Every finding on record at Grantsbrook Nursing and Rehabilitation Center

Based on observations, record review, and staff interviews, the facility failed to provide personal privacy during activities of daily living (ADL) care when Geriatric Care Aide (GCA) #1 video recorded Resident #81 with her cellphone while in the room during care without resident representative consent. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident # 81).The findings included: Resident #81 was originally admitted on [DATE] and readmitted to the facility on [DATE]. Resident #81 expired at the facility on [DATE]. Her diagnoses included diffuse traumatic brain injury without loss of consciousness (a widespread disruption of brain function often caused by the brain shifting inside the skull during an impact, that results in neurological symptoms but does not cause a blackout), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) with mood disturbance (the brain damage also impacts the areas controlling emotions, resulting in symptoms like depression, severe mood swings, apathy, or sudden crying/laughing).The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #81 was cognitively impaired. Resident #81 demonstrated physical and verbal behavioral symptoms directed toward others, as well as rejected care. Resident #81 was dependent on others for activities of daily living (ADLs).Review of the facility's investigative summary report dated [DATE] indicated staff reported Resident #81 was resistant to care and combative at times. On [DATE] NA #1 asked GCA #1 to witness care with Resident #81due to known behaviors. GCA #1 entered Resident #81's room and sat in a chair located behind NA #1 providing care. NA #1 provided ADL care with no concerns identified by GCA #1. Following the care, GCA #1 began video recording while NA #1 was dressing Resident #81 into a gown.The facility's revised Electronic Device Policy dated [DATE] was reviewed. The policy stated, in part, the use of personal electronic communications devices, including but not limited to, cell phones, smart phones, camera phones, texting devices, PDAs (Personal Digital Assistant: a small, handheld electronic device used as a personal organizer to store contacts, manage calendars, and take notes), and the like are prohibited during the interaction with and/or during the delivery of resident care services in non-designated areas of the company. The audio and/or video recording of any individual (employee, resident, visitor, vendor) is strictly prohibited unless approved by management. This applies to the entire company, working and non-working areas. Violation of this prohibition will result in the employee's termination.An interview with Nurse Aide (NA) #1 was conducted on [DATE] at 1:03 PM. She stated on [DATE] she needed to provide care to Resident #81 which included changing her clothes and incontinence care. NA #1 stated she was told by other staff members that Resident #81 was stiff and hard to move at times and she might need assistance to help hold her over. NA #1 stated because she hadn't worked with Resident #81 before, she asked another staff member to come into Resident #81's room with her. NA #1 stated she recalled GCA #1 was in training to be a NA. NA#1 stated GCA #1 sat in the chair in Resident #81's room in case additional assistance was needed to provide care for Resident #81. She stated Resident #81 was moving her arms around and it was initially difficult getting her gown on. NA #1 denied being rough with Resident #81 or forcing her in any way while dressing. NA #1 stated she did not know that GCA #1 video taped her performing care, nor did GCA #1 inform NA #1 that she video recorded. NA #1 further stated she did not ask GCA #1 to record care for Resident #81 and was unsure why she did it. NA #1 stated that prior to this incident, she knew video recording and/or taking pictures was not allowed and if she saw GCA #1 video recording, she would have told her it wasn't allowed and report it immediately. NA #1 stated she was suspended pending an investigation and when she returned to work, the entire facility received in-services on cell phone use and resident abuse.An attempt to reach GCA #1 was made, however she was no longer employed at the facility and the contact number available no longer belonged to her (wrong number) and the facility did not have an alternate contact number for her.Review of GCA #1's written statement dated [DATE] indicated she had been asked by NA #1 to witness care for Resident #81. She indicated she entered the room around 1:30 PM and sat on the chair across the room behind NA #1 to watch. GCA #1's statement indicated NA #1 was standing to Resident #81's right side and the resident's head, right arm, and lower legs; she recorded the care provided. During GCA #1's statement she indicated she recorded the care provided stating How can I be a witness if I didn't have proof? I thought that is what (NA #1) wanted me to do so I would have actual proof that she gave care. GCA #1's written statement further indicated she had not assisted NA #1 in providing care, she did not tell NA #1 she recorded the care, and she deleted the video as she awaited the arrival of management because she thought she was in trouble.An interview was conducted with the Director of Nursing (DON) on [DATE] at 2:10 PM. The DON stated she received a call on [DATE] from the facility Scheduler who initially informed her a staff member was being rough with a resident. Since the DON was not immediately available to complete the call, she instructed the Scheduler to pull both staff members off the floor and await a call back. The DON stated she called the facility back within a few minutes and was told a staff member had video recorded care being provided for a resident. When the DON inquired why the care was recorded, the accused employee (GCA #1) stated another staff member asked her to witness the care she provided. The DON insisted on seeing the video and Facetimed with the Scheduler and GCA #1 to show her the video. The video was played back during Facetime and not sent to any other device for review. The DON stated the video was of poor quality, but she saw an NA's back and the right side of Resident #81's face and right arm. The DON stated there was nothing in the content of the video that was concerning; the concern she had was that there was a video recording of Resident #81 during care. The DON stated she notified the Administrator and called in administrative on call nurses to help with corrective actions that were needed to be implemented for the incident. The DON stated when she arrived at the facility she spoke to GCA #1 who stated she deleted video. The DON and Scheduler obtained verbal permission from GCA #1 to look at her cell phone and confirmed the video was deleted and was not found in any file of her cell phone. When asked again why GCA #1 video recorded in the first place, she indicated she believed she needed proof of something that was witnessed. GCA #1 further informed the DON that NA #1 did not ask her to video record and she did not inform NA #1 she was recording. GCA #1 told the DON that NA #1 could have been gentler and kinder when she was putting on Resident #81's gown.The DON stated after she talked to GCA #1, she then interviewed NA #1, who informed her she asked GCA #1 to witness care since Resident #81 had been not allowing people into her room at times and had been demonstrating physical and verbal behaviors towards others. NA #1 informed the DON that she had not asked GCA #1 to record and she didn't know she was recording her during care. The DON had NA #1 perform a return demonstration with witnesses present, as to how Resident #81 was moving her arm while putting on her gown; no concerns were noted.The DON stated she then interviewed GCA #1 who also performed a return demonstration of how she thought NA #1 was not gentle; she stated she thought NA #1 was rough pulling the gown over her elbow; however, she denied NA #1 used force while performing care, again stated NA #1 could have been gentler and kinder when she was putting on Resident #81's gown. The DON stated both NA #1 and GCA #1 were suspended as the facility conducted their investigation. The facility did not find any concerns regarding abuse during their investigation, however the DON stated video recording or picture taking of any residents was not allowed within the facility and GCA #1 was terminated. The DON stated that all employees upon hire review and acknowledge facility policies which included the prohibition of video recording within the facility.An interview was conducted on [DATE] at 9:40 AM with the Scheduler. She stated she was working as a Medication Aide on [DATE] and was the only administrative staff in the building that day. The Scheduler stated a nurse brought GCA #1 to her and told her there was an issue. GCA #1 began to tell the Scheduler she was asked to assist with Resident #81 and stated while I was recording; and the Scheduler asked her why she was recording. GCA #1 informed the Scheduler that she thought that's what she was supposed to do as a witness. The Schedular stated she told GCA #1 that recording was not allowed and explained she was asked to be a witness because there had been allegations made by Resident #81 against staff. The Scheduler stated she immediately called the DON, Facetimed her showing her the video. The Scheduler stated while reviewing the video recording, she could see there was no evidence of abuse or NA #1 being rough with Resident #81, and in fact NA #1 did a lot of talking and coaching with Resident #81. The Scheduler indicated that GCA #1 didn't say anything about NA #1 being rough with Resident #81 but stated that was how she approached the nurse and the nurse immediately brought GCA #1 to her. That day the facility began re-inservicing on video recording.GCA #1 was employed at the facility beginning on [DATE]. Review of orientation records indicated she received training regarding protecting patient privacy and Health Insurance Portability and Accountability Act (HIPPA: a federal law designed to protect sensitive patient health information from being disclosed without the patient's consent or knowledge, and it provides individuals with control over their own medical records).On [DATE] at 12:07 PM an interview was conducted with Nurse #1 who stated on [DATE] GCA #1 came to her and said she may have witnessed a possible resident abuse situation and videoed it. Nurse #1 stated she didn't want to see the video and took GCA #1 to the administrative staff member working that day. Nurse #1 stated she then got NA #1 and put her in the break room, thereby separating the staff from the resident and from each other. The DON was notified. Nurse #1 further stated it was prohibited to take pictures or videos of residents without consent, and it would be a HIIPPA violation.An Administrator interview was conducted on [DATE] at 1:34 PM. Resident #81 was more challenging with care and NA #1 asked GCA #1 to be her witness while providing care. GCA #1 was behind her and proceeded to record the care on her phone because she believed she needed proof, and that was her way of witnessing something. Once administration staff were notified of the incident both staff members were suspended pending the investigation. Upon completion of the investigation, GCA #1 was terminated. The Administrator further stated the facility had a very clear policy which prohibited use of video or picture taking in any care area, and it was his expectation that all staff followed that policy.

Based on record review and staff, Resident, and Resident Representative interviews, the facility failed to develop and implement a comprehensive care plan for a resident with a shellfish allergy. This was for 1 of 3 residents reviewed for dietary allergies (Resident #63). The findings included: Resident #63 was admitted to the facility on [DATE]. Resident #63's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. A review of Resident #63's care plan dated 1/3/25 and last revised on 3/4/25 did not include a focus area, goal or intervention for shellfish allergies. An interview with Resident #63 was conducted on 5/4/25 at 11:45 AM. Resident #63 stated he was served shrimp shortly after he moved into the facility. He told the aide he was allergic to shrimp, and she removed the meal tray. Resident #63 added, he had an allergic reaction when he was in his twenties, after eating shrimp it felt as if his throat was closing and he could not breathe. An interview with Resident #63's Resident Representative (RR) was conducted on 5/4/25 at 1:35 PM. The RR stated on 2/3/25 when she was made aware the facility had served Resident #63 shrimp, she called the facility and spoke with Nurse #1 to make sure they were aware Resident #63 had a shellfish allergy. An interview was conducted with the Regional Registered Dietician on 5/7/25 at 8:15 AM. She stated she did not know if a food allergy should be included in a care plan. An interview with the MDS Nurse was conducted on 5/7/25 at 9:10 AM and revealed she would not add food allergies to the care plan, but the Dietary Manager would complete that task. The Dietary Manager was interviewed on 5/7/25 at 9:15 AM. She stated she would have been responsible for nutritional screenings and the nursing team would be assigned to discuss allergies. The nurse in charge on the day of the discussion would be tasked with adding any allergies to the care plan. An interview with the Director of Nursing (DON) on 5/7/25 at 9:20 AM revealed the Dietary Manager or any of the nurses would be responsible for adding food allergies to the care plan. She added there was not one person assigned to that task. An interview with the Administrator was conducted on 5/7/25 at 9:30 AM, he stated either the Dietary Manager or the MDS Nurse would be responsible for adding a food allergy to a care plan.

Based on record reviews, and interviews with the Resident, Resident Representative, and staff, the facility failed to obtain a resident's dietary allergies prior to serving food to a resident that would create an allergic reaction. This was for 1 of 3 residents (Resident #63) reviewed for food allergies and preferences. Findings included: Resident #63 was admitted to the facility on [DATE]. There were no allergies listed on the discharge paperwork from the hospital. Resident #63's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. An interview with Resident #63 was conducted on 5/4/25 at 11:45 AM. Resident #63 stated he was served shrimp shortly after he moved into the facility. He told the aide he was allergic to shrimp, and she removed the meal tray. Resident #63 added, he had an allergic reaction when he was in his twenties, after eating shrimp it felt as if his throat was closing and he could not breathe. An interview with Resident #63's Resident Representative (RR) was conducted on 5/4/25 at 1:35 PM. The RR stated on 2/3/25 when she was made aware the facility had served Resident #63 shrimp, she called the facility and spoke with Nurse #1 to make sure they were aware Resident #63 had a shellfish allergy. A progress note dated 2/3/25 and written by Nurse #1 revealed the RR and Resident discussed with dietary that he had a shellfish allergy and the allergy had been added to his medical record. An interview was conducted with Nurse #1 on 5/6/25 at 8:30 AM. She stated she did not remember if Resident had been served shellfish. She further stated the RR called on 2/3/25 and told her the resident was allergic to shellfish. Nurse #1 revealed typically new residents meet with the dietary team within 24 hours of admission to discuss likes, dislikes and allergies if they do not come into the facility with that information. An interview was conducted with [NAME] #1 on 5/4/25 at 11:00 AM. He stated the food allergies and preferences are listed on the tray slips that are used to prepare trays for meal service. An interview with the Dietary Manager was conducted on 5/5/25 at 1:15 PM. She revealed part of her role is to meet with the family at the preadmission meeting and talk with the resident within 36 hours of admission. She went on to say she did not remember meeting with Resident #63's family. An interview with the Nurse Supervisor was held on 5/5/25 at 1:30 PM. He stated the admitting nurse would put allergies into the resident's record upon admission. He was the admitting nurse for Resident #63 and there was not an allergy listed on the discharge summary from the hospital. An interview with the Director of Nursing was conducted on 5/6/25 at 9:15 AM. She revealed her expectation would have been that the admission nurse or hall nurse would add allergies to the record if the information was included in the admission paperwork. She went on to say family/resident preadmission meetings were held with each facility department represented. If there was not a family/resident preadmission meeting each facility department manager should meet with the family or resident within 24 hours of admission. The admission nurse would be responsible for adding allergies to the medical record. An interview conducted with the Regional Registered Dietician on 5/7/25 at 8:15 AM. She stated she would expect food allergies to be reviewed by the Dietary Manager and the nursing team would make a notation on the medical record within 48 hours of admission. An interview with the Administrator was conducted on 5/6/25 at 9:30 AM. He revealed he expected food allergies would be addressed by nurses. He went on to say the admitting hall nurse should address allergies on admission prior to the first meal service.

Based on observations, record review, and staff interviews, the facility failed to implement their policy for enhanced barrier precautions (EPB) when Nurse Aide #1 and Nurse Aide #2 failed to wear a gown when providing incontinence care for Resident #14. This was for 2 of 9 staff members observed for infection control practices. Findings included: A review of the facility's policy titled Enhanced Barrier Precautions dated last revised on 4/1/24 revealed in part the following: Enhanced Barrier Precautions (EBP) are used in conjunction with Standard Precautions to reduce the risk of MDRO [Multidrug-resistant bacteria] transmission during high-contact resident care activities. [It includes] the use of both gowns and gloves.Enhanced Barrier Precautions apply to residents with any of the following: .Wounds with or without the presence of an MDRO infection.Example[s] of chronic wounds requiring EBP include but are not limited to the following types of wounds: Pressure ulcers .Resident care activities that are considered high contact include but are not limited to: .changing briefs or assisting with toileting. During observation on 5/5/25 at 1:36 PM Nurse Aide #1 and Nurse Aide #2 were observed providing incontinent care for Resident #14. Nurse Aide #2 was observed to shut the resident's door, close the window blinds, and then both nurse aides performed hand hygiene. Both nurse aides introduced themselves to Resident #14 and explained what they were about to do. Nurse Aide #1 raised the bed and then lowered the head of bed and both nurse aides used hand sanitizer and then put on gloves. As Nurse Aide #1 pulled the covers back on Resident #14 and the nurse aides were about to start incontinent care, both nurse aides were asked to stop and step outside of the hearing of the resident. During an interview on 5/5/25 at 1:43 PM both Nurse Aide #1 and Nurse Aide #2 stated Resident #14 did have a wound at one point, but due to there being no EBP signage or Personal Protective Equipment (PPE) on the door, the wound must now be closed, and the dressing was a preventative dressing. Due to this, there was no need for them to wear a gown for EBP. Both nurse aides stated they could not remember Resident #14 having Enhanced Barrier Precautions so the wound must have been closed for a long time. The nurse aides then continued to complete incontinent care on Resident #14. While completing the observation of incontinent care on Resident #14 on 5/5/25 at 1:43 PM, a clean and dry border foam wound dressing approximately 2 inches by 2 inches was observed on Resident #14's sacrum. During an interview on 5/5/25 at 1:48 PM the Infection Preventionist stated Resident #14 did have a chronic sacral pressure ulcer with a small opening that on 4/29/25 was measured to be 2.5 centimeters by 2.5 centimeters by 0.1 centimeters depth with no drainage. She stated Resident #14 had the pressure ulcer for over a year and it would not close but was very small and had no drainage. The Infection Preventionist stated that because there was no drainage and the wound was small and could be covered with boarder foam dressing, she did not believe Resident #14 needed enhanced barrier precautions. If residents were on EBP then staff should wear a gown and gloves for incontinence care. She stated she was trained on EBP 3/4/25 and had a refresher course on 3/31/25. During an interview on 5/5/25 at 3:49 PM the Director of Nursing stated Resident #14 should have been on enhanced barrier precautions due to his chronic wound and signage and PPE should have been placed on his door to alert the staff of this. A gown and gloves should have been worn by the nurse aides while providing incontinence care to Resident #14. During an interview 5/6/25 at 12:04 PM the Administrator stated the Enhanced Barrier Precautions policy and procedures should be followed by staff.

Based on observation and staff interviews, the facility failed to remove an expired food item stored for use in 1 of 1 refrigerated walk-in storage cooler. This practice had the potential to affect food served to residents. Findings included: During the initial tour of the kitchen on [DATE] at 9:59 am through 10:35 am, the Dietary Manager was present during the inspection the walk-in cooler was observed with a 1-gallon container of salad dressing that was ,d+[DATE] full dated as opened [DATE]. The Dietary Manager was interviewed during the initial tour on [DATE] at 9:59 am through 10:35 am. She stated that staff were trained on food storage to include dating, labeling, and discarding outdated foods. She further stated that the refrigerated coolers were checked daily for outdated foods and outdated foods should have been discarded at that time. Opened foods were marked with the date opened and should have been discarded 7 days after that date. She disposed of the food item listed above. In a follow-up interview with the Dietary Manager on [DATE] 3:15 pm she stated that the salad dressing was used to make tomato and cucumber salad and it was last used about 3 months ago. She stated that she was responsible for checking the refrigerated coolers daily and she last checked the cooler this morning and the dressing should have been discarded but she overlooked it. During an interview with the Nutrition Consultant on [DATE] at 3:18 PM revealed the salad dressing should have been discarded 7 days after it was opened. In an interview with the Administrator on [DATE] at 9:59 am he stated that the salad dressing was too old and should have been discarded prior to now. He further indicated he did not know how long it could be kept but knew that you could not keep it for months.

Based on record review and staff interviews the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for 1 of 3 residents reviewed for beneficiary protection notification who required the provision of the SNF-ABN form (Resident #40). Findings included: Resident #40 was admitted to the facility on [DATE]. Review of CMS-R-131 (a form used to indicate Medicare Part B services are ending) revealed Resident #40's Medicare Part A skilled services ended on 2-16-24. She remained in the facility with benefit days remaining. Record review revealed that Resident #40 was not given the CMS-10555 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN). On 4/3/24 at 1:29 PM an interview with the Social Worker (SW) indicated she provided Resident #40 with the CMS-R-131 form dated 2/14/24. She stated she must have just looked at the ABN part and printed the wrong form. On 4/4/24 at 9:57 AM an interview with the Administrator indicated he knew an attempt was made to provide Resident #40 with notices because she was refusing therapy services, but he was not sure what notices were provided.

Based on staff interviews and record review the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who discharged from hospice services for 1 of 1 resident reviewed for hospice care. (Resident #55) Findings included: Resident #55 was admitted to the facility on [DATE] with hospice services in place. Review of Resident #55's hospice discharge order dated 11/2/23 revealed Resident #55 was discharged from hospice services on 11/2/23. Review of Resident #55's electronic health record revealed no significant change in status Minimum Data Set assessment had been completed for Resident #55. During an interview on 4/3/24 at 12:07 PM the MDS Coordinator stated Resident #55 was admitted to the facility on hospice and was then discharged from hospice in November 2023. She stated she did not recall being made aware of this change in status until some point in February 2024 during a morning meeting. She stated by this time Resident #55 had been off hospice longer than the two-week window to complete a significant change in status Minimum Data Set assessment. She further stated the resident had not undergone a significant change in status herself other than the hospice discharge, so a significant change in status Minimum Data Set assessment was not completed as they had missed the window. She concluded when resident discharged from hospice, a significant change in status Minimum Data Set assessment should have been completed. During an interview on 4/3/24 at 12:17 PM the Director of Nursing stated during a morning meeting in November, Resident #55's hospice status was discussed by clinical staff. She stated the MDS Coordinator was in the morning meetings, and this was how staff were made aware of the change in hospice status for residents and the MDS Coordinator should have followed up to complete a significant change in status Minimum Data Set assessment. During an interview on 4/3/24 at 1:58 PM the Administrator stated that a significant change in status Minimum Data Set assessment should be completed when a resident elected to receive or discharge from hospices services.

Based on staff interviews and record review the facility failed to accurately code the hospice status of a resident on a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice care. (Resident #55) Findings included: Resident #55 was admitted to the facility on [DATE] with hospice services in place. Review of Resident #55's hospice discharge order dated 11/2/23 revealed Resident #55 was discharged from hospice services on 11/2/23. Review of Resident #55's Minimum Data Set assessment dated [DATE] revealed Resident #55 was coded as receiving hospice care. During an interview on 4/3/24 at 12:07 PM the MDS Coordinator stated on Resident #55's Minimum Data Set assessment dated [DATE] she had incorrectly coded the resident as receiving hospice services at that time and the resident was not receiving hospice services. During an interview on 4/3/24 at 1:58 PM the Administrator stated hospice status should be accurately reflected in the resident's Minimum Data Set assessments.

Based on observations, record review, and resident and staff interviews the facility failed to provide nail care to 1 of 2 dependent residents (Resident #167) reviewed for activities of daily living (ADL) care. Findings included: Resident #167 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #167's comprehensive care plan revealed in part a focus area initiated on 3/22/24 for ADL care. The goal was for Resident #167's ADL care to be completed with staff support. An intervention was 1 person assistance with personal hygiene and grooming. A review of Resident #167's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She exhibited no behaviors or rejection of care. Resident #167 required substantial/maximal assistance with personal hygiene. On 4/1/24 at 4:05 PM an observation of Resident #167 revealed multiple broken and jagged fingernails on both hands. In an interview with Resident #167 at that time she stated her fingernails were breaking off and needed to be clipped. She went on to say she didn't have a nail clipper and so there was nothing she could do about it. She further indicated her fingernails had been like that for a while. Resident #167 stated she got a bath every day, but no one ever offered to clip her fingernails. She went on to say she knew she should have asked someone, but she hadn't. On 4/2/24 at 12:02 PM an observation of Resident #167 revealed multiple broken and jagged fingernails on both hands. In an interview at that time Resident #167 stated she had not yet had her bath that day. On 4/2/24 at 2:18 PM an observation of Resident #167 revealed multiple broken and jagged fingernails on both hands. On 4/2/24 at 2:33 PM an interview with Nurse Aide (NA) #1 indicated she was familiar with Resident #167. She stated Resident #167 had never refused any care that she was aware of. She went on to say she provided Resident #167 with a complete head to toe bed bath earlier that day which included washing Resident #167's hands. NA #1 stated she had access to nail care supplies. She went on to say she was able to provide nail care to residents as long as the weren't diabetic or on a blood thinner. NA #1 stated in that case, she would ask the nurse. She further indicated if she noticed a resident's fingernails were dirty or had any roughness, she would ask the resident if they wanted nail care because she wouldn't want them to scratch themselves. NA #1 stated Resident #167 had not requested nail care and she had not noticed Resident #167 having any broken or jagged fingernails during her bath that day. She went on to say she had not asked the nurse about Resident #167's fingernails. On 4/2/24 at 2:47 PM an observation of Resident #167's fingernails with the Director of Nursing (DON) revealed multiple broken and jagged fingernails on both hands. During an interview at that time the DON stated Resident #167's fingernails had a few rough places and looked like they needed to be filed. On 4/4/24 at 8:26 AM in a follow-up interview the DON stated the only thing she could say was that she had not really been able to see the jaggedness of Resident #167's fingernails just standing by her bed, until she got up close. She further indicated if someone had seen Resident #167's fingernails they should have addressed them. On 4/3/24 at 1:38 PM an interview with Nurse Aide (NA) #2 indicated she provided Resident #167 with a complete bed bath that included washing Resident #167's hands during her shift on 4/1/24. She stated Resident #167 had never refused any care that she was aware of. She went on to say if she noticed a resident had broken or jagged fingernails, she had access to a nail file to file or shape them. NA #2 stated she had not noticed Resident #167 having any broken or jagged fingernails on 4/1/24 when she provided her bath around 9:30 AM. She went on to say Resident #167 had not requested nail care.

Based on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation survey of 10/28/21, and the recertification and complaint investigation survey of and 3/22/23.This was for re-cited deficiencies in the areas of Medicaid/Medicare Coverage/Liability Notices (F582) and Accuracy of Assessments (F641) The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referenced to: F582: Based on record review and staff interviews the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for 1 of 3 residents reviewed for beneficiary protection notification who required the provision of the SNF-ABN form (Resident #40). On the 3/22/23 recertification and complaint investigation survey the facility was cited for failing to provide a completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) In an interview on 4/4/24 at 10:01 AM the Administrator stated last year the problem was the notices were incomplete. He went on to say this year the form was incorrect. He further indicated he felt like these were different issues. F641: Based on staff interviews and record review the facility failed to accurately code the hospice status of a resident on a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice care. (Resident #55) On the 10/28/21 recertification and complaint investigation survey the facility was cited for failing to accurately code the Minimum Data Set (MDS) assessment. In an interview on 4/4/24 at 10:01 AM the Administrator stated it was hard to go back 3 years to look at things. He went on to say the while the QAA Committee did track things like this, he felt the situations were different. He further indicated it would be hard to track the whole process.

Based on observations and staff interviews, the facility failed to ensure a resident's wheelchair or geri chair (a padded recliner with wheels) was clean, sanitary, and free of debris for 3 of 5 residents (Resident #3, #4, and #5) reviewed for environmental concerns. Findings included: a. An observation on 4/19/23 at 8:20 AM of Resident #3 sitting in a wheelchair in the hall by the nurses' station revealed the wheelchair wheel spokes had a layer of dust and the bar inside the bottom of the wheelchair had dust and debris. b. An observation on 4/19/23 at 8:25 AM of Resident #4's motorized wheelchair in her room revealed 6 areas of dried brown debris on the right front wheel [NAME] approximately dime to quarter sized and 2 areas of dried debris on the left front wheel [NAME] approximately dime sized. The wheelchair also had dust on the inner part of the right and left front wheel [NAME] under the chair seat. c. An observation on 4/19/23 at 10:41 AM of Resident # 5 sitting in a geri chair outside in the smoking area revealed the left side of the geri chair had multiple brown stains and dust along the bottom rim on the right and left side. An interview on 4/19/23 at 10:08 AM with Nursing Assistant #1 revealed she was unaware of a wheelchair cleaning process, and she would wipe the resident's wheelchair seat down if she observed any debris on the seat. An observation and interview on 4/19/23 at 1:05 PM were conducted with the Director of Nursing (DON) which included observations of Resident #3's & #4's wheelchairs while they were sitting in the dining room and Resident #5 sitting in his geri chair outside in the smoking room. She stated that the wheelchairs and geri chair were dirty and needed attention. An interview on 4/19/23 at 1:11 PM with the Housekeeping Manager and Administrator revealed there had recently been a change in Housekeeping Manager and the wheelchair cleaning process had 'gotten lost' during the transition. The Housekeeping Manager stated he was new to the facility and was unaware it was housekeeping's responsibility to clean the resident's wheelchairs. The Administrator stated he was new, and his focus had been on the building repairs and had overlooked the resident's wheelchairs.

Based on record review and staff interviews the facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) to 2 of 3 residents (Resident #34 and Resident #2) reviewed for Beneficiary Notification. Findings included: 1. Resident #34 was admitted to the facility on [DATE]. A review of her annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. Resident #34's Medicare Part A Skilled services ended on 9/23/22. She remained in the facility. A review of Resident #34's medical record did not reveal a completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) for this stay. On 3/21/23 at 9:08 AM a telephone interview with Social Worker (SW) #2 indicated she no longer worked at the facility. She stated she did not recall Resident #34. She went on to say it would have been her responsibility to provide the completed form to Resident #34 at that time. She further indicated she thought perhaps she completed the form, but it did not get uploaded into Resident #34's medical record. On 3/22/23 at 11:29 AM an interview with the Director of Nursing (DON) indicated she was not able to find a completed SNF-ABN for Resident #34's Medicare Part A Skilled services stay ending on 9/23/22. 2. Resident #2 was admitted to the facility on [DATE]. A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #2's Medicare Part A Skilled Services ended on 2/13/23. She remained in the facility. A review of Resident #2's medical record did not reveal a completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) for Resident #2's Medicare Part A Skilled services stay ending on 2/13/23. On 3/21/23 at 9:16 AM a telephone interview with Social Worker (SW) #3 revealed she no longer worked at the facility. She stated she would have been responsible for completing the SNF-ABN for Resident #2 at that time. She went on to say she had not received any training on completing these forms by the facility and she had just been doing the best she could. On 3/21/23 at 9:35 AM an interview with the Administrator indicated it would have been SW #3's responsibility to complete the SNF-ABN for Resident #2. He stated he observed the Director of Nursing and the other members of the nursing administrative team providing training to SW #3. On 3/21/23 at 9:40 AM an interview with the DON indicated she trained SW #3 on completing the SNF-ABN forms for residents. She stated she had even walked her through the completion of several.

Based on record review and staff and physician interviews the facility failed to report to the state regulatory agency an incident related to an injury of unknown source (Resident #57) within the required timeframe for 1 of 3 residents reviewed for facility reported incidents. Findings included: Resident #57 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of fall incident report for Resident #57 dated 12/12/22 at 4:35 PM revealed he was found laying on the floor in front of the door to his room. He had socks and shoes on. His call light was not on. Resident #57 had a full body assessment done. He denied pain. He stated he had been trying to go outside. There were no injuries noted. He was assisted back into his wheelchair. His family member and physician were notified. A review his admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He required the extensive assistance of 1 person for locomotion. He used a wheelchair for mobility. Resident #57 had 1 fall with no injury since his admission to the facility. A nursing progress note for Resident #57 dated 12/27/22 at 10:23 PM written by Nurse #1 revealed he was complaining of new left hip and knee pain with movement. His physician was notified and an x-ray of his pelvis, left hip and knee was ordered. A nursing progress note for Resident #57 dated 12/28/22 at 5:30 PM written by Nurse #1 revealed the result of his x-ray was received. His physician and family member were notified. A nursing progress note for Resident #57 dated 12/28/22 at 5:40 PM revealed Resident #57 was sent to the emergency room via rescue squad transportation. A review of the facility's initial allegation report revealed a report for an injury of unknown source was faxed to the state regulatory agency on 12/30/22 at 3:12 PM related to Resident #57 having a left hip fracture. The report was prepared by the facility's previous Administrator. The report further revealed the facility became aware of the incident on 12/28/22 at 5:30 PM. On 3/20/23 at 1:29 PM a telephone interview with the facility's previous Administrator indicated she recalled the incident with Resident #57. She stated he had a fall earlier in December 2022 when he tried to walk to an exit door that initially seemed to have not resulted in any injury. She went on to say while she did not recall who notified her, the time she became aware of Resident #57 having a fracture would have been the time she indicated on the initial report of the incident. She stated she began an investigation by talking with staff who were familiar with him and cared for him at the time of the incident and the Director of Nursing (DON). She went on to say their conclusion had been that the fracture likely resulted from the fall Resident #57 had earlier in the month because no other incidents had been identified. She stated when she reported this to the corporate team, she was advised on 12/30/22 that the time from the fall to when the fracture was identified was too long and she needed to report the fracture to the state regulatory agency as an injury of unknown source. She stated while she was aware that the timeframe for reporting this fracture as an injury of unknown source would have been 2 hours from the time the facility became aware of the incident, she wasn't advised by the corporate team to report it as such until 12/30/22. She stated the 5-day investigation report was sent 5 days after that. On 3/21/22 at 8:03 AM an interview with Resident #57's Physician indicated the facility was very quick to get x-rays after a fall if the resident was complaining of any pain. He stated this had not been the case for Resident #57 after his fall on 12/12/22. He indicated he saw Resident #57 at the facility after his fall and he had not been complaining of pain at that time. He further indicated when Resident #57 began complaining of new pain the facility immediately got an x-ray. He went on to say when this x-ray showed a fracture Resident #57 was sent to the hospital. The Physician stated what he thought likely happened was Resident #57 had the fracture after his fall on 12/12/22 but it had been non-displaced and thus had not been causing Resident #57 any pain. He stated as Resident #57 walked more and participated in therapy the fracture likely became displaced and began to cause him pain. He went on to say while he felt this was most likely, because Resident #57 had not had an x-ray after the fall on 12/12/22, he could not be certain. On 3/21/23 at 9:57 AM an interview with the facility's Corporate Nurse Consultant indicated she had been involved in the discussion with the previous Administrator regarding Resident #57's fracture. She stated when the facility found out about a fracture, they were required to report this to the Corporate Risk Management Team. She went on to say while the Risk Management Team may have been notified of Resident #57's fracture on 12/28/22, they had not held a meeting until 12/29/22. The Corporate Nurse consultant stated this gave the facility time to start their investigation. She went on to say if there was a reasonable suspicion of a crime, the facility had 2 hours to report the incident to the state regulatory agency. She further indicated otherwise, the facility had 24 hours to report. She stated initially the facility was not considering the fracture an injury of unknown source. She went on to say they were attributing it to the fall he had on 12/12/22. She stated when the Risk Management Team held their review meeting, it was decided that because the fracture was identified so long after the fall, the facility should go ahead and report as an injury of unknown source. On 3/22/23 at 8:35 AM a telephone interview with Nurse #1 indicated she was familiar with Resident #57. She stated when he began complaining of new left hip and knee pain with movement she notified his physician. She stated an x-ray was ordered. She went on to say when the results came back showing that he had a hip fracture she notified Resident #57's physician, the DON, the Administrator and Resident #57's family member. She further indicated the physician advised her to send Resident #57 to the hospital which she did.

Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 1 of 2 residents reviewed with a Level II PASRR (Resident #62). Findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities. Review of the Resident #62's electronic medical record revealed an NC MUST (online system used for PASRR screenings) inquiry document dated [DATE] that indicated Resident #62 had a time-limited Level II PASRR ending in an F with an expiration date of [DATE]. Review of the North Carolina Skilled Nursing Facility Preadmission Screening and Resident Review (PASRR) authorization codes document revealed a PASRR ending in F indicated a Level II: 30, 60, or 90 day authorization for time limited skilled nursing facility stays. The admission Minimum Data Set assessment dated [DATE] revealed Resident #62 was coded as Level II PASRR with mental retardation. An interview on [DATE] at 9:19 AM with the Admissions' Coordinator revealed since the Social Worker (SW) was no longer employed at the facility, she was responsible for initiating and coordinating Level II PASRR reviews. She stated she was aware that some resident's PASRR had expired and had submitted renewals for some residents but was unaware that Resident #62's PASRR had expired. An interview on [DATE] at 10:31 AM with the Administrator revealed the PASRR process was for the SW to review the PASRRs to ensure they were renewed in a timely manner, but he did not think that the prior SW had been doing this.

Based on record review, resident representative and staff interviews the facility failed to explain the arbitration agreement to the resident representatives prior to having them sign the agreement. This occurred for 2 of 4 residents (Resident #18 and Resident #4) reviewed for arbitration. Findings included: The facility's Resident and Facility Arbitration Agreement dated 8-1-22 did not document the facility had offered the resident and/or the resident representative the opportunity to read the document in full or have the document read to them for understanding of what they were signing. a. Resident #18 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired. A review of Resident #18's arbitration agreement form dated 2-27-23 revealed the resident's representative signed the arbitration agreement. Resident #18's representative was interviewed by telephone on 3-19-23 at 4:45pm. The representative stated the admissions coordinator had explained the form to her as a form needed in case something should happen to Resident #18's health, the Physician would be aware of the resident's wishes. The representative said the arbitration agreement was not explained to her as a legal document or that she was giving up her right to have any claims decided by a judge and [NAME]. She further stated she may not have signed the agreement if she understood what she was signing. b. Resident #4 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired. The review of Resident #4's arbitration agreement dated 2-16-23 revealed the resident's representative had signed the agreement. A telephone interview with the resident's representative occurred on 3-19-23 at 3:08pm. The representative stated she had received the arbitration agreement in the mail with a letter instructing her to sign the form and return it to the facility. She said no one had explained the agreement to her and she was unaware of what she was signing. The representative explained if the form had been explained to her and she understood what the arbitration agreement was, she would not have signed the agreement. The Admissions Coordinator was interviewed on 3-20-23 at 8:48am. The Admissions Coordinator discussed the facility receiving a new arbitration agreement from their legal department in August 2022. She stated once the new agreement was received, she proceeded in having the resident or their representatives sign the new agreement. The Admissions Coordinator explained some of the representatives were able to come to the facility to sign the agreement and other representatives had to have the new agreement sent to them by mail. She stated the representatives that came to the facility, she explained and/or read the agreement to them prior to them signing the agreement and the representatives that had their agreement mailed to them, she stated she told them she would explain the agreement if they had any questions. The Admissions Coordinator stated she was unaware of any of the representatives signing the agreement without understanding what they were signing. The Administrator was interviewed on 3-20-23 at 9:07am. The Administrator stated he would expect the residents and/or their representatives to have the arbitration agreement explained and to understand the arbitration agreement prior to signing.

Based on record review, resident representative and staff interviews the facility failed to include the selection of a venue that was convenient to both parties in the arbitration agreement. This occurred for 3 of 4 residents (Resident #18, Resident #50 and Resident #4) who entered into an arbitration agreement with the facility. Findings included: a. Resident #18 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was severely cognitively impaired. Review of the arbitration agreement signed on 2-27-23 by the resident's representative revealed there was no information to address the selection of a venue convenient to both parties. During a telephone interview with Resident #18's representative on 3-19-23 at 4:45pm, the representative stated the admissions coordinator had not explained to her the right to select a venue that was convenient to both parties. b. Resident #50 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was severely cognitively impaired. Review of the arbitration agreement signed on 2-15-23 by the resident's representative revealed there was no information to address the selection of a venue convenient to both parties. Resident #50's representative was interviewed by telephone on 3-19-23 at 3:00pm. The representative stated the arbitration agreement had been explained to her but she did not remember being informed of her right to select a venue that was convenient to both parties. c. Resident #4 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired. Review of the arbitration agreement signed on 2-16-23 by the resident's representative revealed there was no information to address the selection of a venue convenient to both parties. A telephone interview occurred with Resident #4's representative on 3-19-23 at 3:08pm. The representative stated the arbitration agreement was not explained to her and she did not remember reading anything in the agreement regarding her right to select a venue that was convenient to both parties. The Admissions Coordinator was interviewed on 3-20-23 at 8:48am. The Admissions Coordinator stated she was unaware of the parties involved in the arbitration agreement had the right to select a venue that was convenient to both parties. She stated when she explained the arbitration agreement to the resident or their representative she had not mentioned their right to select a venue. The Administrator was interviewed on 3-20-23 at 9:07am. The Administrator discussed not being employed by the facility when the new arbitration agreement had been released in August of 2022, so he had not reviewed the agreement. The Administrator explained he typically would review any new documentation requirements to ensure the document met regulation and he expected the arbitration agreement form to follow regulation.

Based on record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitoring interventions that the committee had previously put in place following the recertification and complaint investigation survey of 10-28-21. The deficiency was in the area of pre-admission screening and resident review (PASARR) (644). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag was cross referenced to: F644: Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASARR) before the expiration date for 1 of 2 residents reviewed with a Level II PASARR (Resident #62). During the recertification and complaint survey on 10-28-21, the facility was cited for not referring a resident who had a diagnosis of a mental illness for a pre-admission screening and resident review (PASARR). The Director of Nursing (DON) and the Administrator were interviewed on 3-22-23 at 12:13pm. The DON explained the Social Worker who initially completed the PASARR assessments in 2021 was replaced, however the replacement had left the facility and the facility currently did not have a Social Worker to complete the PASARR assessments. The DON stated the PASARR assessment for Resident #62 had fell through the cracks.

Based on record review and staff interviews the facility failed to post accurate nurse staffing information for 11 of 48 days reviewed for daily posted staffing. Findings included: Review of the daily posted staffing from February 2023 through March 2023 revealed the daily posted staffing sheets, with each individual staffing sheet reflecting all three shifts, were missing at least one shift of staffing information for the following days and shifts: -February 2023: 2/6/23, 2/10/23, 2/12/23, 2/13/23, 2/16/23, 2/24/23, 2/25/23 and 2/26/23 were missing staffing information on the 7:00am to 3:00pm. 2/16/23 was missing staffing information on the 3:00pm to 11:00pm shift. 2/28/23 was missing staffing information on the 11:00pm to 7:00am shift. -March 2023: 3/7/23 and 3/14/23 were missing staffing information on the 3:00pm to 11:00pm shift. During an interview with the Administrator and Director of Nursing (DON) on 3-22-23 at 12:11pm, the DON discussed each shift nurse on hall 400 was responsible for completing the daily posted staffing sheet and provided an example of the 7:00am to 3:00pm nurse on hall 400 would complete the 7:00am to 3:00pm section of the daily posted staffing sheet and the 3:00pm to 11:00pm 400 hall nurse would complete the 3:00pm to 11:00pm section of the daily posted staffing then the 11:00pm to 7:00am 400 hall nurse would complete the 11:00pm to 7:00am section. She discussed believing the daily posted staffing was not completed in part due to a new nurse, who worked 7:00am to 3:00pm on the 400 hall was focused on learning nursing duties and not on completing the daily posted staffing sheet. The DON also stated she could not state why the other shifts also had not completed their section of the daily posted staffing sheet.

Based on observations, record review and staff interviews the facility failed to: meet the requirement of 100 percent (%) staff COVID-19 vaccination rate which resulted in 2.2% of staff being partially vaccinated (Dietary Aide #1 and Housekeeper #1), implement an effective process for tracking COVID-19 vaccinations (Dietary Aide #2), and to follow their policy for source control at all times for staff who were not fully vaccinated (Dietary Aide #1). This was for 3 of 7 staff reviewed for COVID-19 vaccination status (Dietary Aide #1, Dietary Aide #2, and Housekeeper #1). The facility was not in outbreak status and had no positive cases of COVID-19 among residents. The facility's community transmission rate was moderate. Findings included: A review of the facility's Infection Control Manual last revised 12/12/22 Appendix A: COVID-19 Infection Prevention and Control Program Guidelines revealed in part, 9. Immunization Overview: [The facility] strives to provide and maintain a safe workplace for all employees, residents and visitors. Vaccinations have significantly reduced the mortality rate and provided for a reduction in serious illness of COVID-19 making nursing homes, both as a place to live and work, safer. In light of this, and in accordance with CMS (Centers for Medicare and Medicaid Services) mandates, [the facility] will require that all employees be fully vaccinated with some limited exceptions. Vaccination under this policy is a mandatory condition of employment unless a request for reasonable accommodation is approved. Vaccination Recommendations: a. Mandatory HCP (Health Care Personnel) Vaccination under this policy is a mandatory condition of employment unless a request for reasonable accommodation is approved. Applicants are required to be fully vaccinated and proof of full vaccination should be required at the time of hire. 3. Partial Vaccination: If the facility hires staff that are in the process of completing their vaccination series, these staff must follow the same guidelines as staff hired with approved exemptions which include wearing source control at all times. It further revealed, The facility should maintain a log of [health care personnel] which includes employees, contracted staff, volunteers, and/or students' vaccination status. Review of the COVID-19 Staff Vaccination Status Matrix provided by the facility on 3/20/23 revealed 3 staff members of 92 total facility staff were partially vaccinated without an exemption. a. Review of the vaccination documentation provided by the facility revealed Dietary Aide #1's first day of work at the facility was 10/18/22. Dietary Aide #1 received the first dose on 10/17/22 and had not received a second dose. Dietary Aide #1 did not have an approved exemption. Review of Dietary Aide #1's timecard documentation for 3/7/23 through 3/21/23 provided by the facility revealed she was present working in the facility on 3/9/23 through 3/12/23, 3/16/23, and 3/18/23 through 3/20/23. On 3/20/23 at 11:47 AM an observation of Dietary Aide #1 revealed she was working in the facility kitchen. She was not wearing a source control mask. An interview with Dietary Aide #1 at that time indicated she did not wear a source control mask when working in the facility unless the facility's community transmission level was high. She went on to say in addition to working in the kitchen, she would deliver resident meal carts to resident halls and if a resident came to the kitchen door with a request for something, she would provide this to the resident. b. Review of the vaccination documentation provided by the facility revealed Housekeeper #1's first day of work at the facility was 2/7/23. Housekeeper #1 received the first dose on 9/3/21 and had not received a second dose. Housekeeper #2 did not have an approved exemption. Review of Housekeeper #1's timecard documentation for 3/7/23 through 3/21/23 provided by the facility revealed she was present working in the facility on 3/8/23, 3/11/23 through 3/13/23, 3/15/23 through 3/17/23, and 3/20/23. On 3/20/23 at 1:03 PM an observation of Housekeeper #1 revealed she was working in the facility wearing a source control mask. On 3/20/23 at 3:05 PM an interview with the Housekeeping Supervisor indicated she was aware Housekeeper #1 was not fully vaccinated. She stated Housekeeper #1 was required to wear a source control mask when working because of this. On 3/21/23 at 1:33 PM a follow-up interview with the Housekeeping Supervisor indicated she had no role in ensuring employees received their vaccines. She stated the Staff Development Coordinator (SDC) did this and would let her know when employees received their vaccine. c. Review of the vaccination documentation provided by the facility revealed Dietary Aide #2's first day of work at the facility was 12/1/22. Dietary Aide #2 received the first dose on 11/30/22 and had not received a second dose. Dietary Aide #2 did not have an approved exemption. Review of Dietary Aide #2's timecard documentation for 3/7/23 through 3/21/23 provided by the facility revealed he was present working in the facility on 3/10/23 through 3/13/23 and on 3/21/23. On 3/21/23 at 1:23 PM an observation of Dietary Aide #2 revealed he was working in the facility kitchen. He was not wearing a source control mask. In an interview at that time Dietary Aide #2 stated he did not wear a source control mask when working. He stated he had gotten the second dose of vaccine but had not provided the information to the facility. He stated he did not have his vaccine card with him and did not recall when he had gotten his second dose. On 3/21/23 at 3:31 PM an interview with the facility Infection Preventionist (IP) indicated the Staff Development Coordinator (SDC) was responsible for ensuring staff were fully vaccinated. He stated it was his understanding that employees were required to be fully vaccinated or have an approved exemption. He went on to say employees who were not fully vaccinated or had exemptions were required to wear source control masks when working even if the facility's community transmission level was not high. On 3/21/23 at 1:49 PM an interview with the SDC she indicated she had no information regarding Dietary Aide #2 receiving his second dose of vaccine. She stated it used to be that employees had to be fully vaccinated when they were hired but it had gotten looser lately. She went on to say now employees could be hired if they had received their first dose of vaccine if they received their second dose in a timely manner. She further indicated she would notify department heads if employees were not fully vaccinated or had exemptions because these employees were required to wear source control masks when working. The SDC stated she let the Dietary Manager know that Dietary Aide #1 and Dietary Aide #2 were not fully vaccinated. She went on to say she had not seen Dietary Aide #2 in a while. She went on to say she had spoken to Dietary Aide #1 last week and let her know that the facility was going to get some vaccine ordered and she would give her second dose. She further indicated Housekeeper #1 had a bad reaction to her first dose of the vaccine and was hesitant to get a second dose. The SDC stated she let Housekeeper #1 know she would have to get a doctor's note and an approved exemption if she did not want to get it. She went on to say this had not happened yet. She further indicated she really did not think it was a big rush for employees to get the second dose. She stated Dietary Aide #1, Dietary Aide #2, and Housekeeper #1 should be wearing source control masks while working until they provided proof of being fully vaccinated. On 3/21/23 at 1:51 PM an interview with the Dietary Manager indicated when she first took over as the Dietary Manager the previous Dietary Manager let her know that she had 2 employees in the kitchen who had been granted vaccine exemptions. She stated she was aware that these 2 employees with exemptions were required to wear source control masks when they worked. She further indicated she did not keep up with staff vaccination status and had been unaware that Dietary Aide #1 and Dietary Aide #2 were not fully vaccinated. The Dietary Manager went on to say while she did monitor the exempted employees for mask wearing and she had not been monitoring Dietary Aide #1 and Dietary Aide #2. On 3/22/23 at 11:36 AM an interview with the Administrator indicated he thought what was happening was the facility was not following up with tracking employee vaccination status. He stated his role in this process was minimal. He went on to say the SDC gathered employee vaccination status on hire and reported that to him. He further indicated he entered the information into the tracking tool. The Administrator stated the SDC needed to track to be sure employees who were not fully vaccinated either had an approved exemption or got their second dose of vaccine when they were eligible. He further indicated he was not sure whether it was the facility's policy that employees needed to be fully vaccinated on hire as he had not read it.

Based on staff and responsible party interviews, and record review the facility failed to allow a resident with exit seeking and aggressive behaviors to remain in the facility and failed to provide written documentation which specified the resident's needs the facility could not meet as well as the attempts made by the facility to meet those needs for 1 of 1 resident reviewed for facility initiated discharge (Resident #124). The findings included: Resident #124 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #124's minimum data set assessment (MDS), a quarterly assessment dated [DATE], revealed severe cognitive impairment. He had delusions. Resident #124 had daily behaviors not directed towards others, rejection of care 1-3 days, and daily wandering. He required extensive assistance with two or more person assist for bed mobility and transfers. He required supervision from one person for walking and locomotion. Resident #124 received antipsychotic medication on 7 of 7 days. Resident #124's care plan, last reviewed on 6/16/21, revealed the following problem areas: - Use of [CONDITION(S)] drugs related to anxiety/aggressive behaviors. This area was initiated on 3/29/21. The goal area indicated Resident #124 would show improvement in mood/behavior through the next review. The interventions, also implemented on 3/29/21 included, in part to administer medications according to physician orders. - Acts characterized by ineffective coping such as wandering and risk for unsupervised exits from the facility related to cognitive impairment and restlessness. This area was initiated on 6/14/21. The goal area indicated Resident #124 was to have no episodes of unsupervised exits from the facility through the next review. The interventions, also implemented on 6/14/21, included allow resident to wander on the unit and wander guard alarm bracelet to right ankle. A social work progress note dated 7/20/21 revealed a phone call with Resident #124's Responsible Party (RP) which discussed Resident #124's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RP was informed Resident #124 required a more structured environment for safety issues and quality of life. She was informed a facility with a secure unit had extended an offer of acceptance. The RP declined the alternative placement. Record review revealed a letter dated 7/21/21 that stated Resident #124 was going to discharged on [DATE] because of the inability of the facility to meet his needs as he needed a locked unit. The letter further stated Resident #124's responsible party was notified by telephone. A social work progress note dated 7/21/21 revealed a phone call was made to Resident #124's RP to inform her the resident required a more structured environment and another facility had extended an offer of acceptance. The RP declined the alternative placement. Record review revealed Resident #124 discharged home with his responsible party on 7/26/21. Review of Resident #124's record revealed no documentation by the Physician of specific needs the facility could not meet or facility efforts to meet those needs. During an interview with the social worker on 10/11/21 at 3:06 PM he stated he found placement for Resident #124 in another facility with a locked unit and Resident #124's responsible party stated rather than allow him to transfer to another facility she would take him back to his home. He stated he had not known Resident #124's RP's reasons for rejecting the alternative placement. The social worker further stated he had discussed Resident #124's behaviors with Resident #124's RP prior to 7/20/21 but had not documented those discussions in the record. An interview was conducted with Resident #124's RP on 10/28/21 at 8:20 AM. She reported she was unaware that Resident #124 was in danger of being discharged from the facility until she was contacted about the alternate placement found by the social worker on 7/21/21. She stated the alternative facility found by the social worker was not local and would have prevented her from being able to visit as she does not drive. The RP reported Resident #124 cared for Resident #124 when he returned to the home and all his needs were met. An interview was conducted with the Administrator on 10/13/21 at 10:00 AM in which she stated Resident #124's record should have reflected the facility's efforts to meet Resident #124's needs and the needs the facility were unable to meet as required by regulation.

Based on record review, staff interviews, hospital records and medical examiner review, the facility failed to provide constant supervision during toileting for a cognitively impaired resident who was at risk for falls and fell during toileting while unsupervised. The fall resulted in right subdural hematoma (a pool of blood between the brain and its outmost covering) and [MEDICAL CONDITION] vertebra (T1). (Resident #1). Immediate jeopardy began on 01/09/19 when Resident #1 had been left unattended in the bathroom and subsequently fell which caused her to sustain a right subdural hematoma and T1 fracture. The Immediate Jeopardy was removed on 02/23/19 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow for on-going in-servicing and monitoring to be accomplished. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. A review of Resident #1's Fall Risk Evaluation, dated 12/22/18, revealed a score of 16. Instructions on the form indicated a total score of 10 or higher revealed the resident is at risk for falls. A review of Resident #1's Care Plan, last updated on 12/25/18, revealed the following: 1. Activities of Daily Living (ADL)/Personal Care with a goal ADLs/Personal Care will be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. Interventions included, in part, transfers - stand-by assist, provide supervision, cueing, encouragement; toileting - one-person constant supervision and physical assistance for safety to adjust clothing, wash hands and peri-care. 2. Progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought processes related to dementia with a goal resident's safety awareness will improve from marked impairment to mild impairment by next review. Interventions included speech therapy. 3. Risk for falls characterized by history of falls/actual falls, multiple risk factors related to weakness, impaired cognition and resident's attempts to transfer and ambulate without assistance with a goal resident will not sustain serious injury through next review. Interventions included, in part, reminder sign in room to encourage resident to call and wait for assistance with transfers and ambulation, keep call light within reach and answer timely, observe and intervene for factors causing falls and resident to wear proper and non-slip footwear. A review of Resident #1's Resident Care Guide (a communication tool used by staff for direction in the care needs of the resident), last updated 12/25/18, indicated Resident #1 had been placed on falls precautions, had required the use of non-skid footwear and had transferred with stand-by assist. The Resident Care Guide indicated Resident #1 had required one-person constant supervision and physical assistance for safety to adjust clothing, wash hands and peri-care during toileting. A review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had been severely cognitively impaired and required extensive assistance with a 1-person physical assist for toileting. The MDS indicated Resident #1 had not been steady and had only been able to stabilize with staff assistance during transitions and walking. The MDS indicated Resident #1 required the use of a walker or a wheelchair as a mobility device. A review of Resident #1's Care Area Assessment (CAA), dated 12/29/18, revealed Resident #1 had not been steady when moving on and off the toilet and had only been able to stabilize with staff assistance. The Analysis of Findings indicated the problem/need had been actual and stated the nature of the problem/condition as follows: Resident #1 was admitted to this facility from home on 12/22/18 . Her [DIAGNOSES REDACTED]. She is dependent on staff for assistance with all Activities of Daily Living (ADLs) . She has exhibited continence since admission, despite need for assistance with toileting. Resident attempts to perform transfers and ambulation without assistance due to her inability to recognize limitations and she has had falls since admission. The CAA indicated Resident #1's underlying problems that may affect function included changing cognitive status, mood decline and fall. The CAA indicated Resident #1's physical limitations such as weakness, limited range of motion, poor coordination, poor balance, visual impairment or pain resulted in her need for assistance with any of the ADLs. A review of the Incident/Accident reports revealed Resident #1 had three falls from her admission on 12/22/18 to her discharge on 01/09/19. Resident #1 had an unwitnessed fall without injury in her room on 12/23/18. Nurse #1 completed the Incident Report which included the following description: At 5:05 a.m., resident was observed lying on floor on her back trying to lift her torso in an attempt to get up from the floor. Resident's head was near left side of bed and feet were facing window. Resident alert and oriented to self. Denied hitting her head. Active range of motion (AROM) times four. Denied any pain. Resident's socks were removed and grip slippers applied. Assisted to standing position by two staff. Able to bear full weight without pain or difficulty. Assisted to bathroom by one staff with use of walker . Assisted back to bed . Call bell in reach. Bed maintained in low position. During an interview with Nurse #1 on 02/21/19 at 3:33 p.m., Nurse #1 stated she had been the nurse assigned to care for Resident #1 on 12/23/18. Nurse #1 stated Resident #1 had been in her bed prior to the fall and the fall had been unwitnessed. Nurse #1 stated she did not recall how she had been made aware of Resident #1's fall. Nurse #1 stated she went to Resident #1's room and the resident was not lying flat on the floor, her torso was halfway up. Nurse #1 stated she had completed a head-to-toe assessment on the resident which had been negative for injuries. Nurse #1 had asked the resident if she was okay and stated the resident had denied pain. Nurse #1 stated she had also observed the resident for non-verbal signs of pain and there had been none. Nurse #1 stated she had thought Resident #1 had been on her way to the bathroom and she had noticed the resident did not have on non-skid socks which she removed and replaced with non-skid socks and then assisted her to the bathroom and then back to bed. Nurse #1 stated Resident #1 had a history of [REDACTED].#1 had called for assistance. Resident #1 had an unwitnessed fall which resulted in a skin tear over her left eye on 12/28/18 at 3:11 p.m. Nurse #2 completed the Incident Report which included the following description: Code green (resident fall) called to room [ROOM NUMBER]. Resident found on bathroom floor. Injury noted skin tear over left eye. Medical Doctor (MD) and daughter notified. Area cleansed with normal saline solution (NSS), skin prep applied. Area measures 2 centimeters (cm), well approximated, steri-strips (wound closure strips) applied. No dressing, left open to air. Non-skid footwear in use. Intervention, when awake, will be at nurses' station or with staff as resident allows. No other injury noted. Assisted to wheelchair and brought to nurses' station. During an interview with Nurse #2 on 02/21/19 at 4:11 p.m., Nurse #2 stated she had been working on 12/28/19 as the Quality Improvement nurse. Nurse #2 stated whenever a Code Green is announced, all available staff respond. Nurse #2 stated she had helped out the nurse assigned to Resident #1 after the resident had fallen. Nurse #2 stated Resident #1 had sustained a skin tear over one of her eyes as a result of the fall but could not recall whether it had been over the left or right eye. Nurse #2 stated she had cleansed the skin tear and approximated the wound edges with steri-strips. Nurse #2 stated she had wanted to ice the wound however Resident #1 would not allow it. Nurse #2 stated notifications had been made to the MD and the responsible party and neurological (neuro) checks had been performed on the resident. Nurse #2 stated Resident #1 had been at her baseline confusion after the fall. Resident #1 had an unwitnessed fall on 01/09/19 at 2:32 a.m. Nurse #3 completed the Incident Report which included the following description: called by Nursing Assistant (NA) to resident bathroom. Resident observed sitting on floor with walker in front of her. Stated she fell attempting to ambulate from bathroom. Resident assisted up and ambulated with walker with stand-by assist back to bed. Denies complaints of injury. Resident assessed and no apparent injury noted. Neuro checks unchanged. Resident reoriented to calling for assistance, even has signs in room. During an interview with Nurse #3 on 02/21/19 at 3:35 p.m., Nurse #3 stated she had been the nurse assigned to care for Resident #1 on 01/09/19. Nurse #3 stated she did not witness Resident #1's fall. Nurse #3 stated the NA had told her she had turned her back on the resident for a second to get the walker to bring it to the bathroom and when she returned, the resident was on the floor, against the wall in an L shape, close to the toilet paper holder. When asked if the NA had left the bathroom, Nurse #3 stated she did not know. When asked if she investigated the cause of the fall, Nurse #3 stated she just knew what the NA had told her. Nurse #3 stated she had performed a head-to-toe assessment of the resident and it had been negative for injury. Nurse #3 stated neuro checks performed on the resident had been negative. Nurse #3 stated she and the NA stood the resident and she asked the resident if she was hurting and the resident stated no. Nurse #3 stated Resident #1 had been known for not waiting for assistance and her balance had been off. Nurse #3 stated Resident #1 had been able to walk but had always been very unsteady on her feet and the resident would often jump right up without using her walker. When asked about her intervention of re-orienting a cognitively impaired resident to call for assistance, Nurse #3 stated she had been taught by the board of nursing to always educate a patient even if the patient was not able to retain the information. During interviews with NA #1 on 02/22/19 at 10:10 a.m. and 02/23/19 at 5:28 a.m. , NA #1 stated she had been an NA for [AGE] years and had worked at the facility for 5 years. NA #1 stated she had been the NA assigned to care for Resident #1 from 11:00 p.m. on 01/08/19 until 7:00 a.m. on 01/09/19. NA #1 stated she had been making her rounds when she noticed Resident #1 sitting up on the side of her bed. NA #1 stated she entered the resident's room and asked her if she needed something. NA #1 stated the resident told her she had to use the bathroom. NA #1 stated she had raised the bed, put shoes on the resident and got the resident's walker. When asked how she knew the resident's transfer needs, NA #1 stated she asked the resident if she could walk and stated the resident told her she could. NA #1 stated she took Resident #1 to the bathroom and the resident sat on the toilet. NA #1 stated she gave Resident #1 about 10 minutes and then asked her if she was ready to get up and stated the resident told her no because she had needed to have a bowel movement. NA #1 stated she then told the resident, don't move, sit here, I'm going to straighten the bed up, let me know when you're ready. NA #1 stated at that time she did not know whether or not Resident #1 had Alzheimer's but she had been able to answer her questions. NA #1 stated she had been at the resident's bed straightening it up when she heard a bump noise in the bathroom and stated she returned to the bathroom and found the resident on her knees. NA #1 stated she had asked Resident #1 if she had been hurt and stated the resident had said no. NA #1 stated she told the resident to sit there a while, put the walker near her, and called for Nurse #3 to come to the bathroom. NA #1 stated Nurse #3 entered the bathroom and had asked the resident if she was hurt and the resident stated no. NA #1 stated Nurse #3 checked the resident's body for bruises and none were noticed. NA #1 stated she and Nurse #3 stood the resident and took her back to her bed. When asked how residents' care needs are communicated to her, NA #1 indicated she would get a verbal report from the off-going NA or read the resident Point of Care (P[NAME]) in the electronic health record. NA #1 stated this had been the first time she had cared for Resident #1 and stated she had not been aware of the resident's history of falls or cognitive status. NA #1 stated she had not received verbal report from the off-going NA nor read Resident #1's P[NAME] prior to beginning her shift on 01/08/19. NA #1 stated she had planned on talking with Resident #1's nurse prior to beginning of her shift on 01/08/19 but could not find her at the time and began her duties. A review of therapy notes, dated 01/09/19, revealed the following: 1. 9:50 a.m. - patient participated in transfer training to increase level of independence. Patient performed supine to sit with moderate assistance. Patient reports pain in low back. Patient transferred from bed to wheelchair with moderate assist secondary to low back . Notified nurse of patient reports of low back pain. 2. 1:10 pm - patient performed 6 reciprocal steps with lumbar, [MEDICATION NAME] and cervical region flexion along with shuffling gait pattern during gait training with rolling walker, minimal assist and wheelchair follow when patient reported increased pain in lumbar back and required a prolonged seated rest break and reported pain 6/10 after rest break. 3. 2:47 p.m. - patient complained of back pain and discomfort, her nurse was already aware. A review of nurse progress notes revealed the following: 1. 01/09/19 at 1:19 p.m. - obtained order from doctor . via telephone order for lumbar spine x-ray with complaint of lower back pain. 2. 01/09/19 at 3:24 p.m. - complaint of lower back pain; PRN (as needed) pain medication given without any relief. Lumbar spine x-ray ordered. 3. 01/09/19 at 6:36 p.m. - observed resident is in excruciating pain during diagnostic procedure, was not able to tolerate. Order to send to emergency department (ED) for further evaluation and treatment. Responsible Representative (RR) is present. Rescue was called. 4. 01/10/19 at 6:59 a.m. - this nurse called (local hospital) to follow up on resident and was informed that she was being sent to (trauma center) for fractured back . 5. 01/10/19 at 2:40 p.m. - 01/09/19 as day progressed mid-morning to afternoon, resident began to complain of low back pain. MD re-called and order for mobile x-ray obtained. X-ray attempted, resident in pain and daughter asked if resident to go to the ED. New order obtained to transport to ED for evaluation . A review of Resident #1's Medication Administration Record [REDACTED] A review of the Nursing Home to Hospital Transfer Form, dated 01/09/19, listed the reason for Resident #1's transfer to the hospital as pain (uncontrolled). A review of the hospital records indicated Resident #1 had been transferred to a local hospital and then transferred to a trauma center at another hospital. A review of the local hospital ED notes, dated 01/09/19, revealed the following: 1. History of Presenting Illness - . presents to the Emergency Department (ED) after having several falls over the past few weeks, most recently this morning when she was getting up from the toilet . the patient's daughter is at bedside and reports that the patient as had approximately 5 falls in the past few weeks. She reports that she hit her head during some of those falls but the daughter is unsure if she hit her head this morning. Upon Emergency Medical Services (EMS) arrival, the patient was complaining of lumbar back pain and EMS administered 75 mcg of [MEDICATION NAME] (an opiate pain medication) prior to arrival . Patient denies any complaints at this time. 2. Computed tomography (CT) spine cervical without contrast - T1 moderate acute compression fracture. 3. CT head or brain without contrast - interval development of mild temporoparietal subdural hemorrhage. This appears to be subacute in nature. 4. Review of Systems: musculoskeletal - no back pain, neck pain, joint pain, muscle pain, normal range of motion and strength x 4, no tenderness or swelling; neurologic - no headaches, focal weakness, numbness, speech problems, steady gait; general - alert and oriented x 2, no focal deficits, grasps strong and equal bilaterally; eyes - patient's left pupil is irregularly shaped and 4 millimeters (mm) in diameter. Her right pupil is 2 mm. 5. Medical Decision Making: .patient denies any complaints at this time. Upon assessment the patient is oriented to self which the daughter reports is her baseline. She is awake and alert. Her grasps are strong and equal bilaterally. She moves all 4 extremities independently and to command. She has no focal weaknesses appreciated. The patient's pupils, however, are unequal. Her left pupil is irregularly shaped and approximately 4 mm in size. Her right pupil is 2mm and round. The patient's daughter denies any known history of irregularly shaped or unequal pupils. She denies any neck pain or back pain at this time. She does not grimace upon rotation of her hips or movement of her knees, elbows, shoulders. Denis any neck pain . The patient does have a healing laceration to the left portion of her forehead, approximately 3 centimeters (cm) in length . The patient's head CT did reveal a right temporoparietal subdural hemorrhage that appears to be subacute in nature. 6. Clinical Impression: 1) right subdural hemorrhage; 2) T1 compression fracture; 3) fall; 4) dementia; 5) [MEDICAL CONDITION] A review of Resident #1's trauma center's discharge summary, dated 01/17/19 revealed .does not respond verbally much. Grunting slowly. Not in any acute serious distress. admitted initially after fall at nursing home. Found to have acute on chronic subdural hematoma. Was admitted under trauma service. Family decided for palliative care and comfort measures. She was transferred to palliative care unit overnight. All non-comfort medications were stopped. Discussed with doctor . about plan of care. She requested patient to be transferred to inpatient hospice services. A review of Resident #1's Certificate of Death, dated 01/19/19, indicated the immediate cause of the resident's death to be complications of [MEDICATION NAME] force injury of head and back. The Medical Examiner indicated the injury occurred as fell , struck head and back and listed the location of the fall as the address of the nursing facility. During an interview with the Medical Examiner on 03/01/19 at 2:05 p.m., the Medical Examiner stated Resident #1's fall of 01/09/19 played a significant role in her death. The Medical Examiner stated Resident #1's death was brought about from complications of the fall. During an interview with the Director of Nursing (DON) on 02/23/19 at 9:34 a.m., the DON stated it was her expectation nursing staff follow the care guide they have set up for them to use when caring for a resident. During an interview with the Administrator on 02/23/19 at 9:52 a.m., the Administrator stated it was his expectation staff provide residents the care they need as set up in their individualized plan of care. The Administrator was notified of the Immediate Jeopardy on 02/22/19 at 4:30 p.m. On 02/23/19, the facility provided the following credible allegation of Immediate Jeopardy removal: The process that lead to deficiency Resident # 1 is alert and oriented to self. Resident [DIAGNOSES REDACTED]. On 1/9/19 at 2:32 am the assigned 11-7 shift nursing assistant put resident's shoes on and walked resident to the bathroom with assistance of a walker. Once in the bathroom, the Nursing assistant assisted resident with lifting gown, removing the brief, and sitting on the toilet. Nursing assistant left resident in the bathroom to provide privacy while standing at the door. Resident needed more time to have a bowel movement so nursing assistant went to the bed to pull resident's covers back. While pulling the bed covers back, nursing assistant heard a noise in the bathroom. Nursing assistant checked the bathroom and found resident on knees on the floor. Neurological check was completed by assigned hall nurse with no abnormal findings and no injury to resident. On 1/9/19 at approximately 7:30 am, the resident representative and physician was notified of resident #1 fall with no injury. The 11-7 assigned nursing assistant was trained on safe handling and movement which includes reading the resident care guides prior to resident care during orientation on 6/6/14 by the Director of Nursing. The nursing assistant's most recent training on reading the resident's care guide prior to providing care was on 10/5/18 by the Director of Nursing. On 1/9/19 at 9:50am -10:31am resident #1 completed physical therapy with no complaints of pain initially but later complained of lower back pain. At 10:30 am, the assigned hall nurse was notified of resident's pain and reassessed the resident with pain medication administered. On 1/9/19 at 1:10pm-1:40pm resident attended physical therapy with complaint of pain. The hall nurse was notified, reassessed the resident, administered pain medication, and notified the physician of resident's pain. The Physician gave order to obtain lumbar spine x-ray. On 1/9/19 at 6:30pm resident #1 was unable to complete in-house x-ray due to complaints of pain and was sent to the emergency room via emergency medical services for further evaluation. Daughter of resident #1 was at bedside. Resident #1 never returned to the facility. --The procedure to implement a plan of Immediate Jeopardy removal for specific deficiency 100% of all residents' care guides and care plans will be audited on 2/22/19 by the DON and MDS nurse to ensure the care guide and care plan accurately address the residents need for supervision related to toileting and at risk for falls. The care plan and care guide will be updated for interventions to include required supervision related to toileting and at risk for falls during the audits for any identified area of concern. The audit will be completed by 2/22/19. 100% audit of all falls x 30 days was initiated on 2/21/19 by the Facility Consultant to ensure all incidents were investigated for root cause with appropriate interventions initiated based on the root cause, resident was assessed following incident, physician /Resident Representative (RR) notified, and care plan/care guide updated. All areas of concern will be immediately addressed by the Director of Nursing (DON) to include assessment of resident, investigating incident to determine root cause, initiating appropriate interventions based on root cause, notification of Physician/RR and updating care plan/care guide with any new interventions. The audit will be completed by 2/22/19. 100% observation of all nursing assistants and nurses was initiated on 2/22/19 by the Director of Nursing (DON), Minimum Data Set (MDS) nurse and Admission nurse to ensure the care guides and care plans are being read in the mobile iPads and followed for required supervision during toileting to prevent accidents. All areas of concern will be addressed during the audit by the DON, MDS nurse and Admission nurse to include re-training of the nursing assistant and/or nurse. The audit will be completed by 2/22/19. After 2/22/19 any nursing assistant or nurse that has not worked will be audited on the next scheduled shift. 100% in-service of nursing assistants and nurses was initiated by the Admission nurse on 2/22/19 in regards to (1) reading and following the resident care guide and care plan located in the mobile iPad for required supervision and at high risk for falls during toileting to prevent accidents. (2) Definition of constant supervision to include within arm's reach and eyes view of the resident at all times. In-services will be completed by 2/22/19. After 2/22/19, the Medical Records Director will mail the in-services via certified mail to any nursing assistant or nurse who has not received the in-service with instructions to review, sign the in-service, and return to the DON or Admission Nurse prior to next scheduled work shift. All newly hired nursing assistants and nurses will be in-serviced by the Staff Facilitator during orientation. --The procedure for monitoring the plan of Immediate Jeopardy removal The decision to monitor required supervision during toileting was made by the Administrator on 2/22/19. Nurses and nursing assistant are required to read the resident care guide located in the mobile iPads for updates of care to include interventions for residents that require supervision during toileting and are at risk for falls. 25% of nurses and nursing assistants will be observed during toileting and residents at risk for falls by the Admission nurse, treatment nurse and MDS nurse utilizing the Resident Care Toileting Audit Tool weekly x 8 weeks then monthly x 1 month. This audit is to ensure nurses and nursing assistants are reading and following care guide and care plan located in the mobile iPads in regards to providing supervision with toileting to prevent accidents. All areas of concern will be immediately addressed by the Admission nurse, MDS nurse and treatment nurse to include re-training of staff during the audit. The DON will review and initial the Resident Care Toileting Audit Tool weekly x 8 weeks then monthly x 1 month to ensure all areas of concern were addressed. The initial Quality Assurance (QA) meeting to review the plan of Immediate Jeopardy removal was held on 2/22/2019. The DON will forward the Resident Care Toileting Audit Tool to the Executive QA Committee monthly x 3 months. The Executive QA Committee will meet monthly x 3 months and review the Resident Care Toileting Audit Tool to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. --The title of person responsible for implementing the plan of Immediate Jeopardy removal The Administrator and DON are responsible for the implementation of corrective actions to include all 100% audits, in-service and monitoring related to the plan of Immediate Jeopardy removal. --Date corrective action completion Final Immediate Jeopardy removal date was 2/22/19. The Credible Allegation for Immediate Jeopardy removal was validated on 02/23/19 which removed the Immediate Jeopardy on 02/22/19. Interviews were conducted with nursing staff present in the facility on 02/23/19. The staff confirmed the recent in-services and trainings related to following the plan of care as described in the residents' Care Guides and the definition of constant supervision. Reviews of the in-service records, audit tools, audits performed and facility assessments were made.