Every finding on record at Glenbridge Health And Rehabilitation

Based on observation, record reviews and interviews with staff, Nurse Practitioner, Pharmacy Director and Medical Director, the facility failed to have effective systems in place for acquiring a scheduled medication when nursing staff failed to request a prescription from the Nurse Practitioner to avoid a gap in medication administration when refilling a controlled medication which resulted in Resident #56 missing 4 days of the medication. This deficient practice occurred for 1 of 1 resident reviewed for pharmacy services (Resident #56).The findings included:Resident #56 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and neuropathy (condition characterized by damage, disease, or dysfunction of one or more nerves, often causing pain, numbness, tingling, or muscle weakness).Review of Resident #56's physician orders revealed an order dated [DATE] for Lyrica (used to treat nerve pain from diabetes) 25 milligrams (mg) one capsule by mouth one time a day for neuropathy.Review of Resident #56's Medication Administration Record (MAR) for [DATE] revealed the Lyrica was scheduled to be administered at 9:00 AM but was not administered on [DATE], [DATE], [DATE] and [DATE]. Further review of the MAR revealed each day was coded with a 9 which indicated to see progress notes.Review of Resident #56's progress note dated [DATE] was written by Nurse #4 indicated the Lyrica was on order.Review of Resident #56's progress note dated [DATE] was written by Nurse #3 indicated the Lyrica was on order.Review of Resident #56's progress note dated [DATE] was written by Nurse #3 indicated the Lyrica was on order.Review of Resident #56's progress note dated [DATE] was written by Nurse #5 indicated the Lyrica was on order.A telephone interview was conducted with Nurse #4 on [DATE] at 1:03 PM. The Nurse confirmed that she worked first shift on [DATE] and did not have the Lyrica available to give to Resident #56 for his 9:00 AM medication administration. The Nurse explained that she reordered the medication from the pharmacy and reported it to the Weekend Supervisor who told Nurse #4 that they were aware and it was being addressed.An interview was conducted with the Weekend Supervisor on [DATE] at 2:00 PM who confirmed that she worked on [DATE] and explained that she did not recall being notified by Nurse #4 that Resident #56 was out of his Lyrica medication.A telephone interview was conducted with Nurse #3 on [DATE] at 12:32 PM who confirmed that she did not have Resident #56's Lyrica 25 mg to administer on [DATE] and [DATE]. Nurse #3 stated that she requested a refill for the Lyrica on [DATE] from the Unit Manager and still did not have the medication to administer on [DATE] and [DATE]. Nurse #3 explained that she called the pharmacy to see if Resident #56 had a prescription on hand so that she could pull the Lyrica from the Pyxis (a backup supply of medications), but the pharmacy did not have a prescription on hand for the Lyrica therefore she could not pull the Lyrica from the Pyxis. Nurse #3 continued to explain that she informed the Unit Manager on [DATE] that Resident #56 was out of his Lyrica 25 mg capsules and notified the Unit Manager again on [DATE] that she still did not have Resident #56's Lyrica and she could not pull it from the Pyxis. On [DATE] at 9:30 AM an interview was conducted with Nurse #5 who explained that she did not have Resident #56's Lyrica 25 mg to administer to him that morning ([DATE]). The Nurse stated she reported it to Unit Manager #1 who indicated she would take care of it. Review of a progress note dated [DATE] at 12:05 PM and written by the Unit Manager #1 revealed the pharmacy was notified again of Resident #56's Lyrica 25 mg capsules. The pharmacy stated the prescription on file had expired with no further refills. The Nurse Practitioner was notified and prescription sent to the pharmacy with follow up confirmation call. The medication will be delivered on the next run. The next dose was not due until 9:00 AM on [DATE].An interview was conducted with Unit Manager #1 on [DATE] at 10:15 AM who explained that the process to reorder medication was for the nurses to call the pharmacy for refills and the pharmacy would either send the medication or let her know that they needed a new prescription. She continued to explain that most of the time the full-time nurses would let the Unit Manager know that the pharmacy needed a new prescription for a medication, but the agency nurses did not know how to do that. She stated she was constantly educating the agency nurses how to do that but by the time she got the agency nurse educated to the process they were gone, and another one came in and the cycle started all over. The Unit Manager stated she tried to look for the upcoming refills herself, but she did not always have time to do that. She explained that she was informed on Monday [DATE] that they were out of Resident #56's Lyrica 25 mg capsules and when she called the pharmacy, she was told that they would send the medication down in the next delivery. When she was told on Tuesday [DATE] that they still did not have the Lyrica she called the pharmacy again and the pharmacy told her that they needed a prescription before they could send the Lyrica. When the Unit Manager was asked why the nurses did not pull the Lyrica from the Pyxis, she explained that if the resident did not have a current prescription for the medication, then the pharmacy would not give them a code to pull the medication from the Pyxis. The Unit Manager stated she received a prescription notice from the pharmacy on [DATE] and she sent it to the Nurse Practitioner, but the pharmacy did not send the medication, and she did not know why they did not send the medication. She reported the pharmacy did allow the facility to pull the Lyrica from the Pyxis on [DATE] because they had the prescription by that time. The Unit Manager stated they needed a new system to obtain the controlled medications from the pharmacy to prevent the residents from running out since the facility utilized so many agency nurses.During an interview with the Nurse Practitioner on [DATE] at 12:12 PM the Nurse Practitioner explained that he received emails from the facility when it was time to reorder controlled medications and he would send the prescriptions to the pharmacy. The Nurse Practitioner reported that if there was a lag in receiving the medications it was between when he sent the new prescriptions to the pharmacy and when the pharmacy delivered the medications to the facility. The Nurse Practitioner stated he checked his emails for refills multiple times a day, 7 days a week. He reported the last request for Resident #56's Lyrica was that morning on [DATE].An interview was conducted with Resident #56 on [DATE] at 1:08 PM. The resident was sitting on the side of his bed eating his lunch. Resident #56 was asked if he knew that he did not get the pain medication for four days in a row and the Resident replied, No, they give me something for pain if I need it.A telephone interview was conducted with the Pharmacy Director on [DATE] at 1:12 PM who explained that the last refill of Resident #56's Lyrica 25 mg capsules was delivered on [DATE] of 30 capsules and the most recent refill of Lyrica 25 mg capsules was sent on [DATE] which required a new prescription. She stated if the facility did request an early refill, then the pharmacy would have needed a new prescription for an early refill, and she could not find where that was requested. The Pharmacy Director stated if the facility followed the procedure, then there was no reason why they would have run out of Resident #56's Lyrica 25 mg capsules.An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:13 PM. The DON explained that she found out about the nurses running out of Resident #56's Lyrica while she was investigating another issue. The DON stated she knew that the facility needed to develop another system to prevent the nurses from running out of the residents' medications.An interview was conducted with the Medical Director on [DATE] at 2:29 PM who explained that she was not notified that Resident #56 was not given his Lyrica 25 mg daily on [DATE], [DATE], [DATE] and [DATE] but the facility may have notified the Nurse Practitioner. The Medical Director stated running out of the resident's medications should never happen.

Based on observations, record review, and resident and staff interviews, the facility failed to implement an effective system to assess residents for the risk of entrapment from bed rails and monitor and document the ongoing need for bed rails. The facility also failed to maintain evidence that the risk and benefits of bed rails were discussed with the resident or resident representative and informed consent was obtained prior to the installation of bed rails for 4 of 4 sampled residents (Residents #11, #53, #61, and #75).Findings Included: a. Resident #11 was admitted to the facility on [DATE]. His cumulative diagnoses included heart failure, acute kidney failure, chronic atrial fibrillation (irregular heart rhythm), and diabetes.Resident #11's electronic medical record revealed a Siderail Data Collection assessment dated [DATE]. The assessment consisted of four subsections, Bed Mobility, Balance, Type of device, Summary, and included the following:Bed Mobility:Has the resident demonstrated poor bed mobility or difficulty moving within the bed or moving to a sitting position on the side of the beds? Yes.Is the resident currently using side rail for positioning, mobility or support? Yes.Has the resident expressed a desire to have side rails raised while in bed? Yes.Comments/Explanation: nothing documented.Balance:Does the resident have difficulty with balance or poor trunk control? Yes.Does the resident have difficulty with postural hypotension? Yes.Is the resident ambulatory? No.Does the resident have a history of falls? No.Comments/Explanation: nothing documented.Type of Device:Identify the type of device being used by resident - side rails are not indicated, assist rails/quarter rails, double full side rails, double half side rails, single full side rails, single half side rails, bed bolsters, or bed against the wall: single half side rails was selected.Summary: Nothing documented.There was no evidence Resident #11 was assessed for risk of entrapment from the bed rails. There were no further Siderail Data Collection assessments completed after 04/25/23. Resident #11's electronic medical record revealed no evidence the risks and benefits of side rail use was discussed with Resident #11 prior to the installation or use of the bed rails. Resident #11's electronic medical record revealed a Nursing Quarterly/Annual/Significant Evaluation assessment dated [DATE] that was divided into two subsections: A. Potential Restraint Type and B. Side Rail Review. In subsection A (Potential Restraint Type) staff selected resident does not have any potential restraints (including alarms or side rails). Per the assessment instructions, that response disabled the remaining questions in both subsection A (Potential Restraint Type) and subsection B (Side Rail Review). The disabled questions in subsection B (Side Rail Review) left unanswered consisted of the following:Right side rail: Full, Half, Quarter, or NoneLeft side rail: Full, Half, Quarter, or NoneAlarm type: Bed alarm, chair alarm, seat belt with alarm, floor mat alarm, wanderguard alarm, other (specify), or noneIndications (if not considered a restraint): Safety, promote independence, assist with bed mobility, or other (specify)CommentsThere was no evidence Resident #11 was assessed for risk of entrapment from the bed rails. There were no Nursing Quarterly/Annual/Significant Evaluation assessments completed prior to or after 01/20/26.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition. He had an indwelling catheter, was always incontinent of bowel and required partial to moderate staff assistance with toileting hygiene. The MDS assessment also noted that Resident #11 was independent with rolling left-to-right, independent with moving from a sitting-to-lying or lying-to-sitting position, and bed rails were not used as a physical restraint.During an observation and interview on 03/23/26 at 11:36 AM, Resident #11 was lying in bed on his left side with his cellphone in hand. Half-length bed rails were observed in the upright position on each side of his bed. Resident #11 explained he was able to use the bed rails for bed mobility.b. Resident #53 was admitted to the facility on [DATE]. Her cumulative diagnoses included fibromyalgia (widespread body pain), rheumatoid arthritis, low back pain, Alzheimer's disease with late onset, and dementia.Resident #53's electronic medical record revealed a Siderail Data Collection assessment dated [DATE]. The assessment consisted of four subsections, Bed Mobility, Balance, Type of device, Summary, and included the following:Bed Mobility:Has the resident demonstrated poor bed mobility or difficulty moving within the bed or moving to a sitting position on the side of the beds? Yes.Is the resident currently using side rail for positioning, mobility or support? Yes.Has the resident expressed a desire to have side rails raised while in bed? No.Comments/Explanation: nothing documented.Balance:Does the resident have difficulty with balance or poor trunk control? Yes.Does the resident have difficulty with postural hypotension? No.Is the resident ambulatory? No.Does the resident have a history of falls? Yes.Comments/Explanation: nothing documented.Type of Device:Identify the type of device being used by resident - side rails are not indicated, assist rails/quarter rails, double full side rails, double half side rails, single full side rails, single half side rails, bed bolsters, or bed against the wall: assist rails/quarter rails was selected.Summary: Nothing documented.There was no evidence Resident #53 was assessed for risk of entrapment from the bed rails. There were no further Siderail Data Collection assessments completed after 01/17/24.The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had severe cognitive impairment. She had impairment on both sides of the lower extremities, was frequently incontinent of bladder and bowel and required partial to moderate staff assistance with toileting hygiene. The MDS assessment also noted Resident #53 was independent with rolling left-to-right, required supervision or touching assistance with moving from a sitting-to-lying or lying-to-sitting position, and bed rails were not used as a physical restraint.Resident #53's electronic medical record revealed a Nursing Quarterly/Annual/Significant Evaluation assessment dated [DATE] that was divided into two subsections: A. Potential Restraint Type and B. Side Rail Review. In subsection A (Potential Restraint Type) staff selected resident does not have any potential restraints (including alarms or side rails). Per the assessment instructions, that response disabled the remaining questions in both subsection A (Potential Restraint Type) and subsection B (Side Rail Review). The disabled questions in subsection B (Side Rail Review) left unanswered consisted of the following:Right side rail: Full, Half, Quarter, or NoneLeft side rail: Full, Half, Quarter, or NoneAlarm type: Bed alarm, chair alarm, seat belt with alarm, floor mat alarm, wanderguard alarm, other (specify), or noneIndications (if not considered a restraint): Safety, promote independence, assist with bed mobility, or other (specify)CommentsThere was no evidence Resident #53 was assessed for risk of entrapment from the bed rails. There were no Nursing Quarterly/Annual/Significant Evaluation assessments completed prior to or after 01/20/26.Resident #53's electronic medical record revealed no evidence the risks and benefits of bed rail use was discussed with Resident #53 or her representative and informed consent was obtained prior to the installation or use of the bed grab bar. During observations on 03/23/26 at 11:11 AM and 03/24/26 at 3:30 PM, Resident #53 was lying in bed sleeping soundly. A bed grab bar was observed secured to the bedframe and in the upright position on the right side of Resident #53's bed. c. Resident #61 was admitted to the facility on [DATE]. Her cumulative diagnoses included heart failure, chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe) and hypertension.Resident #61's electronic medical record revealed a Siderail Data Collection assessment dated [DATE]. The assessment consisted of four subsections, Bed Mobility, Balance, Type of device, Summary, and included the following:Bed Mobility:Has the resident demonstrated poor bed mobility or difficulty moving within the bed or moving to a sitting position on the side of the beds? Yes.Is the resident currently using side rail for positioning, mobility or support? Yes.Has the resident expressed a desire to have side rails raised while in bed? No.Comments/Explanation: nothing documented.Balance:Does the resident have difficulty with balance or poor trunk control? Yes.Does the resident have difficulty with postural hypotension? No.Is the resident ambulatory? Yes.Does the resident have a history of falls? Yes.Comments/Explanation: nothing documented.Type of Device:Identify the type of device being used by resident - side rails are not indicated, assist rails/quarter rails, double full side rails, double half side rails, single full side rails, single half side rails, bed bolsters, or bed against the wall: assist rails/quarter rails was selected.Summary: Nothing documented.There was no evidence Resident #61 was assessed for risk of entrapment from the bed rails. There were no further Siderail Data Collection assessments completed after 04/25/23.Resident 61's electronic medical record revealed a Nursing Quarterly/Annual/Significant Evaluation assessment dated [DATE] that was divided into two subsections: A. Potential Restraint Type and B. Side Rail Review. In subsection A (Potential Restraint Type) staff selected resident does not have any potential restraints (including alarms or side rails). Per the assessment instructions, that response disabled the remaining questions in both subsection A (Potential Restraint Type) and subsection B (Side Rail Review). The disabled questions in subsection B (Side Rail Review) left unanswered consisted of the following:Right side rail: Full, Half, Quarter, or NoneLeft side rail: Full, Half, Quarter, or NoneAlarm type: Bed alarm, chair alarm, seat belt with alarm, floor mat alarm, wanderguard alarm, other (specify), or noneIndications (if not considered a restraint): Safety, promote independence, assist with bed mobility, or other (specify)CommentsThere was no evidence Resident #61 was assessed for risk of entrapment from the bed rails. There were no Nursing Quarterly/Annual/Significant Evaluation assessments completed prior to or after 01/20/26.Resident #61's electronic medical record revealed no evidence the risks and benefits of bed rail use was discussed with Resident #61 and informed consent was obtained prior to the installation or use of the bed grab bar.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition. She was frequently incontinent of bladder, was always incontinent of bowel and required partial to moderate staff assistance with toileting hygiene. The MDS also noted Resident #11 was independent with rolling left-to-right, independent with moving from a sitting-to-lying or lying-to-sitting position and bed rails were not used as a physical restraint.During an observation and interview on 03/23/26 at 11:56 AM, Resident #61 was sitting up in her wheelchair, well-groomed and dressed. Quarter-length bed rails were observed in the upright position on each side of her bed. Resident #61 stated she used the bed rails to reposition herself when lying in bed.d. Resident #75 was admitted to the facility on [DATE]. Her cumulative diagnoses included Parkinson's disease, cerebral infarction (stroke) and dementia. Resident #75's electronic medical record revealed a Siderail Data Collection assessment dated [DATE]. The assessment consisted of four subsections, Bed Mobility, Balance, Type of device, Summary, and included the following:Bed Mobility:Has the resident demonstrated poor bed mobility or difficulty moving within the bed or moving to a sitting position on the side of the beds? Yes.Is the resident currently using side rail for positioning, mobility or support? Yes.Has the resident expressed a desire to have side rails raised while in bed? No.Comments/Explanation: nothing documented.Balance:Does the resident have difficulty with balance or poor trunk control? Yes.Does the resident have difficulty with postural hypotension? No.Is the resident ambulatory? No.Does the resident have a history of falls? Yes.Comments/Explanation: nothing documented.Type of Device:Identify the type of device being used by resident - side rails are not indicated, assist rails/quarter rails, double full side rails, double half side rails, single full side rails, single half side rails, bed bolsters, or bed against the wall: assist rails/quarter rails was selected.Summary: Nothing documented.There was no evidence Resident #75 was assessed for risk of entrapment from the bed rails. There were no further Siderail Data Collection assessments completed after 10/16/23.Resident #75's electronic medical record revealed no evidence the risks and benefits of bed rail use was discussed with Resident #75 or her representative and informed consent was obtained prior to the installation or use of the bed grab bar.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had severe cognitive impairment. She was frequently incontinent of both bladder and bowel and was dependent on staff assistance with toileting hygiene, rolling left-to-right and moving from a sitting-to-lying or lying-to-sitting position. The MDS assessment indicated bed rails were not used as a physical restraint.Resident #53's electronic medical record revealed a Nursing Quarterly/Annual/Significant Evaluation assessment dated [DATE] that was divided into two subsections: A. Potential Restraint Type and B. Side Rail Review. In subsection A (Potential Restraint Type) staff selected resident does not have any potential restraints (including alarms or side rails). Per the assessment instructions, that response disabled the remaining questions in both subsection A (Potential Restraint Type) and subsection B (Side Rail Review). The disabled questions in subsection B (Side Rail Review) left unanswered consisted of the following:Right side rail: Full, Half, Quarter, or NoneLeft side rail: Full, Half, Quarter, or NoneAlarm type: Bed alarm, chair alarm, seat belt with alarm, floor mat alarm, wanderguard alarm, other (specify), or noneIndications (if not considered a restraint): Safety, promote independence, assist with bed mobility, or other (specify)CommentsThere was no evidence Resident #75 was assessed for risk of entrapment from the bed rails. There were no Nursing Quarterly/Annual/Significant Evaluation assessments completed prior to or after 01/20/26.During an observation on 03/23/26 at 11:12 AM, Resident #75 was observed lying in bed in a supine (flat on back with the face and upper body facing upward) position, alert but unable to respond to questioning. Quarter-length bed rails were in the upright position on both sides of the bed.Additional observations on 03/24/26 at 9:30 AM and 03/25/26 at 8:10 AM revealed Resident #75 lying in bed with quarter-length bed rails in the upright position on each side of the bed.During interviews on 03/24/26 at 10:40 AM and 03/25/26 at 10:00 AM, the Director of Nursing (DON) revealed bed rail assessments were completed quarterly and as needed. She explained that in an effort to streamline the process, the corporate office had consolidated multiple nursing assessments into a single Nursing Quarterly/Annual/Significant Evaluation assessment, which included the bed/side rail review. The DON stated she was not aware that the bed/side rail review was not being completed until the issue was brought to her attention by the surveyor and upon review, she realized that by selecting no to the question Is this a restraint? caused the remaining questions for the bed/side rail review section to automatically disable, leading staff to proceed to the next section of the assessment. The DON further stated it was her understanding that informed consent for bed rail use was only required when residents used full bed rails and that informed consent was not necessary if a resident used grab bars, quarter-length bed rails or half-length bed rails. She stated they had not obtained informed consent for bed rail use since they had no resident utilizing full bed rails.During an interview on 03/26/26 at 11:00 AM, the Administrator explained the corporate office attempted to consolidate multiple nursing assessments into a single assessment and no one had realized that the questions for the bed/side rail review were disabled once the restraint question was marked no. She stated informed consents should be obtained per the regulatory guidelines. The Administrator further stated she felt the breakdown was due to oversight and nursing staff getting used to the new streamlined assessment process.

Based on record review and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address concerns and/or suggestions voiced by residents during Resident Council meetings for 10 of 11 months reviewed (February 2025, March 2025, April 2025, May 2025, June 2025, July 2025, August 2025, October 2025, November 2025, and January 2026).Findings included:Review of the Resident Council Minutes for the period February 2025 through January 2026 revealed the following:a. The Resident Council Meeting minutes dated 02/20/25 revealed in part, the section for Old Business noted that showers were not being provided as often as residents would like, food was served late and cold or undercooked, beds were not being made, and residents clothing was not being taken to laundry to wash. The section for Pending Updates noted working with staff to make sure names are written in clothing so it is returned to the correct room with no further information documented. The section for New Business noted residents voiced concerns regarding medications being administered late, showers not being provided, beds not being made, and clothing not being returned.A Resident Council Concern form dated 02/20/25 noted residents complained the food was served raw or burnt on some days, they were served the wrong texture of food, residents wanted a bigger variety of food and better desserts, and food was often served late or cold. The department assigned to address the concern was listed as dietary. There was nothing documented describing what was done to address the concern. At the bottom of the concern form was an illegible signature of the person assigned to address the concern and the date the concern was addressed was blank.A Resident Council Concern form dated 02/20/25 noted residents stated they were not receiving medications on time and Nurse Aides (NAs) were not changing resident beds as often as they should. The department assigned to address the concern was listed as nursing. There was nothing documented describing what was done to address the concern. The concern form was signed by the Director of Nursing (DON) as the person addressing the concern and dated 02/21/25.A Resident Council Concern form dated 02/21/25 noted residents voiced concerns of missing clothing and that staff were not taking their clothing to laundry to be washed. The department assigned to address the concern was listed as laundry. The department's response noted that clothes labeled with residents' names were returned daily and it was the responsibility of nurse aides to bring soiled linens and resident clothing to laundry. The concern form was signed by the Housekeeping/Laundry Supervisor as the person addressing the concern and dated 02/21/25. b. The Resident Council meeting minutes dated 03/27/25 revealed in part, the section for Old Business noted that showers were not happening as often as residents would like, beds were not getting made and residents were missing clothing. The section for Pending Updates noted working with staff to make sure names are written in clothing so it is returned to the correct room with no further information documented. The section for New Business noted meals were not good and were served late and cold.The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 03/27/25.c. The Resident Council meeting minutes dated 04/22/25 revealed in part, the section for Old Business noted that meals were often served cold or late and residents were missing clothing. The section for Pending Updates was blank. The section for New Business noted residents voiced they were not being changed often enough, beds were not being made, clothing was not being returned from laundry, and meals were served late.The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 04/22/25.d. The Resident Council meeting minutes dated 05/28/25 revealed in part, the section for Old Business noted concerns were voiced regarding residents not being changed often enough, beds were not being made, clothing getting lost in laundry, and meals were served late. The section for Pending Updates was blank. The section for New Business noted concerns were voiced regarding call bells not being answered for long periods of time, rooms were not being cleaned thoroughly, bed sheets were too small to fit the mattress, missing clothing, food portions were too small and/or not appetizing, and sandwiches not provided when requested.A Resident Council Concern form dated 05/28/25 noted concerns regarding small food portions, kitchen staff would not make sandwiches when requested, and food was tough or stale. The department assigned to address the concern was listed as dietary. The department's response to the concern noted the menu was made by the Registered Dietician to ensure all food groups were met and dietary staff were trained on using the proper size of serving utensils. At the bottom of the concern form was an illegible signature of the person assigned to address the concern and dated 05/30/25.A Resident Council Concern form dated 05/28/25 noted a concern regarding rooms not being cleaned thoroughly by housekeeping staff. The department assigned to address the concern was listed as housekeeping. The department's response noted that housekeeping staff removed trash, cleaned bathrooms, dust, swept, and mopped rooms daily. The concern form was signed by the Housekeeping/Laundry Supervisor as the person addressing the concern and dated 06/03/25. A Resident Council Concern from dated 05/28/25 noted concerns regarding bed sheets did not fit the mattress and popped off at the corners, residents were receiving clothing labeled with other residents' names, and clothes shrunk when washed. The department assigned to address the concern was listed as laundry. The department's response noted an order would be placed for larger sized fitted bed sheets, residents clothing was washed in the proper wash cycle and shrinkage could be due to the type of fabric of the garment, and clothes with labeled with residents' names were returned daily. The concern form was signed by the Housekeeping/Laundry Supervisor as the person addressing the concern and dated 06/03/25. e. The Resident Council meeting minutes dated 06/18/25 revealed in part, the section for Old Business noted concerns were voiced regarding residents not being changed often enough, beds were not being made, clothing getting lost in laundry, and meals were served late. The section for Pending Updates was blank. The section for New Business noted concerns were voiced regarding call bells not being answered for long periods of time, rooms not being cleaned thoroughly, bed sheets were too small to fit the mattress, missing clothing, food portions were too small and/or not appetizing, and sandwiches not provided when requested. The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 06/18/25.f. The Resident Council meeting minutes dated 07/21/25 revealed in part, the section for Old Business noted concerns were voiced regarding call bells not being answered for long periods of time, rooms were not being cleaned thoroughly, bed sheets were too small to fit the mattress, missing clothing, food portions were too small and/or not appetizing, and sandwiches not provided when requested. The section for Pending Updates was blank. The section for New Business noted concerns were voiced regarding nurses being disruptive at night and call bells were not being answered for long periods of time. The residents also voiced they would like more showers and bed sheets.The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 07/21/25.g. The Resident Council meeting minutes dated 08/20/25 revealed in part, the sections for Old Business and Pending Updates were blank. The section for New Business noted concerns were voiced regarding nurse aides being too loud at night and not answering call lights in a timely manner. The residents also voiced they would like food to be served faster and have more towels and bed sheets.The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 08/20/25.h. The Resident Council meeting minutes dated 09/25/25 revealed in part, the sections for Old Business and Pending Updates were blank. The section for New Business noted concerns were voiced regarding residents not wanting showers at night, nursing staff not answering call lights in a timely manner, and call lights being turned off without staff providing the requested assistance. The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 09/25/25.i. The Resident Council meeting minutes dated 10/24/25 revealed in part, the section for Old Business was blank. The section for Pending Updates noted new kitchen manager. The section for New Business noted concerns were voiced regarding too many recurring meals like pizza and sandwiches, food to be served faster, clothing not being returned from laundry, nursing staff not answering call lights in a timely manner, and call lights being turned off before the task was completed.The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 10/24/25.j. The Resident Council meeting minutes dated 11/20/25 revealed in part, the section for Old Business noted concerns were voiced regarding over-recurrence of certain foods being served and inconsistent times, call lights not being answered in a timely manner and clothing not being returned from laundry. The section for Pending Updates was blank. The section for New Business noted residents stated the food had gotten better but they still voiced concerns regarding the quality of food, call lights not being answered in a timely manner and clothing not being returned from laundry.The facility was unable to provide documentation of a Resident Council Concern form filed on behalf of the residents attending the Resident Council Meeting on 11/20/25.k. The Resident Council meeting minutes dated 12/30/25 revealed in part, activities were canceled due to a flu and COVID outbreak in the building. The section for Old Business noted the residents agreed the food had gotten better but they still voiced concerns regarding the quality of food, call lights not being answered in a timely manner and clothing not being returned from laundry. The section for Pending Updates noted clothes need to have residents' names in them to be returned and any unlabeled clothing is set aside. There was no New Business noted due to activities being canceled.l. The Resident Council meeting minutes dated 01/29/26 revealed in part, activities had opened back up after being canceled due to a flu and COVID outbreak in the building. There was no Old Business or Pending Updates. The section for New Business noted concerns were voiced regarding call lights not being answered in a timely manner and clothing not being returned from laundry. The residents also voiced they wanted a wider variety of foods and both fruit and dessert served with meals.A Resident Council Concern form dated 01/29/26 noted a concern that clothing was not being returned. The department assigned to address the concern was listed as laundry. The department's response noted clothing labeled with residents' names were returned daily. The concern form was signed by the Housekeeping/Laundry Supervisor as the person addressing the concern and dated 01/29/26. A Resident Council Concern form dated 01/29/26 noted a concern that call lights were not being answered in a timely manner. The department assigned to address the concern was listed as nursing. The department's response describing what was done to address the concern, signature of the person addressing the concern and date the concern was addressed were all blank.A Resident Council Concern form dated 01/29/26 noted a concern that residents wanted a bigger variety of food and wanted both fruit and dessert. The department assigned to address the concern was listed as dietary. The department's response describing what was done to address the concern, signature of the person addressing the concern and date the concern was addressed were all blank.A Resident Council group interview was conducted on 03/24/26 at 1:45 PM with Residents #6, #22, #35, #44, #47, #66, #67, #97, #108, #109, and #118 in attendance. In addition, Residents #31, #56, #58, #100, and #111 also attended but did not verbally participate in the group interview. When the group was asked about the concerns voiced during previous Resident Council meetings, Residents #6, #22, #35, #44, #47, #66, #67, #97, #108, #109, and #118 all agreed concerns regarding call bell response times, cold and/or late food and missing clothing were recurring issues that remained ongoing and were brought up at nearly every Resident Council meeting. Resident #35 and Resident #108 both stated Resident Council was never provided any communication regarding what was done or being done to address the concerns and Residents #6, #22, #44, #47, #66, #67, #97, #109, and #118 all voiced agreement with Resident #35 and Resident #108 statements. During an interview on 03/24/26 at 4:07 PM, the Activity Director revealed she attended and recorded the minutes for the Resident Council monthly meetings. The Activity Director explained when residents voiced concerns and/or suggestions during the monthly meetings, she wrote them on a Resident Council Concern form that was given to the appropriate Department Manager to address. She stated once the concern was addressed and returned to her, she typically discussed the resolution during the next scheduled Resident Council meeting. The Activity Director verified that residents attending the Resident Council meetings voiced the same frequent concerns month-to-month such as call lights not being answered, staff turning off call lights but not providing care, and clothing not being returned from laundry. She stated when facilitating the Resident Council meeting, she reviewed old business, discussed resolution to address the concern(s) previously voiced and asked the residents if they felt the matter had been resolved. She stated if the residents mentioned the same concerns again, she would document the concerns as new business and wrote the concerns on another Resident Council Concern form for the Department Manager to investigate. The Activity Director stated it was up to the Department Manager on how the concerns were addressed. During an interview on 03/26/26 at 11:00 AM, the Administrator stated when residents voiced concerns during a Resident Council meeting, the concerns should be documented in the Resident Council minutes and on a Resident Council Concern form to be investigated by the appropriate department. In addition, she stated the concerns voiced the previous month should be discussed as old business at the next Resident Council meeting which would include the processes that were put into place or what was done to address the concern(s), asking the residents attending the meeting if the concerns had improved or resolved and documenting in the minutes that resolution for the concerns was provided and discussed. If the residents reported the concerns had not improved, then the repeated concerns should be documented in the minutes under new business and the Activity Director should ask more specific questions about what specifically did not work with the previous resolution so that the administration team would have more details to use as a constructive tool when developing a new process to address the concern(s). The Administrator reviewed the Resident Council Concern forms from the February 2025, May 2025 and January 2026 Resident Council meetings and expressed that the department responses did not really address the issues that were voiced by the residents. She explained the Activity Director was still new to the position and going forward, she was going to have the Activity Director provide her with a copy of the Resident Council minutes and Resident Council Concern forms following the meeting so that she could review and assist the Activity Director with what she needed to do.

Based on observations, record review, and resident, staff, Wound Physician Assistant (PA), Hospice, and Physician interviews, the facility failed to complete assessments for 3 of 3 residents reviewed for pressure ulcers (Resident #14, Resident #83, and Resident #48). In addition, the facility failed to initiate wound treatment for Resident # 14's pressure ulcer at the onset. Findings included: a. Resident #14 was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following unspecified cerebrovascular disease (stroke) affecting left non-dominant side.A care plan dated 10/30/25 and last revised on 2/2/26 indicated there was potential for pressure ulcer development related to contractures, limited mobility, and bed bound. The care plan goal was for Resident #14 pressure ulcer to show signs of healing and remain free from infection. The care plan interventions included administering treatments as ordered, to monitor/document/ report any changes in skin status, turn/ reposition at least every 2 hours, pressure reducing device on bed, and weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate.An order dated 5/15/25 read, apply protective foam dressing to sacrum. Check placement daily, every day shift for high-risk area. The order was discontinued on 10/30/25.An order dated 10/17/25 read, Air Mattress Overlay every day and night shift for maintenance. The order was discontinued on 11/26/25.A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 had moderate cognitive impairment. The MDS documented that he was at risk of developing pressure ulcers. The MDS indicated he did not have unhealed pressure ulcers.The electronic medical record documented he was admitted to Hospice services on 11/4/25.A Braden scale (tool used to identify an individual's risk of developing pressure ulcers) dated 1/20/26 indicated Resident #14 was very high risk for skin breakdown. There were no previous Braden Scale assessments documented in his medical record.Review of Resident 14's medical record revealed there were no weekly skin assessments documented in his medical record prior to 1/13/26.Facility shower sheets for Resident #14 dated 11/11/25 and 11/14/25 documented sacral pressure injury written on the bottom of the form. The shower sheets did not include the name of who had completed them.An interview was conducted on 3/25/26 at 12:23 PM with the Assistant Director of Nursing (ADON). She recalled completing a bed bath for Resident #14 and completing the shower sheet on 11/11/25. She could not recall if there was a dressing to his sacrum or if the area was open. The ADON said she thought from what she had documented on the shower sheet that there would have been a dressing in place. She reported if there had not been a dressing in place she would have documented differently. The ADON said she did not remember talking to anyone about the wound. She said if she did not talk to anyone about the wound it would have been because she thought it was already being taken care of by wound care. The ADON stated she thought there must have been a dressing in place to his sacrum because she did not recall ever seeing Resident #14's actual pressure ulcer. The ADON said she was helping with giving Resident #14 a bed bath not assessing his wound so she would not have removed the dressing to his sacrum to look at the wound if there was one in place.It could not be determined who completed the shower sheet from 11/14/25.Hospice notes from 11/4/25 through 11/18/25 were reviewed and did not include documentation of Resident #14 having a pressure ulcer to his sacrum.There was no evidence of treatment orders or treatments provided for a sacral pressure ulcer for Resident #14 from 11/11/25 to 11/18/25.A weekly wound assessment dated [DATE] completed by the Wound Care Nurse documented Resident #14 had a stage 3 pressure ulcer to his sacrum. The wound assessment indicated 11/18/25 was the date of onset for the wound. The wound length was 2.5 centimeters (cm), the width was 2 cm, and the depth was 0.2 cm. The assessment indicated there was granulation (new tissue) tissue, yellow/ brown eschar (dead tissue), and a small amount of drainage present to the wound.A treatment order dated 11/18/25 read: Cleanse sacrum with saline wash, apply foam dressing, change every three days. A hospice note dated 11/20/25 by Hospice Nurse #2 read: facility staff notified this nurse that patient has a pressure injury to sacrum. Patient provided wound care by facility staff wound care nurse.An interview was conducted with Hospice Nurse #1 on 3/25/26 at 1:39 PM. She saw Resident #14 on 11/4/25 and completed his hospice admission. She stated she did not look at the skin on his buttocks during the visit because he was having issues with pain and had told her not to. She reviewed the hospice notes for Resident #14 and stated hospice became aware of his sacral pressure ulcer on 11/20/25.An interview was conducted with Hospice Nurse #2 on 3/26/26 at 11:47 AM. She saw Resident #14 on 11/5/25 and 11/20/25. She recalled Resident #14 was adamant about not letting her turn him, so she did not assess the skin on his buttocks.An interview was conducted with Hospice Nurse #3 on 3/25/26 at 1:09 PM. She was Resident #14's routine Hospice Nurse and had started seeing him on 11/17/25. She reported the facility's preference was to manage and do Resident #14's wound care. She could not recall exactly when Resident #14's sacral wound was identified but indicated his sacral pressure ulcer was first noted in the hospice notes on 11/20/25. She was not sure how frequently the facility did skin assessments but said the facility notifies hospice if they find a new skin concern.An interview was conducted with the Hospice Nurse Aide (NA) on 3/25/26 at 1:29 PM. She reported she was the routine Hospice NA for Resident #14 and typically came to the facility weekly and gave him a bed bath during her visits. She recalled 11/12/25 was the first time she saw Resident #14 after his admission to hospice on 11/4/25. She remembered he had an existing wound on his sacrum when she saw him on 11/12/25. She stated she knew it was existing because he already had a dressing on his buttocks when she saw him on 11/12/25. The Hospice NA said she regularly spoke to the Wound Nurse and the Hospice Nurse about Resident #14 but did not think the wound to his buttocks was something to report because he had a dressing in place and she thought it was an existing wound and not new. She said the dressing to his buttocks looked like a foam dressing.An interview was conducted with the Wound Care Nurse on 3/24/26 at 11:14 AM. She recalled Resident #14's sacral pressure ulcer and stated the date she first documented on his wound (11/18/25) was the date the wound was identified, and his wound was a stage 3 pressure ulcer when it was first identified. She stated someone had reported the wound to her, but she could not remember who it was. She recalled he had previous stage 2 pressure ulcer to his sacrum but said it had healed. The Wound Nurse stated she had kept a protective dressing on his sacrum after his previous pressure ulcer healed for a long time until she had felt comfortable stopping it. She thought Resident #14's wound may have been found before it was a stage 3 pressure ulcer if routine skin assessments had been completed. The Wound Nurse stated that Resident #14's wound was currently a stage 4 pressure ulcer.An interview was conducted with Unit Manager (UM) #2 on 3/25/26 at 4:30 PM. She was the UM for the 100/200 side were Resident #14 resided. UM #2 explained the process for identifying new skin issues prior to January 2026. She reported that the NAs completed skin checks when they gave a resident a bath/ or shower and were supposed to complete a shower sheet. She explained the NAs were supposed to mark on the shower sheet if there were any skin abnormalities seen and then give the shower sheet to the floor nurse to review. UM #2 indicated she did not review the shower sheets. She stated if there was a skin concern the floor nurse was supposed to notify the Wound Nurse and the Wound Nurse would come and assess the area. She said if the Wound Nurse was not at the facility, then the floor nurse was responsible for assessing the wound, implementing a treatment, and entering the order for the treatment. UM #2 reported Braden Scale assessments were completed for residents on admission and then quarterly, every 3 months. She stated the nurse who did the residents admission assessment completed the Braden Scale on admission. She explained that the UM's were responsible for completing the Braden Scale assessment for residents quarterly. She reported about a year ago the facility transitioned to a new combined quarterly nursing assessment which contained the Braden Scale assessment with all the other required quarterly assessments combined into one. She stated Resident #14 did not have a Braden Scale assessment completed in 2025 because that was when the facility transitioned to using the new combined quarterly nursing assessment and thought that was why Resident #14's Braden Scale assessments being completed were missed. She did not recall exactly when Resident #14's sacral wound was found or anyone mentioning it to her before it was identified on 11/18/25. UM #2 thought that if there had been routine skin assessments completed by a nurse for Resident #14 his sacral wound would have been identified earlier before it was a stage 3 pressure ulcer.An observation was completed of Resident #14's wound with the Wound PA and Wound Nurse on 3/25/26 at 11:40 AM. Resident #14's sacral wound was measured and assessed by the Wound PA. The pressure ulcer was circular in shape over the sacrum with no odor or signs of infection present. There was moderate serous (clear/ yellow fluid) drainage. The wound measured 1.5 cm in length, 1.5 cm in width, and 0.4 cm deep with undermining (hidden pocket under the wound edges that mean the wound is wider than the visible wound opening) identified using the clock method (a standardized way to describe and measure a wound imaging a clock face over the wound) at 12:00, 3:00, and 9:00 of 1 cm and undermining at 6:00 of 0.5 cm.An interview was conducted with the Wound PA on 3/25/26 at 11:45 AM. The Wound PA stated today (3/25/26) was the first time he had seen Resident #14's sacral pressure ulcer. He explained he had seen him in the past, but it had been about a year ago before he was admitted to hospice. He said Resident #14 should have had skin assessments completed at least weekly. He thought skin assessments should be completed by a nurse and not an NA due to the level of acuity, nursing background for assessment, and so the nurse could put a treatment in place if it was needed.An interview was conducted with the Physician on 3/26/26 at 1:25 PM. She said Resident #14 did not like to be touched and wanted to be left alone. She said he refused care and she thought that he would develop a pressure ulcer no matter what was done for him. The Physician thought skin assessments for residents should be completed by a nurse at a minimum of weekly. She said it was okay for NAs to look at the resident's skin when doing care and report to the nurse if they saw something but that an NA could not assess. The Physician stated that logically doing skin assessments routinely would help identify wounds earlier before they developed to a stage 3 or 4 pressure ulcer. She was not sure how often the Braden Scale assessment should be done but said the facility should be doing them to identify risk factors and add interventions if a resident was at risk for skin breakdown.An interview was conducted with the Director of Nursing (DON) on 3/26/26 at 4:33 PM. The DON reported in November 2025 during the time Resident #14's wound was identified he had declined and Hospice had thought he was transitioning to actively dying. The DON reported Hospice had been focused on comfort measures and pain. She stated Resident #14 had refused a lot of motion and movement. The DON was not sure what happened were Resident #14's wound was not identified and assessed earlier by a nurse. The DON said she thought maybe someone placed a dressing on the wound but then failed to report it to the Wound Nurse and then everyone saw a dressing was in place and assumed the wound had already been reported and had a treatment in place.b. Resident #83 was admitted to the facility on [DATE]. His diagnoses included Type-2 Diabetes Mellitus with diabetic neuropathy (pain, tingling, numbness of the hands/ feet) and peripheral angiopathy (complication of diabetes causing damage to blood vessels), stage 3 (full thickness wound that extends into the fatty tissue) pressure ulcer, and unstageable pressure ulcer (full thickness wound were the base is covered by dead tissue).A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 was cognitively intact. The MDS indicated he did not have behaviors or rejection or care. The MDS documented that he did not have a pressure ulcer, but he was at risk of developing pressure ulcers.A care plan dated 1/24/24 and last revised on 3/4/26 was in place for Diabetes Mellitus type-2. The care plan stated diabetic complications include neuropathy, history of diabetic foot ulcers, and delayed wound healing. The care plan goals were for Resident #83 to not have complications related to diabetes. The interventions included inspecting feet daily for open areas, sores, pressure areas, blisters, edema, or redness, and to check all of body for breaks in skin and treat promptly as ordered by doctor.A Braden scale assessment dated [DATE] indicated Resident #83 was low risk for skin breakdown. There were no additional Braden Scale assessments documented in his medical record until 12/19/25. Review of Resident 83's medical record revealed there were no weekly skin assessments documented in his medical record prior to 1/15/26.A weekly wound assessment dated [DATE] indicated on 11/11/25 a pressure ulcer to Resident #83's left plantar (bottom of the foot) was identified. The wound measured 1.5 cm in length, 1 cm in width, and 0.2 cm in depth. The assessment indicated the wound was a suspected deep tissue injury with 100% maroon discolored intact skin present. The wound assessment indicated Resident #83 also had a pressure ulcer to his right plantar that was unstageable. The wound to his right plantar measured 4 cm in length, 4 cm in width, and 0.2 cm in depth and was covered 100% by black eschar (dead tissue).A treatment order dated 11/12/ 25 read, cleanse left plantar with saline wash, apply betadine, and cover with foam dressing daily. The order was discontinued on 11/19/25A treatment order dated 11/12/25 read, cleanse right plantar with saline wash apply betadine and cover with foam dressing daily. The order was discontinued on 2/4/26.A Wound PA note dated 11/12/25 indicated Resident #83 had been seen for a deep tissue pressure injury to his left foot and an unstageable pressure injury to his right foot. The note stated that Resident #83's feet lay on the foot of the bed causing this. The note indicated it had been discussed to remove the foot board.A weekly wound assessment dated [DATE] indicated Resident #83's left plantar was a stage 3 pressure ulcer and measured 1 cm in length, 1 cm in width, and 0.2 cm in depth. The assessment indicated the treatment was changed to the left plantar pressure ulcer. The right plantar pressure ulcer remained unstageable with 100 % black eschar and measured 3.5 cm in length, 3.5 cm in width, and 0.2 cm in depth. A treatment order dated 11/19/25 read, cleanse left plantar with saline wash, apply alginate and cover with foam dressing every Monday, Wednesday, Friday. The order was discontinued 11/26/25.An order dated 11/27/25 read cleanse with saline wash. Apply betadine and cover with foam dressing every day shift. The order was discontinued on 11/7/26.A Wound PA note dated 1/7/26 indicated Resident #83's left plantar pressure ulcer was healed. The note indicated his right foot plantar pressure ulcer remained unstageable and covered by 100 % black eschar. The right foot pressure ulcer measured 3 cm in length, 2.5 cm in width, and 0.2 cm in depth. The note indicated the wound was stable but not improved. The treatment was to paint the wound daily with betadine.An observation of Resident #83's wound was completed with the Wound PA and Wound Nurse on 3/25/26 at 11:10 AM. His left plantar foot was observed with a circular open wound. There were no signs of infection, odor, or drainage present.An interview was conducted with the Wound PA on 3/25/26 at 11:15 AM. The Wound PA stated he had seen Resident #83 since the wounds to his foot were identified in November 2025. He reported Resident #83 was not compliant, had poor hygiene, refused to shower, and refused care if he did not want something. He said Resident #83's left foot wound had already healed. He reported the right foot pressure ulcer had been an unstageable area until this week when the eschar came off. He said the pressure ulcer to his right foot was now a stage 3. He said Resident #83 stayed in bed all the time and his feet lying against the footboard was what caused him to develop pressure ulcers to his feet. The Wound PA said, with Resident #83 being diabetic the facility should have been looking at his skin and checking his skin, including his feet at least once a week to identify any skin areas early.An interview was conducted with Resident #83 on 3/26/26 at 10:45 AM. He stated that before he developed the wounds to his feet staff did not check his feet or his skin routinely. Resident #83 said he would have been fine with the nurse doing a once over to check his skin and his feet once a week. He said he could not check his own feet because his knees did not bend. Resident #83 reported he did not have feeling or sensation in his feet because of neuropathy and had not been aware his feet were against the footboard or that he had the wounds on the bottom of his feet.An interview was conducted with the Wound Nurse on 3/24/26 at 3:51 PM. She recalled the pressure ulcers to Resident #83's feet were identified on 11/11/25. She stated he had a pressure ulcer on his right and left plantar, but the one he had on his left foot had healed. She indicated the pressure ulcers on the bottom of his feet were from where he had his feet up against the foot board. She said Resident #83 had diabetes and could not feel his feet and was not aware his feet were against the footboard or he had the wounds. She did not remember who specifically had told her about Resident #83's wounds.An interview was conducted with UM #1 on 3/25/26 at 9:16 AM. She recalled an NA had found the wounds on Resident #83's feet and came and got her. She stated she went and looked at the wounds and then went directly to get the Wound Nurse to assess the wounds. She said Resident #83 only allowed a bed bath once a week. She reported that the NAs looked at his skin when they did a bed bath. She did not think nurses were doing formal skin assessments during the time his wounds were identified or prior to January 2026. She said NAs did skin checks, completed shower sheets when they did a shower/ bath, and were supposed to mark on the shower sheet if there were any new skin issues. She explained starting in January 2026 the Wound Nurses were responsible for doing resident weekly skin assessments until the second Wound Nurse had left about a month ago. She said the Wound Nurse was still responsible for the skin assessments currently, but it was going to be transitioning because the Wound Nurse did not have time to do all the skin assessments with her other duties. UM #1 said there was not a formal schedule for skin assessments currently, just that they had to be completed weekly. She explained she looked in the residents' charts when it was close to the end of the week and if she did not see a skin assessment completed for that week by the Wound Nurse then she would do it. UM #1 said the Braden Scale assessments were supposed to be done on admission, quarterly, and as needed if a resident had a decline or a new pressure ulcer. She stated that the Braden Scale assessment was part of the admission assessment and completed by the nurse who did the admission. She stated the quarterly Braden Scale assessments were done by the UMs. She reviewed Resident #83's skin assessments in his electronic medical record and acknowledged he had a skin assessment documented on 1/5/26 and 1/23/26 but no additional skin assessments were completed. UM #1 said she was not sure why there were no additional skin assessments documented for Resident #83. She reviewed the Braden Scale assessments for Resident #83 and was not sure why he had not had a Braden Scale assessment completed for the period between 3/5/25 and 12/19/25. An interview was conducted with the Physician on 3/26/26 at 1:25 PM. She said the nurses should have been looking at Resident #83's feet and skin to check for wounds. She thought if they had been checking his skin routinely, they would have found the areas on his feet sooner. The physician said maybe because Resident #83 was so with it the staff had assumed he could tell them if something was wrong but that had not been the case.An interview was conducted with the DON on 3/26/26 at 4:33 PM. The DON thought that if routine skin assessments had been completed for Resident #83, they could have seen he was developing a wound and put an intervention in place. She said Residents with diabetes should have their feet checked for wounds at least weekly with the weekly skin assessment and that the assessment should be completed by a nurse.c. Resident #48 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following cerebral infarction (stroke) affecting left nondominant side, pressure ulcer of other site stage 4 (full-thickness wound that extends through the skin to exposed muscle, tendon (tissue that connects muscle to bone), or bone), peripheral vascular disease (progressive disorder involving the narrowing or blockage of blood vessels in the legs).A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 was cognitively intact. The MDS indicated she did not have behaviors or rejection of care. The MDS documented that she did not have a pressure ulcer, but she was at risk of developing pressure ulcers. The MDS documented she had functional limitations in range of motion to upper and lower extremity on one side. A care plan dated 8/24/24 and last revised on 2/18/26 was in place for potential for pressure injury development. The care plan goals included to be free from redness, blisters, or discoloration. The care plan interventions included monitoring/ documenting any changes in skin status including appearance, color, wound healing, symptoms of infection, wound size, and stage.A Braden Scale assessment was completed on 1/2/26 and indicated Resident #48 was low risk for developing a pressure ulcer.There were no weekly skin assessments documented in the medical record from 1/24/26 to 2/9/26. A nursing note by the Wound Nurse dated 2/9/26 read in part, Ulcer noted to posterior left knee. History of recurrent yeast rash to area and recently completed course of nystatin powders in which this area did not heal.An order dated 2/10/26 read, cleanse posterior left knee with normal saline, apply mupirocin 2% ointment (antibiotic ointment) and clean dressing daily for pressure injury. The order was discontinued on 2/18/26.An additional nursing note by the Wound Nurse dated 2/17/26 indicated the wound to Resident #48's left posterior knee was not improving and an order was obtained for a wound care referral. An order dated 2/18/26 read refer to [wound care].A weekly wound assessment dated [DATE] indicated Resident #48 had a stage 4 pressure ulcer with tendon exposed that was identified on 2/18/26 to her left rear knee. The pressure ulcer measured 2 cm in length, 1 cm in width, and 0.4 cm in depth.A Wound PA note dated 2/18/26 indicated Resident #48 was seen for a stage 4 pressure ulcer on the left posterior (back) knee that had been present for about 2 weeks. The note stated the wound was caused by the extensive contracture in the affected leg at her left knee.An order dated 2/18/26 read, cleanse back of left knee with wound cleanser. Apply xeroform gauze, calcium alginate and secure with foam dressing every day shift for pressure injury.An observation of Resident #48's pressure ulcer was completed with the Wound Nurse on 3/24/26 at 10:55 AM. Resident #48 was observed in bed; her left leg was contracted at her knee and unable to be straightened. The pressure ulcer was observed in the bend behind her left knee. The pressure ulcer was difficult to observe due to the location and degree of contracture. A white area of tendon was visualized in the wound. There were no odors or symptoms of infection present.An interview was conducted on 3/24/26 at 3:51 PM with the Wound Nurse. She said Resident #48's wound was identified on 2/9/25 and she made a nursing note about the wound. She recalled on 2/9/25 25 that the wound had a small white area with some drainage that was yellow. She stated when the wound did not improve and Resident #48 was referred to see the Wound PA. She said the wound was behind her left knee that was contracted. She reported when she was doing a treatment on 2/9/26 Resident #48 indicated she had pain behind her left knee. The Wound Nurse reported she looked deeper into the bend of her knee and could see something white and said it looked like an ulcer. The Wound Nurse reported the location of the wound made it hard for the area to be seen. The Wound Nurse reported the tendon was showing when the wound was found on 2/9/26. She reviewed the wound assessments for Resident #48 and stated it was correct that there was not a wound assessment completed until 2/18/25. She reported wounds were supposed to be assessed and measured when they were found and then weekly. She indicated the other Wound Nurse typically did the assessments and treatments for 400 hall were Resident #48 resided. She said the other Wound Nurse had left around that time and she thought that was why Resident #48's wound being documented and assessed prior to 2/18/26 had been missed. She said she was not sure if her wound was a stage 3 or 4 pressure ulcer when it was found on 2/9/26 because she had not documented it. She recalled Resident #48's tendon was exposed when she found the wound on 2/9/26 and said the wound looked the same on 2/9/26 that it did on 2/18/26 when Resident #48 was seen by the Wound PA. She stated on 2/18/26 Resident #48's pressure ulcer was a stage 4 when it was assessed by the Wound PA. She reviewed Resident #48's skin assessments and stated Resident #48 had a weekly skin assessment on 1/23/26 that did not document the pressure ulcer behind her left knee and then her next skin assessment was not until 2/10/26. She said it was unfortunate the area where the wound was located with Resident #48's contracture made the wound difficult to see.An interview was conducted with the Wound PA on 3/25/26 at 11:45 AM. He explained that essentially Resident #48's tendon was creating pressure from the inside because of how tight it was. He reported her wound was a stage 4 pressure ulcer because the tendon was exposed. He said the tendon looked good and healthy with no signs of infection or necrosis (dead tissue). He further explained there was no pressure component from the outside that caused the pressure ulcer. He said the pressure was internal from the tendon itself being so tight. He did not think there was an intervention that could have prevented the wound from occurring or that would be enough to help it heal. He thought it was inevitable that the wound would develop because of how tight Resident #48's tendon and the contracture were.An interview was conducted with the Physician on 3/26/26 at 1:25 PM. The Physician stated Resident #48 had always had the contracture to her left leg at the degree it was currently. She did not think there was any intervention that could have been put into place by the facility that would have prevented her from developing the pressure ulcer. The Physician stated that logically doing skin assessments routinely would help identify wounds earlier before they were a stage 3 or 4 pressure ulcer. The Physician said wounds should be assessed, documented, and measured when they were identifiedAn interview was conducted with the DON on 3/26/26 at 4:33 PM. She reported Resident #48's contractures had been present and unchanged since she was admitted to the facility. She said they had tried therapy, but she was unable to tolerate therapy or any type of positioning device for her left knee contracture. She recalled a wedge had been tried for her left knee contracture but said it put more pressure on the tendon and had caused discomfort. She said pillows were the most comfortable for positioning for Resident #48 and her leg contracture. The DON said she expected for a full wound assessment including measurements and documentation of the wound to be completed when Resident #48's wound was found. She said that Resident #48 should have had weekly skin assessments completed and documented by a nurse.An interview was conducted with the Wound Nurse on 3/24/26 at 11:14 AM. The Wound Nurse stated that prior to January 2026 NAs completed resident skin checks during baths/showers. She explained NAs were supposed to complete a shower sheet when they gave a resident a bath/ shower, mark on the sheet if there were any skin issues seen and then give the shower sheet to the floor nurse to review. The Wound Nurse indicated the shower sheets were also reviewed by the UM's. She said the floor nurses or UM's let her know if there was a new wound she needed to look at. The Wound Nurse stated that starting in January 2026 resident skin assessments were supposed to be completed weekly by a nurse and that the Wound Nurses were responsible for completing the weekly skin assessment. She reported that there had been two Wound Nurses, she stated she typically did the 100/200 side of the building, and the other Wound Nurse did the 300/400 side. She said the other Wound Nurse left about a month ago and she was currently the only Wound Nurse. She said there had been a schedule for routine skin assessment until about a month ago and that the schedule had gone away when the other Wound Nurse left. She said there currently was not a routine schedule for weekly skin assessments just that they were supposed to be completed weekly. The Wound Nurse said that the UM's and floor nurses were currently responsible for doing the weekly skin assessments. The Wound Nurse stated Braden Scale assessments were supposed to be completed for all residents on admission, quarterly, and as needed for changes in mobility or when new wounds occurred. She reported that the UM's were responsible for completing the Braden Scale assessments for residents. She said skin assessments were important to help identify skin issues early. She stated Braden Scale assessments were important to help identify residents who were at risk for skin breakdown and so preventative measures could be implemented. She thought wounds may have been found before they were a stage 3 or 4 pressure ulcer if routine skin assessments had been completed nurses because nurses were better able to assess than NAs.An interview was conducted with the Director of Nursing (DON) on 3/26/26 at 4:33 PM. The DON stated she expected for a full assessment to be completed, documented, and treatment orders to be placed when a new wound was identified. She stated assessing the wound included looking at the wound, measuring it, staging the wound if applicable, and documenting it in the wound assessment or a progress note. The DON stated she was not aware Braden Scale assessments were not being completed. She reported Braden Scale assessments should be completed on admission, quarterly, and with any change in mobility or when a new wound was identified. The DON said she was no

Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.45% for 3 of 4 residents observed during the medication administration (Resident #1, Resident #81 and Resident #119).The findings included:1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included constipation.Review of Resident #1's physician order dated 01/06/26 for polyethylene glycol powder (laxative) give 17 grams by mouth one time a day for constipation.On 03/24/26 at 10:00 AM an observation was made of Nurse #1 during a medication administration. The Nurse prepared the 17 grams of polyethylene glycol powder by mixing it in a cup of water then took the medication to Resident #1's bedside and set the cup on the over bed table. Nurse #1 proceeded to give the Resident the medications from the medication cup then picked up a flavored liquid used to swallow the medications. The Nurse left the room without giving Resident #1 the polyethylene glycol medication.At 10:30 AM on 03/24/26 Nurse #1 was asked about Resident #1's polyethylene glycol medication that she mixed up for the Resident and Nurse #1 stated, Oh, I left it on his table, didn't I? Nurse #1 then went back into the Resident's room where the liquid mixture remained on the table. The Nurse stated she forgot to give the medication to the Resident because she was nervous.An interview was conducted with the Director of Nursing on 03/27/26 at 12:34 PM, who explained that her expectation was that the nurses provide the medications as they were ordered and Nurse #1 should have given Resident #1 his laxative.2. Resident #81 was admitted to the facility on [DATE] with diagnoses that included constipation.Review of Resident #81's physician orders revealed an order dated 12/14/23 for polyethylene glycol (laxative) one packet by mouth every other day for constipation. Dissolve in 4-6 oz of fluid.An observation of a medication administration was made of Nurse #2 on 03/24/26 at 9:20 AM. The Nurse prepared Resident #81's medications which included dissolving the polyethylene glycol in water. The Nurse took the medication to the Resident and administered the medications that she had crushed and gave one drink of the polyethylene glycol mixture then sat the liquid on the Resident's over bed table and left the room.At 10:33 AM on 03/24/26 Nurse #2 was asked about Resident #81's polyethylene glycol and the Nurse stated, Oh, I should not have left the drink in the Resident's room because it had medication in it, I should have made sure he drank all of his medication.An interview was conducted with the Director of Nursing on 03/27/26 at 12:34 PM, who explained that her expectation was that the nurses provide the medications as they were ordered and Nurse #2 should have given Resident #2 all the medication while she was in the room and not left it.3. Resident #119 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease.Review of Resident #119's physician orders dated 03/19/26 for calcium carbonate (antacid) 600 milligrams (mg) one tablet by mouth in the morning for supplement.A medication administration observation was conducted on 03/24/26 at 8:45 AM with Nurse #3. The Nurse prepared and administered the Resident's medications which included calcium carbonate 1000 mg.An interview was conducted with Nurse #3 on 03/24/26 at 1:32 PM. The Nurse was asked to show the calcium carbonate bottle that she dispensed Resident #119's calcium carbonate from and the bottle read 1000 mg per tablet. Nurse #3 stated she did not think calcium carbonate tablets came in 600 mg tablets and stated she would let the provider know about the dosage.An interview was conducted with the Director of Nursing on 03/27/26 at 12:34 PM, who explained that her expectation was that the nurses adhere to the five rights of medication administration and if Nurse #3 had done that then the medication error would not have happened.

Based on record reviews, staff, resident, Pharmacy Consultant and Nurse Practitioner (NP) interviews, the facility failed to ensure medications were administered as prescribed by the physician when Nurse #4 administered Adderall (a central nervous system stimulant containing amphetamine and dextroamphetamine) to Resident #95 that was prescribed for Resident #59. In addition, Nurse #6 administered 100 milligrams (mg) of Lyrica (used to treat nerve pain from diabetes) to Resident #56 instead of the prescribed 50 mg Lyrica at bedtime. This deficient practice affected 2 of 3 residents reviewed for medication errors (Resident #59 and Resident #56).The findings included:1. Resident #59 was admitted to the facility on [DATE] with diagnoses that included attention deficit hyperactivity disorder (ADHD).Review of Resident #59's admission Minimum Data Set assessment dated [DATE] revealed his cognition was moderately impaired.Review of Resident #59's physician orders dated 02/20/26 for Adderall XR (extended release) 10 milligrams (mg) capsules give two capsules by mouth in the morning for ADHD.Resident #95 was admitted to the facility on [DATE] with diagnoses that included urinary retention, metabolic encephalopathy and hypertension.Review of Resident #95's admission Minimum Data Set assessment dated [DATE] revealed his cognition was severely impaired.A Medication Variance Report dated 03/11/26 at 10:01 AM completed by Unit Manager #1 revealed Nurse #4 reported administering Adderall XR 20 milligrams to Resident #95. The Resident had a very similar name to another Resident located two doors down. The Nurse stated she was interrupted by a staff member asking her a question during the medication pass and she inadvertently entered the wrong room. Resident #95 noticed the medications and before taking any additional pills he stated, these don't look like my pills. Nurse #4 immediately collected the remaining pills and went to review the orders. The Nurse immediately reported the medication error as per the facility policy. The Director of Nursing (DON) and Nurse Practitioner (NP) have both been notified. A Name Alert has been put in place for both residents. Staff were reminded to utilize the five rights of medication administration with each resident. This Resident will be monitored closely for adverse reactions.An interview was conducted with Nurse #4 on 03/26/26 at 10:55 AM. Nurse #4 explained that on 03/11/26 she was administering the morning medications when she was distracted by a therapist and inadvertently gave Resident #95 medications that belonged to Resident #59. She stated their names were very similar. The Nurse reported that Resident #95 started taking the medications and telling her that they were not his medications at the same time and before she could get him to stop taking the medications he had taken Adderall. She stated she compared the remaining pills to Resident #59's Medication Administration Record and medication cards and determined that it was Adderall that Resident #95 took before she got the medicine cup from the Resident. She stated she immediately reported the medication error to Unit Manager #1 who informed the Nurse Practitioner while Nurse #4 obtained the Resident's vital signs and monitored him multiple times throughout the shift. Nurse #4 stated Resident #95 did not have any adverse side effects from receiving the Adderall. She included that the facility put a Name Alert sign on the two residents' doors.Review of Resident #95's blood pressure and heart rate on 03/11/26 at 10:08 AM and taken by Nurse #4 were blood pressure 136/80 and heart rate 90 beats per minute. The blood pressure and heart rate taken on 03/11/26 at 10:27 PM was blood pressure 122/76 and heart rate was 78 beats per minute.Review of the Nurse Practitioner's progress note dated 03/11/26 at 10:45 AM revealed the NP was notified by nursing that Resident #95 was accidentally given another patient's medication, just one dose of Adderall. This was meant for the resident across the hallway who has a very similar name to Resident #95. The NP indicated she found Resident #95 seated in his wheelchair and he was in good spirits. He denied feeling any anxiety, chest pain, shortness of breath, no other concerning signs or symptoms. We are monitoring his blood pressure and his heart rate throughout the day today. Plan: Patient is stable, no harm has come to Resident #95 from this medication error. Continue with all treatments and plans of care unless otherwise noted above.An interview was conducted with Resident #95 on 03/26/26 at 10:30 AM. The Resident was smiling and conversant. Resident #95 was asked about taking the wrong medication and he explained that he remembered taking the wrong medication when the Nurse gave him the medication and he knew that there were more pills in the cup than he normally took but he took them anyway. He stated he told the Nurse that those were not his pills and by the time the Nurse told him not to take the pills, he had taken one of them. Resident #95 stated they took his vital signs and checked on him often and he was fine. He stated, it did not bother me at all.On 03/26/26 at 2:13 PM an interview was conducted with the Pharmacy Consultant who explained that after Resident #95 received Resident #59's Adderall by mistake the facility should have monitored his blood pressure and heart rate which they did, and they were within normal limits for his age so she would not consider the medication error a significant medication error. The Pharmacy Consultant stated Resident #95 did not have any negative side effects from receiving the wrong medication.During an interview with the Nurse Practitioner on 03/27/26 at 9:31 AM, the NP explained that he was notified by Unit Manager #1 about the medication error made by Nurse #4 on 03/11/26. The NP reported that he was told that Nurse #4 inadvertently gave Resident #95 Adderall that belonged to Resident #59. The NP continued to explain that he saw Resident #95 that morning and he was not having any adverse side effects from the Adderall and he gave the staff a verbal order to monitor him and take his blood pressure and heartrate and to call him if they needed to, but he did not get a call about Resident #95.On 03/27/26 at 10:00 AM an interview was conducted with Unit Manager #1 who explained that on 03/11/26 Nurse #4 came to her and reported that she was interrupted during her medication pass, and she mistakenly gave Resident #95 medication that belonged to Resident #59. Nurse #4 stated she stopped Resident #95 from taking the medications when she realized what she had done but she knew that he took the Adderall XR 20 mg. The Unit Manager continued to explain that she reported the medication error to the DON and the NP who gave a verbal order to monitor Resident #95's blood pressure and heart rate which they did throughout the day, and Resident #95 was fine. She reported the facility made Name Alert signs on red paper to put on the doors that would alert the nurses of similar names and make them be aware that Resident #95 and Resident #59 had similar names.During an interview with the Director of Nursing (DON) on 03/27/26 at 12:02 PM, the DON stated that the medication error involving Resident #95 was brought to her attention by Unit Manager #1 who explained that Nurse #4 was interrupted during the medication pass and she gave Resident #95 another resident's medications (Adderall) that had a name similar to Resident #95. She continued to explain that Unit Manager #1 notified the Nurse Practitioner who saw Resident #95 that day and gave a verbal order to monitor the Resident and check his vital signs. The DON stated Resident #95 did not have any adverse side effects from taking the Adderall. The DON reported the root cause of the medication error was the two residents' names being similar, so they made Name Alert signs and posted them on the residents' doors to prevent a medication error from occurring again.2. Resident #56 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and neuropathy.Review of Resident #56's physician orders revealed an order dated 12/04/25 for Lyrica (used to treat nerve pain (neuropathic pain) from diabetes) 25 milligrams (mg) one capsule by mouth one time a day for neuropathy.Review of Resident #56's physician orders revealed an order dated 12/31/25 for Lyrica 50 mg one capsule by mouth at bedtime for neuropathy.Review of Resident #56's annual Minimum Data Set assessment dated [DATE] revealed his cognition was moderately impaired.Review of Resident #56's declining count sheet for Lyrica 25 mg capsules revealed the last Lyrica capsule was removed on 03/19/26 at 9:31 AM.Review of Resident #56's declining count sheet for Lyrica 50 mg capsules revealed that on 03/19/26 at 9:00 PM, 2 capsules were subtracted from the count of 22 capsules leaving 20 capsules remaining.Review of the Resident #56's March 2026 Medication Administration Record (MAR) revealed Lyrica 50 mg capsule was given at 9:00 PM on 03/19/26 by Nurse #6. Further review of the March 2026 MAR indicated Nurse #7 held the 9:00 AM dose of Lyrica 25 mg.Review of a Medication Variance Report dated 03/20/26 at 10:02 AM and written by Unit Manager (UM) #1 revealed Nurse #7 reported that Resident #56 was accidentally given 100 mg of Lyrica instead of the prescribed dose of 50 mg for the 9:00 PM scheduled time on 03/19/26. Resident #56 has had no ill effects thus far. The Resident awakened for breakfast and per his usual routine laid back down after eating. Will monitor closely. The Nurse Practitioner and family were both notified. The staff were reminded to always check MAR with medication card to ensure proper medication dosing. Resident #56 was assessed; his vital signs were stable. He is alert and baseline confused.Review of a typed statement by the Administrator on 03/20/26 revealed the Weekend Supervisor notified the Administrator that a medication error had occurred with Resident #56. A phone call to the Director of Nursing was placed with the Weekend Supervisor present. The Supervisor reported to the Director of Nursing what was reported to her and the Director of Nursing instructed her to report the medication error to the Nurse Practitioner, complete a full assessment of Resident #56 and to complete an incident report and highlight the medication cards.Review of a written statement from Unit Manager #1 dated 03/20/26 revealed Nurse #7 reported that Resident #56 was accidentally given Lyrica 100 mg at bedtime on 03/19/26 by Nurse #6. The AM dose (03/20/26) was held. Resident #56 awakened easily for breakfast, answers questions appropriately and voiced no complaints. The Resident was monitored closely throughout the day. The Nurse Practitioner and family were notified. The Nurse Practitioner was in to assess Resident #56 as well. Nursing was reminded to always check MAR with medication card to ensure proper medication dosing. Attempted to contact Nurse #6 but no answer. Director of Nursing was notified.Review of the Nurse Practitioner's progress note dated 03/20/26 at 9:00 AM revealed he was notified by nursing of a medication error that Resident #56 accidently received a higher dose of Lyrica than was prescribed for him. The Resident was awake and alert, in his wheelchair accompanied by his family in the hallway. He is doing quite well, smiling and interacting. His family denies noticing any concerning symptoms. Assessment Plan: to monitor more closely today including his vital signs.Review of Resident #56's progress note dated 03/20/26 at 7:48 PM and written by Unit Manager #1 revealed Resident #56 showing no adverse reactions to Lyrica 100 mg given at bedtime on 03/19/26. Alert, answers questions when spoken to and no voiced complaints.An interview was conducted with Nurse #7 on 03/25/26 12:59 PM who confirmed that she worked on first shift on 03/20/26. The Nurse explained that she counted controlled medications with Nurse #6 during shift change on the morning of 03/20/26 and there were no discrepancies with the counts. When Nurse #7 went to pull Resident #56's Lyrica 25 mg capsule for his 9:00 AM medication administration, there were no 25 mg Lyrica in the drawer and no declining count sheet either. The Nurse continued to explain that there was Lyrica 50 mg capsules for Resident #56 in the drawer and when she reviewed the declining count sheet for the 50 mg capsules, she discovered that Nurse #6 had removed 2 capsules from the 50 mg supply of Lyrica on 03/19/26 at 9:00 PM. Nurse #7 stated that when she discovered the medication error she immediately notified the Weekend Supervisor who notified the Administrator and the Director of Nursing who instructed them to monitor Resident #56 and check his vital signs. The Nurse stated she took Resident #56's vital signs and he appeared sleepy during the morning, but the Nurse was informed by Unit Manager #1 that it was Resident #56's normal routine to lay down after breakfast and sleep. The Nurse stated that the Unit Manager advised her not to give Resident #56 his Lyrica 25 mg that was due on 03/20/26. When the Nurse was asked if she documented the Resident's vital signs she reported she thought she did, but she may not have but insisted that Resident #56's vital signs were within normal limits every time she took them. The Nurse stated that Resident #56 was seen by the Nurse Practitioner that morning on 03/20/26. Nurse #7 reported that the management highlighted Resident #56's Lyrica 50 mg medication card to draw the nurses' attention to the dosage.On 03/27/26 11:01 AM an interview was conducted with the Weekend Supervisor who explained that she was notified on the morning of 03/20/26 by Nurse #7 that Nurse #6 had mistakenly given Resident #56 2 Lyrica 50 mg capsules for the bedtime medication administration on 03/19/26. Nurse #7 discovered the error during her morning medication pass on 03/20/26. The Supervisor stated both she and Nurse #7 went to assess Resident #56 and obtained his vital signs and they were within normal limits. The Supervisor stated she went to the Administrator who called the Director of Nursing on the phone and explained what happened. The Director of Nursing instructed her to assess the Resident which she already had and to highlight the medication cards and write PM on the Lyrica 50 mg card so that it was noticeable for the nurses to see when pulling the medication. The Director of Nursing also instructed her to notify the Nurse Practitioner as well and the Nurse Practitioner assessed Resident #56 as well. The Supervisor stated about an hour after her being notified of the medication error, Resident was observed to be awake and out of bed and she did not observe any side effects of the medication error.An interview was conducted with Unit Manager #1 on 03/27/26 at 10:05 AM who explained that she came in on the morning of 03/20/26 and was notified by Nurse #7 that on 03/19/26 Resident #56 was given two 50 mg Lyrica instead of the one 50 mg dose that was prescribed to be given at bedtime by Nurse #6. The Unit Manager continued to explain that Resident #56 was drowsy which was not unusual for him because he received Lyrica twice a day and used to be on 100 mg of Lyrica at bedtime until recently when it was lowered. She stated she notified the Nurse Practitioner who instructed her to hold the morning dose on 03/20/26 and the Nurse Practitioner was into assess Resident #56 that morning as well and gave her a verbal order to monitor the Resident throughout the day. The Unit Manager reported she checked on Resident #56 several times that day and she did not observe any ill side effects from receiving the Lyrica 100 mg dose. She stated she highlighted the 50 mg Lyrica medication card, so it was more noticeable when the nurses were pulling the medications. The Unit Manager stated she tried to interview Nurse #6, but the Nurse did not return her calls. The Unit Manager reported the Nurse Practitioner did not provide a written order to hold the morning dose of Lyrica, but that he verbally told her to hold the Lyrica.Multiple attempts were made to interview Nurse #6 who made the medication error on 03/19/26, but the attempts were unsuccessful. An interview was conducted with the Nurse Practitioner on 03/27/26 at 10:20 AM who explained that he was notified of the medication error on Resident #56 when he was given a double dose of Lyrica 50 mg and assessed the Resident that morning on 03/20/26. The Nurse Practitioner stated Resident #56 was awake and talkative with him and he did not observe any adverse reactions from the medication error. He stated he gave a verbal order for the staff to monitor the Resident and notify him if there were any changes and to hold the morning dose of Lyrica. He stated he was not notified of any changes with Resident #56.During an interview with the Director of Nursing (DON) on 03/27/26 at 12:13 PM the DON explained that she was notified via telephone on the morning of 03/20/26 about the medication error made by Nurse #6 on the evening of 03/19/26. It was discovered by Nurse #7 when the Nurse was administering Resident #56's morning medications and found that Nurse #6 had signed out for two 50 mg Lyrica instead of one 50 mg Lyrica. The DON stated she thought Nurse #6 was trying to make 50 mg by giving two 25 mg, but she pulled the two capsules from the 50 mg card by mistake. She stated she was unable to verify that because Nurse #6 has refused to return her phone calls and she had not been back to work at the facility. The DON reported Resident #56 was assessed by the Nurse Practitioner and the Nurses throughout the shift and had no adverse side effects from the medication. In fact, she stated that the Resident used to be on Lyrica 100 mg and the dose was lowered. The DON explained that she directed the staff to highlight the directions on her two Lyrica medication cards so that the specific dosage could be determined by the nurses.

Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a serious mental health disorder for 1 of 2 residents reviewed for PASRR (Resident #81).Findings included:A PASRR Determination Notification letter dated 08/29/23 revealed Resident #81 had a Level I PASRR with no expiration date.A review of the North Carolina PASRR Level I screen dated 08/29/23 revealed that major depressive disorder and bipolar disorder were not documented on the North Carolina PASRR Level 1 screen.Resident #81 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, vascular dementia, anxiety disorder, major depressive disorder, and bipolar disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #81's active psychiatric/mood disorder diagnoses were documented as non-Alzheimer's dementia, anxiety disorder, depression (other than bipolar) and bipolar disorder. He received antianxiety medications during the MDS assessment period. A psychiatry initial consultation note dated 07/11/25 revealed psychiatry was consulted to review Resident #81's psychotropic medications (medications used to treat mental health disorders). Resident #81 had diagnoses that included dementia, insomnia, depression, anxiety, and bipolar disorder. The provider recommended no changes to Resident#81's buspirone (antianxiety) 5 milligrams that was taken once in the morning and once in the evening.The facility was unable to provide documentation that a request for a Level II PASRR evaluation had been submitted for Resident #81.During an interview on 3/25/26 at 12:25 PM, the admission Coordinator revealed he did not have access to the North Carolina Medicaid Uniform Screening Tool (NC MUST) to verify if a resident had a PASRR. He stated the hospital had initiated the PASRR screening process for new residents. He confirmed the Social Work Assistant had access to NC MUST and provided him with the PASRR Determination Notification letter for new residents. The admission Coordinator also confirmed that Resident #81 had a Level I PASRR assigned before admission to the facility.An interview was conducted with the Social Worker and Social Work Assistant on 3/25/26 at 12:25 PM. The Social Work Assistant stated the hospital had initiated the PASRR screening process. She looked up a potential resident's PASRR in NC MUST (screening tool used to refer and manage PASRR evaluations) and provided the admission Coordinator with a copy of the PASRR Determination Notification letter. The Social Work Assistant stated she did not verify a new resident's diagnosis before she provided the admission Coordinator with the PASRR Determination Notification letter. She confirmed she had not been informed by the clinical team to submit a request for a Level II PASRR evaluation for Resident #81.An interview with the Administrator on 03/25/26 at 1:57 PM revealed residents were discussed in daily clinical team meetings and if it was determined that a resident needed a Level II PASRR evaluation the Social Work Assistant would be responsible for requesting the Level II PASRR evaluation. The Administrator acknowledged a request for a level II PASRR evaluation should have been submitted for Resident #81 due to Resident #81's mental health diagnoses.

Based on record review, resident and staff interviews, the facility failed to ensure a written grievance decision included all required components and to provide a written grievance decision to 1 of 1 resident reviewed for grievances (Resident #67). Findings included:Resident #67 was admitted to the facility on [DATE].A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was cognitively intact.A grievance form dated 3/5/26 was completed by the Social Worker (SW) on behalf of Resident #67 and indicated Resident #67 had concerns regarding the attentiveness of night shift staff and not being changed during the night or check on every two hours. The form documented education was going to be provided by the Staff Development Coordinator (SDC). The form did not document the following: how the grievance was investigated, a summary of pertinent findings/conclusions regarding the resident's concern, a statement as to whether the grievance was confirmed or not confirmed, or the date the written grievance decision was provided to Resident #67. An interview was conducted with Resident #67 on 3/23/26 at 3:25 PM. Resident #67 reported she still had an issue with incontinence care not being provided routinely on night shift. She stated she had reported her concerns about care on the night shift during a care plan meeting but did not remember the date. Resident #67 said she did not know if her concern about care on night shift had been addressed or if anything had been done. She stated she was never informed verbally of the grievance decision and had never received or been offered a written grievance decision from the facility about this concern.An interview was conducted with the SW on 3/26/26 at 9:39 AM. The SW reported she had completed the grievance form on 3/5/26 for Resident #67 because she had mentioned a concern about care on night shift during a care plan meeting. The SW explained she was responsible for managing grievances. She indicated when a resident or family member reported a concern to her, she completed a grievance form and then assigned the grievance to the appropriate department to address. The SW reported that at the time the resident and/or family member told her their concerns, she told them what she planned to do to address their concern and wrote that on the grievance form. She stated then she made a copy of the grievance form and gave it to the appropriate department to address. The SW indicated she verbally followed up with the assigned department about the grievance to ensure they had addressed it. The SW stated she did not go back and document on the grievance form after talking to the assigned department about how the grievance was investigated, what was found, what was done to address the grievance, or how it was resolved. The SW stated she did not follow up with the individual who filed the grievance on how their grievance was investigated, what was found, how it was addressed by the assigned department, or what the resolution was. The SW was not sure why she did not do those things and indicated she did not know it was a requirement. The SW said she did not provide a written copy or notification of how the grievance was resolved to the party who filed the grievance because she did not know she was supposed to. The SW reported she did not follow up and provide information to Resident #67 regarding how her grievance from 3/5/26 was investigated or what the resolution was.An interview was conducted with the Administrator on 3/26/26 at 5:37 PM. The Administrator stated grievances should be completed when a resident or family member had a concern. She reported the SW was responsible for managing facility grievances. She indicated that once the grievance was investigated and addressed by the appropriate department, it should be documented on the form with dates of how/ when it was investigated, what the findings/ conclusion were, what was done to correct the concern, and what the resolution of the grievance was. She stated the individual who made the grievance should be notified and offered a written copy of the grievance resolution. The Administrator stated it should be documented on the grievance form who was notified of the resolution and the date they were notified. The Administrator stated she was not aware the SW was not doing that.

Based on record review and staff interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 1 of 5 residents reviewed for unnecessary medications (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Lewy Body Dementia (a progressive neurological disorder caused by abnormal protein deposits (Lewy bodies) in the brain, affecting thinking, movement, behavior, and mood).The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe cognitive impairment. He displayed no behavioral symptoms and received antidepressant medications during the MDS assessment look-back period.Review of the December 2025 Medication Administration Record for Resident #4 revealed an active physician order dated 12/04/25 for risperidone (antipsychotic medication) 0.5 milligrams 1 tablet by mouth two times a day for mood disorder. Review of Resident #4's electronic medical record revealed no documentation that Resident #4's Responsible Party was informed in advance of the risks and benefits of initiating risperidone 0.5 mg and consented to the treatment.Interviews were conducted with the Social Worker and the Social Worker Assistant simultaneously on 03/25/26 at 8:59 AM. They both reported that they started in August 2025 and were not responsible for obtaining the informed consents for the psychotropic medications. The Social Workers explained that the Nurse Practitioner was responsible for obtaining informed consent for the psychotropic medications for the residents.During an interview with the Nurse Practitioner (NP) on 03/27/26 at 9:49 AM the NP explained that he was informed that it was his responsibility to review the psychotropic medications and before the last Social Worker left, he was getting a pile of forms every month that he had to sign but that stopped when the last Social Worker left. He continued to explain that when he rounded on the residents, he reviewed medications in general and not just the psychotropic medications and documented that in his progress notes. The NP stated that he was not obtaining informed consents before psychotropic medications were initiated.An interview was conducted with the Director of Nursing (DON) on 03/27/26 at 11:53 AM. the DON explained that when psychotropic medications were initiated the Social Worker notified the NP of the need to obtain informed consent for the new psychotropic medication. The DON indicated that the system failed when the last Social Worker left and unfortunately that system stopped when the Social Worker left. The DON reported the NP would again be responsible for obtaining consent for psychotropic medications.

Based on observations and staff interviews, the facility failed to maintain a clean and orderly interior as evidenced by hall floors being dirty with multiple areas of stains, dirt, debris, and dried fluid/water spots. This was observed on 2 of 6 hallways reviewed for environment (front common area hallway and rear common area hallway).Findings included:A. An observation made on 03/23/26 at 9:40 AM of the facility's front common hallway floor which was located between two resident wings revealed multiple areas that contained stains, dirt, debris, and multiple dried fluid/water spots too numerous to count. The floor appeared to have dirt and debris pushed into the corners of the walls. There was also observed dirt and debris pushed into corners, in a small alcove, underneath a water fountain. Observations were also made of residents, visitors, and staff utilizing this hallway as a pass through to resident rooms.An additional observation of the facility's front common hallway floor was completed on 03/27/26 at 8:15 AM revealed the floor to remain in the same condition as earlier in the week with multiple spots of dirt and debris and dried water/fluid spots that had collected dirt. Observations of residents, staff, and visitors utilizing this hallway continued.B. An observation made on 03/23/26 at 9:49 AM of the facility's rear common hallway floor which was located between the two resident wings revealed multiple areas that contained stains, dirt, debris, and multiple dried water/fluid spots too numerous to count. The floor also appeared to have dirt and debris pushed into corners and along the wall. Staff and residents were also observed to use this hallway as a passthrough to and from the activities room and other resident rooms.Additional observations of the facility's rear common hallway floor were completed on 03/27/26 at 8:23 AM and revealed the floor to remain in the same condition as earlier in the week with multiple spots of dirt, debris, and water/fluid spots.An interview with the Housekeeping Director on 03/27/26 at 8:45 AM revealed she had staff working at the facility 7 days a week. She stated they were responsible for cleaning the common areas first and when that was completed, her staff would move to cleaning the residents' rooms. She reported common area cleaning included sweeping and mopping floors, dusting, and wiping down high touch areas. The Housekeeping Director indicated that Maintenance Staff Member #1 was typically responsible for buffing the floors but was assisting this week with mopping the common area hallways.A walk-through of the front and rear common hallway floors with the Housekeeping Director was started on 03/27/26 9:18 AM in conjunction with an interview. The Housekeeping Director reported the floors were a constant issue due to spills from residents and salt and debris from the winter.During the walkthrough with the Housekeeping Director, an observation was made of a staff member (Maintenance Staff Member #1) mopping parts of both the common area hallway floors on 03/27/26 from 9:20 AM through 9:25 AM. Maintenance Staff Member #1 was observed making his way down the hall with the wet mop, going over the dirty fluid/water spots. After the staff member mopped the area, the water/fluid spots remained. The spots were tested for fastness (how easily the spot could be removed) with the bottom of a shoe. It was observed that the water/fluid spots were easily removed by rubbing the sole of a shoe over them. An observation was made of dirt and debris in an alcove under a water fountain that was pushed against the wall. The Housekeeping Director indicated that water/fluid spots should not remain on the floors if easily removed with the bottom of a shoe. The Housekeeping Director reported that Maintenance Staff Member #1 had been responsible for mopping and cleaning of the front and rear common area hallways that week.An interview with the Maintenance Staff Member #1 on 03/27/26 at 9:22 AM revealed he worked in the maintenance department and normally would only buff the floors. He stated he had been responsible for mopping the floors that week as a favor for the Housekeeping Director. He indicated he had no knowledge of any complaints or concerns about the cleanliness of the floors. Maintenance Staff Member #1 also indicated he felt the floors were getting cleaned how he mopped and did not identify the reason the water/fluid spots remained in areas he had already mopped.During a follow-up interview with the Housekeeping Director on 03/27/26 at 9:26 AM she indicated that while the floors had been mopped by the Maintenance Staff Member #1, they still appeared dirty in areas.A walkthrough of the facility with observations of the front and rear common hallway floors with the Director of Nursing on 03/27/26 at 9:35 AM conducted in conjunction with an interview, revealed she felt that the areas where the Maintenance Staff Member #1 had reportedly already mopped were not clean and indicated it did not appear as though there had been any effort into removing water/fluid spots or getting dirt and debris removed. The Director of Nursing reported she felt the floors throughout the facility were in an unacceptable condition with the amount of dirt, debris, and water/fluid spots. The Director of Nursing also reported she had voiced her concerns to the Administrator previously but did not know if it had been addressed.During an interview and walkthrough of the facility's front and rear common hallway floors with the Administrator on 03/27/26 at 10:09 AM, the Administrator revealed she was not happy with the condition of the floors throughout the entire facility. She verified that it was the responsibility of the Maintenance Staff Member #1 to keep the floors clean. She explained the floors throughout the facility had been stripped and waxed approximately 2 weeks prior but due to the salt from the winter, it broke down the wax quickly, and the floors needed to be rebuffed. She reported the floors in the facility definitely needed to be cleaner and reported it appeared to her as though more effort needed to be exercised into ensuring that dirt, debris, and fluid/water spots were removed when the floors were mopped.

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 on [DATE] from 10:45 AM to 11:00 am an observation with the Assistant Dietary Supervisor of the walk-in cooler revealed the following: - a plastic container sealed with plastic wrap dated [DATE] that was one quarter full of chicken breasts with seasoning dated [DATE] - a plastic container sealed with plastic wrap dated [DATE] that was half full of chicken noodle soup that had started to separate - a plastic container sealed with plastic wrap dated [DATE] that was half full of creamed corn - a metal tray of seven tuna salad sandwiches sealed with aluminum wrap with no date - a metal tray of 10 bologna sandwiches sealed with plastic wrap dated [DATE] The Assistant Dietary Supervisor observed on [DATE] at 11:15 AM the food stored inside of the walk-in cooler that were expired and perishable food items not dated. He revealed the process for food storage was making sure all foods were sealed, labeled, and dated with an opened date and discard date. He verbalized all food dates should be checked by all dietary staff on a regular basis and any expired foods should be properly discarded. He indicated she would have the food items discarded. An interview with the interim Dietary Manager on [DATE] at 12:00 PM revealed all food items should be sealed, labeled, and dated when being stored. She stated dietary staff should be checking food items on a regular basis and discard any items that are not sealed, labeled, dated, or have expired immediately. An interview with the Administrator on [DATE] at 12:40 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 record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours for 6 of 53 days reviewed for staffing (2/15/2025, 3/2/2025, 3/15/2025, 3/16/2025, 3/29/2025, 3/30/2025). Findings included: On 4/1/2025 the Daily Posted Staffing sheet was observed in the front lobby of the facility, it was dated 3/30/2025 and indicated no Registered Nurse (RN) hours for 7am -7pm and 7pm-7a shift. Review of the daily schedule book revealed a calendar from March 2025 labeled RN coverage, which indicated on 2/15/2025, 3/1/2025, 3/2/2025, 3/15/2025, 3/16/2025, 3/29/2025, 3/30/2025 there was RN coverage. Review of daily staffing sheets and posted daily staffing records indicated on 2/15/2025, 3/1/2025,3/2/2025, 3/15/2025, 3/16/2025, 3/29/2025, 3/30/2025 there were no RNs listed on the daily staffing sheets, and no RN hours listed on the posted daily staffing sheets. On 4/2/25 at 3:30pm an interview with the Director of Nursing (DON) stated she was aware there should be 8 consecutive hours of RN coverage daily. The DON stated they had RN coverage and would provide a timecard for the days with missing coverage. The DON provided a timecard that supported on 3/1/2025 there was RN coverage for at least 8 consecutive hours in the facility. There were no additional timecards provided for 2/15/2025, 3/2/2025, 3/15/2025, 3/16/2025, 3/29/2025, 3/30/2025 On 4/3/2025 at 12:55pm during a phone interview the current scheduler stated she was aware of the need to have RN coverage on the schedule but was unaware until 4/3/2025 that the coverage had to be for at least 8 consecutive hours. The current scheduler stated she had told the DON previously, when there was no RN coverage, that the DON needed to make rounds. The current scheduler stated that having an RN scheduled for 8 consecutive hours on every other weekend had been difficult since they had only one RN on staff that worked every other weekend, but recently hired a new RN who would be scheduled on the weekend that did not have RN coverage. The current scheduler stated the DON helped her with the schedule and was aware of the days without RN coverage. On 4/3/2025 at 1:05pm during a telephone interview the previous scheduler stated was not aware that there had to be RN coverage for 8 consecutive hours a day. The previous scheduler stated prior to a RN being hired recently it was not uncommon for there to be no RN working on the weekends. The previous scheduler stated the DON helped with the schedule and was aware there were no RNs scheduled on the weekends. During a telephone interview on 4/4/2025 at 12:40pm the Administrator stated she was aware and expected the facility to have RN coverage for at least 8 consecutive hours each day. The Administrator stated she was now aware the facility had days without RN coverage between the dates of 2/7/2025 and 4/4/2025.

Based on record review, Pharmacist, Nurse Practitioner, and staff interviews, the facility failed to prevent a significant medication error when they failed to administer five daily doses of Metoprolol Succinate (medication to treat heart failure) and Quetiapine Fumarate (an antipsychotic medication that helps regulate mood behaviors and thoughts) for 1 of 3 residents reviewed for medications (Resident #36). The findings included: Review of the hospital discharge summary dated 3/20/2025 revealed orders for Metoprolol Succinate 25 milligrams 24 hr tablet. Take 0.5 tablets (12.5 milligram total) by mouth nightly, and Quetiapine 25 milligram tablet. Take 1 tablet (25mg total) by mouth nightly. Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic peripheral angiopathy (the presence of diabetes which involves damage to the blood vessels particularly to the extremities), hypertensive heart disease with heart failure, unspecified dementia with agitation. Review of Resident #36's medical record revealed on 3/21/2025 the Assistant Director of Nursing (ADON) entered admission orders for Resident #36 into the electronic medical record, which included Metoprolol Succinate, and Quetiapine Fumarate. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had moderate impairment in cognition. The MDS indicated Resident #36 received an antipsychotic medication during the assessment reference period. A physician order dated 3/25/2025 read Metoprolol Succinate ER tablet Extended Release 24 hour 25 milligrams. Give 0.5 (half) tablet by mouth at bedtime HOLD if heart rate less than 60 beats per minute. Review of Resident #36's medication administration record (MAR) dated March 2025 revealed the following: a. Documented by Nurse #1 that on 3/21/2025 Resident #36 did not receive the metoprolol due to the medication not being available. b. Documented by Nurse #2 that on 3/22/2025, 3/23/2025, 3/24/2025, Resident #36 did not receive the dose of Metoprolol Succinate ER or Quetiapine Fumarate due to the medication not being available. Nurse #2 documented on 3/27/2025 Resident #36 did not receive Quetiapine Fumarate due to medication not being available. c. Documented by Nurse #3 that on 3/25/2025 Resident #36 did not receive the dose of Metoprolol Succinate ER or Quetiapine Fumarate due to the medication not being available. Review of Resident #36's medical record revealed multiple electronic Medication Administration Record (eMAR) progress note regarding Metoprolol Succinate and Quetiapine Fumarate which included: An eMAR progress note dated 3/21/2025 at 10:28 pm written by Nurse #1 read Metoprolol Succinate ER Tablet by mouth at bedtime for heart. Awaiting pharmacy. An eMAR progress note dated 3/22/2025 at 10:13 pm written by Nurse #2 read Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligram. Give 0.5 (half) tablet by mouth at bedtime for heart on order. An eMAR progress note dated 3/22/2025 at 10:13 pm written by Nurse #2 read Quetiapine Fumarate Tablet 25 milligram. Give one tablet by mouth at bedtime for confusion on order. An eMAR progress note dated 3/23/2025 at 10:30 pm written by Nurse #2 read Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligrams. Give 0.5 (half) tablet by mouth at bedtime for heart on order. An eMAR progress note dated 3/23/2035 at 10:30 pm written by Nurse #2 read Quetiapine Fumarate Tablet 25 milligram. Give one tablet by mouth at bedtime for confusion on order. An eMAR progress note dated 3/24/2025 at 10:47 pm written by Nurse #2 read Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligrams. Give 0.5 (half) tablet by mouth at bedtime for heart on order. An eMAR progress note dated 3/24/2035 at 10:47 pm written by Nurse #2 read Quetiapine Fumarate Tablet 25 milligram. Give one tablet by mouth at bedtime for confusion on order. An eMAR progress note dated 3/25/2025 at 10:19 pm written by Nurse #3 read Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligrams. Give 0.5 (half) tablet by mouth at bedtime for heart HOLD IF Heart Rate <60 beats per minute waiting for delivery from pharmacy. An eMAR progress note dated 3/25/2025 at 10:20 pm written by Nurse #3 read Quetiapine Fumarate Tablet 25 milligram. Give one tablet by mouth at bedtime for confusion Waiting for delivery from pharmacy. An eMAR progress note dated 3/27/2025 at 10:11 pm written by Nurse #2 read Quetiapine Fumarate Tablet 25 milligram. Give one tablet by mouth at bedtime for confusion on order. Review of Resident #36's vital signs contained in the electronic medical record from 3/21/2025 through 3/31/2025 revealed Resident #36's heart rate and blood pressure were within normal limits. Review of Resident #36's medical record revealed visit notes from the Nurse Practitioner dated on 3/24/2025 and 3/25/2025 which read in part Heart is regular in both rate and rhythm and on 3/25/2025 which read in part resident is calm, smiling and in good spirits. During a telephone interview on 4/2/2025 at 10:59 am Pharmacist #1 stated, it was significant if a resident missed Metoprolol Succinate for five days because it could cause elevated blood pressure and had the potential to worsen heart failure. Pharmacist #1 stated missing quetiapine fumarate for five of seven days was not as significant. Pharmacist #1 stated if a new order was not entered when a resident was admitted the pharmacy would not be aware to send the medication to the facility. During a telephone interview on 4/3/2025 at 12:05 pm the Assistant Director of Nursing (ADON) stated she started at the facility in January of 2025 and was new to long term care. The ADON stated she was still learning but she did try to help the unit managers and enter orders for new admissions. The ADON stated she reviewed Resident #36's hospital records on 3/21/2025 and she entered some new orders and reactivated Resident #36's orders in the electronic health record for Metoprolol Succinate and Quetiapine Fumarate from a previous admission in January 2025. The ADON stated she thought if a resident had an old order in the pharmacy system that was the same, the old order could be reactivated, and a new date added. The ADON stated on 3/21/2025 she had entered new orders and reactivated several old orders in the electronic medical record for Resident #36, which included Metoprolol Succinate and Quetiapine The ADON stated the Director of Nursing had told the ADON on the morning of 4/3/2025 that old orders could no longer be updated, that new orders had to be entered. During a telephone interview on 4/2/2025 at 4:27 pm, Nurse #1 stated he was an agency nurse and 3/21/2025 was the only day he worked at the facility. Nurse #1 stated Resident #36 was admitted to the facility on the evening of 3/21/2025 and at the 9:00 pm medication pass, not all of Resident #36's medications had been received from the pharmacy. Nurse #1 stated after the midnight pharmacy delivery, not all of Resident #36's medications had arrived. Nurse #1 stated he reported that to the oncoming nurse for first shift regarding the medication that had not been delivered. Nurse #1 thought Resident #36's medication had not been delivered since she had just been admitted . Nurse #1 stated since he was an agency nurse, and it was his first shift he was unaware of the process for using the pyxis (back up supply of medication). Nurse #3 was interviewed on 4/2/2025 at 6:00 pm. Nurse #3 stated she was an agency nurse and was not normally assigned to the hall Resident #36 was on. Nurse #3 stated if a resident did not have a medication that was ordered, she would verify the medication had been reordered and indicate on the eMAR the medication was not available, indicated by the number 9, then make a note in the MAR, and notify the unit manager. Nurse #3 stated 3/25/2025 was the only night she was assigned to work with Resident #36. Nurse #3 stated she did not notify the provider. Nurse #3 stated she did not recall if she had notified the unit manager, since a new order had been written on 3/25/2025 and was supposed to be delivered. Nurse #3 stated she was not aware the medication had been missed on previous shifts. Nurse #3 was aware that some staff nurses had access to the pyxis, she did not know which ones. Nurse #3 was not aware she could call the on-call nurse to pull medication from the pyxis. Nurse #2 was interviewed on 4/2/2025 at 7:53 pm and verified she had worked with Resident #36 on 3/22/2025, 3/23/2025, 3/24/2025 and 3/27/2025. Nurse #2 stated if she had entered a number 9, in the eMAR, that the medication was not given and there would be a note to correspond with the reason the medication was not administered. Nurse #2 stated she did not have access to the pyxis since she was an agency nurse. Nurse #2 stated she knew some non-agency nurses had access that worked on other halls, but she did not ask them to pull medication from the pyxis. Nurse #2 stated Resident #36's medication would not be in pyxis because the medications in the pyxis were specific to each resident, not general medications. During a telephone interview on 4/3/2025 at 10:06 am, the Nurse Practitioner (NP) stated he had been notified on 3/24/2025 that Resident #36 had missed doses of Metoprolol Succinate and Quetiapine. The NP evaluated the Resident on 3/24/2025 and 3/25/2025 and documented no acute distress noted. The NP stated missed doses of Metoprolol Succinate could result in an increased heart rate or elevated blood pressure and could cause a decrease in the strength of the heart contraction. The NP stated he had observed her heart rate was regular and from his assessment there did not appear to be any signs of cardiac distress. The NP stated Resident #36 had no behavioral issues when he saw her. During an interview on 4/2/2025 at 5:30pm the Director of Nursing (DON) stated she would expect residents to receive medications as ordered. The DON stated the Pyxis contained general medication for all residents. The DON stated agency nurses do not have access to the pyxis but some staff nurses do and the on call nurses could be called and come to the facility to pull medication from the pyxis. The DON stated she had spoken with the Pharmacy Manager regarding the electronic health record and why old orders were able to be updated, and the Manager was looking into it. The DON stated all new admission orders should be entered in as new orders. During an interview on 4/4/2025 at 12:40pm the Administrator stated she expected the residents to receive medication as ordered.

Based on record review, Nurse Practitioner and staff interviews, the facility failed to notify the provider when five daily doses of Metoprolol Succinate ER (medication to treat heart failure) and Quetiapine Fumarate (an antipsychotic medication that helps regulate mood behaviors and thoughts) was not administered for 1 of 1 resident reviewed for notification (Resident #36). The findings included: Review of the hospital discharge summary dated 3/20/2025 revealed orders for Metoprolol Succinate 25 milligrams 24 hr tablet. Take 0.5 tablets (12.5 milligram total) by mouth nightly, and Quetiapine 25 milligram tablet. Take 1 tablet (25mg total) by mouth nightly. Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic peripheral angiopathy (the presence of diabetes which involves damage to the blood vessels particularly to the extremities), hypertensive heart disease with heart failure, unspecified dementia with agitation. A physician order dated 3/25/2025 read Metoprolol Succinate ER tablet Extended Release 24 hour 25 milligrams. Give 0.5 (half) tablet by mouth at bedtime HOLD if heart rate less than 60 beats per minute. Review of Resident #36's medication administration record (MAR) dated March 2025 revealed the following: a. Documented by Nurse #1 that on 3/21/2025 Resident #36 did not receive the metoprolol due to the medication not being available. b. Documented by Nurse #2 that on 3/22/2025, 3/23/2025, 3/24/2025, Resident #36 did not receive the dose of Metoprolol Succinate ER or Quetiapine Fumarate due to the medication not being available. Nurse #2 documented on 3/27/2025 Resident #36 did not receive Quetiapine Fumarate due to medication not being available. c. Documented by Nurse #3 that on 3/25/2025 Resident #36 did not receive the dose of Metoprolol Succinate ER or Quetiapine Fumarate due to the medication not being available. There were no nursing progress notes that indicated the provider had been notified that Resident #36 had not received the doses of Metoprolol SuccinateER on [DATE], 3/22/2025, 3/23/2025, 3/24/2025 and 3/25/2025, or the doses of Quetiapine Fumarate on 3/22,2025, 3/23/2025, 3/24/2025, 3/25/2025 and 3/27/2025. Nurse #1 was interviewed by phone on 4/2/2025 at 4:27pm. Nurse #1 stated when he worked on 3/21/2025 it was his first and only shift that he worked at the facility. Nurse #1 stated Resident #36 was admitted late in the evening of 3/21/2025 and some of the medications had not arrived from pharmacy in time for the 9:00pm med pass, but arrived in the midnight delivery. Nurse #1 stated he reported to the oncoming shift that not all of Resident #36's medications had arrived from pharmacy. Nurse #1 stated he did not notify a provider regarding the missing medication because the resident had just been admitted . Nurse #3 was interviewed on 4/2/2025 at 6:00pm. Nurse # 3, an agency nurse, stated she was not normally assigned to Resident #36's hall. Nurse #3 stated if a resident did not have a medication that was ordered she would verify the medication had been reordered, indicate on the MAR the medication was not available, add a note in the MAR, and notify the unit manager. Nurse #3 stated that was the only night she had worked with Resident #36 and was unaware the night she worked was the fifth night Resident #36 had not received metoprolol succinate and fourth night Resident #36 did not receive quetiapine fumarate. Nurse #3 stated she normally notified the provider after the first missed dose of medication. Nurse #3 stated if she did not document she had notified the provider, she probably did not notify the provider. Nurse #3 stated she should have notified the provider about the missed medications. Nurse #2 was interviewed by phone on 4/2/2025 at 7:53pm. Nurse #2 verified she had worked with Resident #36 on 3/22/2025, 3/23/2025, and 3/24/2025, and 3/27/2025. Nurse #2 stated she did not notify the provider of the missed doses of metoprolol succinate and quetiapine fumarate because it was the weekend and the on-call providers would say it was a pharmacy issue regarding delivery, not an issue that required a new order or monitoring. During a telephone interview on 4/3/2025 at 10:06am, the Nurse Practitioner (NP) stated he had been notified on the morning of 3/24/2025 through a text chain application on his phone, that Resident #36 had missed doses of two medications over the weekend. The NP stated he was not notified of further missed doses of metoprolol succinate on 3/24/2025 and 3/25/2025, and quetiapine fumarate on 3/24/2025, 3/25/2025, and 3/27/2025. The NP stated the on-call providers on the weekend could have been notified that Resident #36 missed doses of scheduled medications. During an interview on 4/2/2025 at 5:30pm the Director of Nursing (DON) stated she would expect nurses to notify the provider of missed doses of metoprolol succinate and quetiapine fumarate. During an interview on 4/4/2025 at 12:40pm the Administrator stated she would expect the provider to be notified when a nurse became aware a dose of medication was missed.

Based on staff interviews, the facility failed to employ a director of food and nutrition services that met the minimum qualifications, and it affected 108 of 111 residents. Findings included: On 04/01/2025 at 11:00 AM, the Assistant Dietary Supervisor was interviewed and revealed that he did not have any of the following: certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or in hospitality, 2 or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting. The Assistant Dietary Supervisor stated that he did have a dietician that he could consult and call if needed. He revealed that he had been at this facility in this kitchen for a little over six months and that he left for a while and then came back. On 04/01/2025 at 11:56 AM, an interim Dietary Manager at a sister facility was interviewed and stated that she was a Certified Dietary Manager and a Certified Food Protection Professional. She stated that she was at the facility once weekly to help the Assistant Dietary Supervisor. She denied having any regular scheduled meetings with the facility Assistant Dietary Supervisor, but he could call her if needed. She added that she had recently resigned her position and her last day with the company would be 4/16/25. An Administrator interview on 04/04/2025 at 12:40 PM revealed that she was aware of the facility's need to have a certified Dietary Manager. She stated they had hired a certified Dietary Manager that was supposed to have started on 3/25/25 but was unable to start her position on that date due to a family emergency and was scheduled to start her position the week of 4/07/2025. She revealed in the meantime, an interim Dietary Manager from their sister facility had been coming to their facility at least once a week to oversee the kitchen and assist their Assistant Dietary Supervisor. The Administrator stated they also had a Registered Dietician they consulted with and could call if needed. A telephone interview with the Administrator on 04/16/25 at 2:12 PM revealed the certified Dietary Manager they had hired and was scheduled to begin her position the week of 04/07/2025 did not show and they rescinded the job offer. She stated they had made a job offer to another certified Dietary Manager this past week and were in the process of completing a criminal background and dietary certification check. She revealed as long as the criminal background and dietary certification checks cleared, they were hoping the new certified Dietary Manager would be able to start her position next week or the following week. The Administrator stated in the meantime, an interim Dietary Manager from their sister facility would continue coming to their facility at least once a week to oversee the kitchen and assist their Assistant Dietary Supervisor and their Registered Dietician would also be available for consultation if needed.

Based on observation, record review, and staff, Legal Guardian, and former facility Executive Director interviews, the facility failed to exercise the rights of the Resident's Representative when Resident #115 had unsupervised visits with her son despite restricted visitation instructions from the Legal Guardian. The Legal Guardian stated, on Friday 1/24/2025, she informed the Admission's Director and the Resident Concierge Resident #115 was not to have visits from her son without supervision. Resident #115 was cognitively impaired, was adjudicated incompetent, and had history of sexual interactions with her son that included sexual intercourse, open mouth kissing, and inappropriate touching as witnessed by the previous facility's Executive Director. The Admission's Director left the Social Worker (SW) a note on Friday evening after the SW left for the day telling her to call Resident #115's Legal Guardian regarding visitation and concerns with Resident #115's son. The SW did not learn of the restricted visitation until 1/27/2025 at approximately 5:30 PM when the SW spoke to the Legal Guardian by phone. Resident #115's son had unsupervised and unrestricted visitation from 1/24/2025 through 1/27/2025 until he was asked to leave the room by the SW after the phone call with the Legal Guardian. This deficient practice affected 1 of 1 resident (Resident #115) reviewed for guardian directives. Immediate jeopardy began on 1/24/2025 when the Legal Guardian informed the Admission's Director and the Resident Concierge that Resident #115 was to have supervised visitation with Resident #115's son and this was not implemented until 1/27/2025. Immediate jeopardy was removed on 2/1/2025 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The discharge summary from the hospital dated 1/22/2025 did not include Resident #115's Legal Guardian's wishes. Resident #115 was admitted to the facility on [DATE] with a history of dementia, anxiety, and major depressive disorder. A baseline care plan dated 1/22/2025 did not contain any problems or interventions regarding supervised visitation for Resident #115. An admission minimum data set (MDS) dated [DATE] revealed Resident #115 was moderately cognitively impaired, with no behaviors, wandering, or rejections of care. Resident #115 was coded as dependent on staff for eating, oral hygiene, toileting, bathing, upper body dessing, lower body dressing, and personal hygiene. Resident #115 had clear speech and was understood. Review of a document scanned into the Electronic Medical Record (EMR) on 1/31/2025 contained a Letters of Appointment Guardian of the Person State of North Carolina document, dated 5/19/2022. The documentation revealed Resident #115 was adjudicated as incompetent and was appointed a Legal Guardian. Review of a document scanned into the EMR on 1/31/2025 contained a Guardianship Notification document from the Department of Social Services (DSS), that was undated. The documentation revealed Resident #115's son was to have restricted visits, 2 days a week, with supervision. A telephone interview was conducted on 1/30/2025 at 3:20 pm with Resident #115's Legal Guardian. The Legal Guardian stated she believes DSS took guardianship over Resident #115 in approximately 2015 due to a sexual relationship with her son. The Legal Guardian stated she had been responsible for Resident #115 since September of 2024. The Legal Guardian stated when Resident #115 was at a previous facility, Resident #115's son had tried to have sex with Resident #115, which led to supervised and limited visitation. The Legal Guardian stated she had spoken to the hospital when Resident #115 was admitted and informed them of the need for supervision and limitation with Resident #115's son. The Legal Guardian stated she had told the Admission's Director and the Resident Concierge on 1/24/2025 when she visited the facility. The Legal Guardian stated she had given the guardianship paperwork to the Admission's Director and the Resident Concierge when she visited in person on 1/24/2025. An interview was conducted on 1/30/2025 at 10:18 am with the Admission's Director. The Admission's Director stated that he had been in contact with the Legal Guardian via email regarding admission paperwork prior to Resident #115 being admitted to the facility. The Admission's Director stated the first time that he had spoken with Resident #115's Legal Guardian in person was on 1/24/2025 at which time the Legal Guardian reported Resident #115 had to have limited and witnessed visitations because of a previous sexual relationship between Resident #115 and Resident #115's son. The Admission's Director stated this sexual relationship had been perceived as okay by Resident #115 and Resident #115's son. The Admission's Director stated that he had let the SW know and stated he had not received any guardianship paperwork as of 1/30/2025. The Admission's Director stated he did not have the guardianship paperwork or paperwork regarding restricted visitation. The Admission's Director stated he had requested the documentation, but it had not been sent. The Admission's Director stated he had sent the admission's paperwork electronically and had not visited with Resident #115's Legal Guardian in person until 1/24/2025. The Admission's Director stated this was the first time he had admitted a resident with a Legal Guardian. A follow-up interview was conducted on 1/30/2025 at 3:51 pm with the Admission's Director. The Admission's Director stated he left a note for the SW to call Resident #115's Legal Guardian on 1/24/2025 and knew that she would not be back at work until 1/27/2025. The Admission's Director stated he had not told the DON, Administrator, or contacted the SW the evening of 1/24/2025 because he thought the Legal Guardian had just made a request for supervised visitation, not that it was required, based on a history of a sexual relationship between Resident #115 and Resident #115's son. An interview was conducted on 1/30/2025 at 10:38 am with the Resident Concierge (assistant/advocate). The Resident Concierge stated Resident #115's Legal Guardian had stopped by the Admission's Director's office on 1/24/2025 and voiced concerns about family relations and had stated Resident #115's son had sex with Resident #115, which was perceived as being okay by the family. The Resident Concierge explained that he was present in the office at the time of the visit and stated Resident #115's Legal Guardian had requested restricted and supervised visits to ensure that Resident #115 was okay. The Resident Concierge was unable to explain why he didn't tell anyone about the information obtained from the Legal Guardian. An interview was conducted on 1/30/2025 at 9:59 am with the Social Worker (SW). The SW stated Resident #115 was admitted to the facility last week (1/22/2025) and stated she had a Legal Guardian. The SW stated the Legal Guardian had not contacted the facility prior to Resident #115 being admitted . The SW stated last Friday (1/24/2025) the Legal Guardian had come by the facility after she had left for the day and stopped to talk to the Admission's Director and the Resident Concierge regarding concerns about Resident #115's son visiting and left a message for the SW to call her back. The SW stated she made multiple attempts on 1/27/2025 to contact the Legal Guardian and received a call back at approximately 5:30 pm. The SW stated she was told by the Legal Guardian that Resident #115's son was to have supervised visitation due to Resident #115's son attempting to perform sexual acts with Resident #115. The SW stated she had been told by the Admission's Director that the type of relationship Resident #115 and Resident #115's son had been consensual. The SW stated the Legal Guardian informed her at Resident #115's previous facility, Resident #115's son had to have scheduled supervised visitation due to Resident #115's son attempting to perform sexual acts, which she did specify. The SW stated Resident #115's son had been present at the facility every day from 1/22/2025 until 1/27/2025 and no staff members had observed any inappropriate behavior. The SW acknowledged that Resident #115's son had not had any supervised or restricted visitation since admission to the facility. The SW stated Resident #115's roommate was alert and oriented and had not mentioned any inappropriate behavior to staff. The SW stated after her conversation with the Legal Guardian on 1/27/2025 she went to Resident #115's room, where she observed three other men at the bedside in addition to Resident #115's son. The SW stated she asked the visitors to leave and advised Resident #115's son he would have to contact her to schedule supervised visitation and was not to visit Resident #115 unsupervised. A follow-up interview was conducted on 1/30/2025 at 3:48 pm with the SW. The SW stated she was notified by the Admission's Director on the morning of 1/27/2025 that she needed to contact Resident #115's Legal Guardian regarding scheduled visits with Resident #115's son. The SW stated she did not remember notifying the Director of Nursing (DON) or the Administrator on 1/27/2025 prior to speaking with the Legal Guardian around 5:30 pm. The SW was not sure why she had not alerted administrative staff about the concerns voiced by the Legal Guardian. The SW stated she did not have a copy of the guardianship papers and stated the facility had requested those documents. An interview was conducted on 1/30/2025 at 11:55 am with Nurse Aide (NA) #1. NA #1 stated she frequently cared for Resident #115 since she was admitted to the facility. NA #1 stated she worked day shift (7:00 am to 7:00 pm). NA #1 stated she had seen Resident #115's son arrived at the facility as early as 7:00 am and stated he stayed throughout the day. NA #1 stated Resident #115's son kept the curtain pulled in Resident #115's room. NA #1 stated Resident #115's son acted odd but did not specify. NA #1 stated she had not witnessed any inappropriate behavior between Resident #115 and Resident #115's son. Resident #115's son was unavailable for interview. An interview was conducted on 1/30/2025 at 11:25 am with Resident #72. Resident #72 was alert and oriented to person, place, time, and event. Resident # 72 acknowledged that she had been Resident #115's roommate since she was admitted to the facility. Resident #72 stated Resident #115's son visited Resident #115 every day, including the weekend 1/25/2025 and 1/26/2025, since she had been admitted to the facility until Monday (1/27/2025) when the SW came and told him he needed to leave. Resident #72 stated Resident #115's son would arrive around 8:00 am and stay all day until dinner trays were served between 4:00 pm and 5:00 pm. Resident #72 stated staff would bring Resident #115's son a guest tray at lunch. Resident #72 stated when Resident #115's son arrived each day, he would pull the curtain and keep the curtain closed the remainder of the day. Resident #72 stated Resident #115's son made her uncomfortable because he would stand at the door and look at her. Resident #72 stated she left the room on occasion to go to the common area at which time Resident #115 and Resident #115's son were alone in the room. An observation was conducted on 1/27/2025 at 12:47 pm of Resident #115. Resident #115 was not visible from the door due to the curtain being pulled. After entering the room, Resident #115 was observed lying in bed and Resident #115's son was sitting in a chair by the window next to her bed. Both were fully clothed. An observation was conducted on 1/30/2025 at 11:24 am of Resident #115. Resident #115 was lying in bed and did not respond when she was asked questions and did not make eye contact. An interview was conducted on 1/30/2025 at 1:52 pm with the Director of Nursing (DON). The DON stated Resident #115 had recently been admitted to the facility on [DATE] and reported Resident #115 was placed on supervised visitation after DSS notified facility staff of an inappropriate relationship between Resident #115 and Resident #115's son on 1/27/2025. The DON stated she was not made aware that the request for supervised visitation was made on 1/24/2025. The DON stated the Legal Guardian should have made the facility aware of the need for supervision prior to admission to the facility and stated that the Admission's Director and/or Resident Concierge should have notified her or the Administrator on 1/24/2025. The DON stated she would have honored the Legal Guardian's request starting 1/24/2025 if she had been made aware. An interview was conducted on 1/30/2025 at 3:55 pm with the Administrator. The Administrator stated Resident #115 was placed on supervised visitation on 1/27/2025. The Administrator stated she was not made aware the Legal Guardian had requested Resident #115 to have supervised visitation with Resident #115's son on 1/24/2025. The Administrator stated if she would have known on 1/24/2025 she would have implemented the supervised visits immediately. The Administrator was not able to recall what time, or who brought to her attention the concern regarding Resident #115 and her son. A telephone interview was conducted on 1/30/2025 at 12:07 pm with the Executive Director at Resident #115's former facility. The Executive Director stated he was very familiar with Resident #115 and stated that she resided at his facility from 1/29/2024 through 1/22/2025. The Executive Director stated Resident #115 was discharged from the facility to the hospital on 1/22/2025 due to requiring a higher level of skilled care. The Executive Director stated Resident #115 had a Legal Guardian after she was removed from the care of Resident #115's son. The Executive Director stated Resident #115 required supervised and limited visitation with Resident #115's son while at his facility due to inappropriate sexual behaviors such as open mouth kissing and inappropriate touching. The Executive Director stated Resident #115's son had stated Resident #115 was the only woman he had ever known. The Executive Director stated he had not reported the need for supervised visitation or limited visitation to the hospital when Resident #115 was transferred because he assumed Resident #115's Legal Guardian would be responsible for that. The Administrator was notified of Immediate Jeopardy on 1/30/2025 at 5:44 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 01/24/25, the Admissions Director and Resident Concierge were notified by Resident #115's guardian/resident representative that Resident #115 was to have supervised visitation due to a history of a sexual relationship between Resident #115 and Visitor #1 (Resident #115's son). The Admissions Director and Resident Concierge did not report this information to anyone until 01/27/25. The Social Worker was informed via note by the Admissions Director to contact Resident #115's guardian/resident representative regarding visitation on 1/27/25. The Social Worker attempted to reach Resident #115's guardian/resident representative multiple times throughout the day without success. At approximately 2:45pm on 01/27/25 a verbal discussion took place between the Admissions Director and Social Worker regarding the concerns voiced by Resident #115's guardian/resident representative regarding visitation. The Administrator was notified at this time and instructed the Social Worker to place Resident #115 on supervised visitation while waiting to obtain further information from Resident #115's guardian/resident representative. The Social Worker immediately went to Resident #115's room and asked Visitor #1 and two additional visitors to leave the room and meet with the Social Worker. During the meeting Visitor #1 was informed that all future visits would need to be scheduled with the Social Worker and supervised. Visitor #1 voiced understanding and exited the facility. Visitor #1 visited Saturday 1/25/2025 and Sunday 1/26/2025 and per the nurse working on the hall for approximately 6 hours each day. The nurse reported she observed Visitor #1 in Resident #115's room while standing out in the hall at the med cart outside of Resident #115's room. The supervised visits will be monitored by the Social Worker, if the Social Worker is not available at the time of the visit, the Administrator will be notified and will ensure that a staff member is assigned to monitor the visit for resident safety. At approximately 5:30pm on 01/27/25 the Social Worker was able to communicate with Resident #115's guardian/resident representative and was able to obtain specifics regarding the circumstances leading up to appointment of a guardian/resident representative with DSS and history with Visitor #1. On 1/30/25, all Residents with guardian/resident representatives were identified by the Social Worker. On 1/30/2025, all residents with visitor restrictions were confirmed. The care plan for Resident #115 was updated to reflect the visitation restrictions by the Care Plan Coordinator/Minimum Data Set Nurse on 1/30/2025. The Unit Supervisor completed a head-to-toe assessment on Resident #115 on 01/31/25. No signs of injury or distress were noted. Employees (nursing and housekeeping) that worked on Resident #115's unit from 1/24/25- 1/27/25 were interviewed in person or via phone by the Social Worker and Social Worker Assistant on 1/31/25 to determine if the staff witnessed any inappropriate sexual behaviors with Resident #115. No inappropriate sexual behaviors were identified. On 1/31/25 the resident's roommate was interviewed by the Social Worker to determine if any inappropriate sexual behaviors occurred from 1/24/25-1/27/25 during Visitor #1's unsupervised visits. 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: Education was performed by the Regional Admissions Director with the Admissions Director and Resident Concierge regarding proper notification to Administrator and/or Director of Nursing when admitting residents and the resident's guardian/resident representative made request including restricted/supervised visitation on 1/30/25. Regional Director of Admissions implemented a new form 1/31/2025, Guardian/resident representative or Power of Attorney Documentation Form, this form is to be completed for all new admissions prior to admission by the Admissions Director. This form will be used to identify if the Resident has a guardian/resident representative appointed or if any restrictions on visitation are in place, or other specific wishes requested by the appointed guardian/resident representative. This form will facilitate communication and ensure the notification of the Administrator and/or Director of Nursing. When a Resident is identified as requiring restricted or supervised visits or other wishes it will be added to the Resident's care plan by the appointed Administrative Nurse. Effective 1/31/25, Guardian/resident representative wishes will be reviewed quarterly or as needed by care plan coordinator and renewed. In addition to the care plan the information will be documented on the Resident's profile under special instructions by administrative nurse. Education was provided to the Care plan Coordinator and social worker on 1/31/2025 by Administrator and Director of Nursing that during baseline care plan and/ or quarterly care plan meetings the guardian/resident representative wishes are reviewed and ensured the wishes are reflected on the Resident's care plan which will add the information to the KARDEX. On 1/31/2025 the Social Worker was educated by the Administrator on the process for supervised visits and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves. Supervised visits will be conducted as follows: Visitor will call the facility to schedule the visit with the Social Worker. Day of supervised visit visitor will come to the facility and ask for the social worker at the front reception desk. Social Worker will accompany the visitor to the Resident room or room decided on by Resident or visitor. Social Worker will remain present during the visit to monitor for Resident safety. When the visit is completed, the Social Worker will accompany the visitor to the front lobby and the visitor will exit the facility. If the Social Worker is not available, the Administrator will be notified and will ensure that a staff member is assigned to monitor the visit for Resident safety. If a visitor comes to the facility after hours that require supervised visits, the staff will ask the visitor to leave the facility and schedule the visit with the Social Worker. If the visitor refuses to leave, the facility staff will call law enforcement to have the visitor removed from the facility and notify the Administrator and Director of Nursing. On 1/31/2025 all certified nursing assistants were educated by the Staff development Nurse on supervised visitation process, where to identify on the KARDEX visitation restrictions, to notify administrative on call number if restrictions are not followed, and that facility is to adhere to any guardian/resident representative wishes. On 1/31/2025 all Nurses were educated by the Staff development Nurse on supervised visitation process, where to identify on the KARDEX visitation restrictions, where the visitation restriction will be located on the Resident profile chat under special instructions, and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves. Nursing staff will understand this is information that is expected to be passed along in the report. On 1/31/2025 All Administrative Nurses were educated by the Director of Nursing on the process for supervised visitation, how to add to the KARDEX on visitation restrictions, where the visitation restriction will be added on the Resident profile chart under special instructions, and to ensure to respect and follow the guardian/resident representative wishes as though the resident is making the decision themselves. If a resident was identified as needing new restrictions the appointed administration nurse by the Administrator or Director of Nursing will notify the nurse on the hall and front desk, and will add restriction to Kardex, and resident chart under special instructions. IJ removal date: 2/1/2025 A validation of immediate jeopardy removal was conducted on 2/6/2025. An audit was conducted on 1/30/2025 to identify which residents had a guardian or representative and to ensure that any visitor restrictions were honored. Interviews with facility staff (housekeeping and nursing) revealed staff knew who required restricted/supervised visitation and what to do if a restricted visitor showed up at the facility unscheduled or refused to leave (which included notifying law enforcement). Interviews with the Admission's Director and Resident Concierge revealed they had received education regarding changes to the admissions process which included gathering guardianship information, restrictions with visitation, and information regarding limited visitation on a new form. The Admission's Director and Resident Concierge also verbalized guardianship papers would be received/reviewed prior to a resident being admitted and the Administrator and Director of Nursing would be notified immediately. Interviews with staff who participate in baseline care plan meetings and quarterly meetings revealed staff would review guardian/representative wishes at each meeting and their wishes would be reflected in the care plan. Interviews with the Social Worker and Receptionist revealed restricted/supervised visitors were to call to schedule a supervised visit with the SW, when the visitor arrived at the facility, the Receptionist should notify the SW, the SW should remain with the visitor for the duration of the visit and should walk them out following the visit. The immediate jeopardy date of 2/1/2025 was validated.

Based on observation and staff interviews, the facility failed to employ a director of food and nutrition services that met the minimum qualifications, and it affected 106 of 109 residents. Findings included: On 01/27/2025 at 10:10 AM, the Dietary Manager was interviewed and revealed that he did not have any of the following: certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or in hospitality, 2 or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting. The Dietary Manager stated that he does have a dietician that he can consult, but he did not know her name. He stated that he could call her if needed. He revealed that he had been at this facility in this kitchen for a total of six months and that he left for a while and then came back. On 01/28/2025 at 10:50 AM, a Dietary Manager at a sister facility was interviewed and stated that she was a Certified Dietary Manager and a Certified Food Protection Professional. She stated that she was there to help the Dietary Manager. She denied having any regular scheduled meeting with the facility Dietary Manager, but he could call her if needed. An Administrator interview on 01/31/2025 at 2:25 PM revealed that she was aware of the facility's need to have Dietary Manager certifications and thought her personal food safety certification would count.

Based on observations and staff interviews, the facility failed to remove loose and unsecure pills of various shapes, sizes and colors and failed to ensure a medication cart was clean and free of debris for 2 of 3 medication carts reviewed for medication storage (100/200 split hall and 300 hall medication carts). The findings include: a. On 01/29/25 at 1:31 PM an observation was made of medication cart 100/200 hall split along with Nurse #2 which revealed 41 loose and unsecure pills of various shapes, sizes and colors and debris of paper shavings and rubber bands in the bottom of the cart drawers. An interview was conducted with Nurse #2 on 01/29/25 at 1:31 PM who explained that everyone was responsible for keeping the medication carts clean and orderly. The Nurse stated she should have vacuumed the medication cart out prior to the observation. During an interview with Unit Manager (UM) #1 on 01/29/25 at 1:42 PM she explained that the condition of the medication cart was unacceptable and that it was the nurses' responsibility to vacuum the medication carts out once a week. b. An observation was made of medication cart 300 hall along with Nurse #3 at 1:57 PM on 01/29/25. The observation yielded 12 loose and unsecure pills of various shapes, sizes and colors. During the interview with Nurse #3 on 01/29/25 at 1:57 PM the Nurse explained that it was the nurses' responsibility who was on the medication cart to keep it clean and orderly, but she did not have a chance to clean it today (01/29/25) or yesterday (01/28/25). A combined interview was conducted with the Administrator and Director of Nursing (DON) on 01/31/25 at 12:07 PM. The DON explained that it was nursing's responsibility to clean the medication carts weekly and she had recently assigned specific nurses to clean and organize all the medication carts. The DON indicated the nurse on the cart should remove loose pills from the cart on a daily basis.

Based on record review, observations, and resident, visitor and staff interviews and test tray, the facility failed to provide food that was appetizing in temperature, texture and palatability for 3 of 3 residents sampled for food palatability (Resident #59, Resident # 15, and Resident # 57). The findings included: a. Resident #59 was admitted on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #59 was cognitively intact. An interview with Resident #59 occurred on 01/27/2025 at 1:05 PM he stated the food was terrible. They don't give us much breakfast. This morning the eggs were runny and cold. There was no meat. The bread was hard. He said he knew that he could have asked for something different, but he knew it would take a long time and wouldn't be much good either. He stated that he tries to keep a few snacks in his drawer, and the nutrition room never had anything. During an interview with Resident #59 on 01/29/2025 at 5:28 PM, he stated regarding lunch hate them chicken patties. Nobody can eat as much chicken as we have had. The patties were horrible. The cake was not much. It was dry. The slaw had too much mayo. You could squeeze it out. b. Resident # 15 was admitted on [DATE]. A review of a grievance/concern form dated 01/22/2024 stated that meal tickets were not followed, the wrong food was coming out on her tray, and the food was cold. The resolution was signed by both Resident #15 and the Administrator on 01/23/2024 that the Administrator would contact contracted vendor to talk to employees about following meal tickets and the importance of timelines. The quarterly Minimum Data Set (MDS) dated [DATE] reviewed that she was cognitively intact. An interview with Resident #15 on 01/27/2025 at 3:45 PM revealed that sometimes she could not eat the food as it was tasteless, cold or didn't look right. An interview was conducted with Resident #15 on 01/28/2025 at 12:38 PM and revealed that the lunch just wasn't much at all. She stated that it was pasta with little bits of meat and hardly no sauce. It was dry, she explained and that she only had one bite of bread as it was too hard and just didn't taste like nothing. She revealed that she didn't eat a bite of salad, because it looked like it hadn't been washed. It was brown, she stated. Resident #15 was interviewed on 01/29/2025 at 5:12 PM and revealed that lunch wasn't much and not good. At 11:10 AM on 01/30/2025 an interview was conducted with Resident #15's visitor who reported that during her visits over the last six months, she observed thin meat that was unidentifiable and a piece of fish that was as hard as cardboard. She stated that on one visit every food item in the dining room was steamed, and that the stewed tomatoes were runny, and the macaroni and cheese looked tasteless. c. Resident #57 was admitted on [DATE]. A review of the 11/15/2024 grievance/concern form revealed that Resident #57 voiced complaint about the quality of the facility's food. The resolution signed by the Administrator was that the facility would incorporate resident's likes and dislikes on his tray. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident # 57 was cognitively intact The grievance/concern form dated 01/24/2025 was reviewed and revealed that his food was not good and served cold, so he had to buy his own food. The Dietary Manager signed a resolution that the menus would be changed to be a better fit for the facility. The Dietary Manager wrote that test trays and in-services would be held to make food at a good temperature and quality before trays were sent out. An interview on 01/27/2025 at 9:28 AM with Resident #57 revealed that he didn't like the food at all. He had a well-stocked mini refrigerator in his room with food that family members purchased for him. He stated that he can only eat some of the breakfast but not every day and can't eat lunches or suppers. He stated that today the breakfast didn't have any meat, and it was cold and late. Resident # 57 was out of the facility for the lunch meal on 01/28/2025. On 01/29/2025 at 2:40 PM, Resident #57 was interviewed and stated that the lunch was chicken again, and he just could not eat the dry, cold food. He stated that the slaw looked runny, and that he just covered it up and sent it back and ate something from his refrigerator. On 01/30/2025 at 1:30 PM, Resident #57 stated that he could eat his breakfast this morning, but it was a little cold. He revealed that he tried to eat his lunch, but he did not want it. On 01/28/2025 beginning at 11:10 AM, all foods on the steam table were checked for proper temperatures with the Dietary Manager, and a test tray was followed from the serving line with the Dietary Manager to the serving cart on the 300- hall. At 12:20 PM on 01/28/2025 after the other resident trays were delivered, the test tray revealed mushy and bland ziti noodles. The breadstick was flavorful, but it wasn't very warm. The salad was not wilted, but it was iceberg lettuce with sparse shredded carrots. When the Dietary Manager tasted the tray, he agreed that the breadstick could be warmer, and he stated that the ziti was a little mushy. He stated that most of the time he added tomato and cucumbers to the salad to spice things up when he has them in stock. Upon touching the milk carton, it was not very cold; and the Dietary Manager said it was okay. The Dietary Manager stated that it could be better quality for sure, and the food could benefit from being hotter. The Dietary Manager was interviewed on 01/28/2025 at 12:35 PM. He stated that he had a few complaints about the food being bland and cold and said that he would work on it. The Administrator was interviewed on 01/30/2025 at 12:20 PM and revealed that the kitchen had some recent staff turnover, and she was aware of some resident complaints about the food. She stated that a new food vendor was contracted.

Based on observations and staff interviews, the facility failed to store food items off the floor in the dry goods storage area, remove food items with signs of spoilage stored for use in 1 of 2 walk-in freezers and failed to ensure ice cream stored for use in an upright freezer did not have signs of freezer burn in 1 of 3 nourishment rooms (100 Hall nourishment room). The practices had the potential to affect food served to residents. The findings included: a. An observation on [DATE] at 10:02 AM of the dry goods storage room revealed a mesh bag of onions and a wrapped package of water bottles sitting on the storeroom floor. They were pointed out to the Dietary Manager who stated that they should not be on the floor. An item with a split plastic bag on it on the storeroom floor was pointed out, and the Dietary Manager said that it was an old mixer and didn't need to be on the floor. b. Observations of the freezer shelves on [DATE] at 10:07 AM revealed an expired bag of iceberg lettuce dated ,d+[DATE], a container of lettuce covered in plastic wrap with a date of ,d+[DATE] that looked wilted and almost soupy. A bin covered in plastic wrap marked pureed beef and a date of ,d+[DATE] without a year was on the shelf in the freezer. When asked what would keep his staff from serving it, the Dietary Manager stated that they all know the 72-hour rule, but it needs to be thrown out. He stated the pureed beef should not be in the freezer. c. An observation of the 100-hall nourishment room was conducted on [DATE] at 1:43 PM and revealed 5 vanilla ice cream packages that looked melted and refrozen due to darker yellow color on the tops inside each container. The Dietary Manager was notified and stated that he would remove them as they should not be there. An interview conducted with the Administrator on [DATE] at 2:25 PM revealed that these examples of food storage with beef, lettuce, onions and ice cream were incorrect and should not have been stored this way.

Based on observation, record review, staff, nurse practitioner and physician, and family interview, the facility failed to identify residents with COVID-19 by not placing them on Enhanced Droplet Contact Precautions. The facility failed to educate staff on the importance preventing cross contamination by removing all Personal Protective Equipment (PPE) to include gowns and gloves and performing hand hygiene between caring for residents who are COVID-19 positive and COVID-19 negative. The facility failed to screen employees to ensure staff were asymptomatic when on duty. The facility failed to ensure staff were using cleaning chemicals approved and listed on the EPA website to kill COVID-19. The facility failed to educate staff on proper use of cleaning chemicals. Facility failed to screen and test residents before room transfers within the facility to prevent potential exposure of COVID-19 to other residents. Facility failed to implement a policy for storage of PPE (N-95 masks and face shields). These failures in infection control practices occurred during a COVID-19 pandemic and had the potential to affect all residents and staff in the facility through the transmission of COVID-19. The facility resulted in 60 positive residents and 15 positive employees as of 09/26/20. The immediate jeopardy began on 9/13/20 when the facility failed to identify a symptomatic employee (Nurse #5) to care for residents on the 100 Hall New Patient Observation wing. Immediate Jeopardy was removed on 09/25/20 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. The findings included: 1. A memo written by the DON dated 03/17/20 indicated all staff must be screened for symptoms and the employee's temperature taken prior to reporting to their shift. It further indicated all staff must check their own temperature at the time clock and document it next to their name. If a temperature is noted, the on-call nurse was to be called. If afebrile, staff were to proceed to step #2. Step #2 indicated all staff were to report or deny symptoms that included shortness of breath or cough next to their name. If these symptoms are present, the on-call nurse must be notified. Visitors were to be screened which included their temperature taken and logged; however, no questions related to symptoms were asked during the screening process. The employee screening process consisted of a pre-printed employee roster that listed each employees name and job title/department, a column for temperatures to be written and a column for staff to deny symptoms. No symptoms were listed on the screening sheet. Facility documents titled Sunday Temp Log, Monday-Tuesday Temp Log revealed documents with employees pre-printed names and job title in two separate columns. The documents contained two additional columns that were labeled Temp and Denying Symptoms. 1 a. The employee daily screening log for 09/13/20 revealed Nurse #5 reported to work on 09/13/20 with a low-grade fever of 99.0 and symptoms listed as sore throat, headache, congestion, and swollen glands. The employee daily screening log for 09/16/20 revealed Nurse #5 reported to work on 09/16/20 afebrile with a temp recorded of 97.0 but reported a headache. An interview was conducted with Nurse #5 on 09/16/20 at 11:01 AM revealed she worked 100 hall on 09/13/20 on day shift. Nurse #5 reported she came to work and had a low-grade fever of 99.0 degrees and was symptomatic with a headache, sore throat, congestion, and her glands she recalled being swollen and documented this on the daily screening log. Nurse #5 revealed she was educated it was not necessary to report these symptoms to the supervisor since her fever was not greater than 101 degrees Fahrenheit. Nurse #5 reported she had been tested on [DATE] during the facility weekly testing and her results were pending so she worked the shift. Nurse #5 stated on 09/16/20 when she arrived at work, she was again assigned the 100 hall new patient unit and Nurse #5 asked Nurse #3 if the results had been returned for her weekly test since she had been having some symptoms. On 09/16/20, Nurse #5 reported she had a headache. Nurse #3 revealed Nurse #5's result on 09/11/20 had not yet been returned, she was not offered a rapid COVID-19 test, but a polymerase chain reaction (PCR) COVID-19 test was performed and Nurse #5 began her shift since she wasn't running a fever on 09/16/20. It is unknown if Nurse #5 resulted positive for COVID-19 following being symptomatic and febrile. Nurse #5 had a COVID-19 PCR test performed on 09/11/20 which resulted as negative; however, results were not available on 09/16/20 when she was rapid tested and resulted as positive for COVID-19. An interview with Nurse #3 on 09/18/20 at 11:32 AM indicated she had not been made aware that Nurse #5 had been symptomatic on 09/13/20 and did not receive a rapid test for COVID-19 until Nurse #5 approached her on 09/16/20 requesting the results of her testing completed on 09/11/20 and told Nurse #3 that she had symptoms over the weekend and no test had been completed. Nurse #3 indicated she had not known to offer or perform a PCR test for any resident or staff who were symptomatic and had a negative result from a rapid test. An interview with the Infection Control (IC) Nurse/DON and the Administrator was conducted on 09/21/20 at 10:27 AM revealed neither the DON nor the Administrator were aware Nurse #5 had reported symptoms on 09/13/20 on the daily screening log without being reviewed by a supervisor on duty. They were also not aware Nurse #5 had not been rapid tested when symptomatic and allowed to work the shift or additional shifts since that date. The DON explained Nurse #5 should have received a rapid test on 09/13/20 and not allowed to report to her assigned hall until the test had a negative result. The failure occurred when the supervising nurse on duty failed to review daily employee screening logs for temperatures or reported signs and symptoms. The DON indicated she was unable to elaborate why the screening sheet had not been reviewed other than with the amount of COVID-19 positive cases in the facility, staff had been overwhelmed and not had the time. The DON explained she expected staff to report concerns to the supervisor if the staff member was febrile or experienced symptoms of COVID-19. 1b. The employee daily screening log for 09/15/20 revealed Nurse #1 reported to work afebrile with a temperature of 98.4 and no symptoms were listed on the log. A continuous observation was made on 09/15/20 between 11:00AM- 11:35 AM revealed Nurse #1 documenting on a laptop in the hallway. Nurse #1 had a slight cough and mentioned she did not feel well. She was wearing a face shield and a mask. An interview with Nurse #1 on 09/16/20 at 1:46 PM and a follow up interview on 09/17/20 at 11:16 AM revealed Nurse #1 had not felt well and called out of work on 09/14/20 when she reported she didn't feel well with symptoms including a headache, cough, fatigue, and overall weakness. Nurse #1 reported her symptoms to the on-call nurse for the 09/14/20 shift. Nurse #1 stated she was contacted later in the morning by the Director of Nursing (DON) asking if she was planning to come in later in the shift because she was needed. Nurse #1 indicated she told the DON she was not coming in that day. Later in the afternoon, Nurse #1 was again contacted this time by Nurse #2 who told Nurse #1 she needed to be at work on 09/15/20 unless she was running a fever due to staffing concerns. Nurse #1 reported she came to work on 09/15/20 and checked her temperature and was afebrile but does not recall if she documented it on the sign in sheet on that day or not. Nurse #1 reported they were told to check their temperature and record their temperature at the start of the shift and there was an additional column to deny symptoms. There were no specified symptoms to confirm nor deny were listed on the daily screening sheet. Nurse #1 revealed she mentioned to the unit manager Nurse #2 that morning she was not feeling well but did not have a fever when she arrived to work therefore, she reported to her assigned hall. Nurse #1 worked the 200 hall COVID-19 overflow unit on 09/15/20 day shift. She reported after lunch time she started feeling worse and felt so hot she had to go outside for a minute to try to cool off because she felt as if she were going to vomit or pass out. Nurse #1 then texted Nurse #3 from outside the building alerting her that Nurse #1 felt she needed to be tested for COVID-19. Nurse #1 returned to the unit and approximately 30 minutes later Nurse #1 was tested by rapid testing. Nurse #1 revealed she returned to the unit for about 15-20 minutes before Nurse #2 approached her and notified her that she was COVID-19 positive per the rapid test and needed to leave the facility. An interview with Nurse #2 was conducted on 09/17/20 at 2:10 PM revealed she had contacted Nurse #1 on 09/14/20 between 5-7 PM to confirm if Nurse #1 would be at work on 09/15/20. She recalled Nurse #1 informing her she was still not feeling well but she would try to make it. Nurse #2 was unable to recall what symptoms of not feeling well Nurse #1 reported to her on 09/14/20. Nurse #2 revealed she did tell Nurse #1 the building needed her on schedule but did not elaborate further how that statement was conveyed to Nurse #1. Nurse #2 stated in the afternoon on 09/15/20 she was notified that Nurse #1 was again not feeling well and had a headache. An interview with the Infection Control (IC) Nurse/DON and the Administrator was conducted on 09/21/20 at 10:27 AM revealed neither the DON nor the Administrator were aware Nurse #1 had not felt well until after Nurse #2 and Nurse #3 made them aware Nurse #1 had been rapid tested on [DATE] and was positive for COVID-19 . The DON elaborated to say she was aware Nurse #1 was not feeling well on 09/14/20 and had called off from work, but the DON stated she was on vacation on 09/15/20 and was unaware Nurse #1 was still not feeling well and would expect Nurse #1 not to feel pressured to work a shift if she felt she was not well enough or felt she had symptoms of COVID-19. The DON indicated Nurse #1 should have reported she did not feel before she entered the facility for her shift on 9/15/20. The DON stated she expected nurses should know the signs and symptoms to self- assess themselves and report concerns accordingly, but no policy was in place for screening. The DON revealed Nurse #1 should have been asked to stay in her car and a rapid test should have been performed before her shift began. The DON indicated the daily screening sheets are reviewed on the following day by the ADON and kept for records, but was unable to elaborate when questioned if any staff reviewed the daily screening logs during the shift that occurred other than to say with the amount of cases the facility had, staff had been overwhelmed and had not had time. The DON reported staff had been educated to take and record their own temperature and deny symptoms. The DON did not indicate what symptoms staff were educated to be reporting on the daily screening log. According to the DON, she felt this was an effective form of a screening process and logs were collected, reviewed, and stored by Nurse #9; however, the screening logs were not reviewed during the current shift being worked. 2. According to the facility document titled Coronavirus 2020 dated February 2020 indicated in part: rapid recognition, isolation, and appropriate management of a patient suspected of being infected is key to minimizing transmission. Residents are rapidly identified as potential COVID-19 by screening, exposure, and symptoms. Infection control precautions for probable and suspected cases of COVID-19 are to be immediately placed in a single occupancy private room with the door closed. If a N-95 mask is not available, staff will utilize contact and droplet precautions. During the entrance conference on 09/15/20, the Administrator revealed the 400 hall was a designated COVID-19 unit and the end of the 200 hall had been designated as a COVID-19 overflow unit to include rooms 211-220. There were 4 of the 10 rooms occupied on the end of the 200 hall overflow unit. A continuous observation made on 09/15/20 from 11:00 AM to 11:35 AM revealed no signage that indicated Enhanced Droplet Contact Precautions before entering the area on the end of the 200 hall designated as the COVID-19 overflow unit or on the doors of any resident room identified to be COVID-19 positive. There were three COVID-19 positive (Resident #1, #2, and #5) and three COVID-19 negative residents (Resident #3, #4, and #6) on the COVID-19 overflow unit. Resident #1 was single occupancy and Resident #2 and #5 were roommates in a COVID-19 positive room. Resident #3 was in a single occupancy room and Resident #4 and #6 were roommates in a COVID negative room. There were 2 yellow wet floor signs placed in the hallway and were sitting side by side in the center of the hallway next to each other outside of rooms [ROOM NUMBERS]. Neither of these signs had anything posted that indicated you were entering a COVID-19 area. The rooms on the 200 hall were all semi-private; however, some rooms only had one resident occupying them. A nurses' note dated 09/13/20, Resident #1 resulted positive for COVID-19. A progress note written by the Nurse Practitioner (NP) dated 09/14/20 NP indicated Resident #2 had a cough and was positive for COVID-19. A lab documentation dated 09/10/20, Resident #3 was negative for COVID-19. A rapid testing log revealed Resident #5 was tested and resulted in a positive test on 09/13/20. A review of a lab documentation dated 09/14/20 with a resulting date of 09/18/20, Resident #5 was positive for COVID-19. An interview with NA #1 on 09/15/20 at 12:25 PM revealed she was working the 200 Hall COVID-19 overflow unit which included room [ROOM NUMBER]-220. NA #1 was wearing full PPE to include a gown, gloves, face mask, and a face shield. NA #1 stated the unit had 3 residents identified to be COVID-19 positive. (Resident #1, #2, and #5.) NA #1 indicated Resident #3 had been exposed by her former roommate but had tested negative for COVID-19 and NA #1 acknowledged there were no signage posted on the doors of any rooms on her unit that indicated any form of isolation precautions. NA #1 explained the yellow wet floor signs in the floor marked the start of the COVID-19 overflow unit but agreed there was no signage that indicated it was a COVID-19 unit nor a cart outside the unit to don clean PPE before entering the unit. NA #1 further said she leaves her resident doors always open so that she can see her residents to include COVID-19 positive residents. An interview with Nurse #1 on 09/16/20 at 1:46 PM revealed she was assigned to work the 200 hall COVID-19 overflow unit on 09/15/20 which included the lower portion of 200 hall from room [ROOM NUMBER]-220. Nurse #1 was wearing a gown, face mask, and a face shield. Nurse #1 acknowledged there was no signage to indicate Enhanced Droplet Contact Precautions on any door on the unit and there were no signage that indicated the entrance into the designated COVID-19 overflow unit. Nurse #1 stated 2 yellow wet floor signs indicated where the COVID-19 overflow unit with rooms 211-220 were. Nurse #1 explained Resident #1, #2, and #5 were positive for COVID-19. Nurse #1 explained she had been taught to wear full PPE which included a gown, gloves, face mask and a face shield when caring for each resident on the 200 hall COVID-19 overflow unit and to change the gown and gloves between each resident. An interview with the DON was conducted on 09/21/20 at 10:27 AM revealed she was the Infection Preventionist and was unaware the need for Enhanced Droplet Contact Precautions. The DON stated she had researched what personal protective equipment (PPE) was required for COVID-19 resident care and had decided Droplet Precautions was the most appropriate form of isolation. The Droplet Precaution signage only indicated a mask was to be worn when caring for the resident and did not include the use of a gown, gloves, mask, and face shield. The DON indicated she was unaware there was no isolation precaution signage outside the doors of resident rooms who had been identified as COVID-19 positive on the 200 hall COVID-19 overflow unit nor signage outside the COVID-19 care unit to reveal the entrance to the COVID-19 care unit where full PPE to include a gown, gloves, mask, and face shield were required. The DON explained she was not aware the wet-floor signs were the only markers to indicate the entrance to the COVID-19 overflow unit. The 200 hall COVID-19 overflow unit was initiated by the DON, the on-call nurse, and unit supervisor. The DON indicated she was aware there were both residents positive and negative for COVID-19 on the 200 overflow unit. The DON elaborated that she expected these units to be supplied with PPE so that staff were not required to request supplies throughout the shift. An interview with the Administrator was conducted on 09/15/20 at 4:00 PM revealed she was unaware the 200 hall COVID-19 overflow unit did not have signage to indicate isolation on the doors. The Administrator stated she was unaware of the need for signage titled Enhanced Droplet Contact Precautions for COVID-19 precautions. The Administrator explained she was aware there were two wet floor signs to separate the general community population on the 200 hall from the COVID-19 positive overflow unit on the end of the 200 hall. She understood there were both residents positive and negative for COVID-19 on the unit. She stated they currently had adequate supply of PPE to include gowns, gloves, and face shields, but had limited supplies of KN95 and N95 masks. 3. According to a facility document titled Coronavirus 2020 dated February 2020 indicated only essential personnel should enter the room of a resident on COVID-19 precautions and should don PPE to include a gown, N-95 respirator or surgical mask if N-95 unavailable, eye protection and gloves. A nurses' note dated 09/13/20, Resident #1 resulted positive for COVID-19. The rapid testing log confirmed Resident #1 was tested and resulted in a positive test on 09/13/20. A progress note written by the Nurse Practitioner (NP) dated 09/14/20 NP indicated Resident #2 had a cough and was positive for COVID-19; however, the rapid testing log revealed Resident #2 was tested and resulted in a positive test on 09/13/20. A rapid testing log revealed Resident #5 was tested and resulted in a positive test on 09/13/20. A review of a lab documentation dated 09/14/20 with a resulting date of 09/18/20, Resident #5 was positive for COVID-19. An additional continuous observation and interview on 09/15/20 at 12:07PM to 12:25PM revealed Nurse #1 entered the room of Resident #1 wearing full PPE. She sat the tray down on the overbed table. Nurse #1 exited the room, removed her gown and gloves and discarded them. Nurse #1 then donned clean gloves and a gown without washing her hands or using hand sanitizer and obtained a tray from a staff member who handed her the tray from the other side of the yellow wet floor signs and delivered the meal tray to Resident #2 Nurse #1 was then observed to exit the room of Resident #2, doff her gloves and used alcohol-based hand rub (ABHR). Nurse #2 did not remove her gown before she obtained the meal tray for Resident #3 and delivered it. Nurse #1 then exited the room, doffed her gown and gloves and used ABHR. She donned a clean gown and gloves and delivered a meal tray to Resident #4 then exited the room and doffed her gown and gloves and used ABHR. NA#1 who was wearing full PPE to include a gown, gloves, face shield, and a mask obtained and delivered the meal tray of Resident #5 NA #1 began setting up the tray when Resident #4 began to complain that she received the wrong meal. NA #1 then exited the room of Resident #5 wearing full PPE and entered the room of Resident #4 to address her concern. NA #1 touched Resident #4 and asked her about her concern. NA #1 then picked up Resident #4's tray from her bedside table, removed the liquids and the exposed plastic utensils and laid them on the overbed table placed in front of Resident #4. NA #1 exited the room carrying the tray and unwanted food and discarded it in the trash in the adjacent room being used as a soiled utility room. NA #1 then removed all her PPE and performed hand hygiene with ABHR. An interview with Nurse #1 was conducted on 09/16/20 at 1:46 PM revealed she had been educated to change gloves and perform hand hygiene between residents and when in isolation care areas. Nurse #1 indicated she had not thought about changing gloves each time and performing hand hygiene during meal tray delivery. Nurse #1 confirmed Resident #1, #2, and #5 were positive for COVID-19 via testing. Nurse #1 stated Resident #3 was not identified to be COVID-19 positive but had a recent known exposure from her former roommate. Nurse #1 identified Resident #4 and #5 not to be COVID-19 positive. An interview was conducted with NA#1 on 09/15/20 at 12:25 PM revealed she should have removed her gown and gloves, performed hand hygiene, and donned a clean gown and gloves when she exited Resident #5's room and before she entered Resident #4's room to address her concerns. NA #1 reported she had been taught when she was first coming to work about the use of PPE when in an isolation care area. NA #1 indicated she left Resident #5's room and entered Resident #4's room without thinking about changing PPE. An interview was conducted with Nurse #9 on 09/21/20 at 9:46 AM revealed PPE should be changed between each resident interaction on the COVID-19 overflow care unit due to both residents with both positive and negative test results residing together. An interview with the DON/Administrator on 09/21/20 at 10:27 AM revealed PPE including gowns and gloves should be changed and hand hygiene performed between each resident interaction on the COVID-19 overflow unit. 4. According to the facility document titled Coronavirus 2020 dated February 2020 indicated in part: rapid recognition, isolation, and appropriate management of a patient suspected of being infected is key to minimizing transmission. Residents are rapidly identified as potential COVID-19 by screening, exposure, and symptoms. Infection control precautions for probable and suspected cases of COVID-19 are to be immediately placed in a single occupancy private room with the door closed. If a N-95 mask is not available, staff will utilize contact and droplet precautions. A memo written by the DON and dated 03/17/20 indicated new admissions must be placed in a private room, placed on contact isolation for a period of 14 days, respiratory and temperatures assessments every shift, and isolation precautions may be discontinued after a 14 day period if the resident was asymptomatic. A memo written and signed by the DON and Administrator dated 03/19/20 indicated new admissions will not be placed on isolation unless an elevated temperature and cough is noted and ordered by the physician. An observation of the 100 hall unit on 09/15/20 between 10:45 AM- 11:00 AM revealed Nurse #6 exited Resident #7's room. Resident #7 was a new admission from the hospital on [DATE]. Resident #7's door did not contain signage to indicate he was on Enhanced Droplet Contact Precautions. Nurse #6 was wearing only a facemask when she exited the room. Additionally, Resident #8 was also a new admission to the facility on [DATE] and had no signage to indicate Enhanced Droplet Contact Precautions which required full PPE to include a gown, mask, face shield, and gloves when in the room. An interview on 09/15/20 at 3:15 PM revealed Nurse #6 stated the facility had never placed any new admission on isolation since the start of the COVID-19 pandemic. She stated she had not been educated on Enhanced Droplet Contact Precaution isolation and the need to wear full PPE in rooms where new admissions were located or residents who are on an additional 14 day observation post COVID-19 positive testing results if they had isolation precautions posted on the door. An interview with Nurse #5 on 09/16/20 at 11:01 AM revealed she worked the 100 hall new admission observation unit. Nurse #5 indicated new admissions were not placed under any form of isolation for 14 days following admission to the facility. Nurse # 5 indicated she was only educated to wear a mask when in the room of new admissions unless they had a known positive COVID-19 test result. Nurse #5 stated she monitored new admissions for elevated temperatures and signs and symptoms of COVID-19 but did not wear additional PPE when caring for new admission residents. Interview with the DON/ Administrator on 09/21/20 at 10:27 AM revealed since the start of COVID-19 pandemic their corporate company insisted the facility continue taking new admissions and their corporate office decided it was acceptable practice to only observe for signs and symptoms and temperature checks without placing new admissions on isolation precautions. The DON acknowledged the memo dated 03/19/20 that was provided to staff that educated new admissions would not be placed on isolation at the time of entry to the facility. A signed copy of the memo was in the facility's emergency preparedness COVID-19 binder. An additional undated document indicated the screening process for admissions would include temperature checks and respiratory assessments but did not include a 14- day isolation period following admission. 5. An undated memo indicated surgical masks could be reused in between patient rooms not on droplet precautions. Masks can be worn until visibly soiled, difficult to breath, or do not provide proper sealed fit when using N-95 masks. Masks should not be touched without performing hand hygiene and were not to be removed in resident care areas. Surgical mask and N-95 masks can be reused if put in a breathable container (paper bag is recommended) and not wiped or laundered. The container should be labeled with the staff members name. Masks are always to be worn when in the building. An observation made of the 100 hall unit on 09/15/20 at 3:00 PM revealed Nurse #7 who was orienting on the 100 hall unit with Nurse #6. Nurse #7 was wearing cloth face covering that he had provided himself. Nurse #7 was in a resident care area during the observation. An interview was conducted with Nurse #7 on 09/15/20 at 3:05 PM revealed he was on orientation and unaware he was unable to wear a cloth mask in a resident care area. Nurse #7 indicated the mask was a cloth mask but had a built-in respirator included. Nurse #7 had not received on facility-based training on PPE or COVID-19 by the facility but had received training from his agency that masks were always to be worn when inside the facility. An interview with Nurse #3 on 09/15/20 at 3:15 PM revealed Nurse #7 was a new agency nurse and felt he was not aware he could not wear his own mask. She was unaware if the mask contained a respirator behind the cloth covering. An interview with the DON on 09/21/20 at 10:27 AM revealed Nurse #7 was an agency nurse who was unaware he was not allowed to wear his own mask. The DON indicated prior to the outbreak in August 2020, the facility had allowed staff to wear cloth face coverings throughout the facility and did not mandate surgical mask or higher form of face coverings. The DON stated she was not aware staff were continuing to provide their own face coverings at the time of the survey. There is no policy for allowing staff to provide their own mask and she was unaware any staff were continuing to provide their own mask since the COVID-19 outbreak in August 2020. She indicated the facility had previously had cloth masks made but had transitioned to surgical mask or higher since the outbreak in August 2020. The DON explained all new employees receive training on PPE and Transmission-Based Precautions on hire. An interview with the Administrator on 09/15/20 at 3:45 PM revealed she was unaware Nurse #7 was wearing his own cloth mask and that staff should not wear their own face coverings in the facility since the COVID-19 outbreak had occurred. 6. A facility document titled Coronavirus 2020 dated February 2020 indicated a surgical mask was to be placed on a resident during any transport. An observation on 09/15/20 at 1:40 PM revealed Resident #7 was not observed to wear a mask when he exited the 100-hall unit general population where he resided, traveled through the 200 hall residential care unit, through an adjacent corridor, and onto the 300 hall residential care unit. An interview was conducted on 09/15/20 with Nurse #6 who indicated she was unaware Resident #7 had exited the unit to the smoking area and was not wearing a mask. An interview with the DON on 09/21/20 at 10:27 AM revealed Resident #7 should have worn a mask if he left his room. The DON stated Resident #7 was not compliant with care but was alert and oriented and should have been educated on the use of PPE. An interview with the Administrator on 09/15/20 at 2:00 PM revealed Resident #7 was an uncompliant resident who had been admitted and he should have worn a mask if he exited the unit. 7. According to the facility document titled Coronavirus 2020 dated February 2020 indicated in part: rapid recognition, isolation, and appropriate management of a patient suspected of being infected is key to minimizing transmission. Residents are rapidly identified as potential COVID-19 by screening, exposure, and symptoms. Infection control precautions for probable and suspected cases of COVID-19 are to be immediately placed in a single occupancy private room with the door closed. If a N-95 mask is not available, staff will utilize contact and droplet precautions. An observation was made on 09/15/20 at 4:30 PM revealed no signage to indicate Enhanced Droplet Contact Precautions on the exterior or interior doors of the entrance of the designated COVID-19 unit 400 hall. No signage was posted in the unit to designate any resident was on any form of isolation or what PPE should be worn per the Centers for Disease Control and Prevention. An interview with Nurse #2 on 09/15/20 at 4:30 PM revealed Nurse #2 was unaware of the need for posted signage on the unit that indicated Enhanced Droplet Contact Precautions or signage to illustrate what PPE should be worn when caring for COVID-19 patients. An interview with the DON and the Administrator was conducted on 09/21/20 at 10:27 AM revealed they were unaware the need for Enhanced Droplet Contact Precautions. The DON stated she had researched what personal protective equipment (PPE) was required for COVID-19 resident care and had decided Droplet Precautions was the most appropriate form of isolation; however, no signage had been posted in the 400 Hall COVID-19 unit. The Droplet Precautions signage felt to be appropriate only indicated a mask was to be worn when caring for this resident and did not include the use of a gown, gloves, mask, and face shield. The DON indicated she was unaware there was no isolation precaution signage outside the doors of resident rooms who had been identified as COVID-19 positive on the 400 hall COVID-19 unit nor signage outside the COVID-19 care unit to reveal the entrance to the COVID-19 care unit where full PPE to include a gown, gloves, mask, and face shield were required. 8. An undated facility document indicated surgical masks and N95 masks should be stored in a breathable container (paper bag is recommended) and not wiped or laundered. Label the container with the staff member's name for reuse. An observation on 09/15/20 at 4:30 PM revealed eight (8) N-95 masks laying on a two-shelf metal cart in the hallway of the COVID-19 unit. The masks were placed in a side by side fashion with the face portions of the used masks touching one another. They contained staff names but were not separated (TRUNCATED)

Based on observations, record reviews and resident and staff interviews the facility failed to provide a safe environment free from accident hazards during transportation of residents in a facility van when an oxygen tank was left unsecured in the back cargo area of the van which created the potential for injury for 3 of 3 sampled residents transported in a facility van (Resident #38, #9 and #294). The facility also failed to provide a comprehensive training program for transportation drivers which included safe transportation of oxygen tanks. Immediate Jeopardy began on 02/22/18 when an oxygen tank was observed unsecured inside the back cargo area of a facility transportation van. Immediate Jeopardy was removed on 02/24/18 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility Administrator provided a copy of a document titled Maintenance of Oxygen Equipment and a section labeled Procedures indicated in part oxygen must be transported in an oxygen cart, secured on the back of a wheelchair or in the cylinder holder. A review of a document titled Safety Data Sheet for Oxygen indicated oxygen cylinders (tanks) contained gas under pressure and in a fire or if heated, a pressure increase would occur and the container may burst or explode. A section labeled handling and storage indicated cylinders should be stored upright with valve protection cap in place and firmly secured to prevent falling or being knocked over. a. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum (MDS) data set [DATE] revealed Resident #38 was cognitively intact for daily decision making and required limited assistance with transfers. During an interview on 02/21/18 at 02:06 PM Resident #38 stated he went to [MEDICAL TREATMENT] 3 days week and was transported to and from his appointments in the smaller transportation van of the 2 vans the facility used for transportation of residents. He explained the driver always secured the straps in the van to his wheelchair and he did not have any concerns about that but he was concerned about an oxygen tank he had seen in the past in the van that was not secured. He stated he saw the oxygen tank inside the van between the wall of the van and a seat but he could not recall how long it had been since he had seen it. He further stated he had seen the tank unsecured within the last several months and he had told a van driver about his concerns but could not recall her name. He explained he had been transported in the smaller facility van earlier today to his [MEDICAL TREATMENT] appointments but he did not see the oxygen tank during the transport. He stated Resident # 9 was also transported to [MEDICAL TREATMENT] on the same days and they had both been transported to and from [MEDICAL TREATMENT] earlier today in the smaller facility van. b. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual MDS indicated Resident #9 was cognitively intact for daily decision making and required extensive assistance with transfers. During an interview on 02/21/18 at 2:38 PM, Resident #9 confirmed he rode in the smaller facility van 3 days a week to his [MEDICAL TREATMENT] appointments and Resident #38 also rode in the van on the same days with him. He stated his wheelchair was secured in the van during transport but he was concerned about an oxygen tank that was stored in the back of the van. He explained he was not sure how the oxygen tank was secured and could not recall who had told him about the tank or how long it had been there or when he had last seen it but he did not observe it today because he could not see over the back seat of the van. He further stated he had asked a former van driver about it but was not sure what was done about it and he could not recall the name of the driver. During an observation on 02/21/18 at 4:20 PM a large multi passenger van was located under a canopy at the front entrance of the facility but the smaller transportation van was not in the parking area. During an interview on 02/22/18 at 10:14 AM, Transportation Aide (TA) #1 explained she had been transporting residents since July 2017 and transported residents daily. She stated the facility had 2 transportation vans and one was a large multi-passenger van used mostly for activities and a smaller mini-type van that she routinely used to transport residents to physician's appointments and to [MEDICAL TREATMENT] appointments. She confirmed she transported Resident #38 and #9 to [MEDICAL TREATMENT] 3 days a week at the same time and usually transported them in the small transportation van. She explained at the present time she was the only full-time TA but if she was transporting a resident to an appointment the Activities Director (AD) or a Nurse Supervisor transported residents. She stated she had in-service training when she was hired to drive the van and took a test but the test did not include transport of oxygen tanks. She further stated she had to transport Resident #294 to a doctor's appointment today in the smaller transportation van. c. Resident #294 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission (5 day) MDS dated [DATE] indicated Resident #294 was cognitively intact for daily decision making but and required extensive assistance with transfers. During an observation on 02/22/18 at 10:29 AM, TA #1 secured Resident #294's wheelchair with the safety straps in the small transportation van. Resident #294 was not wearing oxygen and did not speak as she was secured in the van. Observations inside the passenger compartment of the van revealed there was no oxygen tank between the wall of the van and a seat. TA #1 then opened the back hatch door of the van and an oxygen tank was lying on its side inside a blue cover behind the back seat of the van. TA #1 did not move the oxygen tank or attempt to remove it from the back of the van and closed the back door of the van. During an observation and follow up interview on 02/22/18 at 4:27 PM TA #1 was observed transporting Resident #294 in a wheelchair from the small transportation van parked at the front entrance of the facility to her room. TA #1 stated she did not know why the oxygen tank was in the back cargo area of the van or who had placed it there or how long it had been there. She further stated she had never used the oxygen tank in the back of the van because oxygen tanks were usually transported in a rack on the back of the resident's wheelchair. She explained she had been trained to drive the facility vans by the Maintenance Director and TA #2 who no longer worked at the facility and the Maintenance Director was in charge of training van drivers. During an observation and interview on 02/22/18 at 4:34 PM, the Maintenance Director opened the back hatch door of the small transportation van and verified an oxygen tank was lying in the cargo compartment in the back of the van behind the back seat. Upon further inspection, the oxygen tank was lying on its side and was partially covered inside a blue cover and had a gauge with a metal handle at the top of the tank and the top of the tank was lying on top of several small black cushions. Observations at the bottom of the tank revealed the end of the tank was next to a bucket with all purpose cleaning supplies inside and miscellaneous packages of briefs were lying next to the oxygen tank. The Maintenance Director picked up the oxygen tank and verified it was not secured to any type of rack or holder in the back of the van. He also verified the gauge on the tank had a needle positioned at 1,000 pounds per square inch (psi) which indicated the tank contained oxygen. The Maintenance Director stated the oxygen tank was not supposed to be stored in the back of the van unsecured and he was not sure who had left it there or how long it had been there but he would take it inside the facility to storage. He further stated when residents were transported in the van with oxygen they were supposed to have their oxygen tank inside a holder on the back of their wheelchair. He confirmed he was assigned to provide training to van drivers but also confirmed the training materials did not cover transportation of oxygen tanks. He stated he checked the van for mechanical problems and he checked the van securement straps but he did not do periodic inspections to see what was stored in the storage compartments of the vans. He further stated he did not know who put the oxygen tank in the van or why it was there but a month or so ago he had seen an oxygen tank inside the small transportation van in the passenger area of the van and he had removed it. He explained at that time TA #2 had left the tank in the van after she had transported a resident and he had reminded TA #1 and TA #2 they could not transport oxygen tanks unsecured in the facility vans. He confirmed he did not document the incident or document any in-service training to the drivers at that time. During a follow up interview on 02/22/18 at 5:53 PM, the Maintenance Director provided copies of in-service materials he used to train van drivers. He explained the documents were copies from a presentation for training van drivers and contained information regarding maintenance and service of the vans and for loading and unloading of residents. He stated the materials also covered responsibilities of the van driver and if a van was involved in an accident the driver was expected to call 911 for assistance. He further stated he was not responsible for hiring van drivers but when a driver was hired the Administrator or Director of Nursing (DON) called him to provide the training to them. He explained the training did not take long and on the first day they reviewed the materials and he gave them a test based on the materials he had provided to them and after that he or the previous van driver (TA #2) went out with the new driver during transports for approximately a week. He stated van drivers were expected to re-take the test annually. He further stated it was his expectation that drivers were not supposed to transport an unsecured oxygen tank in a facility van. He explained no one had reported to him the oxygen tank was in the back of the small transport van but he would have expected van drivers to remove the cylinder and report it so they could get to the bottom of how the oxygen tank got there. During a telephone interview on 02/22/18 at 9:09 PM, TA #2 confirmed she left the facility a little more than 3 weeks ago but had worked at the facility as a van driver for 2 years. She explained she had in-service training when she was first hired as a van driver and she had to take a test annually and demonstrate how to secure a resident's wheelchair inside the van. She further explained she was aware oxygen tanks were supposed to be transported on the back of a wheelchair in a tank holder and were not supposed to be transported unsecured in the back of the van however, she confirmed she had taken an extra tank of oxygen on long transports because she did not want the resident to run out of oxygen before they got to their appointment. She stated when she took an extra tank it was usually stored in the back cargo area of the small transportation van. She explained she usually laid the oxygen tank down on its side and placed packages of supplies such as briefs, boxes of gloves and wipes around it. She confirmed there was also a bucket of cleaning supplies next to the oxygen tank in case a resident had an accident and they had to clean inside the van and there were also small cushions around the oxygen tank they used to put in resident's wheelchairs when they were uncomfortable. She stated she did not remember if anyone told her to transport the oxygen tank that way but she was afraid a resident might run out of oxygen on a long transport and she wanted to have an extra oxygen tank just in case she needed it. She further stated she could not say when she last saw an oxygen tank in the back of the small transportation van but recalled the drivers had been told by the Maintenance Director they were not supposed to carry an oxygen tank in the van that was unsecured and they were told they had to put the tank up inside the facility when they came back with the van but she did not recall when the Maintenance Director talked to them. During an interview 02/23/18 at 10:17 AM, the Maintenance Director stated if there was a mechanical issue with the van he expected the drivers to report it to him. He further stated in the past oxygen issues was reported to the DON or Administrator and his concerns were for drivers to check the safety securement straps to the wheelchairs but not anything related to oxygen. During a follow up interview on 02/23/18 at 10:38 AM the Maintenance Director verified the oxygen tank he removed from the small transportation van on 02/22/18 was a large Type E oxygen tank with capacity for 3000 PSI pressure. He repeated he was not responsible for oxygen or transport of oxygen tanks in the vans. During a follow up interview on 02/23/18 at 11:55 AM, TA #1 confirmed she did not watch a video as part of van training. She explained she was in training for approximately 2 weeks and the first day she spent with the Maintenance Director and after the first day she rode with TA #2 for the rest of the week and the following week. She further explained Resident #38 told her several months ago about an oxygen tank that was unsecured in the small transportation van and he was uncomfortable with it and TA #2 was present. She stated she reported it to the Maintenance Director and he took the oxygen tank out of the van and told TA #1 and TA #2 not to transport oxygen tanks in vans unless they were secure in a rack. She further stated she could not remember a specific date when the Maintenance Director told them not to transport oxygen tanks that were unsecured in the transportation vans. During an interview on 02/23/18 at 1:03 PM, the Administrator stated the Maintenance Director was responsible for training drivers to transport residents in facility vans. She explained TA #2 who no longer worked at the facility had been expected to also train van drivers when she was employed by the facility since she was the senior driver. She also confirmed the training documents the Maintenance Director used to train van drivers were printed documents from a power point type presentation but the facility did not have a video for training van drivers. During an interview on 02/23/18 at 3:45 PM, the DON stated she had worked at the facility for almost 2 years but was assigned less than 3 weeks as the acting DON. She explained she was aware the Maintenance Director was responsible for transportation and training of van drivers. She stated she had no knowledge there was an oxygen tank unsecured in the back of the small transportation van. She further stated it was her expectation for oxygen tanks to be secured when transported to prevent the potential for harm. She explained oxygen tanks should be transported in a metal rack on the back of a wheelchair or they could be in a cloth transport cover that was strapped and secured to the back of the wheelchair. She further stated she expected for van drivers to check supplies that were in the van and training should include transport of oxygen in a van. During an interview on 02/24/18 at 9:18 AM, the Activity Director stated she was one of the back-up van drivers and had been a van driver for approximately [AGE] years. She explained when she first started driving the Maintenance Director rode with her and she had to take a test annually. She further explained she usually drove the large multi passenger van for activities or to pick up a resident if the smaller van was out on a transport. She stated she was aware oxygen tanks were supposed to be secured on the back of a resident's wheelchair and had not seen an unsecured oxygen tank in the large multi-passenger van that was unsecured. During an interview on 02/23/18 at 8:52 AM, the Administrator stated it was her expectation that oxygen tanks should be secured if they were transported in a facility van. She further stated the training needed to be revised to include how oxygen tanks should be transported in facility vans. During a follow up interview on 02/24/18 at 3:55 PM the Administrator confirmed there were no residents currently at the facility who were routinely transported with oxygen. She explained residents who usually were transported with oxygen were newly admitted residents from the hospital. During an interview on 02/24/18 at 11:34 AM, a Nursing Supervisor confirmed she was a back- up van driver but only drove a facility van if TA #1 was out of the facility transporting another resident. She explained she drove the larger multi-passenger van because that was the one she was trained to drive. She further explained the smaller transportation van was the one that was usually used to transport residents to physician appointments or to [MEDICAL TREATMENT]. She stated she was trained to drive the multi-passenger van by a former Maintenance Director and she took a paper test after her initial training. She confirmed she had not had any retraining since her initial training and had only taken the paper test one time when she was first trained as a van driver. She explained if a resident required oxygen they had a cloth bag or a metal rack on the back of their wheelchair and that was where the tank was supposed to be stored. She stated she had not heard before that an oxygen tank was stored unsecured in the back of the small transportation van before now. The Administrator and Director of Nursing were informed of Immediate Jeopardy on 02/23/28 at 1:52 PM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 02/24/18 at 04:57 PM. Credible Allegation of Immediate Jeopardy Removal F689 Free of accident Hazards/ Supervision/Devices On February 21, 2018 Resident #38 and Resident #9, voiced concerns of observing an unsecured oxygen tank in the facility's transport van #1 during a recent transport in this van. On February 22, 2018 at approximately 10:00 am Surveyor requested to speak to transport aid stated she wanted to see her secure a resident in the van, upon request to look in the van Transportation Aide (TA) #1 opened the back-hatch door of the van and surveyor observed an oxygen tank inside a blue cover laying on its side. On February 22, 2018 at 4:34 PM Transportation Aide #1 returned to the facility with the resident that she transported in transport Van #1. Observations of the transport van at this time revealed the tank of oxygen was still laying on its side in bag noted in the van's rear interior storage compartment in same area. The oxygen tank was observed to be unsecured and improperly stored in the transport van. The facility's Maintenance Director immediately removed the oxygen tank from the transport van when it was brought to his attention. He then placed it in the dirty supply room in oxygen holder. Additionally, it was revealed facility transport staff were not adequately trained on how to properly transport oxygen, in the facility transport van. The training for the facility transporters includes a packet of training materials, a power point handout that they reviewed during orientation, and a final exam. Interviews with facility transport staff and the Maintenance Director revealed staff were not completing checks of the facility's transport van's interior or exterior to ensure the van was safe prior to transporting a resident. As of 02/23/18 the facility's maintenance director and TA #1, activity director, LPN unit coordinator who are currently the only staff who transport residents in the two facility transport vans. As of 02/23/18 the facility has a total of 5 residents who were regularly transported in the facility's two transport vans on a weekly basis. Facility Staff interviewed these 5 residents and there were no harmful effects or negative findings. On February 23, 2018 the facility's Clinical Risk Manager put a system in place that included a new check off sheet for transportation aids to assess the van's interior and exterior for safety issues before and after each use. This check off sheet directs staff to observe for hazards including; observing for improper oxygen storage. On 02/23/18 the Administrator provided training to the maintenance director on how to fill out the check off sheet and assess the van for safety prior to resident transports. This training included that when staff conduct the van assessment and find any concerns they are to report these issues immediately to the Administrator and/or the Maintenance Director. On 02/23/18 the facility's Administrator was Trained by Facility Nurse Consultant then Administrator trained maintenance director on how to implement the new audit titled Skill Check list, to assess the facility's vans for safety issues prior to transporting residents, on how oxygen should be properly secured in the van and how to report any safety issues identified. On 02/23/18 Transportation aide #1 was in serviced by the Maintenance Director on how to securely strap oxygen in van if needed for a resident transport, on the new check off sheet to assess the van for safety prior to transporting a resident and the expectation that any issue identified must be reported immediately to the administrator and/or Maintenance Director. This training included completing an in-service entitled Transport which specifies all oxygen tanks must be secured in a holder either in the back of a wheelchair or secured in a van on the back of the wheelchair in an oxygen holder that is made to secure it to wheelchair. On February 23, 2018 all other applicable staff members including; the Activity Director, LPN, Maintenance staff. were included on the in- service titled Transport and the Skills Check List to assess the facility vans for safety issues provided by the Maintenance Director. This training included that when staff conduct the van assessment and find any concerns they are to report these issues immediately to the Administrator and/or the Maintenance Director. Transportation Aid will be trained upon hire and annually thereafter. By the Maintenance Director On 02/23/18 the facility's maintenance director utilized the new check off sheet to assess both of the facility's transport vans for safety issues. Both of the facility's transport vans were found to have no safety issues and to be in safe operating condition. During these checks no oxygen tanks were observed stored in either of the facility's transport vans. On 02/24/18 the facility's licensed and unlicensed nursing staff were trained by the Maintenance Director on the facility's policy on the proper storage of oxygen and how to transport a resident with oxygen. No nursing staff will be allowed to work after 02/24/18 unless they have received this training. On 02/24/18 this training was added to the Facility Orientation program for all newly hired nursing staff, transportation aides and maintenance staff. This training will include how to use the check off sheet to identify possible van transport safety issues and the need to report concerns immediately to the administrator and/or maintenance director. Beginning on 02/24/18 an administrative audit of Van checks off list, and Safety will be completed by the maintenance director five times a week for a month, then weekly for four weeks. Any concerns will be immediately reported to the facility's administrator. Then will continue as a monthly audit. All findings, concerns, and recommendations will be reported to the QI committee during monthly meetings. The facility's administrator is responsible for implementing the facility's Credible Allegation of Compliance. Immediate Jeopardy was removed on 02/24/18 when interviews with van transportation drivers and nursing staff validated they had received in-service training on transportation of oxygen tanks in facility owned transportation vans. An interviews with Maintenance Director revealed he had also received in-service training regarding transportation of oxygen tanks in facility owned vans.

Based on observations, record reviews and resident and staff interviews the facility failed to assure safe handling of an oxygen tank in a facility transportation van used for resident transports when an oxygen tank was observed stored on its side and unsecured in the back of a transportation van with the potential for injury for 3 of 3 sampled residents transported in the van (Resident #38, #9 and #294). Immediate Jeopardy began on 02/22/18 when an oxygen tank was observed stored on its side and was unsecured in the back of a transportation van used for resident transports. Immediate Jeopardy was removed on 02/24/18 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility Administrator provided a copy of a document titled Maintenance of Oxygen Equipment and a section labeled Procedures indicated in part oxygen must be transported in an oxygen cart, secured on the back of a wheelchair or in the cylinder holder. A review of a document titled Safety Data Sheet for Oxygen indicated oxygen cylinders (tanks) contained gas under pressure and in a fire or if heated, a pressure increase would occur and the container may burst or explode. A section labeled handling and storage indicated cylinders should be stored upright with valve protection cap in place and firmly secured to prevent falling or being knocked over. a. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum (MDS) data set [DATE] revealed Resident #38 was cognitively intact for daily decision making and required limited assistance with transfers. During an interview on 02/21/18 at 02:06 PM Resident #38 stated he went to [MEDICAL TREATMENT] 3 days week and was transported to and from his appointments in the smaller of 2 transportation vans the facility used for transportation of residents. He explained he did not have any concerns about how his wheelchair was secured in the van but he was concerned about an oxygen tank he had seen in the past in the van that was not secured. He stated he saw the oxygen tank inside the van between the wall of the van and a seat but he could not recall how long it had been since he had seen it but thought it was within the last several months. He further stated he had told a van driver about his concerns but could not recall her name. He explained he had been transported in the smaller facility van earlier today to his [MEDICAL TREATMENT] appointments but he did not see the oxygen tank during the transport. He stated Resident # 9 was also transported to [MEDICAL TREATMENT] on the same days and they had both been transported to and from [MEDICAL TREATMENT] earlier today in the smaller facility van. b. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual MDS indicated Resident #9 was cognitively intact for daily decision making and required extensive assistance with transfers. During an interview on 02/21/18 at 2:38 PM, Resident #9 confirmed he rode in the smaller facility van 3 days a week to his [MEDICAL TREATMENT] appointments and Resident #38 also rode in the van on the same days with him. He stated his wheelchair was secured in the van during transport but he was concerned about an oxygen tank that was stored in the back of the van. He explained he was not sure how the oxygen tank was secured and could not recall who had told him about the tank or how long it had been there or when he had last seen it but he did not observe it today because he could not see over the back seat of the van. He further stated he had asked a former van driver about it but was not sure what was done about it and he could not recall the name of the driver. During an interview on 02/22/18 at 10:14 AM, Transportation Aide (TA) #1 explained she had been transporting residents since July 2017 and transported residents daily. She stated she usually transported residents in the smaller mini-type van provided by the facility to physician's appointments and to [MEDICAL TREATMENT] appointments and a larger multi-passenger van was available for activities or for back up drivers to use for resident transports. She confirmed she transported Resident #38 and #9 to [MEDICAL TREATMENT] 3 days a week at the same time and usually transported them in the small transportation van and she had to transport Resident #294 to a doctor's appointment today in the small transportation van. c. Resident #294 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission (5 day) MDS dated [DATE] indicated Resident #294 was cognitively intact for daily decision making but required extensive assistance with transfers. During an observation on 02/22/18 at 10:29 AM, TA #1 secured Resident #294's wheelchair inside the passenger compartment of the small transportation van and there was no oxygen tank between the wall of the van and a seat. TA #1 then opened the back hatch door of the van and an oxygen tank was lying on its side inside a blue cover behind the back seat of the van. TA #1 did not move the oxygen tank or attempt to remove it from the back of the van and closed the back door of the van. During an observation and follow up interview on 02/22/18 at 4:27 PM, TA #1 was observed transporting Resident #294 in a wheelchair from the small transportation van parked at the front entrance of the facility to her room. TA #1 stated she did not know why the oxygen tank was in the back cargo area of the van or who had placed it there or how long it had been there. She further stated she had never used the oxygen tank in the back of the van because oxygen tanks were usually transported in a rack on the back of the resident's wheelchair but she had not thought to ask anyone about it. She explained she received training to drive and operate the safety securement straps in the facility vans but her training materials or test she received did not include transportation of oxygen tanks in facility vans. During an observation and interview on 02/22/18 at 4:34 PM, the Maintenance Director opened the back hatch door of the small transportation van and verified an oxygen tank was lying in the cargo compartment in the back of the van behind the back seat. Upon further inspection, the oxygen tank was lying on its side and was partially covered inside a blue cover and had a gauge with a metal handle at the top of the tank and the top of the tank was lying on top of several small black cushions. Observations at the bottom of the tank revealed the end of the tank was next to a bucket with all purpose cleaning supplies inside and miscellaneous packages of briefs were lying next to the oxygen tank. The Maintenance Director picked up the oxygen tank and verified it was not secured to any type of rack or holder in the back of the van. He also verified the gauge on the tank had a needle positioned at 1,000 pounds per square inch (psi) which indicated the tank contained oxygen. The Maintenance Director stated the oxygen tank was not supposed to be stored in the back of the van unsecured and he was not sure who had left it there or how long it had been there but he would take it inside the facility to storage. He further stated when residents were transported in the van with oxygen they were supposed to have their oxygen tank inside a holder on the back of their wheelchair. He confirmed he was assigned to provide training to van drivers but also confirmed the training materials he provided to drivers did not cover transportation of oxygen tanks and he did not routinely check the facility vans for storage of oxygen tanks. During a follow up interview on 02/22/18 at 5:53 PM, the Maintenance Director stated it was his expectation that van drivers were not supposed to transport an unsecured oxygen tank in a facility van. He explained no one had reported to him the oxygen tank was in the back of the small transport van but he would have expected van drivers to remove the cylinder and report it so they could get to the bottom of how the oxygen tank got there. During a telephone interview on 02/22/18 at 9:09 PM, TA #2 confirmed she left the facility a little more than 3 weeks ago but had worked at the facility as a van driver for 2 years. She explained she was aware oxygen tanks were supposed to be transported upright on the back of a wheelchair in a tank holder and were not supposed to be transported unsecured in the back of the van however, she confirmed she had taken an extra tank of oxygen on long transports because she did not want the resident to run out of oxygen before they got to their appointment. She stated when she took an extra tank it was usually stored in the back cargo area of the small transportation van. She explained she usually laid the oxygen tank down on its side and placed packages of supplies such as briefs, boxes of gloves and wipes around it. She confirmed there was also a bucket of cleaning supplies next to the oxygen tank in case a resident had an accident and they had to clean inside the van and there were also small cushions around the oxygen tank they used to put in resident's wheelchairs when they were uncomfortable. She stated she did not remember if anyone told her to transport the oxygen tank that way but she was afraid a resident might run out of oxygen on a long transport and she wanted to have an extra oxygen tank just in case she needed it. She further stated she could not say when she last saw an oxygen tank in the back of the small transportation van but recalled the drivers had been told by the Maintenance Director they were not supposed to carry an oxygen tank in the van that was unsecured and they were told they had to put the tank up inside the facility when they came back with the van but she did not recall when the Maintenance Director had talked with them. During an interview on 02/23/18 at 10:38 AM the Maintenance Director verified the oxygen tank he removed from the small transportation van on 02/22/18 was a large Type E oxygen tank with capacity for 3000 PSI pressure. He repeated he was not responsible for oxygen or transport of oxygen tanks in the vans. During an interview on 02/23/18 at 3:45 PM, the DON stated she had worked at the facility for almost 2 years but had been assigned less than 3 weeks as the acting DON. She explained she was aware the Maintenance Director was responsible for transportation and training of van drivers. She stated she had no knowledge there was an oxygen tank unsecured in the back of the small transportation van. She further stated it was her expectation for oxygen tanks to be secured when transported to prevent the potential for harm. She explained oxygen tanks should be transported in a metal rack on the back of a wheelchair or they could be in a cloth transport cover that was strapped and secured to the back of the wheelchair. During an interview on 02/24/18 at 9:18 AM, the Activity Director stated she was one of the back-up van drivers and had been a van driver for approximately [AGE] years. She explained she was aware oxygen tanks were supposed to be secured on the back of a resident's wheelchair but she had not seen an unsecured oxygen tank in the large multi-passenger van she occasionally drove when she transported residents out of the facility for activities. During an interview on 02/23/18 at 8:52 AM, the Administrator stated it was her expectation that oxygen tanks should be secured if they were transported in a facility van. She further stated the training needed to include how to transport oxygen tanks in facility vans. During an interview on 02/24/18 at 11:34 AM, a Nursing Supervisor confirmed she was a back- up van driver but only drove the larger multi-passenger facility van if TA #1 was out of the facility transporting another resident. She explained if a resident required oxygen they usually had a cloth bag or a metal rack on the back of their wheelchair and that was where the tank was supposed to be stored. The Administrator and Director of Nursing were informed of Immediate Jeopardy on 02/23/28 at 1:52 PM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 02/24/18 at 04:57 PM. Credible Allegation of Immediate Jeopardy Removal F695 Respiratory/[MEDICAL CONDITION] care and suctioning On February 21, 2018 Resident #38 and Resident #9, voiced concerns of observing an unsecured oxygen tank in the facility's transport van #1 during a recent transport in this van. On February 22, 2018 at approximately 10:00 am Surveyor requested to speak to transport aid stated she wanted to see her secure a resident in the van, upon request to look in the van Transportation Aide (TA) #1 opened the back-hatch door of the van and surveyor observed an oxygen tank inside a blue cover laying on its side. On February 22, 2018 at 4:34 PM Transportation Aide #1 returned to the facility with the resident that she transported in transport Van #1. Observations of the transport van at this time revealed the tank of oxygen was still laying on its side in bag noted in the van's rear interior storage compartment in same area. The oxygen tank was observed to be unsecured and improperly stored in the transport van. The facility's Maintenance Director immediately removed the oxygen tank from the transport van when it was brought to his attention. He then placed it in the dirty supply room in oxygen holder. Additionally, it was revealed facility transport staff were not adequately trained on how to properly transport oxygen, in the facility transport van. The training for the facility transporters includes a packet of training materials, a power point handout that they reviewed during orientation, and a final exam. Interviews with facility transport staff and the Maintenance Director revealed staff were not completing checks of the facility's transport van's interior or exterior to ensure the van was safe prior to transporting a resident. On February 23, 2018 the facility's Clinical Risk Manager put a system in place that included a new check off sheet for transportation aids to assess for correct placement of oxygen tanks. This check off sheet directs staff to observe for hazards including; observing for improper oxygen storage. On 02/23/18 the Clinical Risk Manager provided training to the maintenance director on how to fill out the check off sheet and assess the van for safety prior to resident transports. This training included that when staff conduct the van assessment and find any concerns they are to report these issues immediately to the Administrator and the Maintenance Director. On 02/23/18 the facility's Administrator trained the maintenance director on how to implement the new audit titled Skill Check list, to assess the facility's vans for safety issues prior to transporting residents, on how oxygen should be properly secured in the van and how to report any safety issues identified. On 02/23/18 Transportation aide #1 was in serviced by the Maintenance Director on how to securely strap oxygen in van if needed for a resident transport. Any identified issues must be reported immediately to the administrator and/or Maintenance Director. On February 23, 2018 all other applicable staff members including; the Activity Director, LPN, Maintenance were included on the in- service tilted Transport provided by the Maintenance Director. On 02/24/18 the facility's licensed and unlicensed nursing staff were trained Maintenance Director on the facility's policy on the proper storage of oxygen and how to transport a resident with oxygen. No nursing staff will be allowed to work after 02/24/18 unless they have received this training. On 02/24/18 this training was added to the Facility Orientation program for all newly hired nursing staff, transportation aides and maintenance staff. This training will include how to use the check off sheet to identify possible van transport safety issues and the need to report concerns immediately to the administrator and/or maintenance director. The facility's administrator is responsible for implementing the facility's Credible Allegation of Compliance. Immediate Jeopardy was removed on 02/24/18 when interviews with van transportation drivers and nursing staff validated they had received in-service training on transportation of oxygen tanks in facility owned transportation vans. An interviews with Maintenance Director revealed he had also received in-service training regarding transportation of oxygen tanks in facility owned vans.

Based on observation, staff and physician interviews and record review the facility failed to monitor a resident's clotting time while taking an anticoagulation medicine, the resident experienced critical blood levels which increased the risk of bleeding and resulted in treatment in the hospital for 1 of 3 residents (Resident #2) reviewed for anticoagulant therapy. Immediate jeopardy began on 01/22/16 when the facility failed to draw Resident #2's blood for anticoagulation monitoring. Immediate jeopardy was removed on 02/19/16 when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: A policy, not dated, titled ANTICOAGULATION PT/INR MONITORING read in part, residents on anticoagulation therapy will be monitored to ensure the maintenance of safe laboratory parameters as established by the attending physician. The protocol for managing anticoagulant therapy will ensure resident safety and prevent negative effects from the use of anticoagulants. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had severe cognitive impairment, required extensive assist with activities of daily living and had received an anticoagulant for all 7 days of the assessment period. Review of Resident #2's care plan updated on 01/05/16 specified the resident was on anticoagulant therapy related to history of venous [MEDICAL CONDITION] and embolism. An intervention included in the care plan was to perform labs as ordered. An original physician's orders [REDACTED]. Re-check PT/INR ([MEDICATION NAME] time test to measure clotting time) on 12/30/15. Review of the medical record revealed that laboratory testing was performed on 12/30/15 and the PT/INR results were: PT 29.0 High (normal range is 11.6 - 14.4) INR 2.73 High (normal range is 0.86 - 1.13) Further review of the medical record revealed physician's orders [REDACTED]. Laboratory testing was performed on 01/08/16 and the PT/INR results were: PT 28.6 High (normal range is 11.6 - 14.4) INR 2.68 High (normal range is 0.86 - 1.13) The physician was notified of the results on 01/08/16 and ordered to continue the same dose of anticoagulation medication and re-check PT/INR on 01/22/16. Review of the medical record revealed that no laboratory testing was performed on 01/22/16. The Medication Administration Record (MAR) for January 2016 specified Resident #2 was to have her PT/INR checked on 01/22/16 but the box was left blank. Further review of the medical record revealed that on 02/01/16 Resident #2's PT/INR was obtained and the results were: PT >100.0 High (normal range is 11.6 - 14.4) INR >13.5 High High (normal range is 0.86 - 1.13) On 02/01/16 the physician was notified of Resident #2's PT/INR and ordered 5mg Vitamin K to be given. Vitamin K is capable of reversing the anticoagulant activity of the anticoagulant, [MEDICATION NAME]. Review of the nurses' notes from 01/22/16 through 02/01/16 did not indicate if the resident was assessed for signs or symptoms of bleeding. A nurse's note dated 02/02/16 specified Resident #2's family reported that the resident had decreased responsiveness. The nurse documented that Resident #2 was lethargic and not easily aroused. The nurse notified the physician of family's request to send the resident to the Emergency Department. Resident #2 was hosptalized on [DATE] for a urinary tract infection, dehydration and [MEDICAL CONDITION]. Further review of the hospital records revealed Resident #2 received Vitamin K and fresh frozen plasma for her INR of 13.5. On 02/07/16 Resident #2 was readmitted to the facility. On 02/18/16 at 2:23 PM Nurse #3 was interviewed on the telephone and explained that he was assisting with end of month MAR checks. He stated that when he reviewed Resident #2's MAR for January 2016 he noticed that on 01/22/16 the order to draw PT/INR was left blank. Nurse #3 stated that he reviewed the medical record and contacted the lab and learned the blood work was not obtained and Resident #2 had not had her PT/INR level checked on 01/22/16. He stated that he immediately notified the interim Director of Nursing (DON) and the physician. On 02/18/16 at 2:37 PM Nurse #9 was interviewed. She explained that when PT/INR results were returned to the facility, the nurse was responsible for notifying the physician of the results and transcribing new orders on the MAR. Nurse #9 recalled that 01/08/16 she received telephone orders from the physician to continue Resident #2's [MEDICATION NAME] dose and re-check the PT/INR on 01/22/16. Nurse #9 reviewed Resident #2's medical record where she documented on the MAR the lab was due. Nurse #9 was not aware the PT/INR had not been drawn on 01/22/16. On 02/18/16 at 5:20 PM Nurse #2 was interviewed on the telephone and reported that she had been assigned to care for Resident #2. Nurse #2 was aware that Resident #2 had been on [MEDICATION NAME] and required blood work to check PT/INR levels. The nurse explained that her usual practice was to check the lab box located above the medical records for lab slips that specified a lab was to be drawn for a resident; and also she would review the Medication Administration Record (MAR) for residents on [MEDICATION NAME] to see if they had a PT/INR due. Nurse #2 stated that she could not recall what happened on 01/22/16 but that she did not draw blood on Resident #2 to have her PT/INR checked. Nurse #2 offered no explanation as to how the lab was missed. On 02/19/16 at 10:11 AM the interim DON was interviewed and reported that Nurse #3 notified her on 02/01/16 that Resident #2 had missed a PT/INR lab and this was the same day she assumed her role as interim DON. She explained that a STAT (right away) lab was ordered by the physician. The interim DON added that the results came back extremely high and Resident #2 had to be treated with Vitamin K. On 02/19/16 at 11:50 AM the physician was interviewed on the telephone and explained that [MEDICATION NAME] was a powerful blood thinner that required close monitoring to keep PT/INR levels in safe ranges. The physician stated that low PT/INR levels could result in blood clots and high PT/INR levels could be life threatening. The physician added that Resident #2 had experienced an acute illness due to an overall decline in health that resulted in a combination of urinary tract infection, severe [MEDICAL CONDITION] and dehydration from refusing to eat or drink that likely resulted in the increased PT/INR. He stated that he expected labs to be drawn as ordered but stated he did not feel the resident was harmed by the high PT/INR. On 02/18/16 at 2:10 PM the Administrator was notified of immediate jeopardy for failing to obtain blood work to check Resident #2's PT/INR. The facility provided an acceptable credible allegation of compliance on 02/19/16 at 2:53 PM. The following interventions were put into place to remove the immediate jeopardy. GLENBRIDGE HEALTH AND REHAB F329 ALLEGATION OF COMPLIANCE 2/18/16 1) Resident #2 was scheduled to have a PT/INR drawn on 1/22/16 due to chronic [MEDICATION NAME] usage. The lab was not obtained and was not identified as missing until 2/1/16. On 2/1/16, a blood specimen was drawn for a PT/INR and sent to the lab on a STAT basis. Her results indicated both the PT and INR levels were >13.5. The physician was contacted and orders received to hold [MEDICATION NAME] until further notice. Vitamin K 5mg was given by mouth. On 2/1/16, the resident was assessed by the Interim DON and showed no signs or symptoms of bleeding but did have old bruising noted on upper and lower extremities. On the morning of 2/2/16, it was discovered that the resident had not swallowed the Vitamin K tablet. The physician was notified at 9:00am and an order received to give Vitamin K 10mg IM (intramuscularly) now. Also that morning, resident had a change in level of consciousness and was not accepting anything by mouth. Per her MOST (Medical Orders for Scope of Treatment) form, she was to receive comfort measures only and not to transfer to hospital unless comfort needs could not be met. The Interim DON discussed the resident's status with one of the daughters that was present at bedside. She stated she would discuss it with her sister and let us know if they wanted her transferred to the ER (emergency room ). The family did choose to have her sent to the ER for evaluation. Her transfer to the ER was not related to the [MEDICATION NAME] or lab results. Resident's attending physician examined her on 2/18/16 at 6:35pm. He stated that resident had not experienced any harm related to the elevated PT/INR. A progress note written by the physician has been placed in resident's chart. 2) A 100% audit was completed on 2/18/16 on the identified residents receiving [MEDICATION NAME]. Four residents were identified. The MDS Director reviewed/audited the medical records of the identified residents. 100% compliance was found. An audit will be conducted on 2/19/16 for residents receiving other medications that need to be monitored including [MEDICATION NAME], [MEDICAL CONDITION] medications, [MEDICATION NAME] and hypoglycemics. The audit will be conducted by the DON, ADON, MDS Director and/or Medical Records Director. 3) A new policy and procedure was developed on 2/3/16. Our contracted nurse consultants in-serviced the nurses who give [MEDICATION NAME], (7am to 7pm shift nurses) and 2 7pm to 7am nurses on the changes. As this issue was placed in our QAPI (Quality Assessment Performance Improvement) program on 2/2/16, we decided to wait on further training to allow for analysis and revisions of the process. Changes to the policy were as follows: · The nurses transcribe the order for the current [MEDICATION NAME] dosage onto the MAR. A vertical line is drawn and the word STOP is written for [MEDICATION NAME] on the date the next PT/INR is to be drawn. · The order for the next PT/INR is entered onto the MAR by drawing a box around the date the PT/INR is due. This is to remind the nurse that a lab is due that day. · The PT/INR will be drawn on the date due by the day shift nurse assigned to the resident, prior to the arrival of the lab courier and the specimen will be sent to the lab. The weekend RN Supervisor will check for needed labs on Saturday and Sunday and ensure they are obtained and sent to the hospital. · The nurse will obtain the results of the PT/INR from the lab. The nurse will call the attending Physician with the results of the PT/INR as soon as available but no later than 4:00pm to obtain new orders for [MEDICATION NAME]. DO NOT ADMINISTER ANY [MEDICATION NAME] ON THE DATE OF THE PT/INR UNTIL THERE IS A NEW ORDER FROM THE PHYSICIAN. · The physician will order the [MEDICATION NAME] dose and the date of the next PT/INR. · The nurse will enter the new order for the [MEDICATION NAME] with the stop date being the date for the next PT/INR. · The order for the next PT/INR is entered onto the MAR by drawing a box around the date due. If the date falls within the next month, the nurse will note it on the MAR where it states (next PT/INR due). · The nurse will fill out the anticoagulation PT/INR monitoring flowsheet. 4) In-servicing on the new policy began on 2/18/16. All nurses will be in-serviced on the new policy by the DON, ADON and/or the MDS Director. In-service will include a copy of the policy with verbal explanation and an example of how the MAR should look. Any nurse that has not been in-serviced will not be allowed to work until they have completed it. 5) PT/INR's will be reviewed during the morning clinical meeting. A PT/INR board will be utilized during the meeting to record last PT/INR, [MEDICATION NAME] dose and when next lab is due. 6) Nurses are to check the lab book and box every morning for needed labs. Monday through Friday the ward secretary and/or the Medical Records Director will reconcile received lab reports against labs that were drawn to ensure all results have been received. If a result has not been received they will call the lab to obtain it. 7) New nurses will be in-serviced on the PT/INR monitoring policy during orientation. 8) CNA's will be in-serviced on reporting signs and symptoms of bleeding beginning 2/19/16. CNA's will not be allowed to work until they have received the training. The training will be conducted by the DON, ADON, MDS Coordinator, the Weekend Supervisor, and/or hall charge nurse. 9) Facility alleges immediate jeopardy has been removed on 2/19/16. Facility alleges they will be back in compliance with this allegation and immediate jeopardy will be removed on 2/19/16. Immediate Jeopardy was removed on 02/19/16 at 5:22 PM when the facility provided evidence of additional training provided to the nursing staff that proved they were aware of the new system for monitoring and reporting PT/INR lab work and were aware of signs and symptoms of bleeding.

Based on record reviews and staff, resident and physician interviews the facility failed to do an assessment for 1 resident after she was lowered to the floor by staff while being transferred and failed to assess the resident before she was lifted from the floor into a shower chair for 1 of 12 sampled residents for falls. (Resident #24). Immediate Jeopardy began on 11/15/14 when staff failed to assess Resident #24 after she was lowered to the floor by staff during a transfer. Immediate jeopardy was removed on 02/27/15 at 11:35 AM 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 (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective. The findings included: A review of a facility document titled "Falls Policy" that was not dated, indicated in part, the following procedure is to be followed for any resident that sustains a fall: a full body assessment will be conducted to determine if any injury has occurred and monitored for 24 hours after the fall. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Nursing Admission Information sheet dated 02/17/14 indicated Resident #24 was alert and aware, non-verbal but was able to understand others and answered yes and no to questions. The notes also indicated she was dependent for transfers and bed mobility. A review of Resident #24's Fall Risk Assessment on 02/17/14 revealed a score of 14 which indicated a total score of 10 or above represented high risk for falls. A review of a physician's orders [REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 had severe impairment in cognition for daily decision making. The MDS also indicated Resident #24 was totally dependent on staff for bed mobility and transfers and Resident #24 did not speak but was sometimes understood and usually understood others. The MDS indicated Resident #24 had a fall history with a fall in the last month prior to admission to the facility. A review of a Fall Risk Assessment on 05/24/14 for Resident #24 indicated she was high risk for falls. A review of a care plan with a problem statement for accidents/fall risk with an updated date of 10/25/14 indicated approaches to determine possible causes/patterns associated with falls or accidents and lift for transfers. A review of a care plan with a problem statement for total dependence with an updated date of 10/25/14 indicated Hoyer lift to chair every day. A review of a care plan with a problem statement for activities of daily living with updated date of 10/25/14 indicated lift for transfers and out of bed to chair with lift. A review of the monthly physician's orders [REDACTED]. A review of Medication Administration Records (MARs) for November 2014 indicated activity level for a mechanical lift. A review of nurse's notes dated 11/15/14 revealed there were no nurse's notes during the 7:00 AM - 7:00 PM shift. A review of a nurse's note dated 11/15/14 at 8:30 PM indicated Resident #24 was lying in bed grunting when Nurse #2 went to resident's room to administer bedtime medications. The notes further indicated when the head of the bed was raised Resident #24 began yelling out. The notes revealed Resident #24 was nonverbal due to history of a stroke but could answer questions appropriately by nodding her head for yes and no. The notes further revealed when asked where she was hurting Resident #24 pointed to her right leg. The notes indicated an assessment showed no visual injuries or redness but when an attempt was made to roll Resident #24 over she began screaming loudly and Resident #24's responsible party was notified and hospital was notified for transport to the emergency room . A review of a nurse's note dated 11/15/14 at 9:02 PM revealed emergency medical services (EMS) was in the facility to transport Resident #24 to the hospital emergency room for evaluation. A review of an EMS report dated 11/15/14 indicated EMS was at Resident #24's bedside at 9:03 PM. A section labeled narrative indicated Resident #24 initially stated on scene that she did not fall however upon talking to emergency room staff it was found out that she did indeed have a fall earlier today. A review of a nurse's note dated 11/15/14 at 9:25 PM indicated Nurse #2 had a conference with Nurse Aides (NAs) assigned to care for Resident #24 during the 7:00 PM to 7:00 AM shift and there were no reports of injury received from the previous shift to Nurse #2 or to NAs. A review of a nurse's note dated 11/16/14 at 12:30 AM indicated Nurse #2 called the hospital and was informed Resident #24 was admitted to the hospital with [REDACTED].#2 notified Administrative nurse (Assistant Director of Nursing (ADON)) #1 on call and contacted Resident #24's family to give an update. A review of a nurse's note dated 11/16/14 at 12:42 AM indicated staff from the hospital called the facility and reported when Resident #24 was questioned she indicated she had been dropped onto the floor earlier in the day. The notes further indicated Administrative nurse (ADON #1) was notified. A review of a Physician's Report of Consultation dated 11/16/14 indicated a consulting [DIAGNOSES REDACTED].#24 who had a history of [REDACTED]. The notes revealed Resident #24 was found by the nursing staff lying in bed complaining of hip pain and apparently had a history of [REDACTED]. The notes further indicated Resident #24 was brought to the hospital emergency room and x-rays revealed a displaced intertrochanteric/subtrochanteric (upper quarter of the thigh bone) [MEDICAL CONDITION] hip. A review of an Operative report dated 11/17/14 indicated intertrochanteric/subtrochanteric [MEDICAL CONDITION] hip. The notes further indicated surgery was completed with open reduction (to realign bone fracture into normal position) and internal fixation (hardware used to keep bone fracture stable to heal and prevent infection) with a short gamma nail. A review of a facility document titled Investigation of Resident #24's fracture which was not dated but signed by the Director of Nursing (DON) indicated the following summary in part: On the morning of 11/15/14 NA #1 went in to get resident up and ready for shower. NA #1 asked NA #2 to assist with transferring Resident #24 from bed to chair. The 2 NAs attempted to transfer Resident #24 with an arm and arm method. They stood resident without difficulty but when the NAs started to pivot resident to place her in a shower chair the resident "went limp" and was unable to continue to assist the NAs with the transfer. NAs attempted to place Resident #24 in shower chair but due to her weight was unable to get her safely into the chair. Both NAs report they together slowly lowered resident to the floor. NA #2 went immediately to alert the nurse of the incident and get NA #3 to assist them in putting Resident #24 in the shower chair. Nurse #1 reported she could not confirm or deny she was immediately notified of the incident. NA #3 assisted NA #1 and NA #2 in transferring Resident #24 from floor to shower chair. NAs report Resident #24 did not complain of pain or show signs or symptoms of pain during this transfer. After lunch NA #1 and NA #3 transferred Resident #24 from wheelchair to bed. The resident participated with the transfer and did not complain of pain or show signs or symptoms of pain. At approximately 2:00 PM NA #1 and NA #4 was changing Resident #24 and she started yelling out and grabbing at her leg. NA (not named) asked the resident if she was in pain and she nodded her head yes. NA #4 went to get Nurse #1 and she went to check the resident and reported that both legs looked symmetrical and she "didn't see anything out of the ordinary." Nurse #1 noticed Resident #24 was scratching at her groin area and she had just recently administered scheduled Tylenol to Resident #24. Nurse #1 instructed the NAs to clean resident and apply protective ointment. At 4:00 PM Nurse #1 asked Resident #24 if her leg was still hurting and the resident shook her head no. When night shift came in Resident #24 appeared to be in severe pain and Nurse #2 sent resident to the ER and her [DIAGNOSES REDACTED]. During an interview on 02/19/15 at 11:08 AM with Resident #24 she smiled and nodded her head up and down as a response for yes and made repetitive sounds but was unable to form words when spoken to. She nodded her head up and down yes when questioned if she had a hip injury last November. When asked if she had a fall her facial expression changed and she became tearful and attempted to say something but was unable to form the words and then nodded her head vigorously up and down yes. When questioned if her hip was better she shook her head from side to side as a response for no and moved her left hand toward her right hip in a rubbing motion. During an interview on 02/23/15 at 11:48 AM the Assistant Director of Nursing (ADON) #1 stated after review of Resident #24's nurse's notes for 11/15/14 she did not remember being called on 11/15/14 when the resident was sent to the hospital but if the nurses documented they called her then they probably did. She further stated she did not remember going to the facility on [DATE] or 11/16/14. She explained the only thing she remembered was she heard during morning meeting the following week Resident #24 had complained of severe pain in her hip and was sent to the hospital and she had a [MEDICAL CONDITION]. During an interview on 02/23/15 at 12:14 PM the Director of Nursing (DON) upon review of the nurses notes for Resident #24 on 11/15/14 confirmed there were no nurse's notes or nursing assessment during the 7:00 AM to 7:00 PM shift. During a telephone interview on 02/23/15 at 6:44 PM NA #1 explained she and NA #2 were trying to get Resident #24 out of bed into a shower chair on 11/15/14. She stated therapy staff had been working with Resident #24 to stand and transfer her with 2 staff assist and NA #1 stated she had previously stood Resident #24 next to her bed to transfer her and the resident had done fine and that was the way she usually transferred her. She explained during the transfer on 11/15/14 she had her arm under one of Resident #24's armpits and NA #2 had her arm under the other armpit and they stood her up at the bedside but when they turned her to pivot her she went limp. NA #1 stated when Resident #24 started to slide to the floor they tried to lift her up but they couldn't because she was too heavy. She explained when they realized they could not lift her up they lowered her to the floor and she told NA #2 to go get a nurse. NA #1 further explained she held onto Resident #24's shoulders while she sat in the floor and thought her legs were out in front of her. NA #1 stated NA #2 came back with NA #3 and they picked Resident #24 up off the floor and she took her to the shower room and gave her a shower. She stated she did not notice any obvious redness or bruising when she gave Resident her shower and after the shower NA #2 assisted her to stand Resident #24 up from the shower chair and into a wheelchair. NA #1 further stated after lunch she got NA #2 and NA #3 again to transfer Resident #24 and they stood Resident #24 up from her wheelchair and transferred her to bed. She explained about 3 hours after Resident #24 was lowered to the floor she was moaning and holding her right leg and was rubbing it and she reported it to Nurse #1. During a phone interview on 02/26/15 at 5:48 PM received from NA #1 she stated she had remembered when she sent NA #2 to get Nurse #1 the nurse did not come to the resident's room and Resident #24 was not assessed while she was in the floor or when she was lifted into the shower chair or when she was transferred back to bed after lunch. She further stated when NA #3 came back to the room and stated Nurse #1 said to put Resident #24 in the shower chair they lifted her up off the floor and into the chair. During a telephone interview on 02/23/15 at 7:04 PM with NA #2 she stated she went to help NA #1 transfer Resident #24 on 11/15/14 for a shower. She explained they sat Resident #24 up on the side of the bed for a few seconds, then stood her up and turned her towards the left and she started to buckle. She stated Resident #24's right leg did not turn as her upper body turned and she slid down to the floor. She further stated when Resident #24 was in the floor her left leg was straight out but her right leg was crisscrossed under her left leg and was bent at a 90 degree angle at her knee. NA #2 stated she went to get Nurse #1 and the nurse asked if the resident had fallen or slid to the floor and when she told the nurse the resident had slid to the floor the nurse said ok and to go ahead and get Resident #24 up in the shower chair and give her a shower. NA #2 stated she went back to Resident #24's room and she and NA #1 placed their arms under each of Resident #24's armpits and lifted her from the floor and into the shower chair. She stated Resident #24 complained of her right leg hurting a little bit when she was placed in the shower chair but she thought it was caused by pressure on her legs from the shower chair. She stated she did not assist NA #1 during Resident #24's shower and also verified Nurse #1 did not come to Resident #24's room while the resident was in the floor or after they got her into the shower chair. During an interview on 02/24/15 at 1:54 PM with NA #3 she stated NA #1 or NA #2 came and got her to assist with getting Resident #24 off the floor on 11/15/14 because she had slid to the floor. She stated when she went into Resident #24's room the resident was sitting on the floor and she remembered Resident #24's legs were not straight out in front of her because she couldn't straighten her legs out fully due to a previous stroke with paralysis on her right side. She explained she placed her arm under one of Resident #24's armpits and NA #1 placed her arm under Resident #24's other armpit and they lifted her up off the floor while NA #2 held the shower chair. She confirmed Nurse #1 did not come in the room while she was in Resident #24's room and after they placed Resident #24 in the shower chair she left the room to resume her assignment on a different hall. During an interview on 02/23/14 at 8:13 PM with Nurse #1 she confirmed she did not go to Resident #24's room to assess her on 11/15/14 when NA #2 reported the resident had slid to the floor. She stated she was having a very bad day that day and she took full responsibility for not doing what she was supposed to do. She confirmed the only assessment she did was later in the day when Resident #24 was crying out in pain and was reaching toward her peri area and the area was red. She stated she couldn't remember exactly what she saw but remembered she gave Resident #24 some routine Tylenol for pain but did not report it or document it because she did not think anything had happened or that anything needed to be reported or documented. During a telephone interview on 02/23/15 at 7:56 PM with Nurse #2 she stated she worked on the 7:00 PM to 7:00 AM shift on 11/15/14 and that evening the NAs came and got her because they had taken Resident #24 her bedtime snack and she was screaming in pain. She explained she couldn't assess her or touch her because she was in such pain. She further explained Resident #24 had an incontinent episode but they couldn't clean her or turn her because of the pain. She verified she had not received a report from Nurse #1 during shift change that Resident #24 had slid to the floor earlier that day. She stated she sent the resident to the hospital emergency room for evaluation and treatment because Resident #24 did not usually complain of pain and she couldn't figure out why she was having such severe pain. She explained she called the Administrative nurse on call and verified that was ADON #1. She further explained ADON #1 did not come to the facility that night and told her to be sure and document everything so she wrote all she knew in her nurses notes. She stated later that night a nurse from the hospital called and asked about a fall that Resident #24 had earlier that day. She further stated that was the first time she had been told Resident #24 had a fall. During an interview on 02/24/15 at 3:01 PM with Licensed Physical Therapist #1 he explained therapy staff had been working with Resident #24 on standing and transfers with 2 staff assist prior to her fall on 11/15/14. He stated Resident #24's participation varied and some days she would stand but then she would spontaneously sit down. He stated it was his understanding that nursing staff had been transferring Resident #24 with a mechanical lift and the plan of care would have been to use a mechanical lift for transfers until Resident #24 was cleared by therapy to transfer with a maximum assist of 2 staff. During a phone interview on 02/25/15 at 2:00 PM the physician who was also the facility Medical Director stated he was made aware of Resident #24's fall after she had gone to the hospital. He stated the information he had been told about her sliding to the floor did not explain how the fracture happened but he wondered if she had a previous incident or something that had happened which put her at higher risk for a fracture. He stated it was his expectation for nurses to assess and evaluate residents immediately after a fall or when they were lowered to the floor. He further stated he expected the nurses to call the physician to report what had happened, what the resident's level of comfort was, their level of pain and their level of consciousness. He stated residents should be assessed right away then and there and all falls should be considered to be high risk and staff should do what they could to prevent falls. During an interview on 02/27/15 at 9:36 AM with the Rehabilitation Director she stated it was not therapy's intent for nursing staff to mirror what they were doing with residents during therapy sessions and did not instruct nursing staff to do something different with transfers than what was on the care plan. She explained when nursing staff came to her for questions about how to transfer a resident she instructed them to go to the nurse for clarification. She further stated nursing staff should know what each resident required for transfers. During a follow up interview on 02/27/15 at 11:34 AM the DON stated it was her expectations that the nurse should assess for falls whether they were witnessed or un-witnessed and should follow up to make sure the resident was ok. She explained if the resident was injured the nurse should provide first aid or send the resident to the hospital. She explained the care plan should guide staff with care and the transfer technique should match the care plan. She further explained the closet care plan which guided care provided by NAs that was located in the resident's closet should match the care plan. She stated the closet care plan that was in place prior to Resident #24's fall was discarded when she went to the hospital but she would expect it indicated Hoyer lift for transfers since that was what was documented on the care plans. She further stated they would not change the care plan related to transfers unless therapy had released the resident 100 percent for a change in transfer technique. She stated when staff was notified of Resident #24's fracture she should have also been notified. She further stated she was not aware and was shocked to see there were no nurse's notes for Resident #24 on 11/15/14 for the 7:00 AM to 7:00 PM shift until she was questioned about it during the survey. She also indicated she documented the Investigation of Resident #24's fracture after she talked to staff on Monday 11/17/14 and at that time she did not realize Nurse #1 had not gone to Resident 24's room after she slid to the floor and did not assess her. The facility's Administrator and Director of Nursing were notified of Immediate Jeopardy on 02/24/15 at 3:31 PM for Resident #24. The facility provided a credible allegation of compliance on 02/27/15 at 11:35 AM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Credible Allegation of Compliance: Resident #24 was sent to the hospital emergency roiagnom on [DATE] with right hip pain resulting in surgical repair. Two nurse aides involved with resident #24's care on 11/15/14 were verbally instructed on 11/16/14, their next scheduled work day, regarding not moving a resident after a fall before a nurse assessed the resident. On 11/17/14 all 3 CNAs involved received verbal education regarding utilization of gait belt for transfers and assessment required to be completed by a licensed nurse prior to moving any resident after a fall. Nurse #1 received a written coaching on 11/17/2014 regarding completing incident reports and completing resident assessments, including assessing a resident after a fall before the resident is moved. She was also educated regarding fall investigation and assessment after falls on 11/21/2014. All documented falls that occurred in November prior to the identified deficient practice were audited to assess compliance with standards of practice on 11/14/14 -11/16/14 and was utilized to determine if there were other falls that occurred with other resident's and/or problems with transfer techniques. There were no other residents identified. Implemented fall clinical meeting daily Monday through Friday on 11/18/14. This is a subcommittee that specifically looks at falls. Fall audit tool initiated 11/18/14 to ensure timely assessment, appropriate documentation, and updated care plan. On February 24, 2015 at 11 pm nurses and nurse aides present was in serviced on: · New falls and fall risk policy and procedure implemented on February 24, 2015. · Assessment and first aid · Record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities · If evidence of significant injury, nursing staff will provide first aid · Once an assessment rules out significant injury, nursing staff will help resident to a comfortable sitting, lying, or standing position. Resident will not be moved until nursing assessment is completed. · Initial documentation regarding fall and notification of physician and family · Defining details of fall · Identifying causes of fall or fall risk · All off the above items will be documented on Fall: Initial Documentation Note/Progress Notes-5 day · This new form implemented on February 22, 2015 will be placed in the MAR and placed in the nurse's notes after completion of 5 day post fall documentation. · Performing a post-fall evaluation · Within 24 hours after a first fall, the nurse on duty should watch the resident rise from the chair, ambulate several steps if able, and return to sitting. If the resident has no difficulty or unsteadiness, further evaluation may not be needed. If the resident has difficulty therapy referral is initiated. This should be documented on Fall: Initial Documentation Note/Progress Notes-5 day · The nurse should assess the resident and determine if there are any changes or complications as a result of a fall every shift for 5 days and document on Fall: Initial Documentation/Progress Note-5 day · Identifying complications of falls · · requirement for immediate assessment of residents who have fallen and documentation in resident's clinical record · the condition the resident was found · assessment data including vital signs, and any obvious injuries · Interventions, first aid, or treatment administered · Notification of physician and family · All of the above to be documented on Fall: Initial Documentation Note/Progress Notes-5 day within · Completion of fall risk assessment · Appropriate interventions taken to prevent further falls · Signature and title of person recording data · Report fall to DON, ADON, or RN Supervisor An in service on falls and fall risk policy & procedure and transfers and mechanical lift will be completed for all nursing department staff by 8 pm on February 25, 2015. Any nursing department employee that has not attended above in service or participated in phone in service by February 25, 2015 at 8 pm will not be allowed to work until the in service is completed by DON, ADON, or RN Supervisor. At 8 pm on February 25, 2015 a list of nursing department employees that did not receive the above in service will be given to the DON. The DON will monitor the daily schedule to ensure that anyone that has not had the above training will not be scheduled to work until the in service is completed. All new nursing department employees will be in serviced during orientation. Immediate jeopardy was removed on 02/27/15 at 11:35 AM with interviews of direct care and licensed nursing staff who confirmed they received in-service training on new falls and fall risk policy and procedure and use of mechanical lifts prior to reporting for duty. A review of in-service sign in sheets contained documentation of staff who had attended the in-services. The DON had a list of all staff who had not attended in-services and these names were cross referenced with staff schedules and there were no staff who had not been trained listed on the schedules for work. Interviews with NAs revealed they had attended in-service training and were knowledgeable to notify a nurse immediately after a fall which included lowering a resident to the floor. Interviews with nurses revealed they had attended in-service training and were knowledgeable to respond and assess residents immediately after a fall or if they were lowered to the floor. They described the expectations for providing first aid, documentation of the incident, notification of physician, responsible party and administrative nursing staff and completion of the fall risk assessment, post fall evaluation and incident report. Record reviews revealed the Fall: Initial Documentation Note/Progress Notes-5 day form was implemented on 02/22/15 and a new fall risk policy and procedure was implemented on 02/24/15.

Based on record reviews and staff, resident and physician interviews the facility failed to utilize a mechanical (full body) lift during transfers for 1 of 12 sampled residents for falls (Resident #24). The facility also failed to secure a loose side rail for 1 Resident on 1 of 4 hallways (Resident #33). Immediate Jeopardy began on 11/15/14 when staff transferred Resident #24 three times without using a mechanical lift. Immediate jeopardy was removed on 02/27/15 at 11:35 AM 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 (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective. Example 2 is at a scope and severity of D. The findings included: A review of a facility document titled "Falls Checklist" that was not dated, indicated in part, to complete the falls investigation and witness statements; Notify Director of Nursing (DON) and Administrator if injury sustained and resident sent to emergency room ; complete falls investigation to make sure date and time are correct, include what the resident said, include what you observed, what assessments and results for skin, mental, range of motion, vital signs and level of consciousness and plan to prevent further incidents from occurring; complete progress note and it should include in detail all of the above information. 1. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Nursing Admission Information sheet dated 02/17/14 indicated Resident #24 was alert and aware, non-verbal but was able to understand others and answered yes and no to questions. The notes also indicated she was dependent for transfers and bed mobility. A review of a Fall Risk Assessment for Resident #24 on 02/17/14 revealed a score of 14 which indicated a total score of 10 or above represented high risk for falls. A review of a physician's orders [REDACTED].#24 was to be transferred with a mechanical lift. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 had severe impairment in cognition for daily decision making. The MDS also indicated Resident #24 was totally dependent on staff for bed mobility and transfers and Resident #24 did not speak but was sometimes understood and usually understood others. A review of a Fall Risk Assessment for Resident #24 on 05/24/14 revealed a score of 11 which indicated high risk for falls. A review of a care plan with a problem statement for accidents/fall risk with an updated date of 10/25/14 indicated approaches to determine possible causes/patterns associated with falls or accidents and lift for transfers. A review of a care plan with a problem statement for total dependence with an updated date of 10/25/14 indicated mechanical lift to chair every day. A review of a care plan with a problem statement for activities of daily living with updated date of 10/25/14 indicated lift for transfers and out of bed to chair with lift. A review of the monthly physician's orders [REDACTED]. A review of Medication Administration Records (MARs) for November 2014 indicated activity level for a mechanical lift. A review of nurse's notes dated 11/15/14 revealed there were no nurse's notes during the 7:00 AM - 7:00 PM shift. A review of a nurse's note dated 11/15/14 at 8:30 PM indicated Resident #24 was lying in bed grunting when Nurse #2 went to resident's room to administer bedtime medications. The notes further indicated when the head of the bed was raised Resident #24 began yelling out. The notes revealed Resident #24 was nonverbal due to history of a stroke but could answer questions appropriately by nodding her head for yes and no. The notes further revealed when asked where she was hurting Resident #24 pointed to her right leg. The notes indicated an assessment showed no visual injuries or redness but when an attempt was made to roll Resident #24 over she began screaming loudly and Resident #24's responsible party was notified and hospital was notified for transport to the emergency room . A review of a nurse's note dated 11/15/14 at 9:02 PM revealed emergency medical services (EMS) was in the facility to transport Resident #24 to the hospital emergency room for evaluation. A review of an EMS report dated 11/15/14 indicated EMS was at Resident #24's bedside at 9:03 PM. A section labeled narrative indicated Resident #24 initially stated on scene that she did not fall however upon talking to emergency room staff it was found out that she did indeed have a fall earlier today. A review of a nurse's note dated 11/15/14 at 9:25 PM indicated Nurse #2 had a conference with Nurse Aides (NA's) assigned to care for Resident #24 on the 7:00 PM to 7:00 AM shift and there were no reports of injury received from the previous shift to Nurse #2 or to NAs. A review of a nurse's note dated 11/16/14 at 12:30 AM indicated Nurse #2 called the hospital and was informed Resident #24 was admitted to the hospital with [REDACTED].#2 notified Administrative nurse (Assistant Director of Nursing (ADON)) #1 on call and contacted Resident #24's family to give an update. A review of a nurse's note dated 11/16/14 at 12:42 AM indicated staff from the hospital called the facility with questions and reported when Resident #24 was questioned she indicated she had been dropped onto the floor earlier in the day. The notes further indicated Administrative nurse (ADON #1) was notified. A review of a Physician's Report of Consultation dated 11/16/14 indicated a consulting [DIAGNOSES REDACTED].#24 who had a history of [REDACTED]. The notes revealed Resident #24 was found by the nursing staff lying in bed complaining of hip pain and apparently had a history of [REDACTED]. The notes further indicated Resident #24 was brought to the hospital emergency room and x-rays revealed a displaced intertrochanteric/subtrochanteric (upper quarter of the thigh bone) fracture of the right hip. A review of an Operative report dated 11/17/14 indicated intertrochanteric/subtrochanteric fracture of the right hip. The notes further indicated surgery was completed with open reduction (to realign bone fracture into normal position) and internal fixation (hardware used to keep bone fracture stable to heal and prevent infection) with a short gamma nail. A review of a facility document titled Investigation of Resident #24's fracture which was not dated but signed by the Director of Nursing (DON) indicated the following summary in part: On the morning of 11/15/14 NA #1 went in to get resident up and ready for shower. NA #1 asked NA #2 to assist with transferring Resident #24 from bed to chair. The 2 NAs attempted to transfer Resident #24 with an arm and arm method. They stood resident without difficulty but when the NAs started to pivot resident to place her in a shower chair the resident "went limp" and was unable to continue to assist the NAs with the transfer. NAs attempted to place Resident #24 in shower chair but due to her weight was unable to get her safely into the chair. Both NAs report they together slowly lowered resident to the floor. NA #2 went immediately to alert the nurse of the incident and get NA #3 to assist them in putting Resident #24 in the shower chair. Nurse #1 reported she could not confirm or deny she was immediately notified of the incident. NA #3 assisted NA #1 and NA #2 in transferring Resident #24 from floor to shower chair. NAs report Resident #24 did not complain of pain or show signs or symptoms of pain during this transfer. After lunch NA #1 and NA #3 transferred Resident #24 from wheelchair to bed. The resident participated with the transfer and did not complain of pain or show signs or symptoms of pain. At approximately 2:00 PM NA #1 and NA #4 was changing Resident #24 and she started yelling out and grabbing at her leg. NA (not named) asked the resident if she was in pain and she nodded her head yes. NA #4 went to get Nurse #1 and she went to check the resident and reported that both legs looked symmetrical and she "didn't see anything out of the ordinary." Nurse #1 noticed Resident #24 was scratching at her groin area and she had just recently administered scheduled Tylenol to Resident #24. Nurse #1 instructed the NAs to clean resident and apply protective ointment. At 4:00 PM Nurse #1 asked Resident #24 if her leg was still hurting and the resident shook her head no. When night shift came in Resident #24 appeared to be in severe pain and Nurse #2 sent resident to the ER and her [DIAGNOSES REDACTED]. During an interview on 02/19/15 at 11:08 AM with Resident #24 she smiled and nodded her head up and down as a response for yes and made repetitive sounds but was unable to form words when spoken to. She nodded her head up and down yes when questioned if she had a hip injury last November. When asked if she had a fall her facial expression changed and she became tearful and attempted to say something but was unable to form the words and then nodded her head vigorously up and down yes. When questioned if her hip was better she shook her head from side to side as a response for no and moved her left hand toward her right hip in a rubbing motion. During an interview on 02/23/15 at 11:48 AM the Assistant Director of Nursing (ADON) #1 stated after review of Resident #24's nurse's notes for 11/15/14 she did not remember being called on 11/15/14 when the resident was sent to the hospital but if the nurses documented they called her then they probably did. She further stated she did not remember going to the facility on [DATE] or 11/16/14. She stated the only thing she remembered was she heard during morning meeting the following week Resident #24 had complained of severe pain in her hip and was sent to the hospital and she had a hip fracture. She further stated she did not remember being involved in an investigation regarding Resident #24's fall. During an interview on 02/23/15 at 12:14 PM the Director of Nursing (DON) upon review of the nurses notes for Resident #24 on 11/15/14 confirmed there were no nurse's notes or nursing assessment during the 7:00 AM to 7:00 PM shift. During a follow up interview on 02/23/15 at 12:14 PM the DON explained nursing staff was supposed to call the administrative nurse on call when a resident had a fall or injury and the nurse on call should go to the facility to investigate or call the DON and she would go to the facility to investigate. She confirmed she was not called and did not go to the facility on [DATE] or 11/16/14 to investigate Resident #24's fall. During a telephone interview on 02/23/15 at 6:44 PM NA #1 explained she and NA #2 were trying to get Resident #24 out of bed into a shower chair on 11/15/14. She stated therapy staff had been working with Resident #24 to stand and transfer her with 2 staff assist and NA #1 stated she had previously stood Resident #24 next to her bed to transfer her and the resident had done fine and that was the way she usually transferred her. She explained during the transfer on 11/15/14 she had her arm under one of Resident #24's armpits and NA #2 had her arm under the other armpit and they stood her up at the bedside but when they turned her to pivot her she went limp. NA #1 stated when Resident #24 started to slide to the floor they tried to lift her up but they couldn't because she was too heavy. She explained when they realized they could not lift her up they lowered her to the floor and she told NA #2 to go get a nurse. NA #1 stated she held on to Resident #24's shoulders while she sat in the floor and thought her legs were out in front of her. NA #1 further stated NA #2 came back with NA #3 and they picked Resident #24 up off the floor and she took her to the shower room and gave her a shower. She explained she did not notice any obvious redness or bruising when she gave Resident her shower and after the shower NA #2 assisted her to stand Resident #24 up from the shower chair and into a wheelchair. NA #1 stated after lunch she got NA #2 and NA #3 again to transfer Resident #24 and they stood Resident #24 up from her wheelchair and transferred her to bed. She explained about 3 hours after Resident #24 was lowered to the floor she was moaning and holding her right leg and was rubbing it and she reported it to Nurse #1. During a telephone interview on 02/23/15 at 7:04 PM with NA #2 she stated she went to help NA #1 transfer Resident #24 on 11/15/14 for a shower. She explained they sat Resident #24 up on the side of the bed for a few seconds, then stood her up and turned her towards the left and she started to buckle. She stated Resident #24's right leg did not turn as her upper body turned and she slid down to the floor. She further stated when Resident #24 was in the floor her left leg was straight out but her right leg was crisscrossed under her left leg and was bent at a 90 degree angle at her knee. NA #2 stated she went to get Nurse #1 and the nurse asked if the resident had fallen or slid to the floor and when she told the nurse the resident had slid to the floor the nurse said ok and to go ahead and get Resident #24 up in the shower chair and give her a shower. NA #2 stated she went back to Resident #24's room and she and NA #1 placed their arms under each of Resident #24's armpits and lifted her from the floor and into the shower chair. She stated Resident #24 complained of her right leg hurting a little bit when she was placed in the shower chair but she thought it was caused by pressure on her legs from the shower chair. She stated she did not assist NA #1 during Resident #24's shower and also verified Nurse #1 did not come to Resident #24's room while the resident was in the floor or after they got her into the shower chair. She explained the DON talked to her on Monday 11/17/14 to ask what had happened during the transfer of Resident #24 on 11/15/14 and sometime after that staff had an in-service about use of gait belts and gait belts were issued to everybody but that was all that changed. During an interview on 02/24/15 at 1:54 PM with NA #3 she stated NA #1 or NA #2 came and got her to assist with getting Resident #24 off the floor on 11/15/14 because she had slid to the floor. She stated when she went into Resident #24's room the resident was sitting in the floor and she did not think Resident #24's legs were straight out in front because she couldn't straighten her legs out fully due to a previous stroke with paralysis on her right side. She demonstrated she placed her arm under one of Resident #24's armpits and NA #1 placed her arm under Resident #24's other armpit and they lifted her up off the floor while NA #2 held the shower chair. She confirmed Nurse #1 did not come in the room while she was in Resident #24's room and after they placed Resident #24 in the shower chair she left the room to resume her assignment on a different hall. She stated she did not remember anyone asked her about what had happened or what she saw when she went to Resident #24's room. During an interview on 02/23/14 at 8:13 PM with Nurse #1 she confirmed she did not go to Resident #24's room to assess her on 11/15/14 when NA #2 reported the resident had slid to the floor. She stated she was having a very bad day and took full responsibility for not doing what she was supposed to do. She confirmed the only assessment she did was later in the day when Resident #24 was crying out in pain and was reaching toward her peri area and the area was red. She stated she couldn't remember exactly what she saw but remembered she gave Resident #24 some routine Tylenol for pain but did not report it or document it because she did not think anything had happened or that anything needed to be reported or documented. During a telephone interview on 02/23/15 at 7:56 PM with Nurse #2 she stated she worked on the 7:00 PM to 7:00 AM shift on 11/15/14 and that evening the NAs came and got her because they had taken Resident #24 her bedtime snack and she was screaming in pain. She explained she couldn't assess her or touch her because she was in such pain. She further explained Resident #24 had an incontinent episode but they couldn't clean her or turn her because of the pain. She verified she had not received a report from Nurse #1 during shift change that Resident #24 had slid to the floor earlier that day. She stated she sent the resident to the hospital emergency room for evaluation and treatment because Resident #24 did not usually complain of pain and she couldn't figure out why she was having such severe pain. She explained later that night a nurse from the hospital called her and asked about a fall that Resident #24 had earlier that day. She stated that was the first time she had been told Resident #24 had a fall. She explained she called ADON #1 who was the nurse on call and told her what the hospital had reported. She stated ADON #1 told her to make sure she had everything documented. She stated nobody on her shift knew anything about Resident #24's fall earlier that day because nothing had been reported to them during shift report. She explained she expected to see nursing documentation when a resident had a fall or was lowered to the floor and she thought there should have been some investigation to determine why Resident #24 had a hip fracture since she had been lowered to the floor during transfer earlier that day. During an interview on 02/24/15 at 3:01 PM with Licensed Physical Therapist #1 he explained therapy staff had been working with Resident #24 on standing and transfers with 2 staff assist prior to her fall on 11/15/14. He stated Resident #24's participation varied and some days she would stand but then she would spontaneously sit down. He stated it was his understanding that nursing staff had transferred Resident #24 with a mechanical lift and the plan of care would have been to use a mechanical lift for transfers until Resident #24 was cleared by therapy to transfer with a maximum assist of 2 staff. During a follow up interview on 02/24/15 at 3:24 PM the DON verified she wrote the summary titled Investigation of Resident #24's fracture after she talked to staff who had been assigned to care for Resident #24 on Monday 11/17/14 and it was a summarization of what staff had told her. She stated she could not find an incident report related to Resident #24's fall and there was no incident recorded on the incident logs for Resident on 11/15/14. During a phone interview on 02/25/15 at 2:00 PM the physician who was also the facility Medical Director stated he was made aware of Resident #24's fall after she had gone to the hospital. He stated the information he had been told about her sliding to the floor did not explain how the fracture happened but he wondered if she had a previous incident or something that had happened that put her at higher risk for a fracture. He stated it was his expectation for nurses to assess and evaluate residents immediately after a fall or when they were lowered to the floor. He further stated he expected the nurses to call the physician to report what had happened, what the resident's level of comfort was, their level of pain and their level of consciousness. He stated residents should be assessed right away then and there and all falls should be considered to be high risk and staff should do what they could to prevent falls. During an interview on 02/27/15 at 9:36 AM with the Rehabilitation Director she stated it was not therapy's intent for nursing staff to mirror what they were doing during therapy sessions and they did not instruct nursing staff to do something different than what was on the care plan. She explained when nursing staff came to her for questions about how to transfer a resident she instructed them to go to the nurse for clarification. She further stated nursing staff should know what each resident required for transfers. During another follow up interview on 02/27/15 at 11:34 AM the DON stated it was her expectations that the nurse should assess for falls whether they were witnessed or un-witnessed and should follow up to make sure the resident was ok. She explained if the resident was injured the nurse should provide first aid or send the resident to the hospital. She explained the care plan should guide staff with care and the transfer technique should match the care plan. She further explained the closet care plan which guided care provided by NAs that was located in the resident's closet should match the care plan. She stated the closet care plan that was in place prior to Resident #24's fall was discarded when she went to the hospital but she would expect it indicated mechanical lift for transfers since that was what was documented on the care plans. She further stated they would not change the care plan related to transfers unless therapy had released the resident 100 percent for a change in transfer technique. She stated when the nurse on call was notified of Resident #24's fracture she should have also been notified and an investigation should have been done. She emphasized it was her expectation if a resident had an incident with injury she should be notified immediately. She further stated she was unaware there were no nurse's notes for Resident #24 on 11/15/14 for the 7:00 AM to 7:00 PM shift until she was questioned about it during the survey. She stated Nurse #1 had told her she assessed Resident #24 but she did not realize at that time Nurse #1 had not assessed the resident after she was lowered to the floor or before she was moved from the floor to the shower chair. During an interview on 02/27/15 at 12:20 PM the Administrator explained she had just started to work in the facility on 11/11/14 and identified the facility was lacking processes to address a number of issues which included falls. She explained a lot of work had begun to implement new processes and changes but there was still a lot of work that needed to be done. The facility's Administrator and Director of Nursing were notified of Immediate Jeopardy on 02/24/15 at 3:31 PM for Resident #24. The facility provided a credible allegation of compliance on 02/27/15 at 11:35 AM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Credible Allegation of Compliance Resident #24 was sent to the hospital emergency roiagnom on [DATE] with right hip pain resulting in surgical repair. Upon readmission on 11/20/14, resident #24 was assessed by ADON, PT, and nurse with regards to impaired cognition, pain, [DIAGNOSES REDACTED], body habitus, and recent history of a fall with fracture and it was determined that the safest transfer method was mechanical lift by 2 person assist. On 11/17/14 Resident care information sheets were checked for accuracy. Updates made to assure safest transfer method was being used for resident resident #24. Resident care information is located in resident's closets for direct care to refer to for care including transfers for residents. Two nurse aides involved with resident #24's care on 11/15/14 were verbally instructed on 11/16/14, their next scheduled work day, regarding not moving a resident after a fall before a nurse assessed the resident. On 11/17/14 all 3 CNAs involved received verbal education regarding utilization of gait belt for transfers and assessment required to be completed by a licensed nurse prior to moving any resident after a fall. Nurse #1 received a written coaching on 11/17/2014 regarding completing incident reports and completing resident assessments, including assessing a resident after a fall before the resident is moved. She was also educated regarding fall investigation and assessment after falls on 11/21/2014. All documented falls that occurred in November prior to the identified deficient practice were audited to assess compliance with standards of practice on 11/14/14-11/16/14 and was utilized to determine that there were no other falls that occurred with other resident ' s and/or problems with transfer techniques. Implemented fall clinical meeting daily Monday through Friday on 11/18/14. This is a subcommittee that specifically looks at falls. Fall audit tool initiated 11/18/14 to ensure timely assessment, appropriate documentation, and updated care plan. On February 24, 2015 Fall Risk Evaluation was completed on all residents. Care plans will be reviewed and updated with 100% completion on February 25, 2015. On February 24, 2015 at 11 pm nurses and nurse aides present was in serviced on: · New falls and fall risk policy and procedure implemented on February 24, 2015 · Assessment and first aid · Record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities · If evidence of significant injury, nursing staff will provide first aid · Once an assessment rules out significant injury, nursing staff will help resident to a comfortable sitting, lying, or standing position. Resident will not be moved until nursing assessment is completed. · Initial documentation regarding fall and notification of physician and family · Defining details of fall · Identifying causes of fall or fall risk · All off the above items will be documented on Fall: Initial Documentation Note/Progress Notes-5 day · This new form implemented on February 22, 2015 will be placed in the MAR and placed in the nurse ' s notes after completion of 5 day post fall documentation. · Performing a post-fall evaluation · Within 24 hours after a first fall, the nurse on duty should watch the resident rise from the chair, ambulate several steps if able, and return to sitting. If the resident has no difficulty or unsteadiness, further evaluation may not be needed. If the resident has difficulty therapy referral is initiated. This should be documented on Fall: Initial Documentation Note/Progress Notes-5 day · The nurse should assess the resident and determine if there are any changes or complications as a result of a fall every shift for 5 days and document on Fall: Initial Documentation/Progress Note-5 day · Identifying complications of falls · requirement for immediate assessment of residents who have fallen and documentation in resident's clinical record · the condition the resident was found · assessment data including vital signs, and any obvious injuries · Interventions, first aid, or treatment administered · Notification of physician and family · Completion of fall risk assessment · Appropriate interventions taken to prevent further falls · Signature and title of person recording data · Report fall to DON, ADON, or RN Supervisor · All of the above should be documented on the Fall: Initial documentation/Progress Notes-5 day, to be completed by the end of shift An in service on falls and fall risk policy & procedure and transfers and mechanical lift will be completed for all nursing department staff by 8 pm on February 25, 2015. Any nursing department employee that has not attended above in service or participated in phone in service by February 25, 2015 at 8 pm will not be allowed to work until the in service is completed by DON, ADON, or RN Supervisor. At 8 pm on February 25, 2015 a list of nursing department employees that did not receive the above in service will be given to the DON. The DON will monitor the daily schedule to ensure that anyone that has not had the above training will not be scheduled to work until the in service is completed. All new nursing department employees will be in serviced during orientation All residents were assessed for transfers by DON, ADONs, nurse, and therapy. All affected residents who were identified as two person assistant with transfers were referred to therapy on 2.25.15 for screen to verify safest transfer technique. Every resident fall will be reviewed Monday through Friday each morning at the Clinical Meeting and will ensure initial documentation has been completed. A revised falls audit tool has been implemented on 02/25/2015 and will include documentation and confirmation that all fall strategies are implemented and action taken when a fall occurs. Immediate jeopardy was removed on 02/27/15 at 11:35 AM with interviews of direct care and licensed nursing staff who confirmed they received in-service training on new falls and fall risk policy and procedure and use of mechanical lifts prior to reporting for duty. A review of in-service sign in sheets contained documentation of staff who had attended the in-services. The DON had a list of all staff who had not attended in-services and these names were cross referenced with schedules and no staff that had not been trained was listed on the schedules. Interviews with NAs revealed they had attended in-service training and were knowledgeable to notify a nurse immediately after a fall which included lowering a resident to the floor. Interviews with nurses revealed they had attended in-service training and were knowledgeable to respond and assess residents immediately after a fall or if they were lowered to the floor. They described the expectations for providing first aid, documentation of the incident, notification of physician, responsible party and administrative nursing staff and completion of the fall risk assessment, post fall evaluation and incident report. Record reviews revealed the fall: Initial Documentation Note/Progress Notes-5 day form was implemented on 02/22/15 and a new fall risk policy and procedure was implemented on 02/24/15. 2. Review of the medical record revealed Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan last reviewed 11/24/14, stated Resident #33 was at risk for falls and accidents due to impaired mobility, cognition, vision, hearing and/or decision making skills associated with dementia, COPD, anxiety, history of pelvis fracture, and medications. Included in the goals was an environment as free as possible of accident or fall hazards for the next 90 days. Interventions included notifying the maintenance department of any defective equipment such as bed side rails, hand rails, chairs, and beds. Review of the most recent side rail assessment dated [DATE] revealed Resident #33 required bed rails for turning and repositioning, had cognitive impairment, and could identify bed boundaries. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 had severely impaired cognition and required extensive assistance of one person for bed mobility and transfers. Review of the log used to notify maintenance staff of repairs for Resident #33's side of the facility revealed there were 7 side rail related problems documented from 01/01/15 through 02/24/15. Resident #33's bed side rails were not listed on the maintenance clip board. Observations of Resident # 33's bilateral ¼ bed side rails were as follows: - On 02/16/15 at 2:22 PM the right side rail was loose and the top of the rail leaned away from the edge of the mattress approximately 2 inches. The left side rail was not loose and fit properly. - On 02/18/15 at 1:00 PM the right side rail was loose and the top of the rail leaned away from the edge of the mattress approximately 2 inches. The left side rail was loose and the top of the rail leaned away from the edge of the mattress approximately 1 inch. - On 02/19/15 at 1:00 PM the right side rail was loose and the top of the rail leaned away from the edge of the mattress approximately 2 inches. The left side rail was loose and the top of the rail leaned away from the edge of the mattress approximately 1 inch. - On 02/23/2015 at 12:50 PM the right side was loose and leaned away from the edge of the mattress approximately 4 inches. The left side rail was loose an