22/2025 and the results were negative. Per the facility's investigation report dated 04/22/2025, an audit was performed on 04/17/2025 of the declining inventory sheets and each medication on all the medication carts to verify that all narcotic medications and declining inventory sheets were present and accurate. No additional discrepancies were found. The diversion was reported to the local police and the local Department of Social Services on 04/17/2025. Nurse #3 was reported to the Board of Nursing on 04/21/2025. A review of the pharmacy receipt dated 04/22/2025 revealed Resident #117's account was credited for one dose of Methadone 35 mg. An observation and interview was conducted with Resident #117 on 06/17/2025 at 2:13 PM. Resident #117 was sitting up in his wheelchair watching television. Resident #117 appeared comfortable and did not verbalize any complaints of pain or discomfort. Resident #117 stated he has had issues with pain for a long time because he was in an automobile accident in 2023 and suffered severe injuries including multiple broken bones and abdominal trauma. Resident #117 further stated that he had chronic pain as a result of his automobile accident and had received oxycodone for a very long time for pain control, but he was now taking Methadone twice a day. He also stated that the Methadone controlled his pain. Resident #117 stated that he remembered the day when he did not get his morning dose of Methadone. Resident #117 stated that he did not feel well the entire day, and he didn't have any energy, but he did not know if it was because he didn't get his pain medication or not. An interview was conducted with the DON on 06/18/2025 at 3:25 PM. The DON revealed that on 04/17/2025 at approximately 12:00 PM, Nurse #2 notified her that Nurse #3 had signed out 2 doses of Methadone 35 mg on the declining inventory sheet for Resident #117. The DON further explained that Resident #117 stated he only received his nighttime dose of Methadone on 04/16/2025 around 10:00 PM that night. The DON stated that Nurse #3 was on duty in the facility beginning at 3:00 PM on 04/16/2025 and ended her shift at 7:00 AM on 04/17/2025. The DON also stated that she reported the incident to the Administrator and the facility initiated an internal investigation. An interview with the Physician was conducted on 06/19/2025 at 1:19 PM. The Physician revealed she was very familiar with Resident #117, but she was not aware that he missed a dose of his scheduled pain medication. The Physician also stated that she had recently visited Resident #117, and his pain was well controlled with his Methadone. She also stated that Resident #117 had not mentioned anything about having missed a dose of Methadone or having uncontrolled pain or discomfort. An interview with the Physician Assistant (PA) on 06/19/2025 at 2:15 PM revealed he was familiar with Resident #117 who suffered from chronic pain due to an automobile accident which resulted in multiple fractures and a prolonged hospital stay. The PA stated that Resident #117 had received oxycodone (a pain mediation used to treat severe pain) initially when he was admitted to the facility but had transition to Methadone for his chronic pain. The PA revealed he recalled being told about the missing Methadone dose but did not recall the details about it. He stated Resident #117's pain was well controlled with Methadone 35mg twice a day and he didn't think Resident #117 suffered any ill-effects from the missed dose. An interview was conducted with the Administrator on 06/19/2025 at 4:10 PM. The Administrator explained she notified the pharmacy to reimburse Resident #117 for one dose of Methadone. The Administrator further stated they had also reported Nurse #3 to the North Carolina Board of Nursing (NCBON), notified local law enforcement, and the Department of Social Services. She explained they had done in-service education with all staff on abuse and neglect which included misappropriation of resident property. She further explained the education included misappropriation of resident's medications including narcotics for all nursing staff. The education also included the proper procedure for signing out narcotics on the declining inventory sheets. According to the Administrator, since putting these measures in place there had been no further issues with missing narcotic medications. A joint interview was conducted with the Administrator and the Director of Nursing (DON). The DON revealed the facility launched an in-service related to controlled medication process and accountability immediately after the incident to re-educate all the licensed nurses and medication aides. The DON or designee audited the medication carts in-person randomly to ensure all controlled medication counts were conducted appropriately and the declining narcotic count sheets were documented properly. The Administrator stated the interventions were successful as the facility did not have any similar diversion issues since then. The facility provided a plan of correction for past non-compliance with a completion date of 04/23/2025. The plan of correction could not be accepted by the state agency due to lack of interventions to support the prevention of misappropriation of resident property. The plan was not accepted due to the following: 1. The plan did not address a review of the screening and hiring processes. 2. The plan did not include a resident assessment from the physician assistant or the physician, only nursing assessments were included. 3. The plan did not address how the non-interviewable residents were assessed. 4. The plan did not include pharmacy's role in monitoring of controlled substances. 5. The plan did not include how the education on abuse and misappropriation of property was going to prevent further misappropriation.

2. Resident #126 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 04/10/25. A progress note dated 04/10/25 indicated Resident #126 was discharged home with a friend and his medications were given to him upon discharge. Resident #126's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed he was discharged to short term general hospital. During an interview on 06/20/25 at 3:19 PM with the MDS Coordinator and the Regional MDS Coordinator they stated Resident #126 was discharged home with a friend and his assessment was miscoded as being discharged to short term general hospital. The MDS Coordinator stated she would amend the discharge assessment and correct the assessment to reflect the resident was discharged to the community. An interview on 06/20/25 at 4:00 PM with the Administrator revealed she felt like the error was a keying error and the MDS Coordinator was modifying the MDS for resubmission. Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for dialysis (Resident #101) and 1 of 1 resident reviewed for hospitalization (Resident #126). Findings included: 1. Resident #101 was initially admitted to the facility on [DATE] and was readmitted to facility on 05/13/25. Resident #101's diagnoses include end-stage kidney disease. A review of physician orders revealed an order dated 12/11/24 for hemodialysis every Monday, Wednesday, and Friday at 11:30 AM at the local dialysis center. A review of the quarterly MDS assessment dated [DATE] revealed dialysis was not coded on the assessment. An interview with the MDS Coordinator on 06/20/25 at 10:37 AM revealed that Resident #101's most recent MDS assessment had been completed by a remote nurse who was in training. The MDS Coordinator stated that the nurse was given a form with Resident #101's information and dialysis was noted on there but was not coded correctly on the assessment. The MDS Coordinator stated the miscoding was an error due to an oversight. An interview with the Director of Nursing (DON) on 06/19/25 at 1:11 PM revealed the resident's MDS assessments should be accurate and reflect the resident's care needs. An interview with the Administrator on 06/19/25 at 4:15 PM revealed that it was important that MDS assessments were completed accurately.

Based on observations, record review and staff, Physician Assistant, and Medical Director interviews, the facility failed to supervise a severely cognitively impaired resident with wandering behaviors from exiting the facility unsupervised, without staff knowledge, for 1 of 1 resident reviewed for accidents related to unsafe wandering/elopement (Resident #1). The facility also failed to immediately notify administration of the missing resident. The resident exited the facility which was in a rural residential area and walked 1/3 mile on a two-lane road with no streetlights and no sidewalk without shoes, wearing socks. She was found lying in a ditch beside the road by a neighbor walking his dog. On evaluation by Emergency Medical Service personnel, Resident #1's blood sugar was 500 milligrams per deciliter. She was transported to the hospital for evaluation and treatment where she was given intravenous Insulin and fluids. She was later discharged from the hospital to another long-term care facility's locked memory care unit. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of dementia and Diabetes Mellitus. Review of Resident #1's physician's orders dated 3/09/24 and 3/12/24 revealed orders for antidiabetic medications (non insulin). She was not on scheduled blood sugar checks. Antidiabetic medications ordered: - 3/09/24 8:00 PM - Metformin 500 mg by mouth two times a day for Diabetes - 3/12/24 00:00 - Dulaglutide 0.75 milligrams (mg) subcutaneous every Tuesday for Diabetes Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. She exhibited wandering behaviors 1-3 days during the lookback period. The lookback period was 7 days prior to the MDS date. She was independent for walking at least 150 feet. She did not use a wander/elopement alarm. Review of Resident #1's wandering/elopement assessment dated [DATE] revealed she had no history of wandering and wandered within the home without leaving the grounds. The progress note section read in part that resident ambulates within facility, does not exit seek. Resident #1's care plan dated 7/19/24 had a focus which read in part that the resident is an elopement risk/wanderer related to disoriented to place, exit seeks. The intervention included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and book. Another care area focus included the resident had a behavior problem related to dementia. The resident sundowns with increased confusion, wanders, and yells out. The interventions included to divert attention and remove from situation and take to alternate location as needed. Also to monitor behavior episodes and attempt to determine underlying cause. Another care area focus included the resident had Diabetes Mellitus and the interventions included to give Diabetes medication as ordered and monitor for any signs or symptoms of high or low blood sugars. The Weather Underground website revealed the outdoor air temperature where the facility was located on 8/09/24 at 4:54 AM was 71 degrees F with no precipitation. An interview on 8/13/24 at 11:03 AM with Nurse #1 revealed she was the nurse assigned to Resident #1 the night shift of 8/09/24. She stated she had completed a skin assessment on Resident #1 around 3:00 AM and had gone to the nurses' station to document. She heard Nursing Assistant (NA) #2 talking to Resident #1 who had walked out into the hall. Resident #1 did not want to go back to bed and became agitated. Nurse #1 stated she told NA #2 to just let the resident walk in the hall for a little bit. Nurse #1 then left the nurses' station to go to another resident's room and returned to the nurses' station about 20-30 minutes later. Nurse #1 stated that NA #2 was at the nurses' station, and she asked about Resident #1. They looked and Resident #1 was not in her room and they started searching for the resident. Nurse #1 stated that Resident #1 had a history of getting in other resident's beds or going in their rooms. Nurse #1 stated they walked around the outside of the building and were unable to locate the resident. She then informed the Nurse #2 that administration needed to be notified. Nurse #1 stated that they contacted the Director of Nursing (DON) who assisted them in looking at the facility security camera to determine which direction the resident had walked. By looking at the camera, they were able to determine that Resident #1 had walked down the hall toward the front door and had not come back. She stated that the front door was not clearly visualized by the security camera. Nurse #1 was unsure exactly what time the DON had been contacted. She stated she had been educated to notify administration in the event a resident could not be located but was unable to specify a time frame. Nurse #1 stated she did not know how Resident #1 got out the front door. She stated the door was kept locked at all times and required a code to be entered for the door to open. She stated that she had not tested the door during her shift and was unable to state if the door was functioning correctly. An interview on 8/13/24 at 11:35 AM with Nursing Assistant (NA) #1 revealed she was working the night shift and assigned to Resident #1 on the early morning of 8/09/24. She stated around 3:00 AM she and NA #2 were making resident rounds when Resident #1 walked out into the hall. She stated that NA #2 attempted to redirect Resident #1 back to bed, but when the resident got agitated, Nurse #1 just told them to let her walk around the facility. NA #1 stated they continued resident rounds and later Nurse #1 asked them if they had seen Resident #1 and they started searching the facility for her. NA #1 stated she thought this was around 3:50 AM and they looked in and outside the facility for approximately 1 hour prior to calling the DON. NA #1 stated that she had tried all the exit doors when searching for the resident and they were all locked. She stated that she did not know how Resident #1 got out the front door. She also stated that she had seen Resident #1 exit seeking in the past. An interview on 8/13/24 at 11:51 AM with NA #2 revealed that she was working the night shift on the early morning of 8/09/24. She stated that she and NA #1 were making resident rounds when she saw Resident #1 out in the hall. She stated that the resident did not want to go back to bed and Nurse #1 just told them to let the resident walk around. She stated she and NA #1 resumed resident rounds and when they came back to the nurses' station, they noticed Resident #1 was not in her bed. A room-by-room search was initiated for the resident. She stated that she did not know how the resident got outside. An interview on 8/13/24 at 12:15 PM with Nurse #2 revealed that she was in the facility as the Unit Manager on 8/09/24 when Resident #1 eloped. She stated it was around 4:40 AM with the DON was contacted. She stated the DON talked her through accessing the security camera to determine which direction Resident #1 had gone. She stated that she could see the resident go down the hall toward the front door and then didn't see her again. Nurse #2 stated she had no idea how Resident #1 got out the front door and did not believe the resident could have entered the door code. She stated she had observed Resident #1 to exit seek and open doors in the past. Nurse #2 stated she had received education on resident elopement which included notification of administration, and she thought the timeframe for notification was 30 minutes. An interview on 8/13/24 at 1:37 PM with the DON revealed Resident #1 had some wandering behaviors, got confused, and would go in and out of other resident's rooms. She stated that she had no idea how Resident #1 got out the door. She stated that Nurse #2 contacted her at 4:56 AM on 8/09/24 and she drove to the facility. She stated local law enforcement had been notified at 5:19 AM. The DON stated that Resident #1 had never exited the facility in the past. She stated that the staff had looked for the resident for approximately 1 hour prior to notifying her. She stated that the staff had received training on a missing resident which included notifying administration but did not specify a timeframe. Review of Emergency Management Services report dated 8/09/24 revealed they were called to the facility at 6:48 AM and arrived at 7:00 AM. The report narrative read in part that the resident was located sitting in a wheelchair in the front office. She had no obvious injuries and was noted that her blood sugar level was 500 milligrams per deciliter (mg/dL). A normal blood sugar range is 72 to 108 mg/dL. The resident was conscious and alert, however, has severe dementia and is unable to recall any of the events. The resident was transported to the hospital at 7:13 AM. An interview on 8/13/24 at 12:38 PM with the facility Physician Assistant (PA) revealed he had been notified of Resident #1 elopement on 8/09/24 around 7:00 AM and given the order for her to be transported to the hospital for evaluation after she was located. He stated he did not think the resident could have entered the door code. He also stated that he expected the facility to keep the resident safe. Review of the hospital emergency room report dated 8/09/24 at 7:37 AM read in part that this wanderer does not have any apparent injury. The resident was given intravenous Insulin and fluids to bring the blood sugar down to the 200s. The diagnosis read in part that the hyperglycemia was suspected to be stress response. The resident was discharged to a dementia unit in another facility. An interview on 8/13/24 at 10:33 AM with the Maintenance Director revealed when he checked the door on 8/09/24 after Resident #1's elopement, it was working correctly. He stated he tested it with and without the facility electrical power, using the generator, and he was unable to get it to malfunction. He stated the door stayed locked 24/7. An interview on 8/13/24 at 5:17 PM with the Medical Director revealed he had been notified of the situation and it was 'less than ideal'. An interview on 8/13/24 at 5:31 PM with the Administrator revealed that had she had been notified of the elopement after the resident had been located and taken to the hospital. She stated that she and the DON had reviewed the footage and put together a timeline of events. She also stated that staff education and resident elopement assessments had been completed. The Administrator stated that the PA, Medical Director, and resident representatives had all been notified. She stated that the front door had been extensively checked and they were unable to determine how Resident #1 was able to exit the facility. The Administrator stated that Resident #1 was transported from the hospital to another facility with a locked memory care unit which had been approved by the resident representative. An additional interview and observation were completed on 8/13/24 from 2:45 PM until 3:15 PM with the Maintenance Director. The observation was a recreation of the possible path Resident #1 took after exiting the facility front door. As stated by the Maintenance Director, Resident #1 was located by a neighbor walking his dog lying in a ditch calling for help. Maintenance Director stated he had arrived at the facility around 5:00 AM and immediately started looking for the resident. He looked in the wooded area beside the facility and then started looking down the road. The road was a 2-lane paved road with a double yellow line in the center. The posted speed limit was 40 miles per hour. Maintenance Director stated he and the Maintenance Assistant had taken a truck down the road using flashlights to look for the resident. Approximately 3/10th's of a mile down the road they observed the neighbor with the resident. The neighbor had already gotten the resident out of the ditch. The Maintenance Director stated the resident was wearing pants, a sweatshirt, and socks. He stated her clothing was dry and he had not observed any obvious injuries. The Maintenance Director and the Maintenance Assistant had assisted the resident into the truck and brought her back to the facility. The Maintenance Director stated the grass was wet with dew and the roads were dry. He stated that Resident #1 kept saying she was sorry for the trouble and asking for water. Observation of the front door on 8/13/24 at 3:20 PM revealed a single door with a push bar to exit. There was a door code box located on the right side of the door. The exit code was 4 digits with a hashtag to unlock the door. The door automatically closed and locked when released. The door had no audible alarms when opened or when held open. There was no automatic release if the push bar was held down. There was no method to bypass the door code to exit the door. The Administrator was notified of Immediate Jeopardy on 8/13/24 at 5:50 PM. The facility provided a corrective action plan with alleged date of compliance of 8/10/24. The corrective action plan indicated. Problem Identified: Resident #1 was admitted to the facility on [DATE] with the following diagnosis: left femur fracture, diabetes, dementia, cardiovascular disease, hypertension, hyperlipidemia and depression. Resident #1 has a BIMS of 3 as of 5/12/24. On August 9, 2024 at approx. 3:30am Resident #1 had an unsupervised exit via the front door of the facility. Order of events: Approximately 4:15am the facility staff noticed during routine rounds that Resident #1 was not in her bed and began searching for her. The Director of Nursing was notified at 4:56am that Resident #1 was missing and could not be found. The Director of Nursing gave the facility instructions to call the administrator, the police and to continue searching every room, as well as outside. The Director of Nursing arrived at the facility at 5:30am, reviewed the security cameras and noted Resident #1 leaving the facility via the front door at 3:20am. At 5:39am the Director of Nursing notified all management staff that Resident #1 was missing, and all available staff were to report to the facility and search on their way to the building. The sheriff department and Emergency Medical Services first responders arrived at approximately 6:00am and received a description of Resident #1. The Deputy reviewed the security camera footage and issued a silver alert. At approximately 6:30am the Maintenance Director and his assistant located Resident #1 and brought her back to the facility. The Emergency Medical Services with the Director of Nursing present assessed her for injuries and no injuries were identified. Resident #1 was identified as having a blood glucose level in the 500s by Emergency Medical Services. The Nurse Practitioner was notified at 6:45am and based on the resident's glucose levels Resident #1 was sent to the emergency room for further evaluation. Address how corrective action will be accomplished for resident (s) found to have been affected. On 8/9/24 at approximately 6:30am the Maintenance Director and his assistant located Resident #1 and brought her back to the facility. The Emergency Medical Services with the Director of Nursing present assessed her for injuries and no injuries were noted. A full set of vital signs and blood glucose monitoring was also conducted. Resident #1 was identified as having a blood glucose level in the 500's by Emergency Medical Services. The Nurse Practitioner and Medical Director were notified at 6:45am and based on the resident's current condition, orders were given to send the resident to the emergency room for further evaluation. Resident #1 was sent to Mission Hospital at approx. 7:08am. While Resident #1 was in the emergency room arrangements were made with her RP's approval for her to be transferred to a sister facility with a secure unit. Once Resident #1 was cleared to be discharged from the emergency room the facility transported Resident #1 from the emergency room to our sister facility around 12:00pm. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: A 100% review of residents was conducted for the entire facility on 8/9/2024 to identify residents at risk for elopement to ensure they have an elopement risk assessment and care plan to address their behaviors. This review was completed by the Director of Nursing. Those residents identified were added to the Elopement Risk binder. Elopement binders were reviewed, updated accordingly and placed at each nurses' station by the Unit Manager on 8/9/24. These books contain the list of residents with exit-seeking behaviors, their pictures and resident's description. The Admission Coordinator will continue to be responsible for maintaining the elopement binders based on information provided by the Director of Nursing or Administrator. The Admission Director was reeducated on this task by the Administrator on 8/12/24 (upon her return from vacation). Also, those residents identified care plans and care guides were updated by the DON and MDS Coordinator on 8/9/24. Door checks were completed on 8/9/2024 by the Regional Director of Facility Maintenance to ensure all doors are locking properly. All doors were locking properly. Address what measures will be put in place and systemic changes made to ensure that the identified issue does not occur in the future. All staff working on 8/9/2024 were educated by the administrative nurses (Director of Nursing and Unit Managers) and Maintenance Director currently in the facility and completed phone education for those not present in the facility regarding the facility elopement policy, the location of the elopement binder to identify residents who are at risk for elopement, ensuring residents who are assessed at risk for elopement are supervised by facility staff, where to locate care plan intervention regarding residents at risk for elopement, immediate notification of the Administrator and Director of Nursing when it is identified a resident maybe missing. Any staff members who have not received the education after 8/9/2024, will not be allowed to work until they have completed the education. This education will be included in the new hire orientation for employees including agency personnel, which is conducted by the Staff Development Coordinator. The Staff Development Coordinator was educated by the Administrator regarding this matter on 8/12/24 (upon her return from vacation). On 8/9/24, the Interdisciplinary Team (IDT) to include but not limited to the Director of Nursing, Unit Manager, Activities Director, Social Worker, MDS Coordinator, Maintenance Director and Dietary Manager were re-educated by the Administrator on the Elopement Policy to include ensuring residents who are assessed at risk for elopement are supervised by facility staff and signs of elopement risk are recognized. Additionally, they were educated on their role in developing plans/interventions in response to any elopement risk. This includes a written care plan with elopement risk interventions formulated. On 8/9/24 all licensed nurses including licensed agency personnel were educated on completion of the Elopement assessments by the Director of Nursing and Unit Managers. They are completed on admission, then quarterly and/or as needed by the Licensed Nurse. Any newly identified residents noted at risk will be communicated by the licensed nurse during shift huddle at the change of each shift. On 8/9/24 the Maintenance Director was educated by the Regional Director of Facility Maintenance on conducting monthly elopement drills and weekly door checks (with all exit doors). Indicate how the facility plan to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. Effective 8/9/24, the Director of Nursing (DON) will review the residents at risk for wandering or exit-seeking behaviors, which will include the residents currently in the elopement binder and any newly identified residents based on their elopement assessment and/or behaviors weekly for 12 weeks to ensure interventions/behaviors are being managed. Residents exhibiting new behaviors of wandering or exit seeking will be reviewed to ensure the wandering/elopement assessment is accurate, care plan updated, and interventions are in place. The Director of Nursing (DON) will report findings monthly to the Quality Assurance Performance Improvement Team (QAPI) for 3 months. The Maintenance Director will conduct monthly elopement drill and weekly door checks (with all exit doors). The findings and validation of this audit/task will be reported to the Quality Assurance Performance Improvement Team (QAPI) Committee monthly for 3 months. Immediate Jeopardy Removal Date: 8/10/24 The credible allegation of immediate jeopardy removal was verified on 8/13/24. Interviews were conducted with a sample of Nursing Assistants, Nurses, and the Maintenance Director to verify education was conducted for elopement. Documentation of in-service records was reviewed. Documentation of an elopement drill was reviewed. An interview with the Maintenance Director on 8/13/24 at 3:15 PM, he stated that he had received education resident elopement. He stated he will be conducting monthly elopement drills and weekly door checks with all exit doors for 3 months. The facility's alleged date of compliance was validated to be effective 8/10/24.

Based on observation, record reviews, and resident, resident representatives, staff, psychotherapist, Psychiatric Nurse Practitioner (NP), Physician Assistant and Medical Director interviews, the facility failed to protect a resident's right (Resident #3) to be free of sexual abuse from another resident (Resident #52). Resident #3 had severely impaired cognition and Resident #52 had moderately impaired cognition and a history of sexual behaviors. On 3/25/23 Resident #52 was observed by staff inviting Resident #3 into his room and was told by staff to leave the door open. Shortly after, Resident #52 was observed inappropriately touching Resident #3's leg. On 7/25/23 Resident #52 was found in Resident #3's room looking at her while she slept. On 1/30/24 Nurse Aide (NA) #1 heard yelling coming from Resident #3's room. NA #1 and Nurse #1 found Resident #52 in Resident #3's room with his hand inside of her incontinent brief with skin to skin contact. Resident #3 stated stop you're hurting me. Resident #3 was incapable of consenting to the sexual act. Resident #3's Responsible Party (RP) indicated she would have been very upset by the incident. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause trauma. In addition, the facility failed to prevent resident to resident abuse when a resident (Resident #264) used his fist to punch Resident #30 on the right side of the face. This deficient practice affected 4 of 12 residents reviewed for abuse. Immediate jeopardy began on 1/30/24 when Resident #3 was not protected from sexual abuse. Immediate jeopardy was removed on 4/22/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at the lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #2 was cited at a scope and severity of D. The findings included: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), and dementia. Resident #52's care plan dated 10/18/22 indicated he had a behavior problem and had been sexually promiscuous with other residents. Resident #52 would deny and was easily redirected. Interventions included to 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, and remove from situation and take to alternate location as needed. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #52 had moderately impaired cognition and had no behaviors. He was independent with all his mobility and used a manual wheelchair. Resident #3 was admitted to the facility on [DATE] with the following diagnoses: cerebral infarction (stroke), dementia with agitation, Alzheimer's disease and Parkinson's disease. Resident #3's care plan dated 12/2/22 indicated at times, Resident #3 had been verbally and sexually inappropriate while in a heavy traffic area of the facility. Her word for sex is [NAME]. Interventions included to assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation, and psychiatric/psychogeriatric consult as indicated. The quarterly MDS dated [DATE] indicated Resident #3 had severely impaired cognition and no behaviors. Resident #3 was a partial/moderate assist for her mobility and used a manual wheelchair. A review of Resident #52's medical record indicated a progress note dated 3/26/23 at 11:15 AM documented by Nurse #2. The progress note indicated it was a late entry note for 3/25/23 at 10:00 AM. Nurse #2 documented that Resident #52 was heard by several staff members inviting a female resident down to his room. Staff told him he needed to leave his door open. A few minutes later, as a staff member went by the room, the two were seen touching each other inappropriately and were parted from each other by two staff members. Resident #52 immediately denied inviting her to his room and said he did not want her to come back. A phone interview with Nurse #2 on 4/21/24 at 9:22 AM revealed the female resident who was observed in Resident #52's room on 3/25/23 was Resident #3. Nurse #2 stated she could barely remember all the details but Resident #52 was seen inviting Resident #3 into his room earlier that day. Nurse #2 stated she thought it was fine because they were just talking, and she told Resident #52 to keep his door open. Nurse #2 further stated that a few minutes later, it might have been a housekeeper (she was not certain) who witnessed Resident #52 and Resident #3 touching inappropriately. Nurse #2 stated she did not witness it and both residents denied having done anything. From what she could remember, the staff member reported that Resident #52 was seen touching Resident #3's knee. Nurse #2 removed Resident #3 from Resident #52's room. Nurse #2 stated she reported the incident to an on-call provider, but she could not remember whether she reported it to the Director of Nursing or the Administrator. There were no revisions made to Resident #52's care plan related to sexually promiscuous behaviors after the 3/25/23 incident. Further review of Resident #52's medical record indicated he was seen by the psychotherapist on 3/30/23. Resident #52 reported sadness and depression and missing his family. He also reported increased tiredness and sleeping throughout the day. The therapist provided review of alternative symptoms often experienced with depression: irritability, forgetfulness, and lack of interest to engage in activities. The therapist recommended for Resident #52 to increase time he listened to music. A Psychiatry Follow-up Note dated 4/25/23 by the Psychiatric NP in Resident #52's medical record indicated he was made aware of the incident on 3/25/23 between Resident #52 and Resident #3. He documented that Resident #52 could be sexually inappropriate with staff at times. He was prescribed Paroxetine (a medication used to treat depression) 30 milligrams (mg) daily and Estradiol (hormone essential for modulating libido, erectile function, and spermatogenesis or the process of sperm cell development) 1 mg daily for history of sexual inappropriate behavior. Paroxetine had been increased to 40 mg daily on 3/29/23. He was treated with Paroxetine, Trazodone (antidepressant and sedative), Clonazepam (sedative), and Estradiol. He was agreeable to a visit next month. The Psychiatric NP indicated in his note to monitor him closely. A progress note dated 7/24/23 at 5:21 AM documented by Nurse #3 in Resident #52's medical record indicated Resident #52 had insomnia tonight. He had been wandering in the hallways and going into other residents' rooms but was quickly redirected back to his room. A phone interview with Nurse #3 on 4/22/24 at 1:24 PM revealed that on 7/24/23, Resident #52 kept rolling around near the day room and kept heading towards Resident #3's room. Nurse #3 stated that Resident #52 told her that he was just rolling around. She indicated at approximately 1:30 AM she saw Resident #52 enter Resident #3's room, she went down to the room and saw Resident #52 by Resident #3's bedside and he was just looking at her. Resident #3 was sleeping at the time. Nurse #3 stated that she did not see Resident #52 touch Resident #3, and that she moved him out of the room and back to his room. Nurse #3 indicated she was not aware of the 3/25/23 incident between Resident #52 and Resident #3. She reported she was aware of Resident #52's care plan having a care area identified for inappropriate sexual behaviors, but she did not know the history or why he had this care planned. There were no revisions made to Resident #52's care plan related to behaviors after the 7/24/23 incident. The annual MDS for Resident #3 dated 12/9/23 indicated she was severely cognitively impaired, and had no behavioral symptoms. Resident #3 required substantial/maximal assistance with most activities of daily. Resident #3 used a manual wheelchair and was able to self-propel herself. A review of Resident #52's quarterly MDS dated [DATE] revealed that he was moderately cognitively impaired. He did not display any physical or verbal behavioral symptoms towards others but rejection of care occurred 1 to 3 days during the assessment period. He only required supervision from staff with most activities of daily living including bed mobility and transfers. Resident #52 used a manual wheelchair and was able to self-propel himself. On 1/29/24 the Psychiatric NP saw Resident #52. The note indicated one of the chief complaints was staff reporting resident had become more sexually inappropriate. The NP did an examination and found Resident #52 oriented to person, place and situation and found him to be moderately impaired. His findings were Resident #52 had dementia with behavioral disturbances, depression, anxiety, insomnia and sexually inappropriate behavior. The NP's recommendations were no new psychiatric medications at this time. To continue ongoing supportive/behavioral strategies as currently implemented by staff. To encourage participation in recreational activities. He recommended Buspirone 5 mg three times a day for sexual inappropriate behavior. The NP will assess at the next visit. An incident report dated 1/30/24 completed by Nurse #1 indicated that on 1/30/24 at 1:35 AM during rounds Nurse Aide (NA) #1 and Nurse #1 observed Resident #52 at the bedside of Resident #3 with his hands inside the top of her brief. Resident #3 and #52 were separated immediately. Resident #3 was assessed for injury, and none was identified. Resident #3 was moved to his room and Resident #52 was placed on 15 minute checks. No physical or mental injury/harm was identified. On 1/30/24 at 8:30 AM, the local police department was notified of the incident. An observation was made on 4/14/24 at 9:51 AM of the room locations for Resident #3 and Resident #52 prior to the 1/30/24 incident. The residents resided on the same hall with 1 room in between their rooms. An interview with the assigned police officer was attempted by phone on 4/22/24 at 3:00 PM and was unsuccessful. A written statement dated 1/30/24 by Nurse Aide (NA) #1 indicated during his round, he went to check on Resident #3 and found Resident #52 with his hands down Resident #3's pants. Both residents were separated while the nurse was notified. The incident occurred at 1:35 AM on 1/30/24 in Resident #3's room. On 4/19/24 at 10:48 AM, a telephone interview was conducted with NA #1. He stated on the night shift on 1/30/24 around 1:30 AM, he was doing rounds on the floor and he heard yelling coming from Resident #3's room. When he went to check on Resident #3, he found Resident #52 with his hands under Resident #3's brief. There was skin to skin contact. NA #1 was unable to recall if Resident #3 said anything when he entered the room. NA #1 got Nurse #1 to come down and then they separated Resident #52 and Resident #3. He put Resident #52 back in his room. NA #1 stated he could not remember the details of how he notified the nurse but did say he did not leave the two residents. NA #1 stated he had not ever seen Resident #52 in this resident or any other resident's room before. NA #1 was not aware of any previous incidents of sexual behavior. NA #1 also stated that he could barely remember the details regarding this incident between Resident #3 and Resident #52 and he would go by whatever was indicated in his written statement. A progress note dated 1/30/24 at 2:49 AM in Resident #3's medical record documented by Nurse #1 indicated she was alerted by NA #1 to come to Resident #3's room around 1:35 AM. Upon entering the room, Nurse #1 noted Resident #52 at Resident #3's bedside. Upon further assessment, Resident #52 was noted to have his right hand in Resident #3's brief. Resident #3 was stating, stop you're hurting me. Both residents were immediately separated. A skin assessment was completed on Resident #3 and no injuries were noted. Resident #3 was alert per baseline with confusion. No signs and symptoms of pain, discomfort, or acute distress were noted or reported. Resident #3 was relocated to a different room. On 4/19/24 at 8:20 AM, a telephone interview was conducted with Nurse #1. Nurse #1 stated that she was alerted by NA #1 to come to Resident #3's room and saw Resident #52 sitting at her bedside. Resident #52's hand was in Resident #3's brief and there was skin to skin contact. Nurse #1 stated she didn't remember seeing his hand moving but it looked like he was fondling her under her brief because his hand was right over her pelvic area. Nurse #1 stated as she entered Resident #3's room, she heard Resident #3 stating, stop, you're hurting me. After Nurse #1 told Resident #52 to remove his hand from under Resident #3's brief, she asked him what he was doing and Resident #52 stated to her, She asked for it. The two residents were immediately separated, and Resident #3 was moved to another room and eventually off the hall to the other side of the building in an empty room. Nurse #1 notified the administration and the Physician Assistant who saw the residents on the next shift. Nurse #1 stated that she had never seen Resident #52 go into another female's room prior to this incident. Nurse #1 was not aware of the 3/25/23 or 7/24/23 incidents between Resident #52 and Residents #3. Nurse #1 further stated that she assessed Resident #3 and did not find any physical injury. Prior to this incident, Nurse #1 stated that she saw Resident #52 in his room, but she couldn't remember what time. When Resident #52 went back in his room after the two residents were separated, he kept coming down to the nurses' station, and trying to explain about what happened. Resident #52 stated that Resident #3 invited him to her room. Nurse #1 stated she could not remember anything else that Resident #52 said about the incident. Resident #52 was placed on 15 minute checks starting on 1/30/24 till 2/9/24. Nurse #1 stated that in her opinion, what happened between Resident #52 and Resident #3 was sexual abuse because Resident #52 was alert during the incident and he knew what he was doing, while Resident #3 was not able to give consent. On 4/16/24 at 9:30 AM, Resident #52 was interviewed. Resident #52 stated that Resident #3 used to come to his room, and she would flirt with him. When asked if he remembered the incident on 1/30/24 in Resident #3's room, Resident #52 stated that he did not remember the incident. Resident #52 stated that he was a married Christian man. He denied ever going into Resident #3's room. Resident #52 stated he didn't want to talk about it anymore and refused to answer any more questions. On 4/16/24 at 1:20 PM, a telephone interview with Resident #3's responsible party (RP) was conducted. Resident #3's RP said that he was made aware of the 1/30/24 incident and they ended up moving Resident #3 to another room. He stated that Resident #3 was still very confused by the move. The RP stated that Resident #3 was raped 3 times by the age of 9. The RP also stated that Resident #3 did have a history of touching men at a different facility. He was not aware of any other issues with her and other men at this facility other than on 1/30/24. A follow-up phone interview with Resident #3's RP on 4/24/24 at 3:30 PM revealed Resident #3 was not able to give sexual consent. Resident #3's RP stated that she would be offended by a stranger touching her and she would be very upset. The RP indicated he had not spoken with the police. A progress note dated 2/13/24 by Nurse #3 revealed that she overheard a conversation with Resident #52 and another resident at the nurses desk. Nurse #3 stated that Resident #52 noticed that Resident #3 was no longer in the room on the south hall and Resident #52 stated there's a man in Resident #3's room. She's gone. On 4/19/24 at 2:50 PM, a phone interview was conducted with the Psychotherapist. She stated that she saw Resident #52 once a month. She stated that he had not been very engaging the last few months and was more isolated. She said that she had noticed that his cognition was declining since the start of this year. He had been more confused as time went on. She stated that she had not seen any hypersexuality with him prior to the 1/30/24 incident. She was not aware of any other incidents between Resident #52 and a female resident since the incident on 1/30/24. She stated that she thought he would have had an understanding of what he was doing during the 1/30/24 incident. The Psychotherapist also saw Resident #3 every two weeks. She stated that Resident #3 had declined as well in her cognition. The Psychotherapist stated that she did not observe any changes with Resident #3 after the incident on 1/30/24. She stated that Resident #3 told her that she did not remember the incident. On 4/19/24 at 3:18 PM, a phone interview was conducted with the Psychiatric NP. He stated that he met Resident #52 for the first time on 12/4/23. Resident #52 was seen by a different provider prior to this. The Psychiatric NP stated that he usually saw Resident #52 every 4 to 6 weeks unless there was something acute and he would see him sooner. He stated that he was aware that Resident #52 was sexually inappropriate with another resident (Resident #3) on 1/30/24. He stated that Resident #52 had dementia and his ability to make decisions was not good. He shared that when he spoke with Resident #52, he had no recall of the event. The Psychiatric NP stated that he had seen a cognitive decline with Resident #52 since he started seeing him on 12/4/23. He went on to say that Resident #52's confusion fluctuated, and he had times of clarity and times of confusion. On 1/29/24 when he saw Resident #52, he was alert and oriented to person, place and situation. He stated that when he saw Resident #52 on 1/29/24 one of the chief complaints was that staff were reporting that Resident #52 was becoming more sexually inappropriate. The Psychiatric NP made the recommendation of Buspirone 5 mg three times a day for sexually inappropriate behaviors. The Psychiatric NP stated that he couldn't say how Resident #52's cognition was during the incident without being there himself. The Psychiatric NP further stated that he last saw Resident #3 on 2/26/24. Resident #3 had many diagnoses including Parkinson's disease and dementia. The Psychiatric NP stated that Resident #3's mental cognitive ability also fluctuated. When he saw her on 2/26/24, Resident #3 had no recollection of the incident and could not remember any stressful events happening to her. The Psychiatric NP stated that he was not able to say if Resident #3 could give consent sexually, and that it depended on her cognition at that day and time. On 4/19/24 at 4:00 PM, an interview with the Physician Assistant (PA) revealed that he saw Resident #3 on 1/30/24 after the incident had happened but she (Resident #3) did not remember anything. The PA stated that Resident #3 was very confused. The PA also stated that he saw Resident #52 on 1/30/24 and he denied anything had happened. The PA stated that Resident #52 could also be confused but he also had periods when he was not confused. The PA could not say if the incident was sexual abuse since both residents could have times of confusion. He stated that he didn't think there was any intent from Resident #52 to hurt Resident #3. He added that he had never seen Resident #52 in other resident rooms. On 4/22/24 at 1:24 PM, an interview with the Medical Director (MD) revealed he was unsure where the history of sexually inappropriate behavior came from regarding Resident #52. He stated that when the facility received history and physical from the hospital or wherever the resident was coming from, it generally didn't give much detail. The MD stated that the notes from the psychotherapist would indicate more information about Resident #52's sexually inappropriate behavior. The MD refused to answer any questions regarding the incident on 1/30/24 between Resident #52 and Resident #3. The MD asked for guidance on what the facility could have done to prevent the incident that happened between Resident #52 and Resident #3. On 4/18/24 at 2:57 PM, an interview with the Director of Nursing (DON) revealed that she was an MDS Nurse in the facility at the time of the 1/30/24 incident but she remembered Resident #52 being placed on frequent observations. She indicated she had no idea Resident #52 had a history of sexually inappropriate behaviors prior to the 1/30/24 incident. The DON stated that for the past few months Resident #52 mostly stayed in his room while Resident #3 was out and about all the time. The DON shared that Resident #3 usually didn't go into other residents' rooms and that she just stayed in the hallways. She stated that Resident #3 would make sexual remarks to staff at times. She said that after the 1/30/24 incident the staff kept Resident #3 and Resident #52 separated and they did frequent observations. On 4/19/24 at 12:49 PM, a telephone interview was conducted with the former DON. She stated that she remembered the incident that happened on 1/30/24. The former DON stated that she was not working that day (1/30/24), but she remembered calling the local police department about the incident. The former DON further stated that she did not know the details of the incident in March 2023 involving Resident #52 and Resident #3, but she knew that an incident had happened. The previous DON felt that the facility did not do enough to prevent Resident #52 from getting access to Resident #3. On 4/19/24 at 9:00 AM, the Administrator was interviewed. She stated that she was in training when the incident happened on 1/30/24 between Resident #52 and Resident #3. The Administrator stated she remembered the local police department and the on call psychiatric provider were notified. She stated that she knew Resident #3 would make sexual suggestions but Resident #3 was unable to recall the events on that day. The Administrator stated she did not know of any other incidents that involved Resident #52, but the facility gave Resident #52 a 30-day discharge notice after the incident on 1/30/24 but they had been unsuccessful in finding another facility that would take him. The Administrator stated that they ended up substantiating the allegation of abuse because there were witnesses. The Administrator was notified of immediate jeopardy on 4/19/24 at 6:49 PM. The facility provided the following immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 1/30/24, at approximately 1:30 AM, Resident #52 was sitting in Resident #3's room with his hand inside Resident #3's brief as Nurse Aide (NA) #1 staff entered the room. Resident #3 was severely cognitively impaired and was not capable of consenting to sexual activity. NA #1 alerted Nurse #1 to come to the room. Resident #3 was heard stating stop you're hurting me when Nurse #1 walked into the room. Resident #52 and Resident #3 were separated by NA #1 and Nurse #1 immediately on 1/30/24. Resident #3 was examined by Nurse #1 for any injuries including a skin check and no injuries were noted. Resident #3 was moved to 117 on 1/30/24 at 2:00 AM and then after consideration by the Director of Nursing (DON) and Administrator she was moved to room [ROOM NUMBER] on the other side of the facility at 8:30 AM. Resident #52 was taken to his room and was placed on every 15- minute checks from 1/30/24 to 2/9/24. No sexually inappropriate behavior was observed during the observation period and the Interdisciplinary Team (IDT) discontinued every 15-minute checks on 2/9/24. A review of nursing notes dated 1/30/24 and 1/31/24 revealed Resident #3 did not demonstrate or verbalize anxiety and no emotional or physical distress was observed. The facility's Physician Assistant was informed of the incident on 1/30/24. Resident #3 was examined on 1/30/24 by the Physician Assistant. Full assessment completed by Physician Assistant with no bruising noted and the resident denied the event. Resident #3 was seen by Psychiatric services on 2/8/24. It was determined that Resident #3 was at baseline. Observation by Psychiatric services included resident report of decreased memory recall during the examination. The Psychiatry provider for Resident #52 was notified on 1/30/24 of his inappropriate sexual behaviors and emailed an order on 1/30/24 to change Resident #52's Buspirone to 5 mg po three times for inappropriate sexual behaviors and anxiety. This order was initiated on 1/31/24. Resident #52 was seen by Psychiatric services on 3/11/24. The Physician Assistant examined Resident #52 on 1/30/24. On 4/19/24, Resident #52 was placed on 1:1 observation indefinitely. The Administrator reviewed the schedule to ensure that the facility has an individual assigned by the Staffing Coordinator as 1:1 supervision with Resident #52. Resident #52 is not in hallways or other resident areas unsupervised. Any behaviors identified during the 1:1 supervisor will be documented and reported to the facility Administrator and Director of Nursing. Head to toe skin assessments for residents with Brief Interview for Mental Status (BIMs) lower than 11 were completed by the Administrative Nurses (including the Director of Nursing) on 4/19/24. No concerns were identified. On 04/19/24, the Social Worker interviewed all residents with a BIMs score of 12 or above. The questions included with Social Worker interviews with residents were the following: 1. Have you had ever been inappropriately touched/abused/neglected or experienced misappropriation of resident property by another resident or staff here at the facility? 2. Do you feel safe here at the facility? Based on resident interviews there were no other reported incidents of abuse from any residents. Other residents at risk for abuse and other residents with inappropriate sexual behaviors were discussed and identified with the IDT during the Ad Hoc Quality Assurance and Performance Improvement (QAPI) held on 4/19/24. Staff interviews for those currently in the facility were conducted by the Social Worker and Administrator on 4/19/24 in person which included: 1. Have you witnessed or been made aware of inappropriate touching or any other form of abuse by staff or a resident? Staff not interviewed on 4/19/24 will be interviewed by the Staff Development Coordinator (SDC), Staffing Coordinator, and Nursing Supervisors prior to working their next shift. Interviews will be conducted in person, and via phone. The SDC, Staffing Coordinator, and Nursing Supervisors were notified and educated by the Administrator of this responsibility on 4/19/24. Staff will not be allowed to work before they have been interviewed by either the Staff Development Coordinator, Staffing Coordinator or the Nursing Supervisors. The active employee list will be tracked by the SDC and given to the Staffing Coordinator and Nursing Supervisors to ensure all staff have been interviewed prior to their next working shift via phone or in person. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. The Director of Nursing (DON) educated 100% of facility staff, including agency staff, on abuse/neglect/misappropriation policy as well as identification of sexual abuse in the elderly, and reporting of abuse/neglect/misappropriation per facility policy with a review of the F600 regulation including inappropriate sexual behaviors. Abuse education specifics include definition of abuse, forms of abuse, how to recognize abuse, and what to do if abuse is suspected. In addition, education was completed on signs of Sexual Abuse against the Elderly and verbal descriptions of the typical signs. Staff were educated either in person or by phone on 4/19/24. The Staff Development Coordinator (SDC) will continue education for any staff member including Agency staff not available for education on 4/19/24. Any staff member including Agency staff who was not available to receive the education on 4/19/24 will not be permitted to work until education is completed. The SDC will be responsible for tracking staff, including Agency staff not educated on 4/19/24 by comparing the staffing schedule and active employee roster daily to verify education. The Director of Nursing will verify completion of education. The Director of Nursing and the Staff Development Coordinator were notified of the plan on 4/19/24. Nursing supervisors were provided the abuse education and informed on 4/19/24 by the Director of Nursing and the Staff Development Coordinator of the need to provide the abuse education after hours and on weekends. Nursing Supervisors will be notified by the Staff Development Coordinator of the employees that need the education prior to their next working shift. The abuse education will be included for new hires during orientation by the Staff Development Coordinator. Director of Nursing, Administrative Nurses and Social Worker reviewed the electronic medical records and care plans to identify current residents with behaviors of inappropriate sexual behaviors or potential for behaviors of inappropriate touching on 4/21/24. Care plans were reviewed to ensure interventions were in place and any new interventions were added to the resident's Kardex (care plan interventions) documentation for staff to reference key resident information. Staff will be made aware of residents with behaviors of inappropriate sexual behaviors, or potential for behaviors of inappropriate touching by resident specific Kardex interventions. Nurses, Nurse Aides and Department Heads were educated on how to review resident Kardex's by the Staffing Coordinator in person and via phone on 4/21/24. After 4/21/24 Nurses, Nurse Aides, and Department Heads will not be allowed to work their next shift until they have received the education from the Staffing Coordinator or Nursing Supervisors. The Staffing Coordinator and the Nursing Supervisors will compare the staffing schedule and active employee roster daily to verify education. The Staffing Coordinator and the Nursing Supervisors were notified of the plan by the Administrator on 4/21/24. This education will be included for new hires during orientation by the Staff Development Coordinator. On 4/19/24, the facility completed an Ad Hoc QAPI to review the Immediate Jeopardy for sexual abuse, the immediate jeopardy removal plan, education, and discuss and plan for audits and monitoring. Other residents at risk for abuse and other residents with inappropriate sexual behaviors were discussed and identified with the IDT during the Ad Hoc QAPI held on 4/19/24. The Ad Hoc QAPI meeting was attended by the Administrator, Director of Nursing, Unit Managers, Social Worker, Activities Director, Dietary Manager, Housekeeping Manager, Staffing Coordinator, Business Office Manager, Admissions Director, Maintenance Director, and Regional MDS Consultant. The Medical Director was in attendance via phone. The facility Administrator and Director of Nursing are responsible for continued compliance. The alleged date of immediate jeopardy removal is 4/22/24. On 4/25/24, the facility's credible allegation of immediate jeopardy removal was validated. Resident #52 was observed to have a 1 on 1 staff with him. Documentation regarding staff training on abuse/neglect/misappropriation policy as well as identification of sexual abuse in the elderly and reporting of abuse/neglect/misappropriation per facility policy with a review of the F600 regulation including inappropriate sexual behaviors. Staff interviews revealed receipt of training related to the definition of abuse, forms of abuse, how to recognize abuse, and what to do

Based on record review and staff, Transportation Driver, Dialysis Nurse, and Medical Director (MD) interviews, the facility failed to assess a resident after a fall prior to moving them from the floor. Resident #103 fell during a transfer at the dialysis center and was moved off the floor prior to being assessed for injuries. Resident #103 sustained a clavicle fracture and right ankle strain. This was for 1 of 2 sampled residents reviewed for quality of care (Resident #103). The findings included: Resident #103 was admitted to the facility on [DATE] and had a diagnosis end stage renal disease, cerebral infarction, muscle wasting and atrophy. Resident #103's admission Minimum Data Set (MDS) assessment, dated 2/27/24, coded Resident #103 as severely cognitively impaired and as totally dependent on staff for transfers. A physician's order dated 3/6/24 read the resident receives dialysis on Monday, Wednesday, and Fridays in the afternoon. An interview with the Transportation Driver was conducted on 4/16/24 at 1:20 PM. The Transportation Driver stated he had witnessed the incident at the dialysis center on 3/25/24. He said he arrived to transport Resident #103 back to the facility and was told by a dialysis nurse he needed to go back to the nursing facility to get a lift sling and nurse aides to transfer Resident #103 from the dialysis chair to her transport chair. The Transportation Driver stated the dialysis nurse told him Resident #103 was transferred to the dialysis chair without the use of her sling and Resident #103 would not be transferred back to the transport chair manually again because it violated the dialysis center's policy. The Transportation Driver said he called the nursing facility and spoke to the Scheduler and reported the situation, and the Scheduler told him she would get some help for him when he returned to the nursing facility. The Transportation Driver then drove to the facility and picked up Nurse Aide (NA) #3 and NA #2 and a sling. The Transportation Driver stated NA #3 and NA #2 went back to the dialysis center with a sling to transfer Resident #103. At the dialysis center, the Transportation Drives said he saw Resident # 103's blanket and a sling in a biohazard bag laying on the floor and was unsure why they were in a bag. NA #3 and #2 then attempted to put the sling under Resident #103 but were unable to roll her in the dialysis chair to place the sling underneath her. NA #3 and #2 tried to manually transfer Resident #103 from the dialysis chair as to the transport chair, but Resident #103's knee buckled under her and she was assisted to the floor on her knees by NA #3 and NA #2. Both NA #3 and NA #2 decided to move Resident #103 from the floor back into her chair. A dialysis tech then went over to assist the NAs with lifting Resident #103 off the floor and into her chair. The Transportation Driver said each NA was lifting Resident #103 by using their arm under the Resident's arm to lift the resident up. The dialysis tech was in front of the Resident with her arms wrapped around the back of the Resident during the lift from the floor. During the lift, the Transportation Driver heard someone say they heard a pop, and Resident #103 made a noise to indicate she had pain. Once Resident #103 was placed into the chair, one of the NAs said the Resident needs to be assessed. The Transportation Driver said EMS was called by the dialysis center and they were told to leave the facility. Nurse Aide (NA) #3 and NA #2 were interviewed together on 4/16/24 at 3:08 PM. NA #3 stated they were unable to get the lift sling they brought from the facility under Resident #103, and it was decided by her and NA #2 to transfer Resident #103 manually. NA #3 said the first attempt to transfer Resident #103 did not work and the resident slid to the floor with assistance from her and NA #2. NA #3 stated they had lifted the resident with their arms under her arms, and when Resident #103 was standing, her knees buckled, and she was lowered onto her knees upright. NA #3 and NA #2 both agreed Resident #103 was not assessed by a nurse when she was assisted from the floor. While Resident #103 was on her knees, a dialysis technician came over to assist with lifting the resident from the floor and into her chair. NA #2 said he was lifting under Resident #103's right arm, NA #3 was at the back of the resident with her arms around the front of the resident, and the dialysis technician was on the residents left side and a gait belt was used for the transfer. NA #2 said when they were lifting Resident #103, he heard a pop, and Resident #103 complained of pain in her left shoulder and said she was feeling nauseous. A dialysis nurse then assessed Resident #103, and then called EMS. The dialysis nurse told NA #3 and NA #2 they could leave. The Dialysis Nurse who was assigned to Resident #103 on 3/25/24 was interviewed on 4/17/24 at 8:45 AM via phone. The Dialysis Nurse stated she did not recall exactly how the NAs tried to transfer Resident #103 out of the dialysis chair, but the resident slipped and fell to the floor on her left side and hurt her shoulder and ankle. The NAs then lifted Resident #103 back into the chair by placing their arms under her arms and lifting. The interview further revealed Resident #103 complained of pain in her left shoulder and was assessed by the Dialysis Nurse. Emergency Medical Services was contacted and Resident #103 was sent to the hospital for an evaluation. Resident #103's hospital discharge summary dated 3/25/24 was reviewed. The discharge summary revealed the resident was dropped being transferred at a dialysis center on 3/25/24 the resident complained of left shoulder pain, right ankle, right knee pain and right hip pain. Examination of Resident #103 found left side mid-shaft clavicle fracture, and a right ankle strain. The discharge summary did not indicate any pain medication was ordered, and to follow-up with orthopedics. Resident #103 returned to the facility on the same day. A review of progress notes found a nursing note created on 3/26/24 by Nurse #1 with an effective date of 3/25/24 that read in part as follows: Resident #103 returned to the facility from the hospital via Emergency Medical Services. The resident was alert and responsive and had a sling on her left arm due to a fractured clavicle. The Resident was transferred to bed by paramedics, and the resident was not in any distress. A review of Resident #103's medical administration record (MAR) 3/26/24 through 4/17/24 found Resident #103 received acetaminophen once on 3/26/24 with a pain of 6 on a scale of 1 to 10 (10 being the highest level of pain). The review found no other pain medication given to the resident, and the resident's pain level was monitored every shift. The Director of Nursing (DON) documented a progress note dated 3/26/24 that read in part, the Medical Director was notified of the emergency room (ER) visit last night with report of left clavicle fracture and orders for sling. Resident #103's order for acetaminophen as needed (PRN) for pain. The Resident stated she had pain but it was bearable. No further orders at this time. On 3/28/24 a physician's order was written for Resident #103 to receive oxycodone HCL Oral tablet 5 MG, give by mouth every 12 hours as needed for pain. The DON was interviewed on 4/17/24 at 9:12 AM. The DON did not know if Resident #103 was assessed by a nurse after the fall or when her shoulder was hurt, the NAs present could not assess her. Resident #103 was in the care of the dialysis center while she was there, and she did not know the dialysis center's protocol and policies for a fall or injury. A follow up interview was conducted with the DON on 4/19/24 at 12:09 PM. The DON said the facility's policy was to assess a resident after a fall by a nurse and evaluate if the resident is safe to move. The Medical Director was interviewed on 4/19/24 at 11:49 AM via phone. The Medical Director said after a resident in the care of the nursing facility had a fall, the resident should be assessed by a nurse before moving or lifting.

Based on observation, record review, and resident, family member, Transportation Driver, Dialysis Center staff, and Medical Director interviews, the facility failed to ensure a resident was transferred safely. Resident #103 sustained a fractured left clavicle and a sprained right foot from a fall when two nurse aides transferred Resident #103 after completion of her dialysis treatment without the use of a total lift. Resident #103 was not cleared by therapy to be transferred manually. The facility also failed to prevent Resident #37 from obtaining skin tears when the nurse aide continued to provide care after the resident became combative and was hitting his arms on the headboard and siderail. This was for 2 of 5 sampled residents reviewed for supervision to prevent accidents (Resident #103, Resident #37). The findings included: 1. Resident #103 was admitted to the facility on [DATE] and had a diagnosis end stage renal disease, cerebral infarction, muscle wasting and atrophy. A review of Resident #103's physician orders found and ordered dated 2/20/24 for acetaminophen 1000 MG every 8 hours as needed for pain via tube. On 2/20/24 to assess the resident every shift for pain monitoring. Resident #103's care plan, updated on 2/22/24, noted Resident #103 required staff assistance for activities of daily living (ADL) care needs related to generalized weakness. One of the interventions dated 2/20/24 identified Resident #103 required 2-person assist with transfers with a mechanical lift. Resident #103's admission Minimum Data Set (MDS) assessment, dated 2/27/24, coded Resident #103 as severely cognitively impaired and as totally dependent on staff for transfers. A physician's order dated 3/6/24 read the resident receives dialysis on Monday, Wednesday, and Fridays in the afternoon. Resident #103's hospital discharge summary dated 3/25/24 was reviewed. The discharge summary revealed the resident was dropped being transferred at a dialysis center on 3/25/24 the resident complained of left shoulder pain, right ankle, right knee pain and right hip pain. Examination of Resident #103 found left side mid-shaft clavicle fracture, and a right ankle strain. The discharge summary did not indicate any pain medication was ordered, and to follow-up with orthopedics. Resident #103 returned to the facility on the same day. A review of progress notes found a nursing note created on 3/26/24 by Nurse #1 with an effective date of 3/25/24 that read in part as follows: Resident #103 returned to the facility from the hospital via Emergency Medical Services. The resident was alert and responsive and had a sling on her left arm due to a fractured clavicle. The Resident was transferred to bed by paramedics, and the resident was not in any distress. A review of Resident #103's medical administration record (MAR) 3/26/24 through 4/17/24 found Resident #103 received acetaminophen once on 3/26/24 with a pain of 6 on a scale of 1 to 10 (10 being the highest level of pain). The review found no other pain medication given to the resident, and the resident's pain level was monitored every shift. The Director of Nursing (DON) documented a progress note dated 3/26/24 that read in part, the medical director was notified of the emergency room (ER) visit last night with report of left clavicle fracture and orders for sling. Resident #103's order for acetaminophen as needed (PRN) for pain. The Resident stated she had pain but it was bearable. No further orders at this time. On 3/28/24 a physician's order was written for Resident #103 to receive oxycodone HCL Oral tablet 5 MG, give by mouth every 12 hours as needed for pain. An in-room observation of Resident #103 on 4/15/24 at 8:19 AM found the resident laying in bed without distress or indication of pain or discomfort. Resident #103 verbally indicated she was not in any pain or discomfort when asked. Resident #103's Family Member #1 was interviewed on 4/16/24 at 12:16 PM via phone. He stated Resident #103's broken clavicle happened while she was at her dialysis appointment. Family Member #1's understanding was Resident #103 was taken to her dialysis appointment without the sling needed to transfer her, as she normally had with her. Family Member #1 said 2 or 3 staff, unknown if from the dialysis center or the resident's facility or a combination tried to pick up Resident # 103 to transfer and dropped her to the floor, breaking her clavicle. The dialysis center called EMS, and she was sent to the hospital. An interview with the Transportation Driver was conducted on 4/16/24 at 1:20 PM. The Transportation Driver stated he had witnessed the incident at the dialysis center on 3/25/24. He said he arrived to transport Resident #103 back to the facility and was told by a dialysis nurse he needed to go back to the nursing facility to get a lift sling and nurse aides to transfer Resident #103 from the dialysis chair to her transport chair. The Transportation Driver stated the dialysis nurse told him Resident #103 was transferred to the dialysis chair without the use of her sling and Resident #103 would not be transferred back to the transport chair manually again because it violated the dialysis center's policy. The Transportation Driver said he called the nursing facility and spoke to the Scheduler and reported the situation, and the Scheduler told him she would get some help for him when he returned to the nursing facility. The Transportation Driver then drove to the facility and picked up Nurse Aide (NA) #3 and NA #2 and a sling. The Transportation Driver stated NA #3 and NA #2 went back to the dialysis center with a sling to transfer Resident #103. At the dialysis center, the Transportation Drives said he saw Resident # 103's blanket and a sling in a biohazard bag laying on the floor and was unsure why they were in a bag. NA #3 and #2 then attempted to put the sling under Resident #103 but were unable to roll her in the dialysis chair to place the sling underneath her. NA #3 and #2 tried to manually transfer Resident #103 from the dialysis chair as to the transport chair, but Resident #103's knee buckled under her and she was assisted to the floor on her knees by NA #3 and NA #2. Both NA #3 and NA #2 decided to move Resident #103 from the floor back into her chair. A dialysis tech then went over to assist the NAs with lifting Resident #103 off the floor and into her chair. The Transportation Driver said each NA was lifting Resident #103 by using their arm under the Resident's arm to lift the resident up. The dialysis tech was in front of the Resident with her arms wrapped around the back of the Resident during the lift from the floor. During the lift, the Transportation Driver heard someone say they heard a pop, and Resident #103 made a noise to indicate she had pain. Once Resident #103 was placed into the chair, one of the NAs said the Resident needs to be assessed. The Transportation Driver said EMS was called by the dialysis center and they were told to leave the facility. NA #3 and NA #2 were interviewed together on 4/16/24 at 3:08 PM. NA #2 stated he and NA #3 went to the dialysis center with the Transportation Driver to pick up Resident #103 on 3/25/24. NA #2 said the Scheduler had asked them to go with the Transportation Driver to pick up Resident #103. NA #2 said Resident #103 was in her dialysis chair when they arrived, and observed she did not have a sling under her. The dialysis staff did not provide an explanation why Resident #103 did not have a sling under her in the chair. NA #3 stated they were unable to get the lift sling they brought from the facility under Resident #103, and it was decided by her and NA #2 to transfer Resident #103 manually because Resident #103 was transferred without using a sling earlier by the dialysis staff. NA #3 said the first attempt to transfer Resident #103 did not work and the resident slid to the floor with assistance from her and NA #2. NA #3 stated they had lifted the resident with their arms under her arms, and when Resident #103 was standing, her knees buckled, and she was lowered onto her knees upright. NA #3 and NA #2 both agreed Resident #103 was not assessed by a nurse when she with as assisted to the floor. While Resident #103 was on her knees, a dialysis technician came over to assist with lifting the resident from the floor and into her chair. NA #2 said he was lifting under Resident #103's right arm, NA #3 was at the back of the resident with her arms around the front of the resident, and the dialysis technician was on the residents left side and a gait belt was used for the transfer. NA #2 said when they were lifting Resident #103, he heard a pop, and Resident #103 complained of pain in her left shoulder and said she was feeling nauseas. A dialysis nurse then assessed Resident #103, and then called EMS. The dialysis nurse told NA #3 and NA #2 they could leave. Both NA #3 and NA #2 stated they knew Resident #103 was a total mechanical lift but did not know if the resident was weight bearing at that time. The NAs said they were provided with an in-service from the DON when they returned to the facility that day on the uses of slings and lifts for a resident required a total lift. The Scheduler was interviewed on 4/16/24 at 3:59 PM. She stated the Transportation Driver called her at the facility the evening of 3/25/24. The Transportation Driver told her Resident #103 did not have a sling under her at dialysis and could not be transferred to the transport chair. The Scheduler said Resident #103 had a lift pad under her, and dialysis would not let her return to the nursing facility with it. Resident #103 was working with therapy before her dialysis appointment and was placed in her transport chair without the sling she normally had with her when she went to dialysis. The Transportation Driver said he needed to come back to the nursing facility to get a sling and needed help with the transfer. The Scheduler stated she told NA #3 and NA #2 to get a sling and go with the Transportation Driver to pick up Resident #103. The Scheduler said she thought Resident #103 was weight bearing because she was working with therapy, and knew she required a total lift sling to get up. The Scheduler stated her assumption was Resident #103 would have been transferred using the lift sling the NAs were taking back to the dialysis center. The Dialysis Nurse who was assigned to Resident #103 on 3/25/24 was interviewed on 4/17/24 at 8:45 AM via phone. She stated she saw Resident #103 had arrived at the dialysis center for treatment without a sling under her for transferring to the dialysis chair. The Dialysis Nurse stated Resident #103 had always been transferred using a lift, but they had to transfer her using 4 dialysis staff and a lift pad. The dialysis center Administrator told her after the transfer they could not transfer without using a lift. When Resident #103 finished her dialysis treatment, the Transportation Driver was asked to get help from the nursing facility to transfer Resident #103 out of the dialysis chair because they were not allowed. The Transportation Driver came back to the dialysis center with 2 NAs and a sling, and the NAs were unable to place the sling under the resident. The Dialysis Nurse stated she did not recall exactly how the NAs tried to transfer Resident #103 out of the dialysis chair, but the resident slipped and fell to the floor on her left side and hurt her shoulder and ankle. The NAs then lifted Resident #103 back into the chair by placing their arms under her arms and lifting. The interview further revealed Resident #103 complained of pain in her left shoulder and was assessed by the Dialysis Nurse. Emergency Medical Services was contacted and Resident #103 was sent to the hospital for an evaluation. The DON was interviewed on 4/17/24 at 9:12 AM and stated Resident #103 was in her dialysis chair and did not have her sling for transfer because therapy had worked with her prior to her dialysis treatment and did not use a total lift with her. The dialysis center had transferred Resident #103 into her dialysis chair before her treatment but would not transfer her again when the treatment was completed. The Transportation Driver called the facility and spoke to the Scheduler, because she had left for the day. The Transportation Driver came to the facility, picked up NA #3 and NA #2 and a sling, then went back to the dialysis center for Resident #103. The DON said NA #3 and NA #2 were unable to place the lift sling under the Resident #103 and tried to transfer Resident #103 manually from the dialysis chair. Resident #103's legs buckled and was assisted to her knees on the floor by the NA. The DON said a dialysis technician helped NA #3 and NA#2 lift Resident #103 from the floor to her chair. The DON said NA #2 was on one side of Resident #103 and the dialysis technician was on the other side with NA #3 assisting from the residents back. While lifting, they heard a pop, and the dialysis center called EMS and told the NA's they could leave. The DON stated at that time Resident #103 required the use of a total mechanical lift and was only transferred manually when therapy worked with her. The DON did not know if Resident #103 was assessed by a nurse after the fall or when her shoulder was hurt, the NAs present could not assess her. Resident #103 was in the care of the dialysis center while she was there, and she did not know the dialysis center's protocol and policies for a fall or injury. The DON stated Resident #103 was transported to the dialysis center by non-emergent EMS until she was cleared for mechanical lift. A follow up interview was conducted with the DON on 4/19/24 at 12:09 PM. She stated the NAS should have used a lift to transfer Resident #103 as required by her plan of care. The DON said the facilities policy was to assess a resident after a fall by a nurse and evaluate if the resident is safe to move. The Administrator was interviewed on 4/17/24 at 9:29 AM. On 3/25/24 she was on vacation and returned to work on 3/26/24. The Administrator said her understanding was the dialysis center transferred Resident #103 into the dialysis chair but would not transfer the resident back into the transport chair. The Transportation Driver went back to the facility to get a sling and 2 NAs to help transfer Resident #103 at the dialysis center. The dialysis center would not let the NA's use the lift pad they placed under the resident when she was transferred to the dialysis chair. The Administrator stated NA #3 and NA #2 were manually transferring Resident #103 from the dialysis chair to the transport chair and Resident #103's knees buckled, and she was assisted to her knees on the floor by the NAs. Then, with the help of a dialysis technician, the NAs manually lifted the resident up to the chair and someone said they heard a pop. The Administrator stated the dialysis center called EMS and Resident #103 was sent to the ER. The NAs were provided lift training after the incident, and Resident #103 was transported to dialysis treatments by ambulance. The Dialysis Technician was interviewed on 4/17/24 at 12:13 PM via phone. She stated Resident #103 arrived at the dialysis center and did not have her lift sling underneath her. The dialysis RN asked the transportation driver to get a sling and some help to transfer the resident. The Dialysis Technician stated the two NAs tried to transfer the resident from her dialysis chair to the transportation chair as they lifted the resident from under her arms and out of the chair. Resident #103 was assisted to the floor by the NAs and was sitting on her knees, shins and butt while on the floor. Resident #103 did not fall to the floor on her left side or lay on the floor on her side. The Dialysis Technician said the NAs needed help with getting the resident up off the floor and she went to help them. Resident #103 was not assessed by anyone when she was on the floor prior to her being lifted again, the move from the floor to the chair. She said NA #2 was on one side lifting the resident under her arm and she was in front of the resident with her arms wrapped around the resident's back while they were lifting her. During the lift NA #2 lifted the resident's arm from under her armpit. Resident #103's arm did not provide resistance and went straight up, over the resident's head with NA #2's arm. The Dialysis Technician said she heard a loud pop noise and was placed into the chair. The Dialysis Technician did not see the NAs moving the resident's arm when placed into her chair. The Dialysis Technician then told her nurse that she heard a pop and the resident needed to be assessed. The dialysis center then called EMS to the facility, and the resident was sent to the hospital. The dialysis center administrator was interviewed on 4/17/24 at 2:50 PM via phone. She stated the transportation driver was asked to get a sling and some help to transfer the resident from the dialysis chair to the transportation chair. She told the transportation driver they were a no lift facility and would not transfer the resident without her sling. The administrator said she called the nursing facility and spoke to a nurse about this situation and explained they needed to bring a sling and some help for the transfer. She then went home for the day. While at home it was reported to her that the resident had slid down with assistance when the NAs were transferring her to the transport chair. She was told the Resident #103 hit the floor on her side and then the NAS picked her up from the floor into the chair and someone heard a pop noise. The dialysis nurse then called EMS and sent her out to the hospital. The next day she learned about the clavicle fracture and called the resident's family and spoke to the nursing facility about the incident. The dialysis center administrator stated resident #103 had always arrived to the dialysis center with her sling underneath her. She was unaware why the resident did not have her sling with her on that occasion. The Rehab Director was interviewed on 4/17/24 at 3:30 PM and stated Resident #103 was working on transferring, upper body dressing, lower body dressing, and grooming before the incident. The rehab director said the resident required the use of a mechanical lift and sling for all transfers not being done by the therapist. The Rehab Director stated after the incident the resident was not allowed to be transferred with a sling and the therapists were getting the resident up out of bed. The Rehab Director said when he worked with the resident after the accident, she had not expressed any pain or discomfort in her shoulder area, and they continued to work with her on pivot transfers. The Rehab Director stated on 3/25/24, the day of the incident there was miscommunication that occurred. The therapist we're not aware the resident was going to dialysis after therapy and therefore did not have her sling underneath her as she normally would have had for dialysis. The Medical Director was interviewed on 4/19/24 at 11:49 AM via phone. He stated he expected NAs to follow Resident #103's care plan and use a mechanical lift and sling when indicated. The medical director said after a resident in the care of the nursing facility had a fall, the resident should be assessed by a nurse before moving or lifting. 2. Resident #37 was admitted on [DATE] with diagnosis of dementia, hypertension, and chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimal Data Set (MDS) dated [DATE] coded Resident #37 with severe cognitive impairment. He required extensive 2-person assistance with toileting, transfer, and bed mobility. A review Resident #37's care plan revealed he was care planned for resisting care and yelling for help or nurse and not knowing what he needed (11/17/22). Interventions for the care plan included explaining all procedures to the resident before starting care and allowing the resident to adjust to changes. Resident #37 was care planned for being incontinent with bowel and bladder with an intervention that included check resident for incontinence every care round (5/14/22). Resident #37 had a physician order for Geri-sleeves to bilateral arms as tolerated, every day shift for protection (1/13/24). A review of Nurse #3 progress note dated 3/4/24 at 11:25 PM read in part, Resident #37 was yelling out, so this nurse went to his room to check on him. Upon assessment, Resident #37 had 3 large skin tears on his left forearm and a smaller sing tear on his right upper forearm near the elbow. The geri-sleeves were found pushed down on Resident# 37's wrists. Resident #37 stated your boy done this; your boy done this. Nurse Aide (NA) #2 had just finished a round on that hall, and NA #2 was questioned about what happened. NA #2 told Nurse #3, Resident #37 was combative with care and hit his arm on the side rail. NA #2 was counselled to have 2 NAs assist when providing care if the resident is resistive to care and to notify the nurse before providing care. Resident #37's skin tears were cleaned with wound cleaner and xeroform and bordered gauze dressing was applied. Resident #37 kept telling Nurse #3 I'm alright honey. NA #2 was interviewed on 4/18/24 at 3:09 PM. He stated on 3/4/24 he was completing his last round on the floor around 9:00 PM before the end of his shift. NA #2 stated he went into Resident #37's room and told Resident #37 he was going to provide care to him. NA #2 stated Resident #37 became combative and flailed his arms hitting the headboard and the side rail of the bed. Resident #37 told NA #2 to get out, and NA #2 replied he was there to provide care to him. NA #2 said he continued to provide care (incontinence) and Resident #37 calmed down and stopped flailing his arms once his brief was changed. NA #2 did not hold the resident down while providing care. NA #2 said he did not see any injuries or skin tears on the resident's arms and the resident was wearing protective arm sleeves on both arms. He said he would have reported the injuries to his nurse if he had seen any. NA #2 said the next shift's NA went into Resident #37's room and saw the skin tears and reported them to the nurse. NA #2 said he was sent home and was suspended by the facility for 3 days while they investigated. NA #2 went on to say Resident #37 had a history of being combative with care, and he normally got help when Resident #37 was being resistive to care. He said he was trying to finish his resident rounds before his shift ended on 3/4/24, and he should have stopped when Resident #37 became resistive to care. He stated he should have found another NA or nurse to help him with providing care. NA #2 stated he has not been assigned to work with Resident #37 since that incident, and the Director of Nursing (DON) provided him with education on always getting help for another NA when a resident was resistive to care, or to stop care and reapproach the resident later. The previous facility DON was interviewed on 4/18/24 at 3:50 PM via phone. She stated that she was the DON for the building for that incident but was not in the building when it happened. The former DON stated she could not recall the time she was notified by the Administrator of the incident. She stated the Administrator completed the investigation and she then reviewed the interviews and closed the facility reported incident (FRI) investigation. The former DON said she did have a verbal discussion with NA #2 on providing care before his next scheduled shift and she gave NA #2 a write-up but could not recall the details. The former DON said NA #2 was suspended for 2 or 3 days, after the incident. A review of the investigation report dated 3/5/24 revealed the facility became aware of the new skin tears to the left and right forearm for Resident #37 on morning of 3/5/24. The Administrator was notified at 7:30 AM and the DON was made aware. A facility reported incident (FRI) for injury of an unknow origin was started and a 24-hour report was initiated, and the medical director was notified. Nurse #3 reported Resident #37 stated your boy did it on the night of 3/4/24. NA #2 was interviewed and stated Resident #37 was combative with care the night before and the resident had hit his arms on the headboard, but he did not see any skin tears and Resident #37 did not make any complaints to him during or after care. NA #2 stated he didn't think anything had happened to Resident #37 and that was why he did not report it to the nurse. He left the facility after Nurse #3 questioned him. NA #2 was suspended on 3/5/24 while the incident was being investigated. All residents on NA #2 assigned hall had skin assessments completed and alert and oriented residents did not report any concerns with NA #2. Alert and oriented residents were interviewed were asked if they had witnessed any abuse and if they feel safe here and they all reported they have witnessed no abuse and felt safe in the facility. Resident # 37 was interviewed and had not recollection of the incident. The allegation was completed on 3/7/24 and the allegation was not substantiated due to Resident #37 being unable to recall the incident or identify NA #2 and the resident's injury was not intentional. NA # 2 was educated and counseled to always use 2 staff members for residents that have the ability to be combative, and to leave the resident in a safe position and come back and attempt care later and notify his nurse of any out of the ordinary occurrences. Nurse #3 was unavailable for interview. The Wound Nurse Practitioners (NP) progress note dated 3/6/24 was reviewed. The progress note revealed a new wound area on the left forearm with measurement 20 cm x 8 cm x 0.20 cm. The wound NP recommended the wounds to be treated daily and as needed (PRN) using a wound cleanser with xeroform and gauze to cover the wound. The Wound NP provider was interviewed on 4/18/24 at 1:37 PM via phone. He stated he treated Resident # 37's wounds on 3/6/24 and the wound did not look abnormal to him, the skin tears were like previous skin tears the resident had had. Resident #37 had thin and fragile skin and would receive skin tears easily. He wore a protective sleeve on his arms to prevent skin tears. There were 3 skin tears on Resident #37's left forearm, so he took one generalized measurement of the area for treatment. The Wound NP said the skin tears had been resolved. The Administrator was interviewed on 4/18/24 at 3:54 PM. She stated NA #2 had already been sent home when she was notified by Nurse #3 around 7:30 AM the following day that Resident #37 had skin tears on his arms from being combative receiving care from NA# 2. The Administrator said the next morning she had interviewed NA #2. NA #2 told her Resident #37 had become combative with care, and the resident was flailing his arms while he was providing care. NA #2 said he did not know the resident was injured, or he would have reported it to his nurse. The Administrator said the former DON had counseled NA #2 and had given him a write -up on 3/5/24. NA #2 was suspended for 3 days until the investigation was completed. The Administrator said Resident #37 was interviewed on 3/5/24 and did not remember the incident and was unable to identify any staff. The Administrator said generally, when a resident was combative with care, an NA should stop care and reapproach later or get another NA to help with providing care. The DON was interviewed on 4/19/24 at 12:09 PM. She stated Resident #37 had a history of being combative when he received care. The DON said if a resident was combative with care, NA #2 should have stopped providing care and walked away or gotten help from another NA or nurse before attempting to provide care again.

Based on record reviews, staff interviews, and resident interviews the facility failed to maintain dignity and preference by residents not having briefs available. This affected 7 out of 7 (#58, #16, #4, #13, #17, #26, #77) sampled residents. The residents expressed feelings of being upset, it was awful, they were scared, embarrassed and uncomfortable to leave their rooms, it was unacceptable, and that the nursing home did not care about them. The findings included: 1. Resident #58 was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of the quarterly Minimum Date Set (MDS) dated [DATE] indicated Resident #58 was cognitively intact and was total dependent of all activities of daily living (ADL) except for eating. The MDS further revealed Resident #58 was incontinent. An interview was conducted with Resident #58 on 03/28/21 at 9:30 AM revealed that a couple of weeks ago the facility ran out of briefs and he was without briefs for three days. Resident #58 further revealed that he was upset and did not like laying on the bed pad. Resident #58 stated he complained to nursing staff for several days. An interview was conducted with Nurse Aid #2 (NA) on 03/30/21 at 10:13 AM revealed in the month of March there was a shortage of briefs for an estimated time of one week in the facility. She further revealed residents who went without a brief would have a bed pad placed underneath them. The NA revealed residents went three days without briefs and residents complained not wanting to leave their rooms scared they would have an accident in front of other residents. An interview was conducted with Nurse #12 on 03/31/21 at 9:41 AM revealed there was a shortage of briefs in the facility a couple of weeks ago. The Nurse further indicated residents ran out of briefs and would have a bed pad placed underneath them instead. The Nurse revealed Resident #58 did run out of briefs and was very upset. An interview was conducted with the Central Supply Manager on 03/31/21 at 11:00 AM revealed a supply ordered did not get approved on 02/27/21 and caused a supply shortage of briefs. It was further revealed the facility had an abundance of pull ups that were stored in the linen closet for nursing staff to use instead of briefs. She could not recall if nursing staff was educated about the supplies' location. The Central Supply Manager revealed she did not document number of supply inventories in the facility. An interview was conducted with the Director of Nursing (DON) on 03/31/21 at 1:17 PM revealed that the facility missed a supply order which caused a shortage of briefs. The DON further indicated that briefs were borrowed from another facility and there were disposable pulls up for residents. The DON revealed residents were asked if they would use a bed pad instead of a brief during third shift and does not recall any residents complaining. An interview conducted with the Administrator on 03/31/21 at 6:00 pm revealed the supply order was not signed off on 02/27/21 causing the facility to be low on briefs. She further revealed that the facility received supplies from another facility and had abundance of pull ups for the residents. The Administrator revealed she does not recall any residents complaining or being upset. 2. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the quarterly Minimum Date Set (MDS) dated [DATE] indicated Resident #16 was cognitively intact and was dependent requiring extensive assistance with all Activities of Daily Living (ADL) except for eating. The MDS further revealed Resident #16 was frequently incontinent. An interview was conducted with Nurse Aid #2 (NA) on 03/30/21 at 10:13 AM revealed in the month of March there was a shortage of briefs for an estimated time of one week in the facility. She further revealed residents who went without a brief would have a bed pad placed underneath them. The NA revealed residents went three days without briefs and residents complained not wanting to leave their rooms scared they would have an accident in front of other residents. An interview was conducted with Nurse #12 on 03/31/21 at 9:41 AM revealed there was a shortage of briefs in the facility a couple of weeks ago. The Nurse further indicated residents ran out of briefs and would have a bed pad placed underneath them instead. An interview was conducted with Resident #16 on 03/30/21 at 10:30 AM revealed a couple of weeks ago the facility ran out of briefs and went a week without wearing a brief. Resident #16 further revealed he was upset and did not feel comfortable leaving his room without a brief. Resident #16 further indicated nursing staff took his packages of briefs from his room to give to other residents in the facility, and he had to use a bed pad. An interview was conducted with the central supply manager on 03/31/21 at 11:00 AM revealed a supply ordered did not get approved on 02/27/21 and caused a supply shortage of briefs. It was further revealed the facility had an abundance of pull ups that were stored in the linen closet for nursing staff to use instead of briefs. She cannot recall if nursing staff was educated about the supplies' location. The central supply manager revealed she did not document number of supply inventories in the facility. An interview was conducted with the Director of Nursing (DON) on 03/31/21 at 1:17 PM revealed that the facility missed a supply order which caused a shortage of briefs. The DON further indicated that briefs were borrowed from another facility and there were disposable pulls up for residents. The DON revealed residents were asked if they would use a bed pad instead of a brief during third shift and does not recall any residents complaining. An interview conducted with the Administrator on 03/31/21 at 6:00 pm revealed the supply order was not signed off on 02/27/21 causing the facility to be low on briefs. She further revealed that the facility received supplies from another facility and had abundance of pull ups for the residents. The Administrator revealed she does not recall any residents complaining or being upset. 3. Resident #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Date Set (MDS) dated [DATE] indicated Resident #4 was cognitively intact and required 2 or more person assist with of all Activities of Daily Living (ADL) except for eating. The MDS further revealed Resident #4 was frequently incontinent. An interview was conducted with Nurse Aid #2 (NA) on 03/30/21 at 10:13 AM revealed in the month of March there was a shortage of briefs for an estimated time of one week in the facility. She further revealed residents who went without a brief would have a bed pad placed underneath them. The NA revealed residents went three days without briefs and residents complained not wanting to leave their rooms scared they would have an accident in front of other residents. An interview was conducted with Nurse #12 on 03/31/21 at 9:41 AM revealed there was a shortage of briefs in the facility a couple of weeks ago. The Nurse further indicated residents ran out of briefs and would have a bed pad placed underneath them instead. An interview was conducted with Resident #4 on 03/30/21 at 10:45 AM revealed the facility was short on briefs for two weeks and she went without a brief for several days. Resident #4 stated it was awful and she was not okay laying on a bed pad. Resident #4 further revealed she would not leave her scared she would have an accident. An interview was conducted with the central supply manager on 03/31/21 at 11:00 AM revealed a supply ordered did not get approved on 02/27/21 and caused a supply shortage of briefs. It was further revealed the facility had an abundance of pull ups that were stored in the linen closet for nursing staff to use instead of briefs. She cannot recall if nursing staff was educated about the supplies' location. The central supply manager revealed she did not document number of supply inventories in the facility. An interview was conducted with the Director of Nursing (DON) on 03/31/21 at 1:17 PM revealed that the facility missed a supply order which caused a shortage of briefs. The DON further indicated that briefs were borrowed from another facility and there were disposable pulls up for residents. The DON revealed residents were asked if they would use a bed pad instead of a brief during third shift and does not recall any residents complaining. An interview conducted with the Administrator on 03/31/21 at 6:00 pm revealed the supply order was not signed off on 02/27/21 causing the facility to be low on briefs. She further revealed that the facility received supplies from another facility and had abundance of pull ups for the residents. The Administrator revealed she does not recall any residents complaining or being upset. 4. A Resident Council meeting was held on 03/31/21 at 10 AM included cognitively intact residents which included Resident #4, Resident #13, Resident #17, Resident #26, Resident #77, and Resident #16. These residents spoke out they were upset that the facility had a shortage of briefs two weeks ago and it was an issue through the whole facility. Resident #4, Resident #16, and Resident #77 stated they went without briefs several days and felt like the facility did not care about the residents. Resident #4 and Resident #16 further revealed they were scared and embarrassed to leave their rooms in case they had an accident. An interview was conducted with Nurse Aid #2 (NA) on 03/30/21 at 10:13 AM revealed in the month of March there was a shortage of briefs for an estimated time of one week in the facility. She further revealed residents who went without a brief would have a bed pad placed underneath them. The NA revealed residents went three days without briefs and residents complained not wanting to leave their rooms scared they would have an accident in front of other residents. An interview was conducted with Nurse #12 on 03/31/21 at 9:41 AM revealed there was a shortage of briefs in the facility a couple of weeks ago. The Nurse further indicated residents ran out of briefs and had a bed pad placed underneath them instead. An interview was conducted with the Central Supply Manager on 03/31/21 at 11:00 AM revealed a supply ordered did not get approved on 02/27/21 and caused a supply shortage of briefs. It was further revealed the facility had an abundance of pull ups that were stored in the linen closet for nursing staff to use instead of briefs. She cannot recall if nursing staff was educated about the supplies' location. The Central Supply manager revealed she did not document number of supply inventories in the facility. An interview was conducted with the Director of Nursing (DON) on 03/31/21 at 1:17 PM revealed that the facility missed a supply order which caused a shortage of briefs. The DON further indicated that briefs were borrowed from another facility and there were disposable pulls up for residents. The DON revealed residents were asked if they would use a bed pad instead of a brief during third shift and does not recall any residents complaining. An interview conducted with the Administrator on 03/31/21 at 6:00 pm revealed the supply order was not signed off on 02/27/21 causing the facility to be low on briefs. She further revealed that the facility received supplies from another facility and had abundance of pull ups for the residents. The Administrator revealed she does not recall any residents complaining or being upset.

Based on record review, resident and staff interviews and observation, the facility failed to supervise a cognitively impaired resident that demonstrated wandering behavior in the facility (Resident #1) from exiting the facility unsupervised for 1 of 3 residents reviewed for supervision to prevent accidents. Resident #1 who had [DIAGNOSES REDACTED]. Immediate Jeopardy began on 11/14/20 when Resident #1 exited from the facility without staff's knowledge, was unattended and unsupervised and was discovered outside when he started knocking on the door at the end of the North side of the facility on hall six. Immediate Jeopardy was removed on 11/25/20 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had both long-term and short-term memory loss and modified independence for daily decision-making. Resident #1 was usually able to recall the location of his own room, staff names and faces and that he was in a nursing home. Resident #1 was independent with all activities of daily living with no set up or physical help required from staff. Resident #1's balance during transitions and walking was not steady but he was able to stabilize without staff assistance. The MDS further indicated that Resident #1 was usually understood, and he usually understood others. Resident #1 did not exhibit wandering behaviors during the assessment period. A review of the Elopement Risk Evaluation for Resident #1 dated 10/19/20 indicated Resident #1 had potential risk factors for elopement that included psychiatric history, cognitive impairment and independent ambulation but he had no exit-seeking behaviors so Resident #1 was not considered at risk for elopement. Resident #1 did not have a care plan for wandering behaviors or risk for elopement prior to 11/14/20. A review of Resident #1's medical record revealed a late entry nurses' note written by Nurse #1, dated 11/14/20 at 8:30 PM, which read in part: Code green was initiated, an emergency code used to indicate a high-risk resident was missing. All staff except for two on the South side and on the North side began looking for Resident #1. He was found outside walking towards the lower parking lot. Unable to determine which door he left out of. Resident #1 was escorted back to his room by Nurse Aide #1. Nurse #1 completed total body check. No skin issues or injuries noted. 15-minute checklist started. DON (Director of Nursing) was already in the facility and aware of elopement. Resident #1 had been agitated prior to elopement. He wanted to call his (family member). Resident #1 talked with his (family member), began talking loudly and became more agitated. An interview with Resident #1 was conducted with Nurse Aide (NA) #2 present as interpreter on 11/23/20 at 11:20 AM. Resident #1 stated he remembered being outside of the facility about two weeks ago. He said he got out through the front door, but he could not remember how long he had been outside. Resident #1 stated he had a fleece coat, long-sleeve shirt, jeans, socks and shoes on. He remembered it being chilly outside and that he had started to freeze before he could get back inside the facility. Resident #1 further stated that he had been anxious and was tired of being inside the facility, so he decided to leave. During the interview, Resident #1 was asked to show which door he tried to exit from, and he led the way towards the front door. Resident #1 was observed ambulating without the assistance of a device or another individual. Resident #1 wore shoes, walked slowly and appeared slightly unsteady but did not get out of balance while walking in the hallway. During this observation and interview on 11/23/20 at 11:25 AM, NA #2 stated it would have been impossible for Resident #1 to exit through the front door because a code would need to be entered on the keypad prior to unlocking the front door. Resident #1 denied having gone out through the South nurses' station door that led to the smoking area and said that it was locked. A phone interview with Nurse #2 on 11/23/20 at 11:59 AM revealed she was working on the North side of the facility and was giving medications to her residents around 8:30 PM when she started to hear what sounded like someone hollering and knocking on a door. Nurse #2 stated that at first, she thought the noise was coming from inside the facility, so she started checking on her residents. She could not find the source of the noise, but she saw a man standing outside the door at the end of hall six, so she started walking towards the door and realized the man outside looked like Resident #1. She paged the supervisor on call overhead and asked her to come to the North side of the facility. Nurse #2 and NA #1 went outside through the back door and found Resident #1 standing at the top of the steps to the lower parking lot and facing the road. When they saw Resident #1, they told him to come back into the building and he turned around and went back inside with Nurse #2 and NA #1. Resident #1 said to Nurse #2 that he went out because he wanted to go see his family member and that he had just left the hospital. She clarified that Resident #1 sometimes referred to the facility as the hospital. She could not remember for sure what Resident #1 was wearing but added that he always wore his plaid flannel shirt, blue jeans and shoes. She said it had been cold outside the night of 11/14/20 and stated that she had no idea how Resident #1 had gotten out of the building. Nurse #2 further stated she had not seen Resident #1 on the North side at any time on the evening of 11/14/20 except when she saw him outside by the door at the end of hall six. It took Nurse #2 about twenty-five minutes from the time she first heard someone knocking on the door to the time they found Resident #1 outside because she had been checking inside the facility and did not know the knocking was coming from the outside of the building. A phone interview with Nurse #1 on 11/24/20 at 9:16 AM revealed she was the nurse assigned to Resident #1 on the evening shift on 11/14/20. Nurse #1 stated she had been in the back hall on the South side of the facility, so it was hard for her to keep an eye on Resident #1. Nurse #1 further stated that all staff members went outside to look for Resident #1 except for two NAs who stayed on the North and South halls of the facility. She reported when staff escorted Resident #1 back to his room after being outside, she remembered him wearing a jacket, a shirt, blue jeans, socks and shoes. She performed a full head-to-toe assessment and checked his vital signs and did not note any abnormal findings. Resident #1's vital signs that she recorded included the following: temperature of 97.6 degrees Fahrenheit, pulse of 65 beats per minute and oxygen saturation of 97% on room air. She also took Resident #1's blood pressure but did not record it in his chart, and she could not remember what it was. Nurse #1 added that Resident #1 had a phone call with his family member earlier that night on 11/14/20 around 8:00 PM when he got upset and started talking loudly but in a different language so she could not understand everything that Resident #1 was saying. Nurse #1 remembered Resident #1 being upset and hollering that he wanted to go home after he hung up the phone and then he turned around and walked back to his room. She further stated that Resident #1 had made no previous attempts to exit the building even though he liked to wander and walk down the halls and go over to the North side and he lived on the South side of the facility. She said it was hard to monitor him when he was wandering because he walked from one side of the building to the other. An interview with Nurse #5 on 11/23/20 at 10:25 AM revealed Resident #1 often wandered out of his room but did not usually go to the other residents' rooms or try to exit the building. Nurse #5 stated Resident #1 liked to go to the dayroom and to the North side of the facility and walk up and down the halls. An interview conducted with NA #3 on 11/23/20 at 3:38 PM revealed she was the NA assigned to Resident #1 during the time of the elopement on 11/14/20. NA #3 stated she last saw Resident #1 around 7:32 PM when she was doing her rounds and he was lying in bed while wearing jeans, a shirt and a jacket. She was in the breakroom when NA #3 found out that Resident #1 was seen by a staff member outside of the facility. NA #3 stayed on the South nurses' station while the other staff members looked for Resident #1 outside. NA #3 stated Resident #1 could have gotten out through South nurses' station door because this door to the smoking area stayed unlocked and they always had to call the North side to get this door locked because the control panel to lock all the doors was located on the North side of the facility. NA #3 added that the South nurses' station door stayed unlocked because staff used it as well to go out for their smoking breaks. NA #3 also stated that Resident #1 liked to come up to the nurses' station and sometimes verbalized that he wanted to leave and to go home but he had not made previous attempts to exit the building. An interview conducted with NA #1 on 11/23/20 at 3:04 PM revealed she was working on the South side of the facility on the evening shift on 11/14/20 but she was assigned to another group that did not include Resident #1. NA #1 stated when the supervisor on-call got paged overhead, NA #1 went over to the North side of the facility and was asked by Nurse #2 to go outside with her to start looking for Resident #1. NA #1 stated she and Nurse #2 saw Resident #1 standing at the top of the steps to the lower parking lot. NA #1 remembered that it had been cold the night of 11/14/20. NA #1 stated Resident #1 was wearing his jacket, blue jeans and shoes. NA #1 assisted Resident #1 back into his room. NA #1 stated she had not seen him before he exited the building because she was busy with her assigned residents but thought that he might have gotten out of the North nurses' station door. NA #1 stated they hardly had any resident who smoked at 8:00 PM but this door was not always locked because staff used it to go out on their smoking breaks. NA #1 stated that the North nurses' station door was supposed to be locked at all times and one of the staff members could have forgotten to lock it back after coming back from their break. A phone interview with Nurse #4 on 11/23/20 at 1:34 PM revealed she was working on the North side of the facility when she saw Resident #1 walking down to the North side from the South side right before 8:00 PM. Resident #1 was holding a sheet of paper with his family member's phone number and was wanting to call him. Nurse #4 stated Resident #1 did not seem agitated at that time. Around 8:30 PM, Nurse #4 heard a noise that sounded like someone was banging on the wall or pounding on a table. Nurse #4 realized that the sound was coming from the door at the end of hall six. At first, Nurse #4 thought that someone was trying to break into the facility, so she asked Nurse #2 to check the door at the end of hall six. Nurse #2 recognized the man that was knocking on the door at the end of hall six had been Resident #1. Nurse #4 went outside to help locate Resident #1. Nurse #4 stated she could not remember exactly what Resident #1 was wearing but said that he was fully dressed. Nurse #4 thought Resident #1 could have gotten out through the North nurses' station door because this door was not locked all the time although it was supposed to be always locked. Nurse #4 could not remember if there were resident smokers who smoked at 8:00 PM but stated that staff members used this door as well to go out to the smoking area for their breaks. An interview conducted with Nurse #3 on 11/23/20 at 11:51 AM revealed she was the supervisor-on call on 11/14/20 and had to work as a NA on the South side of the facility. Nurse #3 stated she had finished with her NA tasks and was getting ready to go home when she got paged overhead to come to the North side of the facility. Nurse #3 was notified by Nurse #2 that she had seen Resident #1 outside so Nurse #3 directed all staff members except for 2 NA to go outside and search for Resident #1. Nurse #3 went out through the front door and saw Nurse #2 assisting Resident #1 back into the building. Nurse #3 found out that Nurse #2 had seen somebody knocking on the door at the end of hall six and discovered that it was Resident #1. Nurse #3 conducted a head count on both sides of the facility and checked all the doors. Nurse #3 noted that both the North and the South nurses' station doors were unlocked. Nurse #3 stated a staff member might have forgotten to lock the doors back after they went out for their smoking break. Nurse #3 notified the DON (Director of Nursing) and the Administrator. A review of the weather conditions per Weather Underground website revealed the following data for Nebo, North Carolina on 11/14/20 at 7:54 PM: 52 degrees Fahrenheit (F) with no precipitation, South wind speed at 7 miles per hour (mph), 45 degrees F. The conditions at 8:54 PM were 51 degrees F with no precipitation, South-Southeast wind speed of 3 mph, 45 degrees F. An interview was conducted with the Director of Nursing (DON) on 11/23/20 at 1:51 PM who stated that she received a phone call from Nurse #3 when they observed Resident #1 outside the building on 11/14/20. The DON stated Resident #1 was already back in bed by the time she arrived at the facility, so she was not sure what he was wearing when he got out. The DON also stated they were not sure how he got out because nobody saw him exiting the building, but she thought he might have gotten out through the North side of the facility nurses' station door based on Nurse #4's recount that she last saw him around 8:00 PM on the North side. The DON was not sure if any of the residents smoked on the North side of the facility, but she stated that this door should have been locked by the staff member who came in last through the door after taking her break. The DON emphasized that both the North and the South side of the facility nurses' station doors were supposed to be locked all the time. Prior to the elopement incident on 11/14/20, Resident #1 was being monitored at least every two hours when the staff members did their rounds but after the incident, Resident #1's visual monitoring was increased to every 15 minutes. The DON investigated the incident by interviewing all staff members who worked on the evening shift of 11/14/20 about what had happened to Resident #1 and how he was able to exit the building unsupervised. The DON stated the staff were used to seeing Resident #1 walking up and down the halls and since he was not disruptive to the other residents, she did not think he needed a care plan for wandering. An observation was made with the DON on 11/23/20 at 2:55 PM of the outdoor area on the North side of the facility where Resident #1 was observed knocking on the door at the end of hall six. The distance from the North nurses' station door where the DON suspected he exited from to the door at the end of hall six was approximately 105 feet. The area was uncovered and grassy with uneven terrain. This path connected to a cemented walkway which extended towards the top of the steps which led to the lower parking lot. The distance from the side door on the North side to the top of the steps to the lower parking lot where Resident #1 was located was approximately 200 feet. There was a wooded area which was separated from the facility with a wooden fence and it was approximately 300 feet away from the North nurses' station door. The country road was about 200 feet away from the lower parking lot, but the driveway was curved and sloping downwards in an approximately 30-degree incline. The control panel for locking all the doors to the facility which was located on the North nurses' station was also observed and indicated that all the doors were locked during this observation. An interview with the Administrator on 11/23/20 at 2:11 PM revealed she received a call from Nurse #3 on 11/14/20 at the same time as the DON was informed of Resident #1's elopement. The Administrator said she was told by Nurse #3 that staff saw Resident #1 at the top of the steps to the lower parking lot and that he was not agitated. The Administrator stated she was not sure if there was any resident who went out to smoke at 8:00 PM but the staff members had started using both the North and the South nurses' station doors to go out for their breaks to reinforce social distancing during breaktimes. The Administrator further stated they had theorized that the nurses' station doors on both sides did not get locked right away after the staff members used these doors to go outside for their breaks. The Administrator added that they implemented the use of walkie talkie on 11/14/20 for staff to be able to communicate with staff on the other side of the facility since the control panel for the South nurses' station door was located on the North side of the facility. She said the staff should have been monitoring the residents at risk for elopement more often than every two hours and should have been alert and aware of Resident #1's whereabouts whenever he was wandering inside the facility. A follow-up phone interview with the DON on 11/24/20 at 2:00 PM revealed she started education with all staff members on 11/14/20 on the facility's elopement policy and for staff to ensure the doors were locked. The DON stated she read the elopement policy to the staff members and talked to them about what elopement was, what was considered elopement and what to do if a resident was missing or had eloped. The Administrator was informed of Immediate Jeopardy on 11/24/20 at 5:14 PM. On 11/25/20, the facility provided the following Credible Allegation of Compliance: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On November 14, 2020 around 8:30 PM, Nurse #2 heard knocking on the door and observed Resident #1 to be outside the building. Staff brought Resident #1 back into the building, two attempts were made to contact the responsible party for Resident #1, a body audit was performed with no findings, resident was put on elopement risk. Staff had not been aware that Resident #1 was outside of the building and were unable to determine which door the resident had exited from. There was a high likelihood of serious harm for Resident #1 because staff did not realize that Resident #1 was missing until he alerted them that he was outside the building. There was also a high likelihood of serious harm for the 4 residents in the facility with elopement risk. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On November 24, 2020, the Director of Nursing and designees initiated education with 100% of staff on elopement procedure, reporting residents exhibiting potential risk of elopement, how to identify residents identified at risk to elope, clarification that the North nurses' station door is an emergency exit only, clarification that the South nurses' door is to remain locked at all times except during resident smoking, and an introduction to the newly implemented sign-off sheet for coral medication cart nurse for verification of South nurses' station door being locked after resident smoke breaks. The Staff Development Coordinator, educated on November 24, 2020, will include this training in new hire orientation and to any agency staff when used. Training will be completed by the end of the day on November 25, 2020 with all staff being educated in person or by phone, and prior to next shift worked. On November 24, 2020, all door locking mechanisms were checked by the Maintenance Director, hourly checks of external doors (including North and South nurses' station doors) were initiated, and elopement drills were initiated for all three shifts. On November 24, 2020, the interdisciplinary team reviewed all current residents for the risk of elopement, MDS nurses updated care plans with appropriate interventions for elopement, and direct care staff were notified of the care plan updates and interventions. As a part of our 100% staff education we directed staff to the locations of the updated elopement risk lists that are available for review by all staff, including the binders at each nurses' station that are available to clinical staff with specifics about residents that are deemed an elopement risk. On November 24, 2020, the sign-off sheet for coral medication cart nurse for verification of South nurses' station door being locked after resident smoke breaks was implemented. There are up to four resident smoke breaks per day, none of which are during scheduled nurse medication pass times. The staff member who comes into the building with the last resident attends the door until it is locked. South staff use the walkie talkie kept on coral cart to direct North staff to lock the South nurses' station door, and once North staff reply that it has been locked, staff physically check the door to ensure it is locked. At this time, the coral cart nurse signs the sign-off sheet that a verification of the door being locked has been performed. For independent smokers, South staff use the walkie talkie kept on coral cart to direct North staff to unlock the South nurses' station door and contact them again to lock it once the independent smoker has exited the building. The door is attended by the staff member who let the resident out of the building during this time. Once North staff reply that it has been locked, staff physically check the door to ensure it is locked. At this time, the coral cart nurse signs off the sign-off sheet that a verification of the door being locked has been performed. When the independent smoker is ready to come into the building, they ring the doorbell that sounds at the North nurses' station. The staff member that lets them back into the building once the door is unlocked attends the door until it is locked. South staff use the walkie talkie kept on coral cart to direct North staff to lock the South nurses' station door, and once North staff reply that it has been locked, staff physically check the door to ensure it is locked. At this time, the coral cart nurse signs the sign-off sheet that a verification of the door being locked has been performed. There was no system or formal education done before to ensure that the door was locked. We believe that this will solve the issue until we can get a keypad installed on, at a minimum, the South door by the nurses' station. Deer Park therefore alleges compliance and removal of Immediate Jeopardy as of November 25, 2020. The credible allegation was verified on 12/1/20 at 12:30 PM. Elopement books were observed to be at the nurses' stations on both sides of the facility and included a picture and description of the residents currently identified at risk for elopement. In addition, a list of residents with the potential to elope was also posted on the pantry doors on both sides of the facility and in the kitchen. The staff in-services conducted on 11/24/20 through 11/25/20 were reviewed and included: the facility policy on elopement, elopement procedure, residents exhibiting elopement risk, how to identify residents assessed as elopement risk, North nurses' station door was emergency exit only and stayed locked, South nurses' station door stayed locked except during resident smoke breaks and sign-off sheet for coral cart nurse for verification of South nurses' station door being locked after smoking. The attendance records confirmed that all staff had been in-serviced. Random staff interviews were conducted on 12/1/20 from 9:22 AM through 11:29 AM and all staff members were able to describe the topics covered during the in-service on elopement. The sign-off sheets for coral cart nurse for verification of the South nurses' station door was locked after smoking were reviewed and complete. The hourly door audits by the nurses on both nurses' stations to physically check all exit doors and ensure all doors were locked were reviewed and complete. The facility's date of immediate jeopardy removal of 11/25/20 was validated.

Based on record review and staff interview the facility failed to protect a resident's right to be free from physical abuse when a resident was physically grabbed by a Nurse Aide (NA) for 1 of 3 residents reviewed for abuse (Resident #1). NA #1 grabbed Resident #1 by both wrists and held his arms above his head. Resident #1 yelled for the NA to let him go as he struggled to free himself. Following the physical abuse Resident #1 was observed to be visibly upset and had red bruises to both wrists and forearms and had puncture wounds to his left wrist and left forearm that were bleeding from the NA's fingernails digging into his skin. Resident #1's injuries were treated at the facility. After NA #1 physically abused Resident #1 the facility failed to determine if NA #1 had abused any other residents in the facility. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired and was independent with bed mobility, transfers, and locomotion on/off unit. No behaviors or rejection of care were noted during the assessment reference period. Review of a care plan developed on 04/30/19 read in part, Resident #1 was at risk for elopement related to cognitive impairment and mobility. The goal of the care plan read, Resident #1 would remain safe within the facility unless accompanied by staff or another authorized person. The interventions included: if Resident #1 was wandering in potentially unsafe or area or situation redirect to safer area, leave safe and reassess regularly. Review of an incident report dated 05/08/19 at 2:15 AM read in part, Resident #1 was at the end of the hall near the exit door and was upset and cursing. Nurse Aide (NA) #1 was standing behind Resident #1 holding his wrists/forearm causing a 0.5-centimeter (cm) skin tear and 1.5 cm red area to the left forearm. Nurse #1 asked NA #1 to release Resident #1's arms and move away from the resident. NA #1 was asked to leave the facility and Resident #1 was left alone to cool down. Director of Nursing was (DON) notified. The incident report was signed by Nurse #1. Review of a nurses note dated 05/08/19 at 2:15 AM read in part, NA notified nurse resident was hitting staff and pushing the exit door, going in other resident room at the end of the hall. Nurse went to hall and NA #1 held resident's wrist and forearm areas due to resident being combative. Resident had 1.5 cm red area to left forearm and a 0.5 cm skin tear to left hand. The note was written by Nurse #1. Review of a statement provided by NA #1 and dated 05/09/19 read in part, on 05/07/19 I was scheduled to work from 9:00 PM to 4:00 AM and was caring for Resident #1. At approximately 2:15 AM Resident #1 was roaming around in his wheelchair (WC) and was going in and out of other resident rooms. I tried to talk to Resident #1 tried to redirect him to come out of there room, he was hitting, kicking, swinging, and cussing. In the process of kicking, hitting, swinging he was hitting the doorframe and WC armrest he took his feet and shoved the WC back and it slammed me back against the glass door. Resident #1 pinned me against the glass door by rolling his WC back and forth. Resident #1 was still hitting, swinging, and kicking and I put my hand in front of my face to keep him from hitting me in the head and face. I told NA #2 to please get Nurse #1 to help get him off me. Nurse #1, NA #2 and NA #3 came down hall and Nurse #1 stated you know you are not supposed to approach an agitated patient and I replied, when it started Resident #1 was not agitated. Nurse #1 began assessing Resident #1 and I went down the hallway and was sent home at 2:30 AM by Nurse #1. At no point did I put my hands on him. The document was signed by NA #1. Review of the facility's completed investigation dated 05/10/19 read in part, The Corrective Action Following the incident read, 100% staff education was provided on abuse and neglect. Definitions of abuse as well as how and when to report were highlighted in this Inservice. Resident #1 was discharged from the facility on 06/23/19. Attempts to speak to NA #1 on 09/09/19 were unsuccessful. An interview was conducted with Nurse #1 on 09/09/19 at 2:11 PM. Nurse #1 confirmed that she was working on 05/08/19 when NA #1 held Resident #1's wrist and forearms above his head. Nurse #1 stated that Resident #1 had been up wandering on the unit for most of the shift and at one point had wandered into another resident's room. Nurse #1 stated that she had gone outside to take her break at around 2:15 AM. NA #2 came outside and stated NA #1 and Resident #1 were fighting. She added that she could tell that it was not good by the urgency in NA #2's voice. Nurse #1 stated that she and NA #3 both jumped up and ran into the building and as she rounded the corner, she witnessed NA #1 standing behind Resident #1's WC at the end of the hall near the exit door. NA #1 had both of her hands wrapped around Resident #1's wrist/forearm area. She stated that Resident #1 was hollering, Let me go. I don't wanna fight you. The resident was flailing his arms trying to break away from NA #1. Nurse #1 stated she instructed NA #1 to let go of Resident #1 and step away from the WC and she did so easily. Nurse #1 stated that there were visible red marks where NA #1's hands had been wrapped around his wrist/forearm area and there was some bleeding from where NA #1's fingernails had dug into Resident #1's arm. She stated that NA #1 went to the nurse's station and she proceeded to wipe the blood off Resident #1's arm but no further treatment was required. After NA #1 had left the area the rest of the staff let Resident #1 sit in his WC at the end of the hall and calm down and within about an hour, he had dozed off to sleep. Nurse #1 state that they let him sleep there for a bit then offered to lay him down and he accepted with no issues. NA #1 was instructed to leave the facility and did so as she was asked by Nurse #1 who also stated she notified the DON of the situation. Nurse #1 stated that she had worked with NA #1 before and never had any issues but stated she believed this was abuse and did not like the way NA #1 handled the situation. She stated that when she instructed NA #1 to let go of Resident #1 and move away from the WC she did so with ease and could have easily removed herself from the situation before it escalated. She added that it was not appropriate for NA #1 to place her hands on Resident #1 when he was agitated. Nurse #1 stated she should have walked away and approached him at a later time. She added that she had never witnessed Resident #1 being physically combative before, but it was usual for him to wander on the unit. Nurse #1 confirmed that following the incident she notified the DON, completed the incident report and documented in the medical record. She added that the DON began re-educating the staff immediately on abuse and neglect and how to properly respond to agitated residents but stated to her knowledge no resident assessments were completed following the incident. An interview was conducted with NA #2 on 09/09/19 at 1:49 PM. NA #2 stated that on 05/08/19 she worked with NA #1 as that was only her second day of orientation at the facility. NA #2 stated that Resident #1 had been wandering into other resident rooms and NA #1 had gotten him out and placed him back in the hallway. She stated that NA #1 had removed Resident #1 from another room and was trying to push him up the hallway and Resident #1 put his feet down to stop the movement of the WC. NA #2 stated that NA #1 attempted to tilt Resident #1's WC back on 2 wheels and instructed her to pick up his feet so they could move him up the hallway. NA #2 stated she refused and told NA #1 that she was going to go and get Nurse #1. NA #2 stated that when she left NA #1 with Resident #1, she had a hold of his WC. NA #2 stated that she went outside where Nurse #1 and NA #3 were taking a break and told Nurse #1 that she needed her help right now. NA #2 stated that as Nurse #1, NA #3 and herself rounded the corner of the hallway they witnessed NA #1 standing at the end of the hallway behind Resident #1's WC. She stated that NA #1 had both of Resident #1's hand held tightly above his head and Resident #1 was flailing his arms to get loose from NA #1. She explained that Nurse #1 stated to NA #1 let him go and step away from the WC and NA #1 was very agitated and red in face and she stormed off from the incident and went to the nurse's station and sat down. NA #2 stated that Nurse #1 began assessing Resident #1 and she noted blood to his left wrist/forearm area along with red marks from NA #1's hand. She added that Resident #1 did calm down and allowed Nurse #1 to put him in the bed later that shift. She also stated that NA #1 was sent home and did not finish her shift. NA #2 stated that as she was still in orientation she had just been trained on abuse and neglect and when the DON arrived at the facility that night, she again received education about abuse and neglect. She stated that she had been trained to never restrain anyone and if a resident was agitated to let the nurse know and never touch a combative resident. An interview was conducted with NA #3 on 09/09/19 at 11:07 AM. NA #3 stated that on 05/08/19 around 2:15 AM she and Nurse #1 were outside taking a break and NA #2 came outside and stated that she needed Nurse #1 now. NA #3 stated that they all ran to the unit and witnessed NA #1 at the end of the hallway standing behind Resident #1's WC and was firmly holding both of Resident #1's hands above his head. Resident #1 was hollering let me go and she could see red marks to both of his wrist area and some blood on the left wrist/forearm, he was very upset but allowed her to look at his arms. NA #3 stated that she had worked with NA #1 a couple of times and never had any issues with her but stated she felt like NA #1 abused Resident #1 and she should have not responded the way she did. We were trained that if a resident became combative to leave them alone and ensure their safety and approach them at a later time. She added that NA #1 easily removed herself from the situation when Nurse #1 instructed her to do so and she did not feel like she was trapped behind the WC. NA #3 further stated that following the incident that night the DON immediately re-educated the staff on abuse and neglect and how to handle combative residents. An interview was conducted with the DON on 09/09/19 at 2:45 PM. The DON stated that on 05/08/19 she received a call around 2:15-2:30 AM from Nurse #1 who stated she had witnessed NA #1 holding Resident #1's arms above his head and she felt like it was a case of abuse. The DON stated approximately 20 minutes later she arrived at the facility and spoke to NA #2, NA #3, and Nurse #1 and they all 3 witnessed the same thing. They all stated they witnessed NA #1 holding Resident #1's wrists above his head as he struggled to free himself from NA #1. Resident #1 was yelling, Let me go I don't want to fight you. NA #1 only released Resident #1 and stepped away from the situation when instructed to by Nurse #1. The DON stated that when she spoke to NA #1 on 05/09/19 she stated that Resident #1 had her pinned against the door and she could not get away from Resident #1. The DON stated that even if NA #1 was pinned against the door it was not appropriate for her to forcefully hold Resident #1's wrist above his head. She was trained to make sure Resident #1 was safe and then step away from the situation. Abuse and neglect training was started immediately with the staff members on duty which included the definition of abuse and how to deal with combative residents. She added that no formal audits were started at that time, but they did more vigilant monitoring on the hallways. During the first week of (MONTH) 2019 the facility had begun using an abuse questionnaire with the alert and oriented residents. The DON also confirmed that at the time of the incident no skin assessments or other measures had been completed to ensure that no further abuse had occurred. The DON stated that after she talked to the staff and reviewed their statements, she felt that NA #1 had abused Resident #1 and she substantiated the allegation and terminated NA #1 on 05/10/19. An interview was conducted with the Administrator on 09/10/19 at 11:09 AM. The Administrator stated she had been at the facility for 5 weeks but had learned of the situation with NA #1 and Resident #1 by reviewing the report and investigation. She stated that it concerned her because the event had occurred but was relieved when she read that NA #1 had been terminated which is exactly what she would have done. The Administrator stated that she was the abuse coordinator and very involved in the investigations that had occurred during her 5 weeks at the facility to ensure that all the pieces of the investigation and follow up were completed. The Administrator stated that abuse and neglect training had been completed at the time of the incident but was not aware of any further assessment or measure that were completed to determine if NA #1 had abused any other residents.

Based on record review, family, staff and Physician interviews the facility failed to protect a resident's right to remain free from physical abuse or neglect for 3 of 3 sampled residents reviewed for abuse and neglect (Resident #38, #90, and #309) Nurse aide (NA) #1 grabbed Resident #38 by the arms, yelled at her and pushed her while seated in a wheel chair into a linen cart. Resident #38 was observed to have a new skin tear on her left forearm after NA #1 was observed to grab her arms. Staff neglected to assess and implement standing orders for Resident #90 who experienced shortness of breath and an elevated body temperature. Staff failed to prevent Residents #207 and #309 from engaging in physical and verbal altercations with each other. Immediate Jeopardy began on 12/26/18 for Resident #38 when NA #1 grabbed her by the arms, yelled at her and pushed her into a linen cart. Immediate Jeopardy was removed on 02/01/19 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Examples #2 and #3 were cited at a scope and severity of a D where a plan of correction is required. Findings included: 1. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #38's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively impaired for daily decision making and was observed to have verbal and other behaviors directed towards others 1-3 days during the look back period. Resident #38 was coded as being totally dependent with bathing with a 2 person assist. A review of Resident #38's care plan, last updated 12/05/18, revealed care plan areas for verbally abusive behaviors and socially inappropriate and disruptive behavior. Interventions included not to argue with Resident #38, monitor and document behaviors, approach Resident #38 warmly and positively, administer medications as ordered and to allow Resident #38 to make choices and participate in care. A review of a 24 hours report dated 12/26/18 at 8:30 AM revealed two nurse aides (NA #2 and NA #3) observed NA #1 push Resident #38 against a linen cart while he prepared to provide Resident #38 with a bath, grab her arms and yell that she was not going to hit him again. A review of NA #1's written statement dated 12/26/18 revealed he was assisting Resident #38 with a shower and while he was pushing her into the bathroom, Resident #38 kicked him in the face. He reported to step away from Resident #38 while she continued to swing at him (unspecified with what appendage) and he reportedly asked Resident #38 would you please stop hitting me. He then reported noting a skin tear to Resident #38's left forearm. There was no mention in his statement that he placed his hands on Resident #38. Observations made of Resident #38 01/31/19 at 5:43 PM revealed verbal behaviors directed towards staff that included cursing and yelling at them. No physical behaviors by Resident #38 were noted towards staff or other residents. An interview with Resident #38 was unsuccessful as her cognitive state prevented Resident #38 from following the line of questioning. An attempt to interview NA #1 on 01/31/19 at 1:42 PM proved unsuccessful. An interview with NA #2 on 01/31/19 at 11:33 AM revealed she was in the shower room with NA #1, NA #3 and Resident #38. NA #2 reported that she observed NA #1 bend down to move a foot pedal on Resident #38's wheelchair when Resident #38 kicked NA #1. NA #2 then observed NA #1 push Resident #38 back in her wheelchair, then stand up grab Resident #38's arms and heard NA #1 tell Resident #38 that she would not hit him again. NA #2 stated she immediately intervened and told NA #1 to leave and once he left she went and told her supervisor, Nurse #1. She reported Nurse #1 immediately sent NA #1 home. She reported Resident #38 had a skin tear to her left forearm which was treated. She reported she had not seen NA #1 since the incident. During a follow up interview with NA #2 on 01/31/19 at 1:39 PM she reported that she observed Resident #38 kick NA #1 in the face, and after NA #1 was kicked in the face, NA #2 observed NA #1 to stand up and grab both of Resident #38's arms, crossed them and held them against her chest while yelling that she would not hit him again. She reported it was her belief the skin tear to Resident #38's forearm came when NA #1 grabbed Resident #38's arms and held them to her chest. She reported when NA #1 pushed Resident #38 pushed her in her wheelchair into a linen cart she came into contact with the linen cart on her right side and the skin tear was noted on her left forearm. A review of NA #3's written and signed statement dated revealed she was in the shower room at the time of the incident in which NA #1 pushed, grabbed Resident #38's arms and yelled at Resident #38. NA #3's written statement specified she heard NA #1 state to Resident #38 you're not gonna kick me then she reported hearing an unknown collision. She reported never visually seeing the incident. An interview with NA #3 was attempted on 01/31/19 at 10:59 AM and was unsuccessful. Contact with NA #3 proved unsuccessful after several attempts to reach her during the survey. An interview with Nurse #1 was attempted on 01/31/18 at 11:44 AM which was unsuccessful. During an interview with the Director of Nursing (DON) on 01/31/18 at 2:51 PM she reported she was made aware of the incident of NA #1 abusing Resident #38 on 12/26/18 when she arrived at the facility at 8:00 AM on 12/26/18. She reported the incident occurred before she arrived and to her knowledge it was reported that NA #1 became frustrated with Resident #38 and grabbed both of her arms and pushed Resident #38. She reported She reported that NA #2 immediately stepped in and told NA #1 to leave and reported it to her supervisor (Nurse #1) who immediately sent NA #1 home. She reported NA #1 was familiar with Resident #38 and her behaviors and he should have been aware of appropriate interventions to utilize to redirect or attempt to calm Resident #38. The DON verified Resident #38 had been noted with a skin tear to her left forearm after the incident that was treated. An interview with the Administrator on 01/31/18 at 3:11 PM revealed she was made aware of the incident of NA #1 abusing Resident #38 during the morning of 12/26/18. She reported to her knowledge Resident #38 kicked NA #1 in the face while he was preparing to shower her and he retaliated, pushed her into a linen cart, grabbed her arms and yelled at her that she would not hit him again. She reported it was immediately reported and NA #1 was sent home by Nurse #1. She stated NA #1 was very familiar with Resident #38, her behaviors and should have known appropriate intervention to take when Resident #38 began with abusive behaviors. She reported she immediately began an investigation into the incident, and substantiated the allegation due to there being an eyewitness and terminated NA #1. She reported when she spoke with NA #1 about the incident he denied it happening as reported and stated that he politely asked Resident #38 to stop hitting him. She stated NA #1 did not return to the facility during the investigation and only returned long enough to be informed that the allegation was substantiated and he was terminated. She reported while he was in the building he was escorted and had no contact with any of the residents. She reported it was absolutely unacceptable to ever grab a residents arms, cross them and hold them to a resident's chest if the resident was lashing out at a staff member. She reported, once he got kicked he should have backed off, stepped away and asked for another staff member to step in and attempt to provide care. The Administrator was notified of Immediate Jeopardy on 01/31/19 at 6:41 PM. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 02/01/19 at 4:11 PM. Credible Allegation of Immediate Jeopardy removal F-600 FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION Resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 12/26/2018 at approximately 7:00 am, Resident #1 was taken into the shower room, Nurse Aide (NA) #2 stated that Nurse Aide (NA) #1 was trying to adjust the foot rest on the shower chair when Resident #1 kicked (NA) #1in the face. (NA) #1 grabbed the shower chair and pushed it into the linen barrels. Resident #1 then tried to hit (NA) #1 when he grabbed both of her arms, held them to her chest, and proceeded to yell and curse at her. At this time Nursing Aide (NA) #2 took over caring for Resident #1 and (NA) #1 left the shower room. On 12/26/2018 at approximately 7:20 am (NA) #1 was sent home by the supervisor and placed on suspension (officially terminated on 12/28/2018) after exiting the shower room (NA) #1 was accompanied by the nursing supervisor and escorted out of the building. On 12/27/2018 at approximately 3:00 pm (NA) #1 was interviewed. He stated on 12/26/18 he assisted resident #1 with a shower. While taking Resident #1 to the bathroom the resident kicked (NA) #1 in the face. As (NA) #1 was moving away, the resident was swinging multiple times at (NA) #1. (NA) #1 said to Resident #1 would you please stop hitting me, at that time (NA) #1 noticed a skin tear to Residents #1 left forearm. (NA) #1 made no mention of being tired or frustrated at the time of the incident. On 12/26/2018 at approximately 7:30 AM statements from (NA) #2 and NA #3 were was obtained by the DON. Nursing Aide (NA) #3 provided a statement that she was showering another resident in another stall and did not visually witness any actions but did hear (NA) #1 say you are not going to kick me and a noise of something ramming against something else. (NA) #2 stated that (NA) #1 was trying to adjust the foot rest on the shower chair when Resident #1 kicked (NA) #1in the face. (NA) #1 grabbed the shower chair and pushed it into the linen barrels. Resident #1 then tried to hit (NA) #1 when he grabbed both of her arms, held them to her chest, and proceeded to yell and curse at her. On 12/26/2018 after leaving the shower room the treatment nurse assessed Resident #1 for injury and noted two skin tears, one on each forearm, that were cleansed and a dressing applied. On 12/26/2018 at approximately 8:30am the Licensed Nursing Home Administrator (LNHA) was notified of the occurrence. At this time statements were reviewed and the collection of facts began. On 12/26/2018 at approximately 9:25 am the LNHA interviewed Resident #1 and she reported that someone yelled at her and held her arms. On 12/26/2018 at approximately 10:21 am the initial allegation was faxed to DHHS for review. NA #1 returned to the facility on [DATE]. NA # 1 entered the building and immediately was taken into the LNHAs office where his statement was written. NA # 1 was notified at that time that his employment was terminated. The LNHA then escorted NA # 1 out of the building. Law enforcement was not contacted at the time of the incident. On 2/1/2019 McDowell County Sheriff's Department was notified. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 12/27/2018 the DON, staff development coordinator and LNHA began to round the building using an Abuse/Neglect Questionnaires to interview all alert and orientated residents. The questionnaire revealed no further resident's allegations of abuse. On 12/28/2018 the DON, staff development coordinator and LNHA interviewed all residents which also revealed no further allegations of abuse. Skin assessments were completed by the licensed nurses, by 12/29/2018 on all cognitively impaired residents. Residents were assessed for injuries or possible physical abuse with no concerns noted. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On 1/31/2019 the Clinical coordinator, DON, Charge nurse and LNHA initiated small group meetings with 100% of staff, to include Nursing, dietary, laundry, housekeeping and maintenance department discussed the facility's policy and procedures on abuse, abuse reporting, definition of abuse, mistreatment of [REDACTED]. Education was presented to all staff in the facility at that time. No staff will be allowed to work until participating in the small group discussions on abuse, types of abuse and reporting abuse. The small group meetings will be completed by 2/1/2019. The discussion and in-service will be added to new employee orientation. All staff to include Nursing, dietary, laundry, housekeeping and maintenance department receive Hand in Hand, Understanding the world of dementia and The person and the disease annually. Starting on 2/1/2019 the Social Worker (SW) will do weekly rounds asking interview able residents if staff are not abusing resident but treating residents with dignity and respect. The weekly SW rounds will be completed for 6 months and the results taken to the monthly QAPI meetings for review and further recommendations. Starting on 2/1/2019, the administrative nursing staff will monitor direct resident care and observe residents for injuries of unknown origin. 10 % of residents will be observed daily from varied shifts x 4 weeks, then weekly x 4 weeks, then monthly for 6 months to ensure no abuse is occurring. Starting on 2/1/2019, the audit results will be taken to the QAPI meeting monthly for discussion and further recommendations. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) On 2/1/2019, the DON and LNHA notified the daily quality assurance and performance improvement (QAPI) team. The facilities Medical Director was made aware of the plan (MONTH) 1, 2019 and approved. The daily QAPI team's role in this plan of correction includes implementation and monitoring, ensuring the interventions are effective. Beginning 2/1/2019, The Social Worker will do weekly rounds asking interviewable residents if staff are being good to the residents for 6 months. In addition, beginning on 2/1/2019, The Administrative nursing staff will monitor direct care of 10% of resident's daily from varied shifts for 4 weeks, then weekly for 4 weeks, and then monthly for 6 months starting 2/1/2019 to ensure no abuse is occurring. The results of the audits will be presented to QAPI team each week for 6 months. The daily QAPI team's role in this plan of correction includes implementation and monitoring, ensuring the interventions are effective. The QAPI team will also make recommendations for revisions as needed. The daily QAPI review findings will be brought to the next monthly QAPI meeting on (MONTH) 13, 2019 for additional review and recommendations. The results of the audits will be presented to QAPI team each week for 6 months. Beginning 2/1/2019, the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Deer Park Health and Rehabilitation alleges compliance of removal of IJ as of 2/1/2019. Immediate Jeopardy was removed on 02/01/19 at 7:34 PM when interviews with direct care staff, administrative staff and non-nursing staff confirmed they had received in-service training on the facility's Abuse Policy and other interventions spelled out in the Assurance of Compliance were verified in place. 2. Resident # 90 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], noted Resident #90 to be moderately cognitively impaired. The MDS further revealed Resident #90 required extensive, two-person assistance with all activities of daily living (ADL). Review of the nursing note dated 01/28/19 at 12:00 PM written by Nurse #1 revealed Resident #90 was found lying on the floor. Resident #90 stated he told staff 9 times that he wanted to go to bed and that was why he had fallen into the floor. The note revealed Physician #1 was in the facility and notified of Resident #90's fall. Review of nursing note dated 01/28/19 at 3:30 PM revealed Physician #1 had examined Resident #90 and new orders had been obtained to initiate 2 liters of intravenous fluid and lab work for the morning of 1/29/19. Review of the nursing note dated 01/29/19 at 5:00 PM written by Nurse #1 revealed Resident #90 had a temperature of 101 degrees. The note further revealed Resident #90 had stated to the nurse,he did not feel like he was breathing good enough and had a poor appetite. Review of the Physician Standing Orders revealed orders to notify the physician for a fever of 100.0 or greater. The review further revealed an order to start supplemental oxygen at 2 liters/min for shortness of breath for a duration of 72 hours and to notify the physician. Review of the Medication Administration Record [REDACTED]. The review revealed on 01/29/19 Nurse #1 had not initialed giving Resident #90 his scheduled 4:00 PM dose. Review of Nursing Note dated 01/29/19 at 7:30PM written by Nurse #3 revealed Resident #90's wife had requested he be sent to the emergency room (ER) for an evaluation. The note revealed Nurse #3 called the physician and obtained orders to send Resident #90 to the emergency room (ER). On 1/31/19 at 2:18 PM an interview was conducted with Nurse Aide (NA) #1 and revealed she had been responsible for Resident #90 on 01/29/19 7:00 AM to 3:00 PM first shift. NA #1 stated Resident #90 had been restless with an elevated temperature of 101.0 on the morning of 1/29/19 which she stated she reported to Nurse #1. On 1/31/19 at 4:08PM an interview was conducted with Nurse #1. The interview revealed she had been Resident #90's nurse on 01/29/19 for first shift 7:00 AM to 3:00 PM. Nurse #1 stated Resident #90 had an elevated temperature greater than 100.0 on the morning of 01/29/19 for which she administered his regular dose of ordered Tylenol 650 mg at 10:00 AM and rechecked the resident's temperature in which she could not recall the result. She stated Resident #90 had been anxious and told her he wasn't able to catch his breath with an oxygen saturation of 89%. Nurse #1 stated she did not give Resident #90 any supplemental oxygen per physician standing orders because his oxygen saturation had increased to 91% while she was in the room with Resident #90. The interview revealed Resident #90's morning vital signs had not been documented, the physician had not been notified, nor had Nurse #1 assessed Resident #90 after her second medication pass at 2:00PM on 01/29/19 because her shift was ending. On 1/31/19 at 04:46 PM an interview was conducted with Nurse #2. The interview revealed he had received report from Nurse #1 on 01/29/19 at 4:30PM. Nurse #2 stated he was not informed of Resident #90's complaints of shortness of breath, or elevated temperature. Nurse #2 did not assess Resident #90. The interview revealed Nurse #2 normally did not work on the North side of the facility in which Resident #90 was located due to short staffing. Nurse #2 did not assess Resident #90 because no issues were reported from Nurse #1. On 1/31/19 at 4:56 PM an interview was conducted with Nurse #3. Nurse #3 stated she had received report from Nurse #2 on 01/29/19 at 6:00PM and was notified of Resident #90's lab results. Nurse #3 stated she received the critically low carbon [MEDICATION NAME] level, this is when the body fails to remove carbon [MEDICATION NAME] through the lungs or the kidneys or perhaps because of an electrolyte imbalance, particularly a deficiency of potassium, of 16 mEq/L for Resident #90 and informed the physician at 6:50 PM. Nurse # 3 stated Resident #90's wife came to the nurse ' s desk at 7:30 PM requesting her husband to be sent to the ER because she thought he had pneumonia. Nurse #3 stated she did not go to Resident #90's room to assess him due to him being sent to the emergency room at the wife's request. The interview revealed Nurse #3 did not leave the nurse station, Resident #90's wife dressed him and brought him to the nurse' s station awaiting Emergency Medical Service (EMS) arrival. Review of the EMS report dated 01/29/19 at 7:35 PM revealed Resident #90 had a temperature of 100.0. The report revealed Resident #90 had been placed on 4 Liters of supplemental oxygen by EMS staff. The EMS assessment revealed Resident #90 had wheezing in all lobes, was tachypneic, breathing abnormally fast, and showing signs [MEDICAL CONDITION] with an oxygen saturation reading of 91%. Review of the Hospital Discharge Summary dated 1/29/19 revealed [DIAGNOSES REDACTED]. On 2/01/19 at 8:41AM an interview was conducted with the Director of Nursing (DON). The DON stated her expectations were for the nurse to have notified the physician of Resident #90's elevated temperature on 1/29/19 and to have initialed the scheduled 4:00PM dose of Tylenol as ordered. She stated her expectations were for the nurse to follow facility protocol and physician standing orders. On 2/01/19 at 10:10AM an interview was conducted with Physician #1. Physician #1 stated he had not been notified on 1/29/19 of Resident #90's shortness of breath or elevated temperature but had seen Resident #90 on the dates of 1/25/19 and 1/28/19. The interview revealed Physician #1 had been notified of Resident #90's abnormal lab result on 1/29/19 at 6:50 PM in which he initiated orders to obtain a repeat basic metabolic panel (BMP) on the morning of 1/30/19. Physician #1 was notified at 7:30 PM of Resident #90's wife's request for the resident to be sent to the emergency room . The interview revealed his expectations were for the Nurse to administer medications as ordered and to follow facility protocol. 3. Resident #309 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #309 was Hispanic and spoke little English, had short and long term memory problems and had modified independence with daily decision making skills. The MDS also indicated Resident #309 was ambulatory on and off the unit without physical assistance from staff and displayed no verbal or physical behaviors. Review of Resident #309's current undated Care Plan indicated in part that he had a history of [REDACTED]. The established goal was for Resident #309 to have no injuries related to medication usage or side effects through the next review dated 02/13/19. The interventions included to give Resident #309 his medications as ordered by the physician, discuss the side effects of the medications with him and his family, and to monitor him for adverse side effects of his medications, report the adverse side effects to the physician and to monitor his behaviors. Review of Resident #309's Nurse's Notes from 11/02/18 to 11/26/18 had no documentation of aggressive behavior. Resident #207 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission comprehensive MDS dated [DATE] revealed Resident #207 was cognitively intact, displayed no verbal or physical behaviors and ambulated on and off the unit without physical assistance from staff. Review of Resident #207's current Care Plan revealed no care plans developed for aggressive behaviors. Review of Resident #207's Nurse's Notes from 11/08/18 to 11/26/18 had no documentation of aggressive behavior documented. Review of Resident #309's Nurse's Note dated 11/27/18 at 8:50 PM completed by Nurse #5 revealed, Nurse #5 heard Resident #207 yell that's my phone. Upon entering the Resident's room she observed Resident #309 standing face to face to Resident #207 saying television. Resident #207 handed the television remote to Resident #309 and Resident #309 threw the remote to the floor. Resident #207 told Nurse #5 that he could not understand what Resident #309 was saying to him and that he would not sleep in the room with Resident #309 another night. The Nurse's note indicated Nurse #5 moved Resident #309 to another room for the night and the situation could be dealt with on a more permanent basis the following morning. The note also indicated the Director of Nursing (DON) along with the Resident's responsible parties and their physicians were notified. Review of the facility Incident Report (IR) dated 11/27/18 at 8:50 PM completed by Nurse #5 revealed, Nurse #5 heard Resident #207 yell that's my phone. Upon entering the Resident's room she observed Resident #309 standing face to face to Resident #207 saying television. Resident #207 handed the television remote to Resident #309 and Resident #309 threw the remote to the floor. Resident #207 told Nurse #5 that he could not understand what Resident #309 was saying to him and that he would not sleep in the room with Resident #309 another night. The IR indicated Nurse #5 moved Resident #309 to another room for the night and the situation could be dealt with on a more permanent basis the following morning. The IR also indicated the Director of Nursing (DON) along with the Resident's responsible parties and their physicians were notified. Review of Resident #309's nurse's note dated 11/28/18 7:45 AM completed by Nurse #6 indicated she heard Resident #207 yell and upon entrance to the room she observed Resident #207 with his hands around Resident #309's neck and pushed him backwards to the floor with Resident #309 hitting his head on the bed frame. The nurse's note also indicated Nurse #6 checked Resident #309's head for injuries which there were none but because Resident #309 complained of a headache he was sent to the Emergency Department (ER) for assessment. Review of Resident #309's Physician order [REDACTED].#309 to the ED. Review of Resident #309's progress notes from the ED visit on 11/28/18 indicated an X-ray of Resident #309's head was obtained which showed a contusion. The progress notes indicated Resident #309 was transferred back to the facility without any treatment necessary. Review of an Internal Investigation Report (IIR) completed by the facility on 12/03/18 revealed, on 11/28/18 at 9:00 AM Resident #207 was observed with his hands around Resident #309's neck and aggressively pushed Resident #309 across the room which caused him to fall backwards hitting his head on the bed frame. The IIR indicated Resident #309 was sent to the ED for evaluation and treatment. On 01/31/19 at 6:02 PM an interview was conducted with the Social Worker (SW) who explained on the morning of 11/28/18 the management team was made aware of the verbal incident between Residents #309 and Resident #207 the night before and that Resident #309 was initially moved to a different room until a more permanent solution could be implemented. The SW stated during the management meeting they were informed of a physical altercation between Resident #309 and Resident #207 and went to Resident #309 and Resident #207's room and found the altercation had already taken place. Resident #207 was sitting in his wheelchair in the hall while staff were in the room assisting Resident #309 out of the floor. The SW indicated during an interview with Resident #207 afterwards he stated he was in the bathroom when Resident #309 opened the bathroom door and said something he could not understand that made him feel threatened. Resident #207 stated he came out of the bathroom and shoved Resident #309 backwards and Resident #309 fell to the floor. The SW stated the decision was made to move Resident #207 to a room on a different hallway where their paths would not cross and on 12/08/18 Resident #207 had a planned discharge home. The SW added the residents had been roommates since Resident #207 was admitted on [DATE] and there had been no adverse situations between them that she was aware of. During an interview on 02/01/19 at 8:58 AM with Nurse #6 she stated she was on the hall the morning of 11/28/18 and heard Resident #207 yelling and she went to his room and observed Resident #207 with his hands around Resident #309's neck and pushed him backwards to the floor in which Resident #309 hit his head on the bed frame. Nurse #6 stated she immediately went to Resident #309 who was on the floor and by that time other staff members were there to intervene with Resident #207 and took him out of the room. Nurse #6 stated they assisted Resident #309 out of the floor and she assessed the back of his head but there were no apparent injuries. Nurse #6 stated Resident #309 complained of a headache and was sent to the ED for evaluation but returned shortly afterwards with a [DIAGNOSES REDACTED]. Nurse #6 added she worked with the two residents frequently and was not aware of any negative situations between the two before that day. Nurse #6 added Resident #207 was moved to a room in a different part of the facility away from Resident #309 that day and did not think the two residents ever saw each other again. On 02/01/19 at 11:00 AM during an interview with the DON she stated she was made aware of the verbal incident between Residents #309 and #207 the night of 11/27/18 by Nurse #5 and agreed with the decision to move Resident #309 to a different room until a more permanent solution was reached. The DON stated she instructed the Nurse to pass along the incident to the Administration the next day because she was out of town. On 02/01/19 at 1:45 PM during an interview with Nurse Aide (NA) #5 she explained that on the morning of 11/28/18 she and a coworker heard someone yell they are fighting and ran to the room where they observed Resident #309 lying in the floor. NA #5 stated Nurse #6 was already in the room and was assessing Resident #309 while she and her coworker removed Resident #207 from the room. NA #5 stated that afterwards Resident #309 told them he was looking for his shoes and went to his room to get them. NA #5 stated Resident #309 was sent to the ED and came back to the facility later that day and was separated from Resident #207 until Resident #207 was moved to a different room. NA #5 also indicated she was not aware of any time the two roommates did not get along. During an interview on 02/01/19 at 2:40 PM NA #6 stated she heard someone yell they are fighting and ran down to the room. She stated Nurse #6 was already in the room standing between Resident #309 who was on the floor and Resident #207 who was standing behind the Nurse. Resident #207 stated he was in the bathroom and Resident #309 came in on him and he thought Resident #309 was going to attack him. NA #6 stated they took Resident #207 out of the room until they got Resident #309 out of the floor and assessed him then took Resident #309 to the dayroom for his breakfast before they sent h

Based on record reviews and Physician Assistant interview and staff interviews the facility failed to protect a resident from falls and injury who fell 5 times within a 37 hour time frame resulting in lacerations and hematomas to his head and the last fall resulted in a subdural hematoma for 1 of 3 residents sampled for supervision to prevent accidents (Resident #20). The findings included: Resident #20 was admitted to the facility on [DATE] from home with [DIAGNOSES REDACTED]. A review of an Admission Nursing Evaluation dated 09/22/16 at 12:35 PM indicated in part Resident #20 was alert and confused and was uncooperative. The document revealed Resident #20 required no assistance with walking, transfers or bed mobility but was frequently incontinent of bowel and bladder. A section labeled Fall Risk Evaluation indicated Resident #20 was disoriented to person, place and time at all times and had 3 or more falls in the past 3 months and a section labeled Side Rail Evaluation indicated no side rails. A review of an interim admission care plan dated 09/22/16 indicated Resident #20 was at risk for falls related to unsteady gait and had poor safety awareness due to dementia and his fall risk score was 19 (a score of 10 or above indicated fall risk). The goal was listed that Resident #20 would not sustain major injury related to falling over next review and the interventions were listed to complete fall risk screen on admission, place call bell in easy reach, cue Resident #20 for safety awareness and assist for toileting and transfers as needed and keep environment safe. A review of a Care Card indicated Resident #20 required supervision and cueing with transfers, walking, toileting every 2 hours and non-skid socks and shoes. A review of a nurse's note dated 09/23/16 at 9:45 PM by a second shift Nursing Supervisor revealed staff encouraged Resident #20 to go to bed and he would lay down for a short period of time but then got back up. The notes further revealed Resident #20 had a slow, steady shuffle gait and appeared somewhat unsteady when he walked and his Responsible Party (RP) denied Resident #20 had falls at home but another family member who was present indicated Resident #20 had 3 recent falls while at home. A review of a nurse's note dated 09/23/16 at 6:00 AM by Nurse #8 revealed Resident #20 rested very little last night and was walking in and out of resident rooms with a shuffling gait and repeatedly asked how could he get out of there. A review of a nurse's note dated 09/23/16 at 1:35 PM by Nurse #5 revealed Resident #20 was wandering in the hallway with a shuffling gait and had increased confusion. A review of a nurse's note dated 09/24/16 at 2:00 PM by Nurse #5 revealed the on-call physician was notified regarding Resident #20 ' s increased agitation and an order was received for Ativan 1 milligram (mg) intramuscularly (IM) every 6 hours as needed for increased anxiety or agitation. A review of a nurse's note dated 09/24/16 at 4:00 PM revealed Resident #20 was kicking and punching at staff and Ativan 1 mg was given IM. A review of an incident report dated 09/25/16 at 9:10 AM by Nurse #5 revealed Resident #20 was found sitting in the floor in front of a closet with a laceration and a hematoma (a raised area from blood collected under the skin) to his mid forehead. The notes further revealed Resident #20 was assisted with first aid to control bleeding and was sent to the emergency room . A review of a change in condition form titled Situation, Background, Assessment and Request (SBAR) dated 09/25/16 at 9:10 AM by Nurse #5 revealed Resident #20 had an unwitnessed fall with a laceration to his forehead. A review of a nurse's note dated 09/25/16 at 9:30 AM by Nurse #5 revealed a staff member told her Resident #20 was in the floor. The notes indicated Resident #20 was found in his room sitting in the floor in front of a closet and he had a laceration to his mid forehead and bleeding was controlled with gauze pads. The notes further indicated the physician on call was notified and orders were received to send Resident #20 to the hospital for treatment and evaluation. The notes revealed emergency medical services (EMS) was in the facility at 9:55 AM to transport Resident #20 to hospital. A review of a nurse's note dated 09/25/16 at 12:40 PM by Nurse #5 revealed Resident #20 was back in facility from the hospital. A review of the interim care plan revealed it was updated on 09/25/16 to place a fall mat at the side of Resident #20's bed. A review of a nurse's note dated 09/25/16 at 7:20 PM by Nurse #6 revealed Resident #20 was in bed but had refused vital signs and neuro checks and was agitated and combative with staff. The notes indicated Resident #20 did not verbalize his needs and would continue to monitor frequently. A review of an incident report dated 09/26/16 at 1:05 AM by Nurse #6 revealed Resident #20 was found on the floor sitting up in front of the bed with a superficial abrasion on the top of his head and normal saline and gauze were used to clean the abrasion. The report indicated Resident #20 was trying to get out of bed. A review of a nurse's note dated 09/26/16 at 1:10 AM by Nurse #6 revealed Resident #20 was found on the floor sitting in front of the bed with a superficial abrasion on the top of his head that was cleaned with normal saline and gauze. The notes indicated Resident #20 refused vital signs and neuro checks from a previous fall and he had a dressing intact on the midline of his forehead. The notes further indicated Resident #20 was confused and combative with staff, refused to stay in bed, refused to eat, refused oral medications and did not verbalize needs. The notes revealed will monitor Resident #20 frequently. A review of a nurse's note dated 09/26/16 at 3:45 AM by Nurse #7 revealed Resident #20 was found in floor after the nurse heard his head hit floor. The notes indicated Resident #20 had a bruise near the middle of his right ear and a skin tear to the top of his head on the right side. The notes further indicated the skin tear was cleaned with normal saline and a wet to dry dressing was applied. The notes also indicated Resident #20 refused vital signs and was fighting staff when they tried to help him to bed and continue to monitor Resident #20. A review of an incident report dated 09/26/16 at 3:45 AM by Nurse #7 revealed Resident #20 was found in the hall just outside of his room with a bruise over his right ear and a skin tear to the top of his head on the right side. The notes indicated the skin tear was cleaned with normal saline and a wet to dry dressing was applied and the report indicated Resident #20 was walking when he fell . A review of a nurse's note dated 09/26/16 at 4:30 AM by Nurse #7 revealed Resident #20 was in bed and was confused. The notes further revealed Resident #20 raised his hands and arms when approached to obtain vital signs and a bandage to his head was intact with no bleeding through the bandage. A review of the interim care plan revealed it was updated on 09/26/16 for bed in lowest position, physician review of medications, encourage resident to toilet frequently and wear non-skid socks and shoes. A review of a nurse's note dated 09/26/16 at 1:00 PM by Nurse # 1 revealed the Physician's Assistant (PA) was in and reviewed notes and new orders were received to refer to psychiatry for consult. The notes further revealed Resident #20 was disoriented and did not respond appropriately even with his RP and was unable to follow commands or instructions. The notes indicated a fall mat was at bedside, skid proof socks were worn and call bell was in reach but Resident #20 did not demonstrate use of it. A review of a PA note dated 09/26/16 revealed Resident #20 was combative at times and had received IM Ativan which caused him to have ataxia (loss of full control of body movements). The note further revealed Resident #20 had fallen on a couple of occasions and was sent out to the hospital for evaluation and had a Computerized Tomography (CT) scan which was negative for any acute findings but he had a superficial laceration of the scalp which was treated with a dressing. The notes indicated this morning he was lying in bed and at this time and was not responding verbally and was gotten up by a couple of NAs but was very unstable on his feet. The notes indicated to refer to psychiatry for evaluation and treatment of [REDACTED]. A review of a nurse's note dated 09/26/16 at 2:15 PM by Nurse #1 revealed a NA observed Resident #20 was lying on his back on the floor with his feet toward the bed and his head toward the television stand. The notes further revealed a skin tear on the left side of Resident #20's head had reopened and he had 2 protrusions on the left side of his forehead and left side of the top of his head. The notes indicated bleeding was stopped and steri-strips were applied and Resident #20 moved all extremities spontaneously but did not follow commands. The notes also indicated 1 staff stabilized Resident #20's head while 2 staff stabilized his body and 1 staff checked his pupils which were equal and reactive to light and Resident #20 had bit his lower lip during the fall. The notes revealed orders were received from a PA to send Resident #20 to the hospital for evaluation and treatment. A review of an incident report dated 09/26/16 at 2:15 PM revealed staff passed by Resident #20's room and saw him lying on the floor on his back with his feet toward the bed and his head toward a television stand. The notes further revealed a skin tear on the left side of his head from a previous fall had reopened and there were 2 protrusions on the left side of his forehead and on the top of his head on the left side and steri strips were applied and Resident #20 had bit his lip when he fell . The report indicated Resident #20 was ambulating unassisted when he fell . A review of a nurse's note dated 09/26/16 at 2:50 PM by Nurse #1 indicated EMS was in the facility to transport Resident #20 to the emergency room for evaluation and treatment. A review of a nurse's note dated 09/26/16 at 7:50 PM by a second shift Nursing Supervisor revealed Resident #20 returned to facility and was placed in bed but was non-responsive to voices. A review of a nurse's note dated 09/26/16 at 10:00 PM by a second shift Nursing Supervisor revealed Resident #20 was found on the floor with profuse bleeding from his head and had a hematoma at his right temporal lobe with a laceration. The notes indicated bleeding was finally controlled and his blood pressure was 146/100, pulse 96, respiration 18 and oxygen saturation was 98 percent. The note also indicated Resident #20 had been lying in bed prior to the fall and his fall was unwitnessed. A review of an incident report dated 09/26/16 at 10:00 PM by a second shift Nursing Supervisor revealed Resident #20 was found in the floor with a laceration to his right temporal lobe with a hematoma growing. The notes indicated 911 was called and Resident #20 was sent to the emergency room and staff would need to do one on one supervision to prevent falls. A review of a hospital History and Physical dated 09/26/16 revealed Resident #20 had a head injury after multiple falls. The report indicate Resident #20 had fallen as many at 5 times according to family and was sent to the emergency room multiple times in the last 48 hours and each time received a CT of the head. The report further indicated the last CT revealed an acute subdural hematoma of approximately 3 millimeters in width. A review of a hospital Discharge Summary dated 09/29/16 indicated a repeat CT scan completed on 09/28/16 was stable. During an interview on 10/04/16 at 12:55 PM with Nurse #5 she stated Resident #20 had severe dementia and would not stay in his room. She explained when he first came to the facility his gait was steady and he needed no assistance with ambulation but the more he walked the more unsteady he got and staff encouraged him to sit down when his gait was unsteady. She stated she was working when Resident #20 had a fall on 09/25/16 at 9:30 AM and a NA came and got her and when she walked in Resident #20's room another NA was in the room. She explained Resident #20 had a gash in the middle of his forehead and she cleaned it and called the on call physician and got an order to send him to the emergency room . She stated she did not know anything about fall precautions for Resident #20 but they had tried to keep him in common areas where staff could watch him but he would not stay in the areas because he could not stay still. During an interview on 10/04/16 at 1:43 PM with the PA who had examined Resident #20 on 09/26/16 he explained the Medical Director had resigned from his duties at the facility within the last couple of weeks and a new Medical Director would be coming to the facility tomorrow. He stated staff had access to on call physician's 24 hours a day but he was the only medical provider who had seen Resident #20 at the facility and was aware he had fallen several times. He further stated he had told facility staff if Resident #20 continued to fall that eventually he would have a subdural hematoma and confirmed that had happened with his last fall on 09/26/16 at 10:00 PM. He explained he thought Resident #20 had balance problems before he came to the facility and was agitated and was uncooperative with staff. He further explained he had ordered a psychiatric consult because he thought Resident #20 needed a psychiatric evaluation and his medications reviewed but was not sure if that was done since Resident #20 had been sent out to the hospital on [DATE] and had not returned to the facility. During an interview on 10/04/16 at 2:38 PM with Nurse #9 she confirmed she completed some of Resident #20's admission nursing assessment and had interviewed family to get information because Resident #20 was unable to answer her questions. She explained she documented Resident #20 had falls at home and was very uncooperative. She stated he could not follow directions because he had comprehension and communication problems, was disoriented to person, place and time at all times and was severely impaired in cognition for daily decision making. She explained she was working when Resident #20 had the last fall on 09/26/16 at 10:00 PM and it was a bad fall. She stated prior to his fall Resident #20 had been in the bed and then a NA came screaming for the second shift Nursing Supervisor and she went with her to Resident #20's room. She explained Resident #20 was on the floor and there was a lot of blood in the floor and his whole face was bloody but when they cleaned the area on his head the cut was not that big. She stated Resident #20 had his eyes open but did not say anything and it was not a surprise to her that he fell because he had already fallen 3 or 4 times because he would just get up and go as he pleased. She stated she did not feel they were equipped to take care of Resident #20 because they could not watch him constantly. During an interview on 10/04/16 at 3:32 PM with Nurse #1 she explained Resident #20 kept falling and he hit his head every time he fell . She stated she was working on 09/26/16 at 2:15 PM and NA #1 was walking by his room and saw him lying on the floor on his back with his feet toward the bed and his head toward a television stand and NA #1 called her to the room. She explained the skin tear he had gotten on his head from a previous fall had reopened and was bleeding and he had 1 protrusion near his forehead and another protrusion on the left side on the top of his head and both areas were near the skin tear on the left side of his head. She stated she stopped the bleeding and put steri-strips on it and Resident #20 was moving his extremities but he did not follow commands. She explained she called the PA and received orders to send Resident #20 to the emergency room for evaluation and treatment. She stated staff were expected to assess his needs every 2 hours during routine rounds. She further stated she guessed there should have been a discussion about options to prevent Resident #20's falls but she did not see how they could have prevented his falls since he couldn't communicate. During an interview on 10/04/16 at 5:09 PM with NA #2 she stated she remembered Resident #20 got out of bed on his on and he was combative during care. She further stated she was working the day Resident #20 had his first fall on 09/25/16 and she was told to check on him and when she went to his room he was on the floor and was bleeding from his forehead. She stated after he fell there were no changes in interventions for falls that she was aware of and if a resident had increased falls there were no changes that she was told to do to prevent falls. During an interview on 10/04/16 at 5:23 PM with NA #3 she confirmed she had provided care to Resident #20 and he was very confused, disoriented and combative and would get out of bed on his own and walk around. She explained she was working the day of his first fall on 09/25/16 and he had been sleeping but must have gotten up and was walking toward the window and she thought he had tripped over a bedside table and fell . She explained a nurse checked him to make sure he was alright and they got him up and put him into a wheelchair and then into bed. She stated a floor mat was placed next to his bed and his bed was always in the lowest position but she could not recall any other fall precautions. She further stated it was hard to get Resident #20 redirected or to get him to sit down because he was agitated. She explained she thought being around all the people in the facility had caused increased agitation for Resident #20 and she did not think there was anything they could have done to prevent his falls. During an interview on 10/04/16 at 5:35 PM with the second shift Nursing Supervisor she explained she had helped Nurse #9 complete Resident #20 ' s admission nursing assessment when he was admitted to the facility. She further explained during the first night Resident #20 would lay down for a little while but then got up and started walking and then the next day he was not as responsive as he was the day before. She stated night shift staff had reported to her Resident #20 was combative and he had walked all night. She explained she was working when Resident #20 fell on [DATE] at 10:00 PM and it was the worst fall he had with profuse bleeding and a hematoma. She stated she called 911 and the physician on call and Resident #20 was sent to the emergency room for evaluation and treatment. She further stated she felt helpless because Resident #20 just got up and fell and there was nothing she could do to prevent it. She explained Resident #20 could not use his call bell and his dementia was more severe than what they had realized when he was admitted . She explained after the fall on 09/26/16 at 10:00 PM she had written on an incident report that Resident #20 required one on one supervision. She further explained she did not feel the facility was the right place for Resident #20 because the NAs could not stay in the room with him all the time to supervise him. She confirmed the physician would have seen Resident #20 on 09/28/16 for his initial physician assessment but that did not occur since he was sent to the hospital on [DATE] and did not return to the facility. She stated she had talked to Administrative staff to have standing orders or steps to follow for residents who had frequent falls but nothing new had been implemented that she was aware of. During an interview on 10/05/16 at 5:40 AM with NA#4 she confirmed she was working on 09/26/16 during second shift when Resident #20 fell . She explained she was next door in another resident ' s room and heard a big bang and she ran out to look to where the noise came from and saw Resident #20 laying with his feet toward the bed and his head was at the door. She stated she and another NA hollered for a nurse and she came to the room and checked Resident #20 and sent him out to the hospital. She explained NAs were expected to make rounds every 2 hours and it was her routine when she worked night shift to do a round after she clocked in at 11:00 PM then her next round was at 1:00 AM, then 3:00 AM and her last round was at 5:00 AM. She stated she did not recall any interventions to check on Resident #20 more frequently than her routine every 2 hour checks. During an interview on 10/05/16 at 6:05 AM with Nurse #10 she recalled Resident #20 wandered and walked a lot then he started to fall. She explained she was working when Resident #20 fell after 3:00 AM on 09/26/16 and she was aware he had fallen several times on second shift. She explained he had a fall mat beside the bed but that had not helped because he fell in the doorway and his head was partially in the hall and he had a cut on his head. She stated the NA had said she had been in Resident #20's room 10 minutes prior to his fall but after she left the room he got up and fell . She explained she thought frequent monitoring meant for NAs to check on the resident anytime the NA had a few minutes in between their routine rounds. During an interview on 10/05/16 at 7:59 AM with Nurse #7 she recalled Resident #20's gait was unsteady and he was agitated. She explained she came to work on 09/25/16 at 3:00 AM and was told in report Resident #20 had fallen several times and the last fall was at 1:30 AM and as the nurse was reporting to her Resident #20 fell again at 3:45 AM. She stated Resident #20 was sitting in the doorway to his room and he had a skin tear on the right front of his head and they cleaned his head but he was agitated and fighting and didn't want them to touch him. She stated she was not sure how to prevent Resident #20 from falling unless someone sat with him all the time. During an interview on 10/05/16 at 8:20 AM with the South Wing Unit Manager she explained the only contact she had with Resident #20 was on Monday morning 09/26/16. She stated the NAs who were assigned to Resident #20 came to her in distress because they were so involved with him they couldn't take care of their other residents. She further stated she went to assess Resident #20 and he was agitated and she could not redirect him. She explained she pulled a shower tech to sit with Resident #20 but his RP came in and Resident #20 went to sleep so she sent the shower tech back to her duties. She stated the RP left after lunch while Resident #20 was sleeping but then he woke up and was agitated again and he got up and fell at 2:15 PM. She explained they tried to keep his shoes on but he wouldn't keep them on but he kept his non skid socks on. She stated routine monitoring was done when Resident #20 came back from the emergency room and that meant staff were to check on him at least every 2 hours for turning and toileting and staff were expected to look in on him if they passed by his room. She stated she thought Resident #20 needed to have been evaluated and supervised but they were not equipped to handle his behaviors or prevent him from falling. She further stated she was not sure what frequent monitoring meant but would have expected to see parameters for how frequently Resident #20 should have been monitored. During an interview on 10/05/16 at 9:20 AM the Director of Nursing stated the fall intervention for Resident #20 to monitor frequently was subject to differences in opinion and it was her expectation if a resident required frequent monitoring for it to be defined so staff would know what was expected. She explained the facility was not equipped to provide one on one supervised monitoring for Resident #20 but she expected for staff to increase the frequency of rounds for residents who had frequent falls. During a follow up interview on 10/05/16 at 11:30 AM with the South Wing Unit Manager she confirmed the psychiatric consult was put in the psychiatrist's book on 09/26/16 after the PA wrote the order but the psychiatrist made his rounds in the facility after 09/26/16 and Resident #20 was in the hospital. During an interview on 10/06/16 at 10:03 AM with NA #1 she recalled she worked on 09/26/16 when Resident fell at 2:15 AM. She explained she was walking by his room and saw him lying in the floor next to the bed and he had reopened a scab on his head from a previous fall and bit his lip and it was bleeding. She stated she was also working when Resident #20 had a really bad fall on 09/26/16 at 10:00 PM and he was very combative and super agitated and the nurse sent him out to the hospital. She explained Resident #20 could not use his call bell but his room was near the nurse's station. She stated she had no clue how to prevent his falls because he did not understand what they told him. During an interview on 10/06/16 at 10:14 AM with NA #7 he stated Resident #20 was constantly in motion and would not lay in bed unless he was asleep and the only way he kept him in bed was to stand with him because Resident #20 did not realize what was going on around him. He stated he worked on 09/26/16 when Resident #20 fell at 10:00 PM. He stated he was nearby Resident #20's room and heard him hit the floor and when he got to the room it was the worst fall he had seen. He explained he was not sure what Resident #20's head hit but it was either the floor or his head hit the kick plate on the bottom of the door to his room. He stated he and another NA ran to the room as fast as they could and Resident #20 had a cut on the top of his head on the right side and it was swelling. He stated the second shift Nursing Supervisor assessed him and sent him out to the emergency room . During a follow up interview on 10/06/16 at 11:10 AM the DON explained she heard about Resident #20's falls on 09/25/16 during her morning rounds on 09/26/16 and they had discussed them during the morning meeting on 09/26/16. She stated she was called on 09/26/16 after the 10:00 PM fall because the nurse was sending him to the emergency room and when she came to work the next morning it was reported to her that a nurse had called the hospital and found out Resident #20 had a subdural hematoma as a result of his fall. During an interview on 10/06/16 at 12:17 PM the Administrator explained she was aware of Resident #20's falls because they had discussed them in the morning meeting on 09/26/16. She further explained after the morning meeting on 09/26/16 she didn't have a good feeling so she went with the Social Worker and talked with his RP. She stated she told the RP they were trying to not let Resident #20 fall but they could not provide one on one supervision for him because it was already a challenge to keep the floors covered in order to provide care to other residents. She explained the DON called her on 09/26/16 after the 10:00 PM fall and Resident #20 did not return to the facility.

Based on observations, staff interviews and record review the facility failed to supervise a resident who fell and sustained a head injury for 1 of 3 sampled residents (Resident #2). The findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognitive skills, required extensive assistance with activities of daily living (ADL), was not steady moving from seated to standing position but propelled herself in her wheelchair. The MDS also specified the resident had falls with minor injuries. Review of Resident #2's fall care plan (not dated) specified the resident was at risk for falls and interventions included: - monitor whereabouts and what she is doing to prevent falls - canary alarm (personal alarming device) attached to wheelchair - resident is not to be left unattended in dayroom (03/21/13) Further review of the resident's medical record revealed [REDACTED]. Resident #2's "care card" specified the resident was at risk for falls. A nurses' entry made by Nurse #1 dated 03/19/13 at 2:30 AM specified the resident was found in the South Dayroom laying on her right side and noted to have a 2.3 centimeter (cm) laceration to her forehead. The nurses' entry indicated the physician was notified and ordered the resident to be sent to the Emergency Department for evaluation. A document titled "Discharge Summary" dated 03/21/13 was reviewed and revealed Resident #2 was evaluated at a local hospital for a brain bleed and was transferred to a trauma center for further treatment. On 04/08/13 at 9:30 AM Resident #2 was observed in her room sitting in a wheelchair with her family. She stated to her family that she wanted to lie down. The resident was able to follow the instructions from the family member during the transfer. On 04/08/13 at 11:40 AM Nurse #1 was interviewed and reported that Resident #2 at times was very impulsive and would attempt to stand unassisted. She added that the resident was at risk of falls and required close supervision. She stated that staff were expected to stay with the resident during times when she appeared agitated and keep her in areas that were highly visible. Nurse #1 reported that on 03/19/13 Resident #2 was refusing to stay in bed and the resident was kept in the dayroom to not disturb other residents. She explained that the nurse aides had taken turns monitoring the resident while she was in the dayroom. She added that Nurse #2 walked by the South dayroom and observed Resident #2 on the floor. She stated that Resident #2 was alone in the dayroom at the time of the fall. She stated the physician was contacted and ordered the resident to be sent to the Emergency Department for evaluation. On 04/08/13 at 11:50 AM the Director of Nursing (DON) was interviewed and reported that staff were expected to never leave residents at risk for falls unattended. She added she was aware that NA #1 had left Resident #2 unattended in the South dayroom when the resident attempted to stand, fell and struck her head sustaining a head injury. The DON reported that NA #1 should have taken the resident to the nurses' station for someone else to monitor before she left the resident in the dayroom unattended. She added that the NA was aware that Resident #2 was impulsive and made attempts to stand and required close supervision. She offered no explanation why NA #1 left the resident unattended in the dayroom. On 04/09/13 at 1:00 PM the physician was interviewed on the telephone and reported the resident sustained [REDACTED]. He added that it was possible the bleed would resolve on its own over time. He stated the resident returned to the facility under the care of Hospice because of the [DIAGNOSES REDACTED]. He stated he assessed the resident on 03/28/13 and was unable to detect a change in her condition. On 04/09/13 at 7:00 PM NA #1 was interviewed on the telephone. She reported that Resident #2 required frequent supervision because she was at risk for falls and added that when the resident was agitated and made attempts to stand she needed one on one supervision. She stated that the night of 03/19/13 she reported for work at 11 PM and Resident #2 was refusing to go to bed which was not unusual for the resident. NA #1 explained that Resident #2 was kept in the dayroom and offered snacks and fluids. The NA added she and other staff working that night would go in and out of the dayroom to check on the resident and sit with her. The NA stated that the resident was not agitated and was not making attempts to stand unassisted and did not required one on one supervision during this time. She added that the resident had a personal alarm that would alert staff when the resident attempted to stand. She confirmed the alarm was on the resident the night she fell . She also explained that the resident would remove the alarm. She stated that she needed to answer a call light and left Resident #2 and NA #3 in the dayroom together. She added that while she was in a room assisting a resident she heard a nurse call for help and observed Resident #2 in the floor. She added that since the fall the resident continued to act the same and that she required the same level of assistance with her ADL. On 04/09/13 at 7:15 PM NA #2 a telephone interview was conducted. She reported that Resident #2 was at risk for falls and needed close supervision when she was in her wheelchair. She stated the resident had a personal alarm that would alert staff if the resident attempted to stand up in her wheelchair. She added that the resident removed the alarm at times. NA #2 reported that when Resident #2 was agitated she needed to be monitored more closely. She added that on 03/19/13 she helped to watch Resident #2 in the dayroom but confirmed the resident was not agitated and was not making attempts to stand up in her wheelchair. She stated that she left the dayroom to answer a call light and that Resident #2 was in the dayroom with NA 1 and NA #3 prior to the fall. She reported that since the fall the resident appeared the same. On 04/09/13 at 7:30 PM NA#3 was interviewed on the telephone and reported that Resident #2 had been in the dayroom for the duration of the night shift on 03/19/13. She added that the resident was not agitated and appeared her usual self. NA #3 explained the resident did not want to go to bed which was not unusual for the resident so staff took turns sitting with her in the dayroom between making rounds and answering call lights. NA #3 was aware the resident required close supervision and stated the resident could not be left alone in her room because of the resident's risk for falls. She stated that prior to the fall she was in the dayroom but left to assist another resident. She stated that when she left the dayroom Resident #2 was with NA #1 and NA #2. She added that while she was in a resident's room she heard a call for help and observed the resident in floor of the dayroom. She explained that the resident had propelled herself near the door of the dayroom and attempted to stand and fell . She reported that since the fall the resident's physical abilities had not changed and added the resident still talked about her children which she often did with the NA.

Based on medical record review, staff interviews, physician interviews and pharmacist interviews the facility failed to review changes in readmission physician orders [REDACTED]. (Resident #3) Immediate jeopardy began on 09/21/11 when Resident #3 was readmitted to the facility with physician's orders [REDACTED]. On 09/28/11 Resident #3 was admitted to the hospital and was diagnosed of [MEDICATION NAME] toxicity. Immediate jeopardy was removed on 10/12/11 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 (isolated deficient practice, no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place and completion of employee training. Then findings are: Review of the Manufacturer's "Dosage and Administration" information for [MEDICATION NAME] (an anti [MEDICAL CONDITION] medication) specified the following information: "General: Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations may be necessary for optimal dosage adjustments- the clinically effective serum level is usually 10-20mcg/mL. With recommended dosage, a period of seven to ten days may be required to achieve steady-state blood levels with [MEDICATION NAME] and changes in dosage (increase or decrease) should not be carried out at intervals shorter than seven to ten days. Adult Dosage: Divided daily dosage: Patients who have received no previous treatment may be started on one 100-mg [MEDICATION NAME] ([MEDICATION NAME] sodium) Extended Oral Capsule three times daily and the dosage then adjusted to suit individual requirements. For most adults, the satisfactory maintenance dosage will be one capsule three to four times a day. An increase up to two capsules three times a day may be made, if necessary." Resident #3 was readmitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's readmission orders [REDACTED]. Review of Resident #3's Medication Administration Record (MAR) from 09/10/11 to 09/16/11 revealed he received four hundred (400) milligrams of [MEDICATION NAME] each day as ordered. On 09/17/11 a physician's orders [REDACTED]. Review of Resident #3's hospital records revealed he was admitted to the hospital on [DATE]. Review of Resident #3's hospital MAR revealed that during his hospitalized from [DATE] to 09/21/11 he received the following daily dosages of [MEDICATION NAME]: 09/17/11: 100 milligrams 09/18/11: 400 milligrams 09/19/11: 400 milligrams 09/20/11: 400 milligrams 09/21/11: 200 milligrams Review of Resident #3's Hospital "Clinical Discharge Summary" of 09/21/11 revealed two (2) [MEDICATION NAME] orders, which would provide eight hundred (800) milligrams per day, were listed as medications to be taken after being discharged from the hospital. These [MEDICATION NAME] orders were as follows: [MEDICATION NAME] 100 milligrams four times a day and [MEDICATION NAME] 200 milligrams twice a day. Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's readmission orders [REDACTED]. These readmission physician's orders [REDACTED]. [MEDICAL CONDITION] Disorder was the [DIAGNOSES REDACTED]. The readmission orders [REDACTED]'s physician on 09/22/11. A nurse's note written by LN #1 on 09/21/11 at 5:00 p.m. specified that copies of Resident #3's discharge summary and MARs were faxed to the resident's physician and the facility's dispensing pharmacy. Review of Resident #3's MAR for the dates of 09/21/11 to 09/28/11 revealed both of the [MEDICATION NAME] readmission orders [REDACTED]. Further review of the MAR revealed staff documented that Resident #3 received the following daily amounts of [MEDICATION NAME] during this facility stay: 09/21/11: 600 milligrams 09/22/11: 800 milligrams 09/23/11: 800 milligrams 09/24/11: 800 milligrams 09/25/11: 800 milligrams 09/26/11: 800 milligrams 09/27/11: 600 milligrams 09/28/11: 400 milligrams On 09/28/11 at 7:30 a.m. a nurse's note specified that Resident #3 was alert and verbal, in no apparent distress, but some of his words were "slurred and garbled." On 09/28/11 at 1:00 p.m. a nurse's note specified that Resident #3 had a decreased level of consciousness with a decreased oxygen saturation level of eighty-five percent while receiving one liter per minute of oxygen. On 09/28/11 at 1:30 p.m. a nurse's note specified that orders had been received for Resident #3 to be evaluated and treated at the hospital. Review of hospital laboratory results of 09/29/11 revealed Resident #3 had an elevated [MEDICATION NAME] ([MEDICATION NAME]) level of 31.3 micrograms per milliliter (mcg/ml). The lab report specified the normal reference range for [MEDICATION NAME] ([MEDICATION NAME]) was 10.0 to 20.0 mcg/ml. Review of Resident #3's 09/30/11 Hospital discharge summary of 09/30/11 revealed a [DIAGNOSES REDACTED]." The resident's discharge summary specified; "A [MEDICATION NAME] level was checked the morning after admission and noted to be elevated at 31. I reviewed the MAR from the prior nursing facility and it seems as if he was discharged on both [MEDICATION NAME] 200 mg twice daily and [MEDICATION NAME] 100 mg 4 times a day. He was receiving 800 mg of [MEDICATION NAME] a day. Review of his previous history and physicals seemed to indicate that he was only on 100 mg 4 times a day. This appears to be a medication error and his [MEDICATION NAME] has now been held. I am requesting a repeat [MEDICATION NAME] level to be checked on Sunday, and his [MEDICATION NAME] can be restarted once it falls below 20 at 100 mg 4 times daily." Interview with the facility's Administrator on 10/10/11 at 2:30 p.m. revealed the facility did not have a written policy which specified how staff was to process readmission physician orders. The Administrator stated that Licensed Nurse (LN) #1 was the facility's admissions nurse and was responsible for transcribing readmission orders [REDACTED]. On 10/10/11 at 4:00 p.m. an interview was conducted with LN #1, who processed Resident #3's facility readmission orders [REDACTED]. LN #1 stated that while transcribing these orders she realized the resident had two orders for routine [MEDICATION NAME], which would provide a daily dose of eight hundred (800) milligrams. LN #1 explained that she did not check the resident's prior [MEDICATION NAME] orders or MARs, so she was unaware that the readmission [MEDICATION NAME] orders were four hundred (400) milligrams more than what was previously prescribed for Resident #3. LN #1 stated that she did not contact the resident's physician and did not attempt to contact the hospital for clarification on any of the resident's 09/21/11 discharge instructions or physician's orders [REDACTED].#3's readmission orders [REDACTED]. LN #1 stated that after she faxed this information she did not recall receiving any response from the physician or dispensing pharmacy regarding the resident's readmission orders [REDACTED]'s order sheet and MAR and was to then fax this information to the resident's physician and the facility's dispensing pharmacy. On 10/10/11 at 4:15 p.m. an interview was conducted with Resident #3's physician. The physician stated that when a resident is readmitted to the facility nursing staff should review the resident's readmission orders [REDACTED]. The physician explained that if the admitting nurse discovered the resident's new orders reflected changes in the resident's medications the nurse should then notify him of these changes. The physician stated that he did not recall facility staff notifying him of any concerns regarding Resident #3's readmission orders [REDACTED]'s readmission orders [REDACTED]. The physician stated that he was unsure why Resident #3 needed eight hundred (800) milligrams of [MEDICATION NAME] per day because his [MEDICAL CONDITION] disorder was being effectively managed with a daily dose of four hundred (400) milligrams. On 10/10/11 at 5:20 p.m. the facility's Director of Nurses (DON) was interviewed. The DON confirmed that Resident #3's daily dosage of [MEDICATION NAME] was increased from four hundred (400) milligrams to eight hundred (800) milligrams when he was readmitted on [DATE]. The DON stated that the facility's Medical Director and Resident #3's physician had recently informed staff that they wanted the facility's admission nurses to only transcribe a resident's admission or readmission orders [REDACTED]. The DON stated that the physicians specified that they wanted to be responsible for reviewing a resident's admission and readmission orders [REDACTED]. On 10/11/11 at 12:30 p.m. an interview was conducted with one of the facility's consulting pharmacists. The Pharmacist stated that no pharmacy review of Resident #3's medical record was performed during his readmission stay from 09/21/11 to 09/27/11. The pharmacist stated that to her knowledge the facility had not requested a pharmacist to review the resident's medications during this readmission stay. The pharmacist explained that if Resident #3's medications had been reviewed the increase in his daily dose of [MEDICATION NAME] from four hundred milligrams to eight hundred milligrams per day would have been identified as an irregularity and the resident's physician would have been asked why this increased dosage was necessary. On 10/12/11 at 8:45 a.m. an interview was conducted with the facility's Medical Director regarding resident admission and readmission orders [REDACTED]. If during this review the nursing staff identify any changes or concerns they should then contact the hospital to get clarification of the orders and notify the resident's physician. On 10/12/11 at 3:20 p.m. an interview was conducted with a pharmacist at the facility's dispensing pharmacy. This interview revealed that on 09/21/11 the pharmacy received Resident #3's readmission orders [REDACTED]. The pharmacist stated that from the information available he did not see where the pharmacist, who processed Resident #3's readmission orders [REDACTED]. The Administrator was notified of the Immediate Jeopardy on 10/11/11 at 3:00 p.m. The facility provided a credible allegation of compliance on 10/12/11 at 6:40 p.m. The following interventions were put into place by the facility to remove the Jeopardy: Resident #3 was identified during survey with readmission physician's orders [REDACTED]. So, upon Resident #3's readmission to the facility on [DATE] he had orders to receive a total of 800 milligrams of [MEDICATION NAME] per day which was 400 milligrams more than previously ordered for this resident. Resident #3 was discharged from the facility on 09/28/11. On 10/11/11 an audit was performed by the Assistant Director of Nurses (ADON) and Director of Nurses (DON) on all residents receiving [MEDICATION NAME] to check their current ordered dosage and method of administration, their last lab level and when drawn to ensure that no other residents are at risk. As a result of this audit no problems were identified. On 10/11/11 and 10/12/11 an audit of all resident admissions within the past thirty (30) days was conducted by facility licensed nursing staff as overseen by the Administrator. Any Discrepancy identified from this audit required minor adjustments to resident physician orders [REDACTED]. Upon a resident's admission or readmission to the facility each resident's physician orders, including medication orders, will be reviewed by the facility's admission nurse or a Licensed Nurse. If this is a readmission to the facility the nurse will review the physician orders [REDACTED]. orders [REDACTED]'s new readmission medication orders. If the admissions nurse or Licensed Nurse identify changes in the resident's drug regime they will communicate these changes by calling the resident's physician. A second licensed nurse will also review resident admission and readmission physician orders [REDACTED]. On 10/12/11 a new policy was developed by the Administrator and Director of Nurses (DON) describing the new process for reviewing physician's orders [REDACTED]. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) will in-service all facility nurses on the facility's admission process regarding the review of resident admission and readmission orders [REDACTED]. on 10/11/11. The two nurses who were unable to receive this inservice information will be inserviced prior to being allowed to return to work. The Director of Nurses, Assistant Director of Nurses and Treatment Nurse will audit all resident admission and re-admission physician orders [REDACTED]. Results will be reported to Quality Assurance Committee monthly. Immediate Jeopardy was removed on 10/12/11 at 7:40 p.m. based on review of the facility's new policy for processing admission and readmission orders [REDACTED]'s new process on admission and readmission orders [REDACTED]. Resident interviews regarding the facility's medication administration procedures.

Based on observation, record review, staff and family interviews, the facility failed to prevent one (1) of nine (9) cognitively impaired residents with wandering behaviors from exiting the facility unsupervised. Resident #1 eloped from the facility on 03/26/11 and walked down a hill off of the facility property and across the roadway. Staff located the resident walking up a hill toward a residential dwelling. Immediate Jeopardy began on 03/26/11 when Resident #1 eloped from the facility unsupervised without staff's knowledge. Immediate jeopardy was removed on 04/01/11 at 3:00 p.m. when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, 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 education. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS further assessed him with exhibiting wandering behaviors which occurred every four to six days, but less than daily and was at risk of wandering to a potentially dangerous place. Review of the Yellow Alert Program dated 02/26/09 which is the facility's policy to address unsafe wandering and elopement of residents who have been identified to be at risk. Interventions included placement of a bright yellow band on the identified resident's wrist, placement of a yellow dot beside their name on the nameplate of their assigned room and daily monitoring of band placement. Review of the Patient information form (FL-2) completed by Resident #1's physician dated 03/07/11 indicated the resident was constantly disoriented and had wandering behavior. Review of the initial Interdisciplinary Care Plan for Resident #1 dated 03/11/11 did not address the wandering behavior identified on the FL2. The elopement risk score documented on this care plan identified only the resident having dementia and being ambulatory. Review of Nurses Notes written as a late entry on 03/14/11 at 9:00 a.m. indicated Resident #1 was going out the front door of the facility with visitors. Resident #1 was redirected back into the building. Documentation at 1:00 p.m. revealed Resident #1 walked to the end of the South Hall, pulled the fire alarm and exited through the door. A Nursing Assistant (NA) escorted the resident from the outside back into the facility. Documentation at 2:00 p.m. on 03/14/11 revealed Resident #1 walked to the end of the North Hall, pulled the emergency exit and opened the door. Attempts were made by the NA to block the resident from exiting the door and the resident was redirected back into the facility. Review of Nurses Notes dated 03/15/11 at 8:00 a.m. revealed Resident #1 was observed walking to exit doors and attempting to get out. The resident was also observed trying to get out a window; however a screen was in place to prevent his exiting. Documentation at 7:10 p.m. revealed the Director of Nursing (DON) was notified of Resident #1's attempts to enter the kitchen, increased agitation, and attempts to hit NAs. The Responsible Party (RP) was notified of the resident's behavior. The RP stayed with the resident until he fell asleep the same evening. Review of the Resident Social Progress Note dated 03/16/11 completed by the social worker as a follow up to the admission Social Service History documented, "Resident #1 has been agitated and wanting to leave. He has threatened staff when they try to intervene with him leaving and he has pulled the fire alarm, too" Review of an Elopement Evaluation Screen dated 03/17/11 completed by the MDS coordinator revealed Resident #1 triggered a score of six (6) which placed him at high risk for elopement. Triggers included verbal/non-verbal comments/behaviors, wandering in the last three (3) months, behaviors, independent in ambulation, and [DIAGNOSES REDACTED]. Review of care plan updated and implemented on 03/23/11 identified as a problem, Resident #1 had threatened staff, hit them, pulled the fire alarm and wandered about the facility. Care Plan goals included resident will wander within safe boundaries of facility with interventions to monitor frequently to ensure he wandered within safe boundaries of facility and implementation of "Yellow Alert Program" to alert staff of elopement potential. Review of Nurses Notes dated 03/23/11 at 2:00 a.m. revealed Resident #1 wandering in hallways, pointing to doors and asking if that is the way out. Resident #1 was redirected back to his room. Review of Nurses Notes dated 03/26/11 revealed Resident #1 was medicated a second time for wandering and increased agitation at 12:00 p.m. with Haldol 0.5 milligrams (mg) by mouth. At 12:45 p.m. Licensed Nurse (LN) # 1 documented she was notified that Resident #1 was found across the road going up the driveway of a private residence. The resident was directed back to the facility, the on-call physician and the responsible party was notified. On 03/30/11 at 12:10 p.m. Resident #1's responsible party was interviewed. She stated the resident was admitted to the facility because he had tried to leave the residence four times since moving in with her in December, 2010 and had actually left the house on one occasion and was found 10 minutes away from home. She stated she made the facility aware of his behaviors at the time of his admission. On 03/30/11 at 12:30 p.m. an interview with LN # 1 revealed she medicated Resident #1 at 12:00 p.m. with an as needed (PRN) dose of Haldol 0.5 mg for wandering and agitation. LN#1 also revealed LN #2 and LN #3 notified her at 12:40 p.m. on 3/26/11 Resident #1 had eloped from the facility and was being brought back into the building. LN #1 further revealed prior to the elopement on 03/26/11, Resident #1 would push on a door and if unable to get out would try another door. She stated she would consider these actions to be exit seeking. LN #1 was uncertain when the yellow bracelet was placed on Resident #1. On 03/30/11 at 1:05 p.m. NA#3 was interviewed and indicated the yellow bracelet on a resident's arm is for fall precaution. An interview with NA #4 on 03/30/11 at 3:30 p.m. revealed she was unsure what a yellow alert program meant. An interview with the DON on 03/30/11 at 2:40 p.m. revealed the facility did not provide staff education related to elopement after Resident #1 eloped. The DON stated staff from all shifts was informed of the elopement of Resident #1 and to "monitor him." An interview on 03/30/11 at 2:44 p.m. with NA#1 assigned to Resident #1 on 03/26/11 revealed he looked for the resident to take him to the dining room for lunch. When he was unable to locate the resident he notified the nurse and started searching. NA#1 stated he went out to the back parking lot and saw the resident on an embankment in front of a big house across the road from the facility. NA #1 stated the weather was a little cool, foggy and drizzling rain. He acknowledged the resident was wearing a light weight jacket. Resident #1 was assisted back into the facility, vital signs were taken and "evening staff kept a close eye on him." NA#1 further revealed the yellow wrist band meant fall risk. On 03/30/11 at 3:10 p.m. an interview with NA#2 revealed on 3/26/11 prior to Resident #1 leaving the facility, she noticed the resident packing his things, saying he was going to leave and asking for the directions to Black Mountain. An interview with LN #2 on 03/31/11 at 10:15 a.m. revealed a visitor walked by her while she was at the medication cart on the 100 hall and said "I think one of your residents has gone out the door and looks like he is going to the house across the road". LN# 2 called for assistance to bring Resident #1 back into the building. Following the interview an observation was made with LN#2 from the door where the resident was persumed to have exited to the area where Resident #1 was found. The distance from the facility was approximately 370 paces. The resident crossed the road near a blind curve, walked up the driveway of a residential dwelling, and was found behind the dwelling. On 03/31/11 at 10:37 a.m. an interview with the MDS Coordinator, revealed on admission resident information was obtained from the medical record, FL2 form and family to complete the initial interdisciplinary care plan. The MDS coordinator also revealed a second elopement screen was completed on 03/17/11 as part of the MDS completion and Resident #1 scored six (6) which placed him at high risk for elopement. Resident #1's care plan was updated on 03/23/11 to include Yellow Alert Program. The Administrator was notified of the Immediate Jeopardy on 03/31/11 at 10:53 a.m. The facility provided a credible allegation of compliance on 04/01/11 at 3:00 p.m. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Resident #1 was returned to the facility accompanied by staff at 12:40 p.m. A head to toe assessment was completed on Resident #1 by a Licensed Nurse on return to the facility at 12:40 p.m. on 03/26/11. The assessment included vital signs, skin assessment and assessment of extremities for fractures. The findings included stable vital signs, no bruising, skin tears or fractures. A visual checklist and one on one observation of the resident was implemented on 03/26/11 at 12:40 p.m. to monitor Resident #1's whereabouts and activities. Visual checks were done and documented every thirty minutes beginning 03/26/11 at 12:40 p.m. and ending 03/27/11 at 11:30 a.m. Resident #1's on call physician was notified at 12:45 p.m. on 03/26/11. Resident #1's Responsible Party was notified at 12:50 p.m. on 03/26/11 and she came to the facility at 4:00 p.m. and sat with him until 5:30 p.m. Beginning 03/27/11 at 12:30 p.m., and ending 03/30/11 at 3:00 p.m., hourly visual checks which included the resident's whereabouts and activities were performed. Resident #1 was discharged to a facility with a secured unit on 03/30/11 at 3:00 p.m. Additional corrective actions taken by the facility included: ? On 30/28/11 at 7:00 a.m., a sign located next to the key pad by the front entrance door requesting visitors to see a nursing staff member before letting a resident out the door was removed and placed directly on the door. The sign was revised which included an increase in front size and bold print for easier visualization. The revised signs were placed on all visitor entry doors on 03/31/11 at 3:30 p.m. ? The Yellow Alert Program dated 02/26/09 which is the policy to identify residents who are at risk for unsafe wandering and/or elopement, either per their own choice or due to impaired cognition/awareness of their actions was reviewed by the facility administration on 04/01/11. This policy will be updated to include obtaining permission from the responsible party to utilize the yellow bracelets and placement of yellow dots on the resident's door to identify residents who are at risk for wandering and/or elopement. ? On 03/31/11 the Social Worker and MDS Nursing Staff audited all residents and assessed them for risks of elopement. The audit revealed two residents that were no longer at risk for elopement. One resident triggered one positive response but this did not put him at risk. Residents that are currently on the Yellow Alert Program which entails placement of a yellow bracelet on resident, picture in yellow alert notebook along with the policy on yellow alert. Notebooks are located at each nursing station and in the front office for staff access. A yellow dot is placed beside the resident's name on the name plate outside of the resident's room which identifies the resident is at risk for unsafe wandering and/or elopement. Care Plans for the residents identified for risk of elopement were updated with the Yellow Alert Program information to alert staff of elopement potential, frequent monitoring to ensure wandering is within safe boundaries of the facility and monitoring of behaviors which puts a resident at risk for elopement. Care Plans updated and revised on 03/31/11. ? All current staff will be in-serviced by the QA nurse and/or DON by 04/01/11. For any staff members unable to complete the education by 04/01/11 will be required to complete the education prior to returning to work. Education will include a review of the Elopement and Wandering Program. Key points of the education module include assessment of residents behaviors associated with wandering and/or elopement, process to report behaviors and implementation of interventions to help prevent chances of elopement. Interventions include a photo in a notebook, yellow bracelet placed on resident, yellow dot on name plate and information placed inside the resident's closet doors. All new staff will have education on the Elopement and Wandering Program as part of their orientation beginning 04/01/11. ? All current residents' responsible parties were notified on 03/31/11 by telephone or mail to notify nursing staff before assisting any resident outside. The resident admission packet was updated on 03/31/11 to inform residents and their responsible parties/visitors to check with nursing staff before assisting any resident outside. On 04/01/11, staff which included nursing, housekeeping, and dietary from all shifts were interviewed and confirmed they had received in-service training on the Yellow Alert Program, the use of yellow bracelet, on residents who were at risk for exit seeking behaviors and on procedures to implement if a resident eloped from the facility. Visual confirmation was made on 04/01/11 that a sign was placed on all entry doors requesting visitors to check with nursing staff before letting a resident out. Visual confirmation was made on other residents identified to be at risk for elopement for update of care plan, placement of yellow bracelet, yellow dot on resident's door name plate and information documented in the notebooks. Medical record review revealed all residents had been assessed with [REDACTED]. The audit further revealed two residents that were no longer at risk for elopement. A sample of Responsible Parties of the residents identified to be at risk for elopement were interviewed and confirmed the facility had notified them of their family member's risk assessment and implementation of the Yellow Alert Program.

Based on medical record review and resident and staff interviews the facility failed to consistently implement physician standing orders for constipation for one (1) of eight (8) sampled residents. (Resident #55) The findings are: Resident #55 was admitted to the facility 7/2/10 for therapy services following a fall and [MEDICAL CONDITION] ankle. Resident #55 had other [DIAGNOSES REDACTED]. Medications on admission for Resident #55 included 40 milligrams every day of [MEDICATION NAME] (a diuretic), [MEDICATION NAME] (a stool softener) PRN (as needed) and [MEDICATION NAME] (pain medication) PRN every six hours. The facility had standing orders which included: Milk of Magnesium 45 ml every other day as needed for constipation, [MEDICATION NAME], 1 or 2 tabs orally every other day as needed for constipation (may use [MEDICATION NAME] suppository instead) and Soap suds enema or fleets enema as needed for constipation. The MDS (Minimum Data Set) dated 8/31/10 assessed Resident #55 with no impairment of short or long term memory and independent with decision making skills. The assessment identified Resident #55 as requiring extensive assistance of two people for toilet use. The current care plan for Resident #55 included the following problem areas, 1. Requires extensive assist with most activities of daily living. Dx:[MEDICAL CONDITION] right lower extremity weakness. Right ankle fracture and chronic pain. The goal for this problem area was, "Will ensure physical care needs are met and is appropriately dressed and groomed with decreased complaints of pain through next review." 2. Leaves 25% or more of most meals uneaten and has insufficient fluid intake at times. Diagnosis: [REDACTED]." On 9/23/10 at 9:20 AM the Director of Nursing (DON) and Quality Assurance (QA) nurse reported there was not a facility bowel policy. The DON and QA nurse stated the facility practice was for nursing assistants to record residents bowel movements on the ADL (activity of daily living) flow sheet. The DON stated that second shift nursing assistants then record each of their residents name on a Laxative List and the date of the residents last bowel movement. The DON stated second shift nurses were to review the Laxative List daily and implement standing orders for bowels if the resident reported any discomfort or if the resident did not have a bowel movement at least every three days. Review of the ADL sheets for Resident #55 revealed the following: 1. From 7/5/10 third shift to 7/9/10 third shift (4 days) Resident #55 went without a bowel movement. Review of the resident's MAR indicated [REDACTED]. 2. From 7/15/10 third shift to 7/19/10 third shift (4 days) Resident #55 went without a bowel movement. The resident was given a [MEDICATION NAME] on 7/18/10 and the bowel movement on 7/19/10 was recorded as "small." On 7/20/10 nurses notes indicated, ".."[MEDICATION NAME] given for nausea and pain"..."continues to complain of hard stool"..."assisted to bathroom related to complaint of hard stool. Some relief noted. Small amount of bowel movement noted." Review of the July Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"hard stool". On 9/24/10 at 12:45 PM the DON stated the nurse working with Resident #55 on 7/20/10 should have given her one of the PRN medications for bowels when she reported problems with a "hard stool". The DON stated the nurse that worked on 7/20/10 wasn't available for interview. 3. From 7/20/10 second shift to 7/24/10 second shift (4 days) Resident #55 went without a bowel movement. The resident was given [MEDICATION NAME] on 7/23/10 with results on 7/24/10. 4. From 8/1/10 second shift to 8/5/10 first shift (a little over 3 days) Resident #55 went without a bowel movement. The Laxative List from 8/1/10-8/4/10 all indicated the resident's last bowel movement was on 8/1/10. The resident was not given any PRN medication for her bowels on 8/4/10. 5. From 8/14/10 third shift to 8/21/10 second shift (6 1/2 days) Resident #55 went without a bowel movement. The facility was unable to locate the Laxative List for 8/15/10, 8/17/10 and 8/18/10. The Laxative List for 8/14/10 indicated the resident's last bowel movement was 8/14/10. The Laxative List for 8/16/10 indicated the resident's last bowel movement was 8/14/10. The resident's August MAR indicated [REDACTED]. The Laxative List for 8/19/10 indicated the resident's last bowel movement was 8/14/10. The Laxative List for 8/20/10 indicated the resident's last bowel movement was 8/14/10. Next to the 8/20/10 entry was recorded that Resident #55 was given [MEDICATION NAME] and an enema. 6. On 8/23/10 the resident's physician wrote an order to "Obtain GYN consult due to continued vaginal discharge." Review of a consult note written on 9/1/10 revealed Resident #55 saw the gynecologist. The consult note in the resident's medical record noted, "I can feel a fairly large impaction of stool in the rectum. There is some watery stool at the rectal opening that is contaminating the lower vagina and Foley." The recommendation by the gynecologist was: 1. Patient needs constipation prescription through service of her physician and 2. Needs improved care after bowel movement to avoid developing a urinary tract infection in the future. A nurses note on 9/1/10 referenced the resident's appointment with the gynecologist and noted the resident had a bowel impaction and that, " We are to try to dissolve the feces by using [MEDICATION NAME] and Senna." Review of the August MAR indicated [REDACTED]. The ADL flow record indicated the resident had a small bowel movement on 9/1/10 and 9/2/10 (first shift). The ADL flow record revealed that from 9/2/10 first shift to 9/5/10 first shift the resident did not have another bowel movement. The Laxative Sheet for 9/1/10 indicated the resident's last bowel movement was 9/1/10 and was small. The Laxative Sheet for 9/2/10 indicated the resident's last bowel movement was 9/2/10 and was small. The Laxative Sheet for 9/3/10 indicated the resident's last bowel movement was 9/2/10 and was small. The facility could not locate the Laxative Sheet from 9/4/10. The 24 hour reports (used by nurses on all three shifts to relay specific concerns of a resident) were reviewed from 9/1/10-9/4/10 and there was no mention of the resident's bowels or the impaction. On 9/5/10 at 4 AM a nurses note stated, "Resident has complained of lower abdominal pain and rectal pain. States she is constipated. When checked large amount of stool noted in rectal vault. She stated she has been given stool softeners but they are not working and she hurts so bad she needs some relief Fleet enema given at 1215 AM with no relief. Required soap suds enema. Soap suds enema given. Had a medium result. States it has helped her pain and she believes she can go to sleep." On 9/5/10 at 2:00 PM a nurses note stated, "Resident up to bedside commode this morning and had XXL bowel movement. Back to bed and has slept most of the day." On 9/23/10 at 1:50 PM the resident's physician stated he expected staff to use the standing orders if a resident went for an extended time without a bowel movement and, if the standing order medications were not effective, he expected to be contacted. The physician stated he remembered Resident #55 had problems with her bowels but thought it had been addressed. The physician stated when the resident was sent to the gynecologist he wasn't anticipating a problem with constipation. The resident's physician stated he signed the gynecologist consult on 9/2/10 which would indicate it had been reviewed but had no comment about the recommendations. The physician stated he would have expected staff to use the enema, [MEDICATION NAME] or Milk of Magnesium for any problems with constipation. On 9/24/10 at 10:15 AM Resident #55 stated that since her admission on 7/2/10 she had been having trouble with constipation. The resident stated she felt her immobility and pain medication were contributing to problems with her bowels. Resident #55 stated that when she was at home she took a laxative every day which kept her bowel movements regular. Resident #55 stated early in her stay at the facility she asked the doctor if she could have a laxative on a regular basis and he told her he would see what he could do about it. Resident #55 said no changes were made and that she still would like to have a laxative every day to prevent future problems. On 9/24/10 at 12:45 PM the DON stated that she was in the process of changing the standing orders. The DON stated the plan was that any resident on a pain medication or any other medication that could cause constipation would receive a routine laxative. After reviewing the ADL sheet, MARs and nurses notes for Resident #55 the DON stated the nurses were not consistently addressing the bowel records of Resident #55 and that when a pattern of constipation was seen she expected facility staff to recommend a routine laxative. The DON stated Resident #55 should have received medication on 7/20/10 when she complained of a hard stool, between 8/1/10-8/5/10 when she didn't have a bowel movement and between 8/14/10-8/21/10 (something before the [MEDICATION NAME] on 8/18/10 and after 8/18 /10, when there were no results). The DON stated she didn't understand why something wasn't ordered or more wasn't done after 9/1/10 when the impaction was noted. After the conversation on 9/24/10 at 12:45 PM the DON called the resident's physician and a routine laxative was ordered for Resident #55.

Based on observations, record review and staff interviews, the facility failed to consistently implement and/or change interventions to prevent falls and or injuries for five (5) of six (6) sampled residents. (Residents #34, #51, #52, #78, and #139) The findings are: 1. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was readmitted to the facility on [DATE] following a fall resulting in a fractured femur. Resident #34 was receiving daily Coumadin, an anticoagulant. A significant change Minimum Data Set ((MDS) dated [DATE] coded her with short term memory impairment and moderately impaired decision making skills. She was coded as needing limited assistance with bed mobility, transfers and toileting and needing set up for room ambulation and supervision with ambulation in the halls. The Fall Resident Assessment Protocol (RAP) summary dated 1/18/10 described Resident #34 has having a history of falls. The RAP stated her gait and balance were unsteady at times and she used a rolling walker in and out of her room and was supervised for safety. The RAP noted the resident's desire to be independent and she was encouraged to call for assistance. The most recent MDS, a quarterly dated 9/15/10, coded Resident #34 as needing limited assistance with most activities of daily living including ambulation. The care plan which addressed Resident #34's history of falls was developed 10/14/09 and last updated 9/7/10. The goal was to prevent and manage future likelihood of falls. Interventions included "may use canary (clip) alarm to alert staff if she attempts to get up without assistance. (she will remove)" and "ambulatory with RW (rolling walker) and supervision for safety." On 9/23/10 at 2:05 PM, the nursing notes and occurrence reports relating to Resident #34 were reviewed with the facility's Quality Assurance (QA) nurse. The facility's QA nurse was interviewed during this 9/23/10 review and the following was revealed: *11/7/09 at 12:45 PM canary alarm sounded and resident was found on floor beside bed in urine. The QA nurse stated that no changes were made in the resident's planned interventions to prevent future falls. *11/8/09 at 3:00 AM found on floor with large hematoma on right side of forehead and a skin tear on her right arm. The canary alarm was on but not sounding. Resident went to emergency room where she was treated for [REDACTED]. *12/1/09 at 11:30 AM found on floor, resident stated she was going to bed, alarm was sounding. The investigation noted that Resident #34 cannot remember to ask for help. The QA nurse stated that a trial of a table top to her wheelchair was implemented but not used long (no time frame) as corporate did not permit any table tops used in the facility. The QA nurse stated that no other changes were made in the resident's planned interventions to prevent future falls. *12/19/09 at 7:30 AM found resident sitting on floor in front of closet with feces on floor by bed. The resident received an abrasion to her left knee. The report did not indicate if alarm was sounding. Per QA nurse no change in intervention. *1/8/10 at 7:30 AM found sitting on floor beside bed in front of wheelchair. Alarm was on bedside table. Resident stated she took it off. The QA nurse stated she could not think of anything else to try as an intervention to prevent this resident from falling. *1/10/10 at 7:30 AM alarm sounding, found on knees beside bed with urine and stool on floor. Per QA nurse, she turned it over to the care plan committee as she did not know what else to do for Resident #34. The QA nurse stated she was unaware of any changes in the interventions to prevent further falls. *8/6/10 at 2:15 PM found a half dollar size bruise on shoulder. Resident reported she fell in the bathroom and hit shoulder on commode. The QA nurse stated that no changes were made in the resident's planned interventions and no additional follow up was done and no additional follow up was done to prevent future falls. *9/18/10 at 2:40 PM resident found sitting beside recliner. Resident was noted with ted hose on and no shoes. Investigation noted the resident does not remember to call for help or use walker when she gets up. The incident report indicated an alarm was not applicable. Per QA nurse, there was no change to the planned interventions. She wasn't sure about the alarm at this time, the daughter was visiting but had left the room. *9/21/10 at 4:20 PM resident found on bathroom floor with urine on the floor. Again the alarm was noted to not be applicable on the incident report. The resident was sent to the emergency room and returned with five stapled to the back of her head. Per QA nurse this was not investigated yet and no changes had been made to prevent future falls. On 9/23/10 at 3:00 PM another interview with the QA nurse was conducted. She revealed that Resident #34 was alert but would not ask for assistance. She stated that she used what she had available in the facility, i.e. canary alarms, as intervention but could not think of anything else to do to prevent the resident from falling. Observations of Resident #34 during the survey revealed the following: *On 9/23/10 at 11:41 AM and at 1:34 PM Resident #34 was observed in a wheelchair in the dayroom without any alarms and sleeping. No staff were present. *On 9/23/10 at 3:04 PM Resident #34 was in her personal recliner behind the privacy curtain. No alarm was visible. She had the call bell by her side but could not explain how to use it or show the surveyor how she would get staff to assist her. She had five (5) staples to the back of her head. Her walker was by the closet door. *On 9/24/10 at 10:17 AM the resident was in the recliner in her room with no alarm visible and her walker out of reach. On 9/24/10 at 11:49 AM Resident #34 remained in recliner and canary alarm was attached to left shoulder and box resting on seat of recliner. *On 9/24/10 at 2:02 PM the resident was in recliner totally behind the privacy curtain and out of view. The walker and wheelchair were out of reach. The alarm was noted dangling from her shoulder. At 2:09 PM, NA #3 assisted Resident #34 to a standing position. Because the alarm box was not connected to the chair, when the resident stood the alarm did not disengage and swung from her shoulder. Staff interviews during the survey revealed the following: *On 9/23/10 at 3:07 PM Nurse aide (NA) #2 stated that Resident #34 was usually independent and gets up and goes to bed on her own. In the month that NA #2 had been at the facility, she stated she was unaware of the need for any alarm. *Interview with MDS staff on 9/23/10 at 4:19 PM revealed that the most recent care plan update was for the resident to be careful when she went out with her family. When asked about the use of the canary alarm, MDS staff stated that if the alarm was in use that was great but if the alarm was not in use, she would not be too concerned. She further stated that she has not talked with nursing about interventions in awhile. MDS stated she updates the care plans as needed. *On 9/24/10 at 2:20 PM Licensed Nurse (LN) #4 stated that per care plan, the canary alarm could be used but did not have to be used. She further stated it would depend on how Resident #34 was acting that day. LN #4 stated that she was on duty on 9/21/10 when Resident #34 fell and required stapled in her head. She stated that she was unaware Resident #34 fell on [DATE], three days earlier, and had she known, she would have expected the canary alarm to be in place. *On 9/24/10 at 2:58 PM, LN #3 stated that the facility was attempting to get rid of all the canary alarms and that he hadn't seen an alarm on Resident #34 for awhile. He further stated that he was unaware of any additional interventions that had been attempted since a fall in May when she was out of the facility with family *On 9/24/10 at 2:10 PM, NA #3 stated that the walker and wheelchair were not close to resident #34 when she was in her recliner because once in the recliner, the resident will not get up and she will ring for assistance with her call light. 2. Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set ((MDS) dated [DATE] coded him with short term memory loss, moderately impaired decision making skills, independent ambulation, supervision with transfers, hygiene, toileting, falls and unsteady gait. The Resident Assessment Protocol (RAP) summary dated 3/29/10 described him with having a history of falls, ambulatory with a rolling walker and assist as needed for safety, having an unsteady gait, and needing reminders at times. The care plan initiated 4/8/10 which addressed a history of falls and a potential for continued falls included interventions of allowing him to ambulate independently, check him frequently, and encourage him to ask for assistance. On 9/22/10 at 2:54 PM the Quality Assurance (QA) nurse stated that Resident #78 initially used a canary alarm in the bed and wheelchair. At this time, Resident #38's nursing notes and occurrence reports were reviewed with the facility's Quality Assurance (QA) nurse. The QA nurse was interviewed and this review revealed the following: *on 3/30/10 at 10:35 AM resident was found by the housekeeper on the floor as he was calling out for help. Although the canary alarm was on the wheelchair, it did not sound. Per QA nurse there was no change in interventions to prevent falls with injuries. However, the record reflected Physical therapy was initiated on 3/21/10 and Occupational therapy was initiated 3/23/10. *on 4/2/10 at 1:00 AM resident was found on the floor with therapeutic stockings on and no shoes. Per QA nurse, he was reminded to ask for assistance. Nothing was noted about an alarm. *on 4/8/10 at 11:45 PM resident was found on the floor by the bathroom door. It was suspected he removed the alarm. QA nurse stated there was no change in the care planned interventions. *on 4/19/10 at 9:30 PM roommate called for staff and resident was found on floor out of bed. The alarm was still on the chair although the resident was in bed. The QA nurse was unaware of any follow up to determine why the alarm was still on the chair. Review of the fall care plan revealed that on 4/20/10, the resident was to ambulate with a rolling walker and assistance for safety, the canary alarm was discontinued, a dip mattress was placed on the bed and the bed was to be in the lowest position with half rails for mobility. Review of the therapy notes revealed Occupational therapy ended 5/21/10 and Physical therapy ended 7/9/10. Ongoing review of nursing notes and occurrence reports with the QA nurse revealed: *on 6/10/10 at 8:45 PM resident fell transferring self from the wheelchair to bed after removing the canary alarm and not locking the wheelchair. Per QA nurse, there were no changes in care planned interventions. *on 7/31/10 at 6:00 AM Resident reported that he fell going to the bathroom. The QA nurse stated the resident was reminded to call for assistance. *on 8/2/10 at 2:15 AM resident found on his knees at bedside. The resident stated he wanted to go to the bathroom. At this time, Resident #78 was to be placed on a toileting program. *on 8/4/10 at 3:15 AM resident was found on the foot of the bed. He reported that he fell trying to go to the bathroom but got himself up on the bed. Per QA nurse he was placed on toileting program. *on 8/22/10 at 1:30 AM resident found at bottom of bed, he stated he had fallen and got up on the foot of the bed. Per QA nurse no changes in interventions were made. *on 8/23/10 at 12:45 AM resident was found leaning over his chair and he stated he fell to the floor reaching for his walker. Per QA nurse, no changes in interventions were made. *on 8/23/10 at 5:00 AM found on bathroom floor. No new interventions. The most recent MDS, a quarterly dated 8/25/10, coded Resident #78 as having short term memory impairments, moderately impaired decision making skills, being independent with bed mobility and transfers and needing supervision and set up for ambulation. No changes were made to the fall care plan. Ongoing review of nursing notes and occurrence reports with the QA nurse revealed: *on 9/12/10 at 5:05 PM found on floor. He stated his legs gave out. Per QA nurse, there were no new interventions tried. Per QA nurse on 9/22/10 at 3:43 PM, Resident #78 had gotten stronger and was doing more for himself. She stated that she would have to confirm with the nurse aides that he was being prompted to go to the bathroom during rounds. She was unsure if he could or would use a urinal. She further stated that the reports don't mention the use of the canary alarm so she was not sure if they were using one. She stated she assumed they removed it. She stated that the nurses decide if alarms are necessary or not and implement them. Upon further interview on 9/23/10 at 3:01 PM the QA nurse stated that because Resident #78 was getting stronger and he was only falling at night, she figured the falls would resolve themselves. She was unable to provide evidence that a toileting plan was implemented as a fall precaution. Resident #78 was observed transferring himself from the wheelchair to a regular chair on 9/21/10 at 6:35 PM and on 9/22/10 at 9:25 AM. The resident did not lock the wheelchair during either of these transfers. He had no alarm on the wheelchair at either time. Staff were not present during this observation. Interview with Nurse Aide (NA) #4 on 9/22/10 at 2:23 PM revealed that he needed supervision when he first arrived, but now he takes himself to the bathroom during first shift. Interview with NA #5 on 9/22/10 at 2:30 PM revealed they used to use a canary alarm but now he walks around a lot. She stated that Resident #78 needed more assistance at night. Interview with NA #6 on 9/24/10 at 4:10 AM revealed that she makes rounds every two hours at night and he usually does not want to go to the bathroom on their rounds, but then he will get up and try to take himself without calling for assistance. Currently there was no alarm being used. She could not think of anything other than an alarm being tried. 3. Resident #139 was readmitted to the facility 2/19/10 with [DIAGNOSES REDACTED]. The initial Resident Assessment Protocols (RAP) dated 2/25/10 assessed Resident #139 in the following areas: Cognitive Loss/Dementia-"Resident is alert to name, family and events of long ago but she cannot recall where she is, the month, what she has eaten today or when her family last visited. Short term memory is impaired. She has impaired decision making abilities in new situations only such as a change in her living arrangements." ADL (activities of daily living)/Rehab Potential-"...was readmitted to Sunrise Rehab and Care on 2/19/10 from (hospital)for short term rehab. She plans to return home with her family as soon as she is able. She was previously admitted here on 1/29/10 but was discharged to hospital on [DATE]...Alert with confusion and impaired decision making. Wears glasses for vision. Unable to perform complete balance testing due to weakness and inability to follow commands. Receives psychoactive meds and condition can be unstable at times. Receiving Occupational Therapy, Physical Therapy and Speech Therapy services. Resident and staff believe she is capable of some increased independence as her condition improves and she regains her strength and mobility. Requires total assist with wheelchair locomotion off unit/distances due to weakness. Extensive assist with ambulation and bathing. Limited assist with transfers, dressing, toileting and personal hygiene. Continent of bowel and bladder with assist to bathroom. Out of bed as tolerated in wheelchair and can self propel on unit. Ambulatory with rolling walker and assist for short distances. Gait unsteady. Rolling walker or wheelchair as transfer aid. Half rails up X 2 in bed for safety, mobility and transfers. Potential for falls due to history of falls and meds. No falls noted since admission here. Last noted fall was while in the hospital this last time." The admission care plan dated 2/22/10 looked at the area of falls with the notation, "Have reviewed nurse's notes. Fall risk screen and plan of care. Fall risk score 11." Documentation on the fall risk score notes that a score of 7-18 places a resident at high risk of a fall. Approaches to prevent falls were identified as: glasses, ambulate with rolling walker, out of bed in wheelchair. On 9/23/10 at 4:35 PM the Director of Nursing (DON) reviewed the facility practice for handling falls. The DON stated a Resident Occurrence Report is completed by the nurse involved at the time of a fall and would include what the occurrence was, the resident's condition at the time of the occurrence and immediate action taken. The DON stated an Investigation of Occurrence witness statement is completed by all staff that witnessed the fall. And lastly, an Occurrence Investigation is completed by the Quality Assurance (QA) nurse, Assistant Director of Nursing (ADON) or care plan team. The DON stated the action taken to prevent future falls would be documented on this form. The DON stated she reviews all three forms for each fall and returns them to the appropriate staff if any pieces of information are not contained in the investigation. The DON could offer no explanation for the inconsistent lack of response to the falls Resident #139 had while at the facility. During her admissions to the facility 2/19/10-3/7/10, 3/16/10-3/17/10 and 3/23/10-7/19/10, 7/22/10-current, Resident #139 had sixteen falls, eight resulting in injury. Review of nurses notes, the Resident Occurrence Report, Investigation of Occurrences report and Occurrence Investigations the falls were noted as follows: Fall #1 3/4/10 4:15 AM "Found resident on floor in room. She had removed her canary alarm-had been reapplied several times prior. Two small skin tears noted on left elbow. Moves all extremities well. No other injury noted. Has multiple bruises already present. Assisted resident back to bed with two assist. Reminder to use call light, canary reapplied." The Occurrence Investigation did not identify any measures put into place to prevent further falls. On 9/24/10 at 10:30 AM the QA nurse that completed the investigation stated the resident was reminded to use her call bell. The QA nurse stated it may not be the most appropriate measure to put in place due to the resident's memory impairment but it was a measure they put into place for all the residents. Fall #2 3/5/10 6:00 PM "Patient states she slid out of wheelchair. No apparent injuries, range of motion performed. Reminder to ask for help, not to lean out of wheelchair" The witness statement indicated, "On 3/5/10 around 6:30 PM as I was picking up trays from supper I came out of a residents room and saw (Resident #139) lying in the floor (canary alarm going off). She said she slid out of her wheelchair." There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 10:35 AM the QA nurse could not find the Occurrence Investigation and reported there were no changes to prevent further falls. On 3/7/10 the resident was discharged home. On 3/16/10 the resident was readmitted to the facility. The admission care plan dated 3/17/10 looked at the area of falls and noted the resident had 2 falls on 3/17, has fallen and/or sustained an injury since the last care plan, have reviewed nurses notes. Fall risk screen and plan of care. Fall risk score of 11 with a score of 7-18 indicating a high risk for falls. Approaches put into place to prevent falls were: glasses, out of bed to wheelchair and oxygen at two liters a minute. Fall #3 3/17/10 12:30 AM "Heard resident yell help. Looked down hall toward her room. She was sitting on floor at room doorway. She stated I fell . No apparent injury noted. Two assist back to bed. Call light within reach. Reminded how to use call light." There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 10:40 AM the QA nurse could not find the Occurrence Investigation and reported there were no changes to prevent further falls. Fall #4 3/17/10 2:30 AM "NA passed by residents room and saw her sitting on floor. No apparent injury noted. She was sitting on floor beside of bed on bed linens. Canary alarm applied. Call light within reach." The witness statement indicated, "3:00 AM Staff made a bed for the resident on the floor to prevent falls. Resident slept-moved back to bed at 7:00 A.M." There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 10:40 AM the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated the canary alarm was put in place and a permanent low bed was placed in the resident's room. Potential Fall #5 3/17/10 5:00 PM "As patient was getting out of wheelchair, nursing assistant heard canary alarm. Tried to get to patient to hold her up preventing fall. Caused a skin tear 1 1/2 inch on right forearm trying to grab patient as she was falling. Nursing assistant aware not to grab residents by arms and hands, reminded not to do so." The witness statement indicated, "Was filling out laxative list in dayroom when resident's canary went off and she was standing up. The wheelchair started rolling and she was fixing to fall. I ran over and grabbed her arm to try to prevent her falling and it caused a skin tear on her right arm." The Occurrence Investigation did not address measures to prevent falls. On 9/24/10 at 10:45 AM the QA nurse stated no changes were made involving the resident, only counseling was done with the nursing assistant. Fall #6 3/17/10 6:30 PM "Patient stood up from wheelchair and fell in hallway with canary alarm sounding. Lying on left side propped on left arm, holding head up." The witness statement indicated, "I heard canary alarm, as I ran to see where and who it was seen resident in floor right across from nursing desk. She is always trying to get out of chair. You can tell her to please not do so and when you turn your back she is at it again." Nurses notes on 3/18/10 at 3:00 AM indicated, "When nursing assistant in to dry resident and to turn her she yelled out and started crying out in pain. Complaining of left hip pain. Left leg noted to be rotated outward. She would not move leg, kept it still and straight when assessing, the least movement she would yell out in pain." The resident's physician was called and the resident was transferred to the hospital. Hospital records and X-rays indicated the resident was admitted from 3/18/10-3/23/10 for surgical repair of a left hip fracture. The resident was readmitted to the facility 3/23/10. The resident's care plan on admitted d 3/23/10 included the following problem areas: 1. Alert to name but is confused and disoriented. Does not know the day, the year, when her family last visited or what she has eaten today. Short term and long term memory and decision making are impaired. 2. Potential for falls due to history of falls and meds. Receives Remeron 7.5 milligrams every evening and Ativan 2 milligrams three times a day as needed. [DIAGNOSES REDACTED]. The goal to the problem area was, "Will suffer no falls and have no negative side effects from psychopharmacological meds thru next review." Approaches to prevent falls included: Administer meds as ordered, Monitor for medication side effects, Chart any behaviors to assist physician with medication reviews and/or dosage adjustments, Attempt to determine cause/source of anxiety when exhibited and remedy same if possible, Out of bed as tolerated in wheelchair, Monitor whereabouts frequently as she attempts to get up without assistance, Bed in lowest position (on floor with mat) with call light within easy reach, Encourage her to call for assistance as needed, Ensure glasses are clean and in place and Ambulatory with rolling walker and assist rolling walker or wheelchair as transfer aid. Fall #7 3/29/10 11:00 AM "Called into dayroom by another patient. Found patient on floor lying on sheet from chair. Abductor wedge in between legs. No apparent injuries. Moves all extremities well." The Occurrence Investigation did not address measures to prevent further falls. On 9/24/10 at 10:40 AM the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated the resident was placed in a geri-chair. Fall #8 4/3/10 11:00 AM "Called to dayroom found resident lying in floor on right side. Had removed shoes, oxygen. Geri chair was reclined and patient had slid to end of chair and in floor. Two centimeter tear back of right hand, closed with steri strips. Patient put in runabout wheelchair with canary alarm." Fall #9 4/6/10 2:40 AM "Heard resident talking to self/moaning. Nursing assistant in to check on her. Found her sitting on floor upright with back against bed. She had removed her gown-canary alarm on attached to gown and not sounding. No injury noted. After assessment dressed for bed. Assist back to bed with canary alarm attached." There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 10:45 AM the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated the resident's bed was placed against the wall. Fall #10 4/9/10 11:00 AM "When we got to residents room was found in the floor on right side. Range of motion adequate. Hip red, no bruising noted. Skin tear to right elbow. Cleansed with normal saline and bandage applied. Resident placed by nurses desk to be watched more closely. The Resident Occurrence Report indicated the canary alarm was on but did not mention if the alarm was sounding or operational. There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 10:45 AM the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated Dycem was placed in the resident's wheelchair to prevent her from sliding out. Fall #11 4/10/10 9:00 AM "Resident noted to have fallen in floor out of wheelchair in dayroom on to her right side. Obtain skin tear right wrist, abrasion on forehead and nose. Place resident out in hallway where she can be more observed. Ice pack applied to forehead." The Resident Occurrence Report did not indicate if the Dycem was in place in the resident's wheelchair. There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 10:50 am the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated the decision was made to put a torso support on the resident when in her wheelchair Fall #12 4/18/10 7:00 PM "fell on floor out of wheelchair landed on left side of body. Has reddened area on left cheek, skin tear on left pinky, skin tear on left outer wrist." The witness statement indicated, "...the patient leaned forward and fell on the floor. She hit on her left side. Canary was on but was so faint in sound" The Occurrence Investigation did not address approaches to prevent further falls. On 9/24/10 at 10:50 AM the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated the torso support was not in place because it was being laundered. The QA nurse stated another torso support was ordered so there would always be one available for use. Fall #13 4/19/10 2:30 PM "Nursing assistant found resident on pad on floor. Resident received skin tear to left upper arm. Resident was placed back on mattress and first aid given." There was not an Occurrence Investigation included with the fall report. On 9/24/10 at 11:00 AM the QA nurse could not find the Occurrence Investigation and stated no changes were made. On 4/21/10 the resident was seen by a geriatric nurse practitioner, "per staff request to evaluate some issues with ongoing pain with recurrent falls, unsteady gait and osteoarthritis. She also has some severe ecchymosis to the left side of her face from a fall sustained this weekend." "The patient is a [AGE] year old female who is here status [REDACTED]. The patient, however continues to have an unsteady gait and has fallen multiple times, the most recent of which was 4/18/10 when she fell hitting the left side of her face. The bruising and swelling have actually worsened instead of improving and the patient states that the area is very painful. She tolerates touch to her forehead and her right cheek, but not at all to left cheek. The patient does have some level of dementia, which makes communicating the etiology of her falls very difficult, however, she is just very unsteady. Staff has concerns that she could be having some chronic pain particularly because of her dementia she is not able necessarily to report her pain effectively. She does have fractures as well as significant bruising. The patient does have significant ecchymosis with swelling, significant dark purple bruising, and severe pain to her right cheek. She is not tolerating even light touch to the skin on her entire cheek, all the way down to the mandible. The patient has bruising on the upper periorbital area as well, but no pain with palpation of the upper bones. She does have significant bruising even of the eyelid." The plan, "The patient does have some severe facial bruising and swelling. I am concerned about a possible fracture. We will get an X-ray today and also I will order Tylenol 500 milligrams three times a day and continue with the Vicodin for breakthrough pain. I am hesitant to use the Vicodin on a routine basis, because I do not want to increase her sedation at this point just because of her fall risk. We will follow up as indicated by the facial X-ray results. A facial X-ray was done on 4/21/10 and there was no evidence of a fracture. On 6/24/10 there was a physician's orders [REDACTED]. Fall #14 6/30/10 6:30 AM "NA heard alarm went to check found resident sitting on floor, lap buddy lying on table and canary alarm sounding. No injuries or complaint of pain. Only stated and began to cry, I want to go home-could you call my son. 6:50 AM Removed lap buddy again and threw behind door, states, I hid it." The Occurrence Investigation did not address measures to prevent falls. On 9/24/10 at 11:05 AM the QA nurse stated no changes were made. Fall #15 7/6/10 7:11 AM "Called to dayroom to find resident sitting in floor beside wheelchair. She states, I just slid in the floor. Checked without any injury found. Moves all extremities well. NA shown how the alarm turns on. Found turned off when checked." The Occurrence Investigation did not address measures to prevent falls. On 9/24/10 at 11:05 AM the QA nurse could not find the Occurrence Investigation but located personal notes kept in her office which indicated the nursing assistant working with Resident #139 was new and didn't know how to turn on the canary alarm. The nursing assistant was taught how to turn on the canary alarm. No changes were made to the plan of care for the resident. Fall #16 7/13/10 9:05 AM "Entering south day room to give residents morning medication. Canary alarm sounding. Saw movement on left side of room, saw resident fall from standing position onto left side and hit head causing skin tear to left temple, left elbow and left fifth finger. She is alert and complains of headache. Able to move all extremities. Left pupil reactive, right pupil not reactive." The resident's physician was contacted with orders to send the resident to the emerge

Based on record review and staff interviews the facility failed to address significant weight loss for one (1) of four (4) residents reviewed for weight loss. (Resident #7) The findings are: Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Dietary Progress Note, prepared by the Dietary Manager (DM), dated 05/27/10, indicated Resident #7 was a tube feeder and received Ensure Plus. The progress note further revealed his current weight of 192 pounds was 27 pounds above his acceptable weight of 135-165 pounds. The DM noted Resident #7 had lost 6.8 pounds since his last review on 02/26/10. The progress note further stated, "Tube feeding is lacking in calories, protein and fluids. His fluid needs is figured by his acceptable weight. He is above acceptable weight, we will monitor for any weight loss." The progress note was signed by the Dietary Manager (DM). An admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 was totally dependent on staff for all activities of daily living including eating. The admission MDS further revealed the resident weighed 192 pounds, had no weight loss or gain, and received 76% to 100% of his total calories through a feeding tube. The Resident Assessment Protocol (RAP) summary for feeding tube status dated 08/25/10 stated Resident #7 had Dysphagia and received nothing by mouth. The RAP summary for nutritional status dated 08/25/10 indicated he received one can Ensure Plus and 120 milliliters (ml) water flush every six (6) hours and also received 120 ml water flush with medications. In addition, the nutritional status RAP summary noted the tube feeding lacked adequate calories, protein and fluids but the resident could not "tolerate any more fluids." A care plan dated 08/21/10 indicated Resident #7 received nothing by mouth and a [DEVICE] (feeding tube) was used for all nutrition and hydration. The goal stated the resident would maintain adequate nutrition and hydration from the feeding tube with a stable weight through the next review on 11/17/10. Interventions included: Monitor skin turgor, mucous membrane and urine output for signs and symptoms of dehydration. Notify MD as needed for increase in feeding or water orders. Feeding- Ensure Plus- give [MEDICATION NAME] one (1) can every six (6) hours and flush with 120 ml of water. Review of the medical record revealed the following recorded weights: - 04/12/10- 195.3 pounds - 05/06/10- 191.2 pounds - 05/26/10- 192.0 pounds - 06/03/10- 196.5 pounds - 07/02/10- 195.4 pounds - 08/03/10- 194.0 pounds - 08/21/10- 192.0 pounds - 09/01/10- 183.4 pounds Review of Resident #7's physician's orders [REDACTED]. A Dietary Progress Note dated 08/31/10 stated Resident #7 received one can of Ensure Plus four (4) times a day and 120 ml water nine (9) times every 24 hours. This progress note further revealed his current weight was 192 pounds and was two (2) pounds above his acceptable weight of 140-190 pounds. The progress note further stated, "Tube feeding is lacking in calories, protein and fluids. His fluid needs is figured by his acceptable acceptable weight. He is above acceptable weight, we will monitor for any weight loss." The progress note was signed by the DM. Review of an Enteral Nutritional assessment dated [DATE] noted Resident #7 required 2772 calories per day/received 2133 calories per day, required 90 grams of protein per day/received 78 grams of protein per day, and required 2045 ml of fluid per day/received 1858 ml of fluid per day. No signature was noted on the nutritional assessment. During an interview on 09/23/10 at 11:00 AM the DM stated she usually asked the Dietitian to see residents with poor intake and weight loss. She could not recall if she specifically mentioned Resident #7's weight loss to the Dietitian after she entered the resident's September weight into her computer. The DM further stated Resident #7's tube feeding had been reduced to one can of Ensure Plus every six (6) hours at some point due to weight gain and had maintained his weight within the guidelines for acceptable weight. During a follow up interview on 09/23/10 at 4:00 PM the DM located the original physician's orders [REDACTED]. In addition, the DM was not able to confirm if Resident 7's weight loss was discussed during a morning meeting or weight committee meeting. Interviews were conducted with the Dietitian on 09/23/10. At 12:40 PM the Dietitian stated she worked in the facility once a week and tried to see all new admissions, residents with weight loss, and any Physician ordered consults. The Dietitian indicated once she reviewed a progress note or nutritional assessment prepared by the DM she signed behind her on the document. The Dietitian explained estimated needs for tube feedings were calculated by a computer program which utilized the residents Body Mass Index (BMI), acceptable weight and risk factors such as, pressure ulcer, diagnoses, activity, and lab results if available. During the interview the Dietitian confirmed the weight report she printed on 09/02/10 indicated Resident #7 had significant weight loss in the last thirty (30) days of 5.8% and the last six (6) months of 11.0%. The Dietitian further stated she had worked in the facility three times since 08/21/10 but had not seen Resident #7 or reviewed his chart since his readmission on 08/21/10. In addition, the Dietitian recalled Resident #7's tube feeding had been reduced at some point due to weight gain but could not recall when this occurred. During a follow up interview at 2:37 PM the Dietitian stated she had reviewed and recalculated the Enteral Nutritional assessment dated [DATE] and found an error in the calculation. The Dietitian further explained the DM entered entered six (6) feeding per day instead of four (4) feedings per day when she prepared the 08/31/10 Enteral Nutritional Assessment. The Dietitian confirmed Resident #7's current tube feeding, which was his only source of calories, did not meet his nutritional needs and would need to be evaluated due to the downward trend in weight. The Dietitian reviewed the progress notes (dated 05/27/10 and 08/31/10) and nutritional assessment (dated 08/31/10) and confirmed she had not signed behind the DM on any of the documents. An interview was conducted with LN #10 on 09/23/10 at 3:15 PM. During the interview LN #10 stated she had discussed Resident #7's recent weight loss with nursing staff familiar with the resident and was told his tube feedings order had not changed. LN #10 could not recall if she spoke with the Dietitian and also could not recall if Resident #7's weight loss had been discussed during a morning meeting in September 2010. During an interview on 09/24/10 at 3:00 PM the Director of Nursing (DON) revealed LN #10 is responsible for entering residents' weights into the weight notebooks. The DON further revealed LN #10 usually notified the DM if she noticed weight loss so the Dietitian assess the resident and decide if any changes needed to be made to a resident's plan of care.

Based on staff interviews and document review the facility's Quality Assurance program failed to implement an action plan to prevent residents from sustaining serious fall related injuries for two (2) of six (6) sampled residents (Residents #34 and #78). The findings are: Cross refer F323 examples 1 - 5. Based on observations, record review and staff interviews, the facility failed to consistently implement and/or change interventions to prevent falls and or injuries for five (5) of six (6) sampled residents. Residents #34, #51, #52, #78, and #139. The facility had a Quality Assurance (QA) committee that met monthly that included the Administrator, Director of Nurses (DON), Quality Assurance Nurse, Assistant Director of Nurses, the Medical Director and Assistant Medical Director among other department heads. The DON, responsible for the QA meetings, was interviewed on 9/24/10 at 10:50 a.m. and reported the meeting is held monthly to discuss areas of concern generated by occurrence reports and concerns reported to staff. The DON confirmed that each month falls are reviewed and that the facility had a problem with ongoing falls with injuries to residents. She reported no further plan of action had been developed to address the ongoing number of falls with injuries in the facility. On 9/24/10 at 10:45 a.m. the Medical Director was interviewed and confirmed that falls were a problem in the facility and that he was unaware of specific actions implemented to reduce the number of fall related injuries. He reported he attends the QA meeting monthly and that a falls report was presented at each meeting. On 9/24/10 at 11:00 a.m. the Quality Assurance (QA) Nurse was interviewed and reported each month she presented fall statistics at the QA meeting. The QA Nurse reported that falls with injuries were an ongoing problem in the facility. She additionally reported no further action plan had been developed to prevent or reduce the number of falls with injuries for the facility.