Every finding on record at Hickory Falls Health and Rehabilitation

Based on record review and staff, Nurse Practitioner and Medical Director interviews, the facility failed to maintain a complete and accurate medical record when identification of a new pressure injury and the completion of wound treatments were not documented in the medical record for 1 of 3 residents reviewed for accurate medical record (Resident #303). The findings included: Resident #303 was admitted to the facility on [DATE]. A physician's order dated 1/3/2025 read: Cleanse sacrum with wound cleanser, pat dry, apply betadine and secure with foam patch once a day was written by the Wound Nurse. Review of the medical record revealed no documentation regarding a change in Resident #303's skin integrity on 1/3/2025. A physician's order dated 1/15/2025 that read cleanse sacrum with wound cleanser, pat dry, apply calcium alginate and secure with foam patch once a day. Review of Resident #303's January Treatment Administration Record (TAR) revealed there were two days when ordered treatments had no documentation on the TAR (1/16/2025 and 1/17/2025) and four days documented as not administered other (1/6/2025, 1/8/2025, 1/13/2025, and 1/24/2025). During a telephone interview on 05/21/25 8:35 AM NA #2 stated she was familiar with Resident #303. NA #2 stated Resident #303 had frequent loose bowel movements and redness to her bottom and a barrier cream was applied. NA # 2 stated she remembered reporting a new skin issue for Resident #303 to the Wound Nurse on 1/3/2025, but did not recall what the skin issue was. NA #2 explained if she reported it to the Wound Nurse, it would have been more than redness because that is why the barrier cream was applied. During an interview on 5/20/2025 at 2:59 PM the Wound Nurse stated she was notified of a new skin issue for Resident #303 on 1/3/2025. The Wound Nurse stated she assessed Resident #303 and must have seen a dark purple spot on Resident #303's sacrum since the order that was obtained was for betadine and a cover dressing, which is the treatment normally utilized for deep tissue injury wounds. The Wound Nurse stated she measured the area, obtained an order for treatment and notified the MDS department so the care plan would be updated. The Wound Nurse stated she did not know why she did not document the new pressure injury for Resident #303 on 1/3/2025 and stated she normally documents new skin issues. The Wound Nurse verified the documentation on Resident #303's TAR showed no treatment completed on 1/16/2025 and 1/17/2025, and documentation on 1/6/2025, 1/8/2025, 1/13/2025 and 1/24/2025 that revealed the ordered treatment was documented and not administered other. The wound nurse stated if she was working the treatments were completed, but she may not have signed the TAR. The wound nurse stated she is normally in the facility until around 4:45 PM but the treatment orders show on the electronic medication administration record as late after 3:00 PM and sometimes the second shift nurses sign it off as not administered to remove it from their screen. Review of the facility's daily staffing sheets from January 2025 revealed the wound nurse was scheduled on 1/6/2025, 1/8/2025, 1/13/2025, 1/16/2025, 1/17/2025, and 1/24/2025. During a telephone interview with Nurse #2 she verified when she signed not administered other on 1/8/2025, 1/13/2025 and 1/24/2025 she had not completed the treatment because it was ordered for 1st shift and showing not completed on her screen. During an interview on 5/20/2025 at 4:45 PM the Nurse Practitioner (NP) stated a new skin issue should be documented in the medical record when it was discovered. During a telephone interview on 5/21/2025 at 8:19 AM the Medical Director stated he would expect the nurses to complete documentation to the best of their ability when a new pressure injury was identified. The Medical Director stated he expected ordered treatments be documented accurately to the best ability of the nurse. During an interview with the Director of Nursing (DON) on 5/20/2025 at 4:35 PM the DON stated she expected the TAR to be completed accurately and for documentation to reflect care provided. During an interview on 5/21/2025 at 10:03 AM the Administrator stated he expected for the medical record documentation to be complete and accurate.

Based on observations, record review and staff interviews, the facility failed to clean and disinfect an individually assigned glucometer per manufacturer recommendations and the facility also failed to follow their infection control policy when staff wore a torn glove during blood glucose check for 1 of 3 staff observed during blood glucose monitoring (Nurse #3). Findings included: A review of facility policy entitled Blood Glucose Monitoring last updated 01/02/25 stated the nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Individual glucometers for residents must have proper identification to distinguish between residents and these should not be shared between residents. A review of facility policy entitled Personal Protective Equipment last updated 01/02/25 under section indications/consideration for PPE - gloves stated change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. A review of the manufacturer's cleaning and disinfection procedure guide, the glucometer should be cleaned with an Environmental Protection Act (EPA) approved disinfectant after use on each patient. Hand sanitizing wipes were not listed as an appropriate disinfectant for glucometers on the manufacture's guide. Super Sani-cloth Germicidal disposable wipes were listed as an approved disinfectant on the manufacturer's cleaning instructions, and the facility had these wipes available on the medication cart. An observation of Nurse #3 who performed blood glucose check on Resident #109 on 05/19/25 at 11:57 AM revealed that Nurse #3 obtained Resident #109's glucometer from the drawer on medication cart. Glucometer was stored in the protective case labeled with Resident #109's name. Nurse #3 then cleaned the individually assigned glucometer with alcohol-based hand disinfectant wipes prior to use. She was observed applying gloves and the glove on left hand was torn over the entire palm area. She entered the room to check Resident #109's blood glucose level. Blood glucose check was performed while Nurse #3 wore the torn glove. An error message on glucometer indicated insufficient sample and she was not able to obtain glucose level on the first attempt. Nurse #3 wore the same torn glove to obtain a new glucometer test strip out of container to recheck blood glucose a second time. She then performed the blood glucose check again. Nurse #3 was able to obtain blood glucose level on second attempt. The glove remained torn during both blood glucose checks. She removed the torn, used gloves after completion of procedure and disposed of them in the trash. She then cleaned the glucometer with the alcohol-based hand disinfectant wipes after use. The glucometer was returned to the individual case labeled with Resident #109's name and stored in the drawer in the medication cart. During an interview with Nurse #3 on 05/19/25 at 12:11 PM she stated that she was not aware that her glove was torn during the blood glucose check. She stated that her understanding of the disinfection of glucometers was to use sani wipes and the disinfecting hand wipes say sani on them, so she thought that was sufficient. She stated she thought the disinfectant hand wipes were adequate and she was not familiar with the manufacturer's glucometer disinfection recommendations. An interview with the Director of Nursing on 05/19/25 at 1:06 PM revealed that the expectation was for the facility's blood glucose monitoring policy to be implemented during blood glucose checks. Intact gloves were to be worn during the procedure. Her expectation would be that the nurse would stop and change out glove if torn or damaged. According to the manufacturer's directions, alcohol-based hand disinfectant wipes were not approved to disinfect the glucometer and purple top disinfectant wipes were to be used.

Based on observations, record review, and resident, staff, NP and Law Enforcement Detective interviews the facility failed to protect a resident's right to be free from physical abuse when Nurse Aide (NA) #1 punched Resident #1 in the face. On 5/9/24 Resident #1 was sent to the Emergency Department (ED) for evaluation where it was noted the resident had significant bruising around the left eye and a small laceration at the corner of the left eye. A CT (computed tomography) scan of the head was completed and confirmed comminuted fractures (fracture in at least 2 places) of the left nasal bone, left maxillary sinus wall, left maxilla (the bone that forms the upper jaw) and left orbital rim (broken bone in the outer edge of the eye socket). Resident #1 returned to the facility on [DATE]. Resident #1 was seen by an ENT (ear, nose, and throat) Provider on 5/21/24 and was scheduled for surgical repair of the fracture of left nasal septum (the thin wall that separates the nostrils) on 6/5/24. A reasonable person would expect to be free from physical abuse in their own home and could experience anger, fear, apathy and depression. This affected 1 of 3 residents reviewed for abuse (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of dementia. A quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #1 had severe cognitive impairment; dependent with toileting hygiene, showering, and dressing; maximal assistance with personal hygiene, bed mobility, sit to stand, lying to sitting on side of the bed, chair/bed to chair transfers; dependent on staff for transfers to toilet and shower; and rejected care 1 to 3 days. Resident #1 was care planned for the following: 9/11/23 - mood- At risk for combative behaviors during direct care with interventions to administer medications according to physician orders, be alerted to mood changes, sleep pattern, appetite, and behaviors; explain procedures prior to doing care. 8/31/23 - behavioral symptoms- Maintain a calm environment and approach the resident. During a phone interview on 5/22/24 at 11:14 am Nurse Aide (NA) #2 revealed she worked on 5/9/24 (3:00 pm -11:00 pm shift) and as she entered Resident #1's room about 3:15 pm to pass ice she observed Resident #1 with blood on his face, shirt, bed rail facing the room door and bed sheet. NA #2 further revealed she went to the hall to call for assistance and Nurse #1, the Director of Nursing (DON), and Administrator responded, checked his body and surroundings in the room to see how he could have been injured. NA #2 stated after she assisted the Administrator with cleaning Resident #1's face and changed the sheets, as she was leaving the room, she overheard someone tell Nurse #1 the DON would notify the family that the resident had a fall and take care of the incident report. NA #2 stated about 4:00 pm she informed Nurse #1 that she was going on break before dinner trays came out. NA #2 stated when she returned from break, she checked on Resident #1 and found him lying on his left side and there was projectile vomit on the wall, floor and bed. NA #2 revealed she went to get Nurse #1 who came into the room and stated she was going to call the DON to have the resident sent out to the emergency room . NA #2 further revealed she cleaned up the vomit, returned to the hall to continue working and she observed Resident #1's family member arrived on the hall. NA #2 stated the family member asked her to walk with her to the room and wanted to know what happened. When the family member entered the room and observed the resident, she became upset and stated, 'there's no way this was a fall.' A review of a nurse's progress note dated 5/9/24 indicated Nurse #1 was approached by a nurse aide (NA) at the beginning of the shift to report resident was bleeding from his face. Nurse #1 walked down the hall with the NA and found the Resident #1 laying in the bed with blood on the sheets and siderail. The resident was bleeding from the left side of face and noted resident had bruising and swelling around left eye, small laceration to left side of face, and right front tooth to be broken and loose. The note further indicated, after evaluating resident Nurse #1 immediately went to get management. Management came to evaluate the resident and stated the resident was in stable condition and they would do a fall report as well as neuro checks every hour. Resident #1 was provided with first aid and ice was applied to left eye. The resident's vitals taken BP 166/82, pulse 79, O2 95 % on room air and temp 98.5. While Nurse #1 was rounding resident was found with emesis in bed and on resident's floor after another assessment from Nurse #1. The DON was notified of the resident's condition and Nurse #1's concerns. Nurse #1 recommended that he be sent out for further evaluation. The DON stated Nurse #1 could send him out via EMS to hospital for further evaluation. The family member arrived at the facility shortly after and stated she would like him sent to the hospital for further evaluation. Resident was sent to local ED for further evaluation. During a phone interview on 5/24/24 at 9:58 am Nurse #1 indicated she was assigned to Resident #1 on 5/9/24 (3:00 pm -11:00 pm shift) and NA #2 came to get her about 3:45 pm to check on Resident #1. Nurse #1 further indicated she directed an NA to get the first aide cart and bring it to Resident #1's room. Nurse #1 stated when she arrived at the resident's room, she observed the resident to have a laceration under the left eye that was swollen and bruised, and a right upper front tooth was broken. Nurse #1 stated the resident's bed was positioned at waist level. Nurse #1 stated she went to get the DON and the Administrator who responded and took over to find out what happened. Nurse #1 was instructed to get an ice pack for the resident's eye then assisted the nurse aides clean Resident #1 and change his bed linen that was stained with blood. Nurse #1 stated the DON indicated she would write the nursing note and contact Resident #1's family to report the incident instead of Nurse #1 writing the note and contacting the family. Nurse #1 stated she started hourly neurological checks (assesses neurological functions, motor and sensory response, and level of consciousness) on the resident and about 5:30 pm she and NA #2 went to the resident's room and discovered the resident had vomited on the wall and fall mat near the window. Nurse #1 stated she messaged the DON because she felt the resident needed to be sent out to the emergency room for further evaluation. Nurse #1 stated the resident's family member arrived at the same time the DON gave permission for the resident to be sent out. Nurse #1 stated she contacted 911 emergency services and first responders (medics) arrived within minutes to transport the resident to the hospital. Nurse #1 stated she could not recall the exact time she called 911. A review of hospital records indicated Resident #1 was transferred from the facility to the emergency department on 5/9/24 after being found in bed with left eye hematoma (significant bruising) and swelling around the left eye due to possible fall but unknown how the injury occurred. The ED Physician observed significant bruising around the left eye and a small laceration at the corner of the left eye. A CT scan of the head noted a comminuted fracturing of the left nasal bone, anterior left maxillary sinus wall, and left maxilla with extension into the root of the left posterior maxillary molars. It was noted that the fracturing extended into the inferior left orbital rim. The ED Physician consulted with an ENT (ear, nose, and throat) Specialist who suggested treatment with Keflex (antibiotic) follow up with his office on 5/13/24 or 5/14/24. A nursing note dated 5/10/24 entered by Nurse #5 revealed Resident #1 returned to the facility after a short-term emergency room visit with a new order received from emergency room visit for Keflex (an antibiotic) 500mg (milligrams), take 2 capsules by mouth twice a day for 10 days. Nurse #5 also noted the resident had a right front tooth missing; denied any pain and voiced no complaints. The resident was unable to describe the incident or hospital visit. A review of NA #1's written statement dated 5/9/24 indicated he went into Resident #1's room around 2:20 pm during the NA's last round and found the resident had already put himself in bed. The statement further indicated the resident was in his wheelchair prior. NA #1 changed the resident's brief and when he left resident's room, the resident was awake and in his bed with no injury to his face. NA #1's statement also indicated Resident #1 self-transferred several times per day. During a phone interview on 5/21/24 at 5:23 pm NA #1 stated he worked on 5/9/24 and was assigned to Resident #1 on the 7:00 am - 3:00 pm shift. The NA revealed towards the end of his shift, he entered Resident #1's room to change the resident's brief but the resident did not want to be changed and lunged at NA #1. NA #1 stated he pushed Resident #1 backwards in the bed and the Resident hit his head on the side rail of the bed causing a skin tear and blood in the corner of his eye. NA #1 stated he then wiped the blood from the resident's face, continued with incontinent care and left the room. NA #1 stated after he left the faciity on [DATE], he received a call from the DON and was asked about his interaction with Resident #1. NA #1 stated he lied to the DON and Administrator about not knowing what happened to Resident #1. NA #1 stated after he was re-interviewed by law enforcement 5/13/24 and 5/14/24, he agreed to take a polygraph test on 5/15/24 and did not pass it. NA #1 stated after he did not pass the polygraph test, he told law enforcement he pushed Resident #1 causing injuries to his face when he hit his head on the bed rail. NA #1 stated he was re-interviewed via telephone by the Administrator on 5/15/24 and was terminated from the facility after he told her that he pushed the resident. During a phone interview on 5/21/24 at 6:02 pm NA #4 indicated she worked 7 am - 3 pm on 5/9/24 and stated she last observed Resident #1's feet in bed but did not see his face because the curtain was pulled when she and other NAs walked the hall together to give report to the next shift. NA #4 stated when she asked who put the resident to bed and changed him, NA #1 stated when he put the resident to bed and changed him, everything was good. During a phone interview on 5/21/24 at 6:46 pm NA #5 revealed she worked 7 am - 3 pm on 5/9/24 and completed rounds (around 2:55 pm) by performing brief changes and checking on her residents before her shift ended. She completed walk-downs (walked past each resident's room with the next shift and gave report) with the next shift. NA #5 further revealed she observed Resident #1's lower half of his body covered with a blanket and the curtain was drawn halfway. NA #5 stated she did not see the resident's face. She did not do rounds on resident because NA #1 stated he already rounded on the resident. During an interview on 5/22/24 at 12:09 pm Resident #1's family member revealed she received a phone call from a nurse at the facility on 5/9/24 about 4:00 pm and was told multiple times during the call that everything was okay but Resident #1 face planted (fell on his face). The family member stated she lost it when she walked into the room and saw Resident #1's injuries. The family member then stated Resident #1 hardly ever complained of pain because his dementia was so bad, and she could tell Resident #1's injuries did not look like the results of a fall while trying to get out of his wheelchair and into bed and hitting his head on the bed rail. The family member stated she went to speak with Nurse # 1 to inquire why Resident #1 had not been transported to the hospital and Nurse #1 stated she was in the process of having the resident sent out to the hospital. The family member stated she went to the hospital after the resident was transported via medic and she was informed the Resident sustained a broken nose, cheek and bone in the eye area. The family member stated she took pictures of the resident before he left the facility and after he arrived at the hospital. The family member stated the resident also lost a tooth and another tooth was cracked/loosened. The family member stated she contacted law enforcement about the incident while she was still at the hospital, and they went to the facility to investigate. The family member stated she received a voicemail message from the DON about 10:00 pm the same evening. The family member recalled she met with the Director of Nursing (DON) and the Administrator on the following morning of 5/10/24 to discuss the incident and the family member informed the DON and Administrator that while at the hospital, she contacted law enforcement about the incident because the explanation on how Resident #1's injuries occurred, just did not add up. The family member stated the resident was discharged from the hospital and was transported back to the facility after 3:00 am on 5/10/24. The family member recalled during the meeting with the DON and Administrator, they informed her that the first shift staff did not find the resident with injuries. The family member indicated when she arrived at the facility to pick up the resident for the appointment with the ENT Provider, he did not feel good, and the appointment was rescheduled to 5/21/24. As a result of the rescheduled follow-up appointment, it was determined the resident would need surgery to place stents (a sinus stent is a device that can be implanted in the sinus cavity after surgery to help maintain the surgical openings) in his nose to remove the bone that was blocking the nasal passageway and surgery was scheduled for 6/5/24. A review of the ENT provider examination dated 5/21/24 indicated Resident #1 had complete obstruction of his left nasal cavity, moderate severe left septal deviation at the nasal valve region on left side. Recommendations: undergo open reduction internal fixation of nasal septal fracture (the nasal septum is the thin wall that separates the nostrils) and bilateral turbinoplasty (surgical procedure that shrinks the size of the small, bony structures inside your nose to improve airflow and breathing); hold aspirin one week prior to surgery, get clearance from his facility physician. During an interview on 5/21/24 at 7:00 pm the Administrator indicated Nurse #3 came to her office on 5/9/24 about 3:20 pm and informed her that she needed to go to Resident #1's room. Upon arrival, the Administrator stated she observed the Resident in bed with his face leaning against the assist bar and there was blood coming from a cut under his left eye/ check bone. The Administrator indicated she asked the resident what happened, and the resident stated, I hope she falls just like I did and dies. The Administrator stated she sent for the DON, who came to the room. The Administrator recalled the DON removed Resident #1's right front tooth that was dangling to prevent him from swallowing it. The Administrator stated while nursing staff was cleaning up the resident, she instructed the DON to contact all first shift staff to inquire about their contact with Resident #1 that day. The Administrator revealed the DON contacted NA #1 who stated Resident #1 had already self-transferred back to bed when NA #1 arrived and was not combative when NA #1 provided incontinent care about 2:20 pm on 5/9/24. The Administrator further revealed all staff from the 1st and 2nd shift were interviewed appropriately, Resident #1's family was contacted, and it was determined Resident #1 had an unwitnessed fall. Neuro checks were initiated and about 7:00 pm the Administrator received a call from the DON that Resident #1 had a change in condition related to drowsiness/vomiting and was being sent out to the hospital. The Administrator stated the DON contacted her on 5/9/24 at 9:56 pm and informed her law enforcement arrived at the facility to investigate the resident's injuries related to an unwitnessed fall. The Administrator stated on 5/9/24 at 10:15 pm she received an update from the DON who had received a copy of the hospital CAT scan that showed a fractured left nasal bone, left maxillary sinus wall and left maxilla with extension into the root of the left maxillary molars, fracturing extends into the interior left orbital rim. The Administrator stated she and the DON met with the family member the following morning of 5/10/24 at 10:15 am and the family member did not indicate she called law enforcement because she suspected abuse. The Administrator noted the facility had already taken steps to schedule a follow up appointment with the eye/sinus/allergy provider as well as the dentist who was scheduled to be in the facility on 5/10/24. A review of the DON's written statement dated 5/16/24 indicated on 5/9/24 at approximately 3:15 pm/ 3:20 pm Nurse #4 came to tell her that she was needed in Resident #1's room with the Administrator. The DON stated upon entering the resident's room, she recalled Nurse #1, NA #2, the Administrator, and Nurse # 4 were present, and she noticed a small amount of blood coming from the corner of the resident's left eye, a cut under his left eye, and his right front tooth was dangling. The DON stated she asked the resident what happened, and he responded, 'a girl threw a rock and hit his eye from Afghanistan.' The DON's statement also indicated she asked the resident if he fell and he replied 'no.' She then asked the resident if someone hurt him and the resident replied 'no, a girl in a truck spinning rocks.' The DON obtained and applied a bag of ice wrapped in a towel to the resident's eye until the resident could no longer tolerate it. The DON's written statement indicated she began calling the three NAs who worked the first shift (NA #1, NA #4 and NA #5) to get a timeline and to see if any of them knew anything about the resident. The written statement further indicated the DON and other staff started investigating what could have happened and concluded that the resident must have self-transferred and fell or hit the side rail. The DON's written statement indicated the Administrator asked the DON to make the nurse's note and to contact the resident's family. The written statement indicated the DON contacted the family member around 3:45 pm, informed her of the resident's injuries and she would be notified if anything changed. The DON was notified by the facility that law enforcement had arrived at the facility between 9:45 pm and 10:00 pm on 5/9/24 and they were told to contact the DON or Administrator. The law enforcement detective returned to the facility on [DATE] around 11:00 am, then spoke with the Administrator and the resident before going to the resident's room to observe where the incident occurred. The law enforcement detective met with the DON and Administrator then returned to get employee names and phone numbers. The DON contacted NA #3, NA #4, and NA #5 to let them know the detective would be contacting them for a statement. In addition, the detective interviewed other employees that were present. Attempts to contact the DON by phone were not successful and she did respond to voice mails. During an interview on 5/23/24 at 1:43 pm the Nurse Practitioner (NP) revealed on 5/13/24 she reviewed Resident #1's hospital discharge note that indicated three fractured facial bones and recommendation for surgery to repair the resident's nose. The NP stated she was made aware Resident #1 initially suffered an unwitnessed fall on 5/9/24 and she was later made aware there was an allegation of abuse. The NP stated although she believed what she was told, she was surprised the resident was found in bed with those injuries. The NP stated on 5/13/24, she assessed the resident post readmission while he was sitting in a wheelchair at the nurse's station, and he did not present with any pain. The NP further revealed the left side of Resident #1's face was swollen, bruised and the laceration under his left eye was scabbed over. The NP stated she cleared the resident for nose surgery scheduled for 6/5/24. During a follow- up interview on 5/22/24 at 10:03 am the Administrator revealed on 5/14/24 she spoke with the law enforcement detective to determine the status of their investigation and the Administrator was told by the detective abuse was being alleged and NA #1 had agreed to take a polygraph exam on 5/15/24. The Administrator then stated she received a call from law enforcement on 5/15/24 and was informed NA #1 failed the polygraph exam then confessed that he pushed Resident #1, causing injuries to his face. The Administrator indicated she contacted NA #1, reinterviewed him and terminated his employment after the NA confirmed he did push Resident #1 on 5/9/24, causing injuries to the face. The Administrator stated it was her expectation that all residents are free from abuse and neglect. The Administrator stated she initiated the abuse investigation, followed protocol for abuse and alleged past non-compliance. During an interview on 5/21/24 at 12:45 pm the Law Enforcement Detective indicated he charged NA #1 with abuse on 5/15/24, after the NA failed a voluntary polygraph test then admitted that he had not been truthful about what had occurred on 5/9/24 with Resident #1, when he was previously interviewed by law enforcement on 5/13/24 and 5/14/24. The Law Enforcement Detective further indicated during an interview on 5/13/24, NA #1 stated on 5/9/24 his last interaction with the resident was when he went into the resident's room at shift change, to change the resident's brief, the resident was flopped (lying in bed kind of sideways with his legs hanging off) in bed. The Law Enforcement Detective stated NA #1 reported he straightened (repositioned) the resident and changed his brief. The Law Enforcement Detective NA #1 then reported the resident was fine and he left the resident in bed with no injuries. The Law Enforcement Detective revealed he re-interviewed NA #1 on 5/14/24 because he struggled with the details on how the resident had an unwitnessed fall and got back in bed by himself, if a previous interview with NA #5 indicated she had assisted a therapist with getting the resident out of bed around 12:30 that day. The Law Enforcement Detective stated NA #1 reported the resident did not get out of bed when he left him at 2:20 pm and was found in bed by the next shift. The Law Enforcement Detective then asked NA #1 if the resident was still in bed and never got out of bed, how did the resident get injured. The Law Enforcement Detective stated when NA #1 did not provide a definitive answer, he asked NA #1 to submit to a polygraph test and NA #1 stated yes. The Law Enforcement Detective indicated NA #1 submitted to a polygraph test on 5/15/24 and failed the test. During a post polygraph interview on 5/15/24, the Law Enforcement Detective indicated NA #1 told a different version of the incident once he was informed, he failed the test. The Law Enforcement Detective stated NA #1 admitted to pushing Resident #1 when he became aggressive toward him, then the resident fell back onto the bed and was unharmed when NA #1 left the room. The Law Enforcement Detective stated after NA #1 was questioned further about the resident's injuries, NA #1 admitted to pushing the resident, who hit the side rail on his bed and there was blood on the resident's face. NA #1 reported to the Law Enforcement Detective he wiped the blood off the resident's face and left him in the bed because he looked fine. The Law Enforcement Detective also stated NA #1 reported he knew the policy of the facility was to disengage and not go hands on and that was why he lied. The Law Enforcement Detective stated he asked the NA if any complaints had been filed against him in the past and the NA stated there were complaints that had been investigated and closed. During a follow up phone call on 5/24/24 at 10:16 am the Law Enforcement Detective revealed after he viewed pictures of Resident #1's injuries on 5/23/24, he determined the injuries were probably not consistent with a push backwards in the bed. The Law Enforcement Detective reinterviewed NA #1 in person on 5/24/24 and showed him the pictures. As a result, NA #1 stated he had been thinking about things for the past few days and it was time for him to stop lying because God had been talking to him. NA #1 admitted he punched the resident one time (instead of pushing him), saw the blood on his face, wiped it off since the resident was not fighting anymore, thought the resident was fine and left the room. instead of pushing him, as he previously stated on 5/15/24. The Administrator was notified of the immediate jeopardy on 5/23/24 at 6:20 pm. The facility provided the following corrective action plan. How will the corrective action be accomplished for those residents found to have been affected by the deficient practice. On May 9th, 2024, Resident #1 sustained a 0.3 mm (approximately 0.01 in) laceration on the inferior portion of the nose just proximal to the left eye, comminuted fracture of the left nasal bone, and fracturing of the left maxilla with extension into the left orbital rim. The facility initiated an investigation of the incident and suspected the injury occurred from Resident #1 attempting to self-transfer resulting in an unwitnessed fall. The hospital discharge report under Emergency Department (ED) Course and Medical Decision-making revealed that it appeared that resident had fallen and injured the left side of his face. Nurse Aides (NAs) were interviewed including NA #1 and revealed Resident #1 was last seen at 2:20pm by NA#1 and he was in bed with no concerns noted. A police officer arrived at the facility on May 9th, 2024, at approximately 10:45pm to follow up with a report they had received regarding Resident #1. He briefly interviewed multiple staff and asked if the Administrator was the same and who was the Director of Nursing. The staff gave him the Director of Nursing's information. No calls from the officers were made to the Administrator or the Director of Nursing on May 9th, 2024, nor did the officer request the presence of the Administrator or Director of Nursing at the facility. On May 10th, 2024, at approximately 10:00am, the Administrator and Director of Nursing met with Resident #1's family member to discuss the incident. Per Administrator and Director of Nursing report, Resident #1's family member stated that she called the police per instruction from another family member. She stated she had no specific complaints or allegations with specific person but thought the police could investigate to find the cause of the injury. The Administrator and Director of Nursing stated during the meeting that they suspected that resident sustained an unwitnessed fall while trying to get into bed, resulting in documented injury. At approximately 4:15pm, two employees from Adult Protective Services (APS) entered the facility and interviewed the Administrator and Director of Nursing regarding Resident #1. Health care records for Resident #1 were provided per request. The APS employees visited Resident #1 in his room and exited the building with no allegation or concern of abuse made. On May 13th, 2024, a Detective with the police department arrived at the facility around 11:00 AM to begin investigation on the report filed on May 9th, 2024. Several staff members were interviewed in-person and via telephone by the Detective at this time. The Detective indicated to the Administrator that he was just investigating the incident and did not indicate abuse had been alleged. On May 14th, 2024, the Detective entered the facility at approximately 11:00 AM to further interview Nurse Aide (NA) #1, NA #1 was the last one to provide care to Resident #1 before NA #2 found him with injuries. The Detective informed the Administrator there were inconsistencies regarding his investigation. Upon the Detectives exit, the Regional Operator put in a call to the [NAME] Detective to try and obtain further detail as to what was being alleged on May 14th at approximately 4:30pm. It was reported they were investigating abuse per what was reported from Resident#1's family member to the police on 5/9/24. Nurse Aide #1 was suspended pending investigation. The facility began abuse investigation and submitted 24-hour report to DHSR. Resident's responsible party, law enforcement, Ombudsman and Adult Protective Services were notified that facility investigation of abuse was initiated. On May 15, 2024, the facility was notified that during Nurse Aide#1's voluntary polygraph test he told the detective he pushed Resident #1 when he became combative during care. Nurse Aide #1 was terminated effective May 15, 2024, and was interviewed during a call with Administrator to notify of termination. During interview with NA#1, he stated, I went in to change Resident#1 and he was already in bed. He lunged at me, and I pushed him back and he hit the bed rail. He had one little skin tear with a small amount of blood, and I wiped it with a paper towel. He appeared fine and I left the room. On May 15, 2024, facility abuse investigation continues. Staff interviews were conducted. They were asked if they were aware of any abuse, neglect or exploitation of residents and if they were aware of any concerns related to abuse. Staff working on Resident #1's unit (B Hall) provided written statements regarding this allegation and day. On May 17, 2024, a 5-day investigation report was made to DHSR which included the facility investigation. How the facility will identify other residents having the potential to be affected by the same deficient practice. All other residents are at risk of suffering from the deficient practice and residents who are resistive to care were identified as more at risk for abuse. On May 15, 2024, all residents with a Brief Interview of Mental Status (BIMS) of 12 or above were interviewed by the Administrator or designee to determine if they have experienced any type of resident abuse or were fearful in any way. No concerns were found. On May 15, 2024, an audit consisting of thorough skin assessment of all residents with a BIMS of 11 or less was completed by licensed nurses to determine if there is evidence of abuse. No concerns were found. An ad hoc Quality Assurance (QA) meeting was held on May 15, 2024, to discuss the deficient practice and to initiate a plan of correction and education for staff regarding abuse and neglect, audits and inclusion in QA. What measures will be put in place or systemic changes will be made to ensure deficient practice will not recur. 0n May 15, 2024, education was provided to the Administrator and the Assistant Director of Nursing by the Regional Operations Manager, regarding the definition of abuse as defined in the abuse policy and the resident's right to be free from abuse. On May 15, 2024, after being reeducated as outlined above, education for all staff was completed in person and via phone by the Administrator or designee. The education consisted of the following: - The definition of abuse, neglect and misappropriation of property and the need to immediately notify the Administrator or Director of Nursing of all issues related to these infractions. If Administrator or Director of Nursing are not present in the facility, supervisors must be notified, and they must inform the Administrator or Director of Nursing immediately in person or by phone. - Signs and symptoms of abuse and mental anguish such as loss of interest, change in routine, mood alterations, or difficulty eating. - Our facility does not condone and has zero tolerance for resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. - The education focused on tactics to deal with difficult residents such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distr [TRUNCATED]

Based on record review and staff interviews the facility failed to protect a resident from verbal and physical abuse when Nurse Aide (NA) #2 proceeded to provide care to a resident (Resident #257) while he was agitated and combative. NA #2 taunted, aggressively pushed, aggressively turned, slapped the resident on the hip, and grabbed his arms and held them on his neck resulting in the resident asking, are you trying to choke me, and leaving a bruise on his right hand and redness to his chest for 1 of 3 residents reviewed for abuse (Resident #257). The findings included: Resident #257 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #257 moderately cognitively impaired and required extensive assistance for majority of activities of daily living (ADL). The MDS further revealed Resident #257 was not coded for behaviors. Resident #257's care plan dated 4/25/22 revealed the resident was at risk for episodes of being upset and was cognitively impaired. The care plan's goal indicated Resident #257's mood and behaviors would be stable. Interventions included to administer medicines per medical director and monitor effectiveness and be alerted to changes in mood, sleep pattern, appetite, cognition, behaviors and keep MD informed. Review of the facility initial allegation report dated 6/14/22 revealed on 6/13/22 at 10:30 PM an employee, NA #2, was changing the brief of a combative Resident #257, and slapped the resident on his hip and pressed the resident's arm to the resident's throat. The report further revealed NA #1 witnessed the incident and NA #2, was suspended pending investigation on 6/13/22. The facility substantiated abuse and NA #2 was terminated. Review of the investigation completed by the Administrator on 6/13/22 related to Resident #257's incident revealed the following: -Nurse Aide (NA) #1 statement dated 6/13/22 revealed NA #1 saw NA #2 hit Resident #257 while they were changing him. NA #1 further revealed resident #257 was combative, but NA #2 rolled him and slapped him hard on the hip. The statement indicated NA #1 tried to calm the resident down and NA #2 rolled Resident #257 back and he began to hit at NA #2. NA #2 grabbed Resident #257 arms and held them on his neck, and he stated, what, are you choking me? NA #1 revealed care was completed on Resident #257 and NA #2 stated to NA #1 what are you doing? You work to much. NA #1 indicated she cared too much for the residents and the incident was very upsetting. A phone interview conducted with Nurse Aide (NA) #1 on 9/13/22 at 3:35 PM revealed she and NA #2 entered Resident #257's room on 6/13/22 after 7:00 PM to give care. NA #1 revealed NA #2 went to the right side of the bed and NA #1 went to the left side. NA #1 stated NA #2 started to pull down the sheet to give care and Resident #257 was grabbing at the sheet and appeared to be agitated muttering. NA #1 stated Resident #257 was commonly agitated when given care and his speech was unclear. NA #1 revealed NA #2 continued to give care by undoing the brief and Resident #257 tried to grab at NA #2. NA #2 then aggressively pushed Resident #257 on his left hip by placing one hand on his shoulder and the other on his hip. Resident #254 became more agitated and pushed against NA #2 and NA #2 took her right open hand and smacked the resident on the hip. NA #1 revealed it was a loud smack and she was in shock of what had happened. NA #2 stated, You can't do anything? What you going to do? taunting Resident #257. NA #1 revealed NA #2 observed to be frustrated and angry and laid the resident on his back aggressively. Resident #257 was muttering more words and was gritting his teeth and observed to be very angry. Resident #257 grabbed at NA #2 and NA #2 immediately grabbed the resident's wrist and placed them down on his chest under his neck in a forceful way. NA #1 indicated Resident #257 stated what are you doing? Are you trying to chock me? NA #1 revealed Resident #257 had quit being combative and observed eyes to be wide like he was scared. Resident #257 quit fighting the NAs and eyes appeared to be wide and in shock. NA #1 revealed NA #2 at this time let go of his wrist and completed care. NA #1 further revealed NA #2 wanted to move Resident #257 up in the bed. NA #1 stated she told NA #2 to stop and that they needed to go get help. NA #1 stated NA #2 threw the cover up on Resident #257 and stated, you are awful mean for someone who pisses on themselves. NA #1 indicated they left the room and she reported to the charge nurse within 15 minutes. A follow up phone interview conducted on 9/16/22 at 2:08 PM revealed NA #1 wanted to clarify her previous statement. NA #1 revealed she and NA #2 entered Resident #257's room and he began to grab at NA #2 when starting care. NA#1 indicated NA #2 rolled the resident on his left hip to give care and slapped the resident with her right open hand. NA #2 rolled the resident on his back and immediately grabbed both his hands and the resident stated, what are you doing choking me? NA #1 stated NA #2 wanted to pull him up in the bed and NA #1 said, stop and let's get someone in here to help. NA #2 pulled the sheet over Resident #257 and left the room together. As they were walking out of the room NA #1 stated NA #2 made the comment you sure are mean for someone who pisses himself. NA #1 and NA #2 stated they had walked out of the room at the same time and NA #1 reported the incident to the charge nurse. NA #1 was asked to clarify when she said stop to NA #2 during the incident. NA #1 was unable to be specific when she had told NA #2 to stop giving care to Resident #257. NA #1 continued to state the incident happened so quick that when NA #2 slapped the resident and grabbed the resident's wrist it appeared to be one motion. -Nurse Aide (NA) #2 statement dated 6/14/22 revealed NA #2 and NA #1 entered Resident #257's room to change him. NA #2 further revealed the NAs moved resident #257 and he hit both NAs with his hands and feet. NA #2 noted she held Resident #257's arms under hers to keep him from hitting both NAs. Resident #257 stated he couldn't breathe, and NA #2 removed her hands from the resident's arms. NA #2 noted Resident #257 hit her with his fist and NA #2 had a reflex and hit Resident #257's hip not meaning too. NA #2 indicated both NAs rolled Resident #257 and NA #1 put the residents brief on, lowered the bed, and left the room. A phone interview with Nurse Aide (NA) #2 was unable to be completed after several attempts. -Unit Charge Nurse statement dated 6/14/22 revealed NA #1 had come to her last night around 10:00 PM and stated that NA #1 and NA #2 were providing care to Resident #257 and he became combative and NA #2 hit the resident. The statement further revealed the Unit Charge Nurse went and assessed the resident immediately, called the Director of Nursing (DON), and was instructed to have NA #1 write a statement, and to send NA #2 immediately and that a staff member would be in contact with her the next day. Review of the skin assessment completed by the Unit Charge Nurse dated 6/13/22 revealed redness noted on the resident's chest and a bruise forming on the right hand. An interview conducted with the Unit Charge Nurse dated 9/14/22 at 3:24 PM revealed NA #1 had disclosed NA #2 hit Resident #257 on the hip at 10:30 PM on 6/13/22. The Nurse further revealed she contacted the DON immediately and was instructed to complete an assessment on Resident #257, and NA #1 write a statement on what had happened and send NA #2 home immediately. NA #2 was in the shower room cleaning and had not worked with any other residents. The Unit Charge Nurse's assessment revealed Resident #257 had a quarter size bruise forming on his right hand and did not show any kind of emotions of being sad, scared, or angry. The Nurse indicated Resident #257 was unable to recall the incident. She revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. The Nurse also indicated the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, and wait till they are calm, to complete care. An interview conducted with the Assistant Director of Nursing (ADON) on 9/14/22 at 5:09 PM revealed the Administrator and the DON joined her at the facility right after the incident occurred on 6/13/22. The ADON revealed she assisted the Administrator and DON with body checks and attempted to interview Resident #257, but the resident was not interviewable. An interview conducted with the Director of Nursing (DON) on 9/14/22 at 4:00 PM revealed she came to the facility when she was notified of the abuse by the Unit Charge Nurse and assessed Resident #257. The DON further revealed Resident #257 had a small bruise on his right hand and a small red mark on his chest from the pressure where NA #2 had held his arms down. The DON stated NA #2 admitted to slapping and holding down the resident and knew that it wasn't acceptable. NA #2 disclosed to the DON it was the reaction of Resident #257 being combative. The DON indicated Resident #257 was unable to recall the incident when interviewed. DON revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. The DON also indicated the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, or wait until they calm, to complete care. An interview conducted with the Administrator on 9/14/22 at 5:55 PM revealed she arrived at the facility on 6/13/22 and NA #2 had already been sent home. The Administrator revealed full body checks and resident interviews were completed that night. The Administrator indicated Resident #257 was unable to disclose information about the incident. The Administrator revealed she interviewed NA #1 and NA #2 the next day. It was further revealed NA #2 denied any incident at first the Administrator, but then admitted to the Administrator that she had smacked him but didn ' t ' t mean to and held his hands down but did not think it was hard. The Administrator interviewed NA#1 who revealed she and NA #2 were giving care to Resident #257 who became agitated and aggressive and NA #2 slapped Resident #257 on the hip and then proceeded to grab his wrist and hold his arms down on his chest. The Administrator indicated Resident #257 was the last resident to need care and NA #2 did not work with any other residents that shift. It was revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. She reported the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, and wait till they are calm, to complete care. The Administrator was notified of immediate jeopardy on 9/15/22 at 9:00 AM. The corrective action plan for noncompliance dated 6/15/22 was as followed: On 6/13/22, the Director of Nursing and Administrative Nurse initiated a skin sweep on 100% of all in house residents assessing for any signs of abuse, as all residents have the potential to be affected. This sweep was completed on 6/14/22, approximately at 3:00am. No additional concerns were identified. On 6/14/22, the Social Worker and Administrator interviewed all in-house alert and oriented residents with a BIMS of 10 or higher, to ensure no allegations of abuse were reported. No residents verbalized concerns. The Licensed Social Worker observed Resident #1 for any behaviors that would alert to any mental anguish, fear or pain from 6/14/22 to 6/16/22. Residents who are cognitively impaired and have combative behaviors during care are at higher risk to be affected by this deficient practice. Education on the abuse policy, preventing, protecting, and reporting, and caring for residents with aggressive behavior in long term care continued 6/13/22 through 6/15/22 for 100% staff and therapy contract staff by the Director of Nursing, Nurse Supervisors and Administrative Departmental Managers. Any staff member who did not receive an education by 6-15-22 was not allowed to work until this education was provided. The abuse policy, prevention, protecting, and reporting will continue to be provided during new hire orientation. Education on caring for residents with aggressive behaviors was added to the new hire orientation education on 6-15-22 and will be completed by the Director of Nursing or a member of the Nursing Administration team. The Director of Nursing and the members of the Nursing Administration team was notified on 6-14-22 by the Administrator of the new process. Education on the abuse policy, preventing, protecting, and reporting, and caring for residents with aggressive behaviors in long term care will be provided in the monthly All-Staff meeting by the Administrator or Director of Nursing to staff x 6 months. The next staff meeting was held on July 13 th, 2022 and is ongoing monthly. The Director of Nursing and Nursing Administration team conduct random observations of staff while providing care and interacting with residents with a cognitive impairment and combative behaviors. These routine audits have been on-going prior to the 6/13/22 allegation and will continue. The Director of Nursing and Nursing Administration team were educated by the Administrator on 6/14/22 to continue and begin documenting their observations of staff while providing care and interacting with residents with a cognitive impairment and combative behaviors. Documentation of the observations will continue until a pattern of compliance is sustained. To ensure continued compliance, The Director of Nursing will be responsible for bringing the special focus audits and observations on care provided to residents with a cognitive impairment and combative behavior to the Quality Assurance team for further review and to make any needed changes to our audit process for three consecutive months or until a pattern of compliance is sustained. Date of Immediate Jeopardy Removal: 6-15-22 On 9/20/22, the facility's credible allegation for immediate jeopardy removal effective 6/15/22 was validated by the following: Staff interviews revealed they had received education on resident abuse and how to care for aggressive and combative residents. Skin assessments were conducted on all residents and identified, and alert and oriented residents were interviewed with no concerns identified. The facility's action plan was validated to be completed as of 6/15/22.

Based on record review, and staff interviews, the facility failed to intervene to stop verbal and physical abuse and/or failed to immediately call for assistance from administrative staff or licensed staff to stop the abuse. The facility policies and procedures failed to include reporting abuse to the state survey agency, APS and local law enforcement. The facility failed to report the abuse to APS and to the state survey agency, and local law enforcement within the required timeframes for 1 of 3 residents reviewed for staff to resident abuse (Resident # 257). Immediate Jeopardy began on 6/13/22 when the facility witnessed verbal and physical abuse and did not intervene to stop it, or immediately call for licensed staff or administrative staff to stop it. Immediate Jeopardy was removed on 9/18/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place effective. Findings Included: A review of the facility policy and procedure titled Reporting Abuse to Facility Management, with a revised date of April 2010, read in part it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The Policy Interpretation and Implementation section specified in part: 2a. 4. Employee's facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to the facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. The policy did not indicate time frames of reporting to outside agencies. Resident #257 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #257 was moderately cognitively impaired and required extensive assistance for majority of activities of daily living (ADL). Review of the facility initial allegation report dated 6/14/22 revealed on 6/13/22 at 10:30 PM an employee, NA #2, was changing the brief of a combative Resident #257, and slapped the resident on his hip and pressed the resident's arm to the resident's throat. The report further revealed NA #1 witnessed the incident and NA #2, was suspended pending investigation on 6/13/22. The facility substantiated abuse and NA #2 was terminated. The report revealed law enforcement and adult protective services (APS) were not contacted. Review of the investigation completed by the Administrator 6/13/22 related to Resident #257's incident revealed the following: -Nurse Aide (NA) #1 statement dated 6/13/22 revealed NA #1 saw NA #2 hit Resident #257 while they were changing him. NA #1 further revealed Resident #257 was combative, but NA #2 rolled him and slapped him hard on the hip. The statement indicated NA #1 tried to calm the resident down and NA #2 rolled Resident #257 back and he began to hit at NA #2. NA #2 grabbed Resident #257 arms and held them on his neck, and he stated, what, are you choking me? NA #1 revealed care was completed on Resident #257 and NA #2 stated to NA #1 what are you doing? You work to much. NA #1 indicated she cared too much for the residents and the incident was very upsetting. A phone interview conducted with Nurse Aide (NA) #1 on 9/13/22 at 3:35 PM revealed she and NA #2 entered Resident #257's room on 6/13/22 after 7:00 PM to give care. NA #1 revealed NA #2 went to the right side of the bed and NA #1 went to the left side. NA #1 stated NA #2 started to pull down the sheet to give care and Resident #257 was grabbing at the sheet and appeared to be agitated muttering. NA #1 stated Resident #257 was commonly agitated when given care and his speech was unclear. NA #1 revealed NA #2 continued to give care by undoing the brief and Resident #257 tried to grab at NA #2. NA #2 then aggressively pushed Resident #257 on his left hip by placing one hand on his shoulder and the other on his hip. Resident #254 became more agitated and pushed against NA #2 and NA #2 took her right open hand and smacked the resident on the hip. NA #1 revealed it was a loud smack and she was in shock of what had happened. NA #2 stated You can't do anything? What you going to do? taunting Resident #257. NA #1 revealed NA #2 observed to be frustrated and angry and laid the resident on his back aggressively. Resident #257 was muttering more words and was gritting his teeth and observed to be very angry. Resident #257 grabbed at NA #2 and NA #2 immediately grabbed the resident's wrist and placed them down on his chest under his neck in a forceful way. NA #1 indicated Resident #257 stated what are you doing? Are you trying to chock me? NA #1 revealed Resident #257 had quit being combative and observed to be scared. Resident #257 quit fighting the NAs and eyes appeared to be wide and in shock. NA #1 revealed NA #2 at this time let go of his wrist and completed care. NA #1 further revealed NA #2 wanted to move Resident #257 up in the bed. NA #1 stated she told NA #2 to stop and that they needed to go get help. NA #1 stated NA #2 threw the cover up on Resident #257 and stated, you are awful mean for someone who pisses on themselves. NA #1 indicated they left the room and she reported to the charge nurse within 15 minutes. NA #1 revealed she did not intervene during care because she was in shock and was scared of retaliation from NA #2. A follow up phone interview conducted on 9/16/22 at 2:08 PM revealed NA #1 wanted to clarify her previous statement. NA #1 revealed she and NA #2 entered Resident #257's room and he began to grab at NA #2 when starting care. NA#1 indicated NA #2 rolled the resident on his left hip to give care and slapped the resident with her right open hand. NA #2 rolled the resident on his back and immediately grabbed both his hands and the resident stated, what are you doing choking me? NA #1 stated NA #2 wanted to pull him up in the bed and NA #1 said, stop and let's get someone in here to help. NA #2 pulled the sheet over Resident #257 and left the room together. As they were walking out of the room NA #1 stated NA #2 made the comment you sure are mean for someone who pisses himself. NA #1 and NA #2 stated they had walked out of the room at the same time and NA #1 reported the incident to the charge nurse. NA #1 was asked to clarify when she said stop to NA #2 during the incident. NA #1 was unable to be specific when she had told NA #2 to stop giving care to Resident #257. NA #1 continued to state the incident happened so quick that it appeared to be one motion. -Nurse Aide (NA) #2 statement dated 6/14/22 revealed NA #2 and NA #1 entered Resident #257's room to change him. NA #2 further revealed the NAs moved resident #257 and he hit both NAs with his hands and feet. NA #2 noted she held Resident #257's arms under hers to keep him from hitting both NAs. Resident #257 stated he couldn't breathe, and NA #2 removed her hands from the resident's arms. NA #2 noted Resident #257 hit her with his fist and NA #2 had a reflex and hit Resident #257's hip not meaning too. NA #2 indicated both NAs rolled Resident #257 and NA #1 put the residents brief on, lowered the bed, and left the room. A phone interview with Nurse Aide (NA) #2 was unable to be completed after several attempts. -Unit Charge Nurse statement dated 6/14/22 revealed NA #1 had come to her last night around 10:00 PM and stated that NA #1 and NA #2 were providing care to Resident #257 and he became combative and NA #2 hit the resident. The statement further revealed the Unit Charge Nurse went and assessed the resident immediately, called the Director of Nursing (DON), and was instructed to have NA #1 write a statement, and to send NA #2 immediately home and that a staff member would be in contact with her the next day. - Review of skin assessment completed by the Unit Charge Nurse dated 6/13/22 revealed redness noted on the resident's chest and a bruise forming on the right hand. An interview conducted with the Unit Charge Nurse dated 9/14/22 at 3:24 PM revealed NA #1 had disclosed NA #2 hit Resident #257 on the hip during 2nd shift on 6/13/22. The Nurse further revealed she contacted the DON immediately and was instructed to complete an assessment on Resident #257, NA #1 write a statement on what had happened, and send NA #2 home immediately. NA #2 was in the shower room cleaning and had not worked with any other residents. The assessment revealed Resident #257 had a quarter size bruise forming on his right hand and did not show any kind of emotions of being sad, scared, or angry. The Nurse indicated Resident #257 was unable to recall the incident. She revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. The Nurse also indicated the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, wait till they are calm, or get another employee to complete care. An interview conducted with the Director of Nursing (DON) on 9/14/22 at 4:00 PM revealed she believed NA #1 was upset and scared of NA #2 and is the reason NA #1 did not intervene to stop NA #2. The DON completed the initial investigation and did not complete a report to the state, adult protective services, or law enforcement within two hours. The DON stated she had spoken to law enforcement the next day, but a report was not made. The DON indicated a report was not made to APS. The DON indicated she was not aware that the initial intake report had to be sent in within two hours. The DON further revealed she believed to have 24 hours to report the incident. The DON revealed she expected for nursing staff to intervene and stop any abuse and to report immediately to upper management. An interview conducted with the Administrator on 9/14/22 at 5:55 PM revealed she thought she had 24 hours to send the initial investigation report once the incident had happened. The Administrator further revealed the DON had contacted law enforcement the next day after speaking to their corporate, but an official police report was not made. The Administrator indicated a report was not made to APS because she was not aware the facility needed too. The Administrator expected for staff to intervene and stop any kind of abuse, but felt like NA #1 was upset and scared of retaliation from NA #2. The Administrator was notified of immediate jeopardy on 9/15/22 at 9:00 AM. The facility provided the following credible allegation of immediate jeopardy removal. The corrective action plan was as followed: On 6/13/22, the Director of Nursing and Administrative Nurse initiated a skin sweep on 100% of all in house residents assessing for any signs of abuse, as all residents have the potential to be affected. This sweep was completed on 6/14/22, approximately at 3:00am. No additional concerns were identified. On 6/14/22, the Social Worker and Administrator interviewed all in-house alert and oriented residents with a BIMS of 10 or higher, to ensure no allegations of abuse were reported. No residents verbalized concerns. Nurse #1 began abuse in-servicing to Nurse Aide #1 immediately after notifying the Director of Nursing and Administrator of the alleged event with Nurse Aide #2 to reeducate on the abuse policy, prevention, protecting and reporting, and dealing with residents with aggressive behaviors in long term care. Nurse #1 then in-serviced all other staff in the facility on the abuse policy, prevention, protecting and reporting, and providing care for residents with aggressive behaviors in long term care. This education included what to do if witness to abuse and when to report. All staff were trained in empathy, prevention, and de-escalation. The Director of Nursing and the Administrator arrived at the facility at approximately 11pm to continue with the investigation of abuse. Education on the abuse policy, prevention, protecting and reporting, and dealing with residents with aggressive behaviors in long term care to all staff was completed on 6/15/22. Any staff not educated by 6/15/22 will not be allowed to work until education is completed. On 9-15-22, all facility staff were interviewed on the education provided on What is abuse, who reports abuse, what to do if you witness an abuse, and when to report abuse. No issues were identified. The Regional Operations Manager educated the Administrator and the Director of Nursing on 6-21-22 on the abuse policy, prevention of abuse, protecting residents, staff & visitors, and reporting abuse to include reporting to The Healthcare Personnel Registry and Police Department within 2 hours of an abuse allegation. As of 6-21-22, the Regional Operations Manager and/or the Regional Clinical Manager will review all reportable allegations to ensure timely reporting to the State Agency and other officials as required by the regulation, and to ensure that there is no failure for timely reporting an allegation to a nurse, supervisor, or Administrator. Any issues identified during this monitoring process will addressed promptly. On 9-17-22, Department of Health and Human Services educated the Administrator on the requirement for reporting to APS. The Administrator educated the Director of Nursing on 9-17-22 regarding reporting to APS. On 9-15-22, all facility staff, to include those not in the facility on 9-15-22, were interviewed by the Director of Nursing and Nurse Administration on the re-education that was provided on 6/13/22-6/15/22 by Administrator or designee validating what is abuse, who reports abuse, what to do if you witness an abuse, and when to report abuse. No issues were identified. Education on the abuse policy, preventing, protecting, and reporting, and caring for residents with aggressive behaviors in long term care will be provided in the monthly All-Staff meeting starting July 7/13/22 by the Administrator or Director of Nursing to staff x 6 months. Date of Immediate Jeopardy Removal: 9-18-22 On 9/20/22, the facility's credible allegation for immediate jeopardy removal effective 9/18/22 was validated by the following: Staff interviews revealed they had received education on resident abuse and how to care for aggressive and combative residents. Skin assessments were conducted on all residents and identified, and alert and oriented residents were interviewed with no concerns identified. The regional operational manager educated the Administrator and DON on abuse policy, prevention of abuse, protecting residents, staff and visitors, and reporting abuse Education was received regarding reporting in a timely manner to agencies. All reportables would be reviewed to ensure that that they are reported timely.

Based on record review and staff interviews, the facility failed to accurately code the Prospective Payment System (PPS) and Minimum Data Set (MDS) assessments in the areas of [CONDITION(S)], hospice, Preadmission Screening and Resident Review (PASRR), and activities of daily living for 6 of 30 sampled residents (Residents #79, #309, #45 #44, #153, and #65) reviewed for MDS accuracy. Findings included: 1. Resident #79 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A staff progress note dated 07/09/22 written by the Social Worker revealed Resident #79 was scheduled to go to [CONDITION(S)] on Tuesday, Thursday, and Saturdays. Review of Resident #79's comprehensive care plans, last reviewed/revised 07/18/22, revealed he had the potential for complications related to hemodialysis. Interventions included hemodialysis three times a week as ordered on Tuesday, Thursday, and Saturday. The 5-day PPS assessment dated [DATE] revealed Resident #79 was not coded as having received [CONDITION(S)] services. During an interview on 09/14/22 at 10:32 AM, the MDS Coordinator confirmed Resident #79 received [CONDITION(S)] and stated it was a coding error that [CONDITION(S)] was not indicated as received on the 5-day PPS assessment dated [DATE]. During an interview on 07/01/22 at 7:40 PM, the Administrator stated she would expect for PPS assessments to be coded appropriately and accurately reflect a resident's status at the time of the assessment. 2. Resident #309 was admitted to the facility 08/05/21. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Hospice Recertification for the period 06/06/22 through 07/30/22 revealed Resident #309 was admitted under hospice care on 12/03/21 related to a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] revealed Resident #309 was not coded as having a prognosis that might result in a life expectancy of less than 6 months and receiving hospice care. During an interview on 09/14/22 at 10:32 AM, the MDS Coordinator confirmed Resident #309 received hospice services. The MDS Coordinator revealed she did not code hospice services or prognosis of life expectancy of less than 6 months on the MDS assessment because he was currently listed as private pay. She explained Resident #309 admitted to the facility with a Medicare replacement as his payor source then went to private pay due to having to spend down before he qualified for Medicaid. She added, once he became eligible for Medicaid hospice would become the payor source. During an interview on 07/01/22 at 7:40 PM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's status at the time of the assessment. 3. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Preadmission Screening and Resident Review (PASRR) Level II Determination Letter dated 05/23/19 indicated Resident #45 had a Level II PASSR that ended in a C with no expiration date. Review of the North Carolina Skilled Nursing Facility PASRR authorization codes document revealed a PASRR ending in C indicated Level II: no end date, no limitation unless change in condition, specialized services required. The annual MDS dated [DATE] revealed Resident #45 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. During interviews on 09/14/22 at 10:32 AM and 11:57 AM, the MDS Coordinator explained when they reviewed Resident #45's PASRR information via the North Carolina Medicaid Uniform Screening Tool (NC MUST) website, it was noted as no under the column sent to Level II. The MDS Coordinator stated based on what she was instructed, Resident #45's PASRR did not meet the criteria and did not need to be coded as a Level II PASRR on the MDS assessment dated [DATE]. During an interview on 07/01/22 at 7:40 PM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's status at the time of the assessment. 4. Resident #44 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was confined to his wheelchair due to [CONDITION(S)]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 had walked in his room once with minimal assistance from staff. An interview with the MDS Coordinator on 09/15/22 at 2:38 PM revealed Resident #44 was paraplegic and was not able to walk on his own or with assistance and this had been an error in coding the MDS. She explained some of the information on the assessment automatically populated from documentation by the Nurse Aides (NAs) but said the MDS nurses should have caught the error. The MDS Coordinator stated the assessment would be modified and corrected. An interview with the Director of Nursing (DON) on 09/15/22 at 6:29 PM revealed the information on the Activities of Daily Living on the MDS assessment automatically populated from documentation of the NAs but said the MDS nurses should verify the information as correct prior to signing off on the assessment. An interview with the Administrator on 09/15/22 at 7:40 PM revealed some of the information on the MDS assessment automatically populated from the NAs documentation. She stated they were no longer going to auto-populate that section from documentation but rather were going to code it according to the resident at the time of the assessment to ensure the MDS was accurate. 5. Resident #153 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #153 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #153 had walked in his room independently and had walked in the corridor at least once with minimal assistance from staff. The MDS further indicated Resident #153 had impairment on both sides of his lower extremities. An interview with the MDS Coordinator on 09/15/22 at 2:38 PM revealed Resident #153 was non-weight bearing and was not able to walk on his own or with assistance and this had been an error in coding the MDS. She explained some of the information on the assessment automatically populated from documentation by the Nurse Aides (NAs) but said the MDS nurses should have caught the error. The MDS Coordinator stated the assessment would be modified and corrected. An interview with the Director of Nursing (DON) on 09/15/22 at 6:29 PM revealed the information on the Activities of Daily Living on the MDS assessment automatically populated from documentation of the NAs but said the MDS nurses should verify the information as correct prior to signing off on the assessment. An interview with the Administrator on 09/15/22 at 7:40 PM revealed some of the information on the MDS assessment automatically populated from the NAs documentation. She stated they were no longer going to auto-populate that section from documentation but rather were going to code it according to the resident at the time of the assessment to ensure the MDS was accurate. 6. Resident #65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was able to feed herself with set up of her meals. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #65 required supervision from 2 or more staff physical assistance with eating. An interview with the MDS Coordinator on 09/15/22 at 2:38 PM revealed Resident #65 was independent with eating after being set up and this had been an error in coding the MDS. She explained some of the information on the assessment automatically populated from documentation by the Nurse Aides (NAs) but said the MDS nurses should have caught the error. The MDS Coordinator stated the assessment would be modified and corrected. An interview with the Director of Nursing (DON) on 09/15/22 at 6:29 PM revealed the information on the Activities of Daily Living on the MDS assessment automatically populated from documentation of the NAs but said the MDS nurses should verify the information as correct prior to signing off on the assessment. An interview with the Administrator on 09/15/22 at 7:40 PM revealed some of the information on the MDS assessment automatically populated from the NAs documentation. She stated they were no longer going to auto-populate that section from documentation but rather were going to code it according to the resident at the time of the assessment to ensure the MDS was accurate.

Based on observation and staff interviews, the facility failed to discard an expired medication available for use in 1 of 5 medication carts (F hall medication cart). The findings included: An observation of the F hall medication cart on [DATE] at 6:38 AM with Medication Aide (MA) #1 revealed a large, opened bottle of Thera-tabs which was about ,d+[DATE] full of oblong-shaped reddish-brown tablets. (Thera-tabs is a multivitamin and iron product used to treat or prevent vitamin deficiency.) The bottle was marked with a best by date of ,d+[DATE]. (Best by date is the date at which the manufacturer can still guarantee the full potency and safety of the drug.) An interview with MA #1 on [DATE] at 6:40 AM revealed she was not sure if any of the residents on her hall took Thera-tabs, but she didn't give it to any of her residents on her shift. MA #1 stated the staff just used the bottle of Thera-tabs to prop up the narcotic cards in the narcotic drawer. MA #1 also stated that the bottle did not need to be left inside the medication cart and that it needed to be disposed of. An interview with the Director of Nursing (DON) on [DATE] at 6:51 PM revealed she had just been made aware of an expired bottle of Thera-tabs being used to hold up the narcotic cards in the F hall medication cart. The DON stated all nurses and medication aides who worked on the medication carts were responsible for checking the dates on the medications and discarding any that were expired. She also stated that the expired bottle of Thera-tabs should not be stored in the medication cart and should have been discarded when it went out of date.

Based on observations, record reviews and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place on after COVID-19 Focused Infection Control and complaint investigation survey completed on [DATE] and the recertification survey completed on [DATE]. This was for two repeated deficiencies in the areas of labeling and storage of drugs and biologicals and freedom from abuse and neglect. These areas were cited again on the current recertification survey with an exit date of [DATE]. The continued failure of the facility during the three federal surveys shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag was cross referenced to: F-761: Based on observation and staff interviews, the facility failed to discard an expired medication available for use in 1 of 5 medication carts (F hall medication cart). During the recertification survey of [DATE] the facility failed to discard an undated opened multi-dose vial of influenza vaccine in 1 of 1 medication room, discard an opened single-dose vial of an injectable medication, undated and opened insulin pens, and loose pills in 5 of 5 medication carts (A hall, B hall, C hall, D hall and F hall). They also failed to store undated and unopened vials of insulin per manufacturer instructions and failed to secure a narcotics drawer in 1 of 5 medication carts. F- 600: Based on record review and staff interviews the facility failed to protect a resident from verbal and physical abuse when Nurse Aide (NA) #2 proceeded to provide care to a resident (Resident #257) while he was agitated and combative. NA #2 taunted, aggressively pushed, aggressively turned, slapped the resident on the hip, and grabbed his arms and held them on his neck resulting in the resident asking, are you trying to choke me, and leaving a bruise on his right hand and redness to his chest for 1 of 3 residents reviewed for abuse (Resident #257). During the COVID-19 Focused Infection Control Survey and complaint investigation survey completed on [DATE], the facility failed to transfer a resident with the required level of staff assistance. As a result, the resident was unable to support her weight during the transfer and fell . The fall was not reported to the assigned nurse, the next shift nurse or administration; the resident was not thoroughly assessed after the fall and the fall was not documented in the medical record. A day after the fall the resident complained of pain and an x-ray revealed a fracture of the outer layer of the femur just above the knee joint on the right leg. This was for 1 of 3 sampled residents for provide supervision to prevent accidents. An interview was conducted on [DATE] at 7:35 PM with the Administrator who also headed the QAA committee. The Administrator stated the facility had completed medicine cart audits by the Administrator, nurses, and pharmacist after the last recertification, discussed medicine storage frequently at quarterly QAA meetings, and had staff complete in-service and education on medicine storage. The Administrator further revealed she could did not know why medicine storage had been an issue again but indicated one on one training would be completed with staff.

Based on record review and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of the discharge date for 1 of 1 sampled resident reviewed for discharge (Resident #35). Findings included: Resident #35 was admitted to the facility on [DATE]. A Social Worker progress note dated 08/02/22 at 8:00 AM noted Resident #35 was sent out to the hospital on 07/31/22 and was admitted . Review of Resident #35's medical record revealed the last completed MDS assessment was a quarterly dated 07/26/22. There was no discharge assessment completed or transmitted. During an interview on 09/14/22 at 10:54 AM, the MDS Coordinator explained typically MDS assessments showed up on their computer dashboard to indicate when an MDS assessment was due and/or had not been transmitted but for some reason Resident #35's discharge MDS assessment wasn't. The MDS Coordinator stated it was an oversight and should have been completed within the regulatory time frame. During an interview on 09/15/22 at 7:36 PM, the Administrator stated she would expect for MDS assessments to be completed and transmitted within the regulatory timeframes.

Based on observations and staff interviews, the facility failed to discard an undated opened multi-dose vial of influenza vaccine in 1 of 1 medication room, discard an opened single-dose vial of an injectable medication, undated and opened insulin pens, and loose pills in 5 of 5 medication carts (A hall, B hall, C hall, D hall and F hall). They also failed to store undated and unopened vials of insulin per manufacturer instructions and failed to secure a narcotics drawer in 1 of 5 medication carts (B hall). The findings included: a. An observation of the medication room with the Assistant Director of Nursing (ADON) on 5/20/21 at 7:15 AM revealed an opened and undated vial of influenza vaccine in the medication room refrigerator. Half of the vial was left available for use. An interview with the ADON on 5/20/21 at 7:18 AM revealed she was not sure when the influenza vial had been used last but it should have been dated when it was opened because it was only good for 30 days after being opened. The ADON stated the medication room was supposed to be checked every shift by the charge nurses but the log revealed it had not been checked by the night shift nurse from the night before. b. An observation of the F hall medication cart with Nurse #1 on 5/20/21 at 6:45 AM revealed an unlabeled and opened single-dose vial of [MEDICATION(S)] injectable, a medication used to treat [CONDITION(S)] caused by various medical problems including heart failure, pulmonary [CONDITION(S)], kidney and liver disease, stored in the top drawer of the medication cart. Half of the vial was left available for use. An interview with Nurse #1 on 5/20/21 at 6:47 AM revealed that the vial of [MEDICATION(S)] must have been a stock medication that was pulled to use on a resident on F hall. He stated he was not sure for which resident it was given to. Nurse #1 also stated that the opened vial of [MEDICATION(S)] was only good for 28 days after being opened but he could not tell the date when it had been opened so it should have been discarded. Nurse #1 added that he checked the F hall medication cart but did not see that the [MEDICATION(S)] vial was not labeled or dated. An interview with the ADON on 5/20/21 at 7:20 AM revealed the vial of [MEDICATION(S)] should have been discarded after being used because it was a single-dose vial that should only have been used one time. c. An observation of the A hall medication cart with Nurse #2 on 5/20/21 at 11:05 AM revealed the following: * An opened and undated Novolog insulin [MEDICATION(S)] labeled with Resident #93's name was available for use. * An opened and undated Torjeo [MEDICATION(S)] pen labeled with Resident #20's name was available for use. * An unopened vial of [MEDICATION(S)] insulin, labeled with Resident #257's name with a sticker attached that read refrigerate until opened. An interview with Nurse #2 on 5/20/21 at 11:08 AM revealed both opened insulin pens should have been dated when opened because they were good for only 28 days after opening. The [MEDICATION(S)] should not have been taken out of the refrigerator for storage in the medication cart until needed for use because it was good for only 28 days after opening or after being taken out of refrigeration. d. An observation of the C hall medication cart with Medication Aide (MA) #1 on 5/20/21 at 1:15 PM revealed the following: * An unopened vial of [MEDICATION(S)] insulin labeled with Resident #44's name with a sticker attached that read refrigerate until opened. * An opened and undated [MEDICATION(S)] insulin pen labeled with Resident #23's name was available for use. * Two opened and undated [MEDICATION(S)] insulin pens labeled with Resident #71's name were available for use. An interview with Medication Aide (MA) #1 on 5/20/21 at 1:18 PM revealed she did not pay attention to the opened, undated insulin pens because she was not responsible for giving them. MA #1 stated Nurse #2 was assigned to help her out on C hall and gave the insulin to the residents. An interview with Nurse #2 on 5/20/21 at 1:20 PM revealed he was helping MA #1 on C hall and he reported the unopened [MEDICATION(S)] vial should have been dated whenever it was taken out of the refrigerator for storage in the medication cart because it was the same as opening the vial and would only be good for 28 days after opening. Nurse #2 stated all the [MEDICATION(S)] pens should have been dated as well when they were opened and discarded after 28 days. He did not know why the nurses did not use up Resident #23's [MEDICATION(S)] pen before opening another one. e. Right after inspection of C hall medication cart with MA #1 in the medication room, the B hall medication cart was observed with the lock mechanism in the unlocked position (the push-button to lock the medication cart was protruding about an inch from the medication cart). MA #1 agreed to stay in the medication room while the surveyor inspected the B hall medication cart. An observation was made of the B hall medication cart with MA #1 on 5/20/21 at 1:25 PM revealed the following: * An opened and undated vial of [MEDICATION(S)] insulin labeled with Resident #90's name was available for use. * The narcotics drawer was unlocked and popped open when the second left drawer of the B hall medication cart was pulled. An interview with MA #1 on 5/20/21 at 1:28 PM revealed she was not responsible for the B hall medication cart and did not know why the narcotics drawer was unlocked and popped open after the drawer was pulled. An interview with Nurse #3 on 5/20/21 at 2:07 PM revealed she was unaware that she had left the B hall medication cart unlocked with the narcotics drawer unlocked as well. Nurse #3 stated she should have made sure her medication cart was locked before leaving it. Nurse #3 added that she had been working on checking the insulins in the B hall medication cart but did not see the undated opened vial of [MEDICATION(S)] for Resident #90. An interview with the Director of Nursing (DON) on 5/20/21 at 5:57 PM revealed Nurse #3 should have made sure the narcotics drawer was locked prior to leaving the B hall medication cart. f. An observation of the D hall medication cart with MA #2 on 5/20/21 at 1:55 PM revealed the following: * An opened and undated [MEDICATION(S)] insulin pen labeled with Resident #204's name was available for use. * A plastic medication cup with a loose pill was stored in the first drawer of the D hall medication cart. An interview with MA #2 on 5/20/21 at 1:58 PM revealed the loose pill in the medication cup was Losartan which belonged to Resident #81 and was scheduled to be given at 9:00 AM. MA #2 stated the Losartan pill had to be pulled by Nurse #4 out of the stock medications because Resident #81 had run out of it. MA #2 disclosed that Nurse #4 gave her the Losartan pill at 12:00 PM but she did not administer it right away to Resident #81 because she was supposed to get a newly-ordered antibiotic pill at 1:00 PM and Resident #81 told her she wanted to take both medications at the same time. MA #2 said she was still waiting for Nurse #4 to pull the antibiotic pill out of the stock medications and decided to wait to give the Losartan with it. MA #2 stated she did not know anything about the opened and undated [MEDICATION(S)] insulin pen as she did not give this medication to Resident #204. An interview with Nurse #4 on 5/20/21 at 3:04 PM revealed she pulled Resident #81's Losartan pill out of the stock medications and gave it to MA #2 at 12:00 PM. Nurse #4 stated she assumed MA #2 gave the Losartan pill to Resident #81 after she handed it to her. She was unaware that MA #2 kept the pill in the D hall medication cart while Resident #81 waited to get the antibiotic dose at 1:00 PM. An interview with the DON on 5/20/21 at 5:57 PM revealed that all medications in the medication room and the medication carts should be labeled and dated and discarded when no longer in use. The DON stated all insulin vials and pens should be dated when they are opened as they expire after 28 days of opening. An interview with the Administrator on 5/20/21 at 6:33 PM revealed she expected all medications in the medication room and the medication carts to be labeled and dated. The nurses should also make sure that they lock the narcotics drawer in their medication carts prior to leaving it.

Based on record review, resident interview, staff interviews, and family interviews, the facility limited visitation time and days for 1 of 3 residents (Resident #13) reviewed for visitation. The findings included: Resident #13 was admitted to the facility on [DATE]. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. On 05/19/21 at 2:00 PM, the Activity Director explained that visitation was Monday, Wednesday Thursday, and Friday visitation was 10:30 AM to 4:30 PM and Saturday and Sunday from 9:30 AM to 11:30 AM. Resident #13 was not present to hear this. An interview conducted with Resident #13 on 05/18/21 at 3:40 PM revealed that her visitation with family was one day per week for thirty minutes out in front of the facility, and after her 30-minute visitation staff would come get her. Resident #13 further revealed visitation was denied for a family member because it was after 5:00 PM and the family had to visit at Resident #13's room window which was difficult because she had to talk on the phone to communicate. An interview conducted with Resident #13's legal representative on 05/18/21 at 4:25 PM revealed visits at the facility were frustrating because they must be scheduled and only allowed 30 minutes to visit. It was further revealed he had called and tried to schedule a visit the same day, but the facility would not allow him to see Resident #13 until the following day. The legal representative stated he had family members show up at the facility and they visited through the window because it was not scheduled and was after 4:30 PM. An interview conducted with the Wellness Coordinator on 05/20/91 at 4:10 PM revealed she oversees visitation in the facility and resident's legal representative received an automated call which explained the visitation schedule and rules. It was further revealed family and friends contact the receptionist at the facility and schedule times to visit the resident. The Wellness Coordinator stated she does not know if the families were aware that visitation did not have to be scheduled. An interview conducted with the Administrator on 05/20/91 at 6:45 PM revealed the facility does not deny any kind of visitation but did schedule visitation so that all residents have a chance of visiting with families. It was further revealed residents' friends and families should never be turned away for any kind of visitation.

Based on record review, staff interviews, and observations, the facility failed to implement a care plan for the use of fall mats for 1 of 1 resident (Resident #14) reviewed for fall prevention. The findings included: Resident #14 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired needing extensive assistance of two staff members with transfers and bed mobility. Review of Resident #14's care plan revised on 03/16/21 indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was for Resident #14 to sustain from falls without an injury. Interventions in place included fall mats to reduce risk of injury of future falls. An observation was conducted on 05/17/21 at 10:15 AM which revealed Resident #14 was in bed asleep without fall mats placed on either side of the resident's bed. An observation was conducted on 05/17/21 at 3:15 PM which revealed Resident #14 was in bed asleep without fall mats placed on either side of the resident's bed. An interview conducted with Nurse Aide #2 on 05/18/21 at 3:20 PM revealed Resident #14 should have had fall mats on both sides of her bed, but stated there had been times when the facility had not had enough fall mats for all fall prevention residents and they had to share. Nurse Aide #2 further revealed she did recall coming onto shift a few times and staff had forgotten to place fall mats out for Resident #14 when she was in the bed asleep. An interview conducted with the Assistant Director of Nursing (ADON) on 05/20/21 at 10:10 AM revealed she was aware of Resident #14's history of falls and it was expected for fall mats to be used as stated in the resident's care plan. An interview conducted with the Director of Nursing (DON) on 5/20/21 at 5:00 PM revealed it was expected for Resident #14's care plan to be followed by fall mats being placed on the floor when the resident was in the bed. An interview conducted with the Administrator on 05/20/21 at 6:35 PM revealed Resident #14's care plan should have been followed by fall mats being placed in the floor when the resident was in bed to prevent injury from a potential fall.

Based on record review, staff interviews, and observations, the facility failed to revise a care plan for the use of reclining wheelchair for 1 of 1 resident (Resident #14) reviewed for fall prevention. The findings included: Resident #14 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severaly cognitively impaired needing extensive assistance for transfers. Review of Resident #14's care plan revised on 03/16/21 indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was for Resident #14 to sustain from falls without an injury. Interventions in place included a dump wheelchair (drop seat to prevent foward fall) to reduce risk of future falls from wheelchair. An observation was conducted on 5/18/21 at 11:40 AM which revealed Resident #14 outside of the resident's room in a standard high back wheelchair with no recline. The observation further revealed Resident #14 fidgeting with her clothes causing her to fall forward, but a staff member was able to re-adjust her before she fell out of her chair onto the floor. An observation conducted on 05/19/21 at 4:35 PM revealed Resident #14 sitting outside of her room in a standard high back wheelchair with no recline. An observation conducted on 05/20/21 at 8:20 AM revealed Resident #14 in the residents' room in a high standard back wheelchair with no recline. An interview conducted with Nurse Aide #1 on 05/20/21 at 8:30 AM revealed she was aware of Resident #14's history of falls and stated the resident should be reclined back in her wheelchair when she was not supervised to prevent falls. The Nurse Aide further revealed she could not recall why Resdient #14 wa not reclined or what type of wheelchair Resident #14 was care planned for. Follow up interview conducted with the Therapy Manager on 05/20/21 at 10:45 AM revealed when Resident #14 was discharged from therapy previously on 03/13/21, the resident should have been discontinued from a dump wheelchair and switched to a high back reclining wheelchair to prevent falls. It was further revealed Resident #14's current wheelchair should always be at a 30-degree angle and the resident should never be sitting unattended straight up with no recline. The Therapy Manager stated the care plan should have been revised from a dump wheelchair to a reclining wheelchair. An interview conducted with the Director of Nursing (DON) on 5/20/21 at 5:00 PM revealed it was expected for Resident #14's care plan to be followed and for the resident's wheelchair to be reclined to prevent falls. It was further revealed Resident #14's care plan should have been revised for the appropriate wheelchair for the resident. An interview conducted with the Administrator on 05/20/21 at 6:35 PM revealed Resident #14's care plan should have been revised from a dump wheelchair to a reclining wheelchair when the resident was discharged from therapy.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 2 of 3 staff members (Nurse Aide #1 and Nurse Aide #2) on the COVID-19 unit failed to wear eye protection while providing resident care to 5 of 8 residents (Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10) reviewed for infection control. This failure occurred during a COVID-19 pandemic. The findings included: The Centers for Disease Control and Prevention (CDC) guidance entitled, Preparing for COVID-19 in Nursing Homes, updated on 11/20/20 indicated the following statement: *Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. A review of the facility's policy entitled, Personal Protective Equipment for COVID-19 or Suspected COVID-19 Residents, dated April 2020 read, in part: Personal Protection Equipment (PPE) will consist of gowns, gloves, goggles or face shields, and appropriate masks. The facility's policy entitled, Admission/Readmission/Isolation/COVID-19 Positive Units, dated July 2020 included the following statement: Staff providing care for residents who are COVID-19 positive and in isolation for recent diagnosis, will wear full PPE in the resident's rooms. During the entrance conference on 2/23/21 at 11:45 AM, the Director of Nursing (DON) indicated that the current residents who tested positive for COVID-19 were located on the C hall. A review of the facility census revealed the current COVID-19 positive residents occupied rooms 308 to 316 on the C hall. During a continuous observation on 2/23/21 from 4:45 PM to 5:55 PM of the COVID-19 unit, all resident doors had posted signage for enhanced droplet isolation precautions requiring mask, gown, gloves and face shield or goggles. Two plastic hanging [MEDICATION NAME] were placed on either side of the entrance to the COVID-19 unit and contained masks and goggles. Plastic bins containing gowns and gloves were in the hallway outside the doors in the COVID-19 unit. a. On 2/23/21 at 5:15 PM, Nurse Aide (NA) #1 was observed entering room Resident #7's room after putting on a gown and gloves. She was wearing an N95 mask. She did not have a face shield or goggles on and was only wearing her prescription eyeglasses. After five minutes, NA #1 removed her gown and gloves, exited Resident #7's room and used hand sanitizer out in the hallway. At 5:25 PM, NA #1 was observed going into Resident #6's room after putting on a gown and gloves while still wearing an N95 mask and her regular eyeglasses. She proceeded to assist with feeding Resident #6. An interview with NA #1 on 2/23/21 at 5:45 PM revealed this was her first time working on the COVID-19 unit but she had been told to wear an N95 mask, gown and gloves when going into a resident's room and to use hand sanitizer before going into and after leaving a room at the COVID-19 unit. NA #1 confirmed that she had been wearing her prescription eyeglasses and stated she was supposed to wear shield goggles over them, but she admitted that she forgot to get some. She also stated she had not been having any issues with the shield goggles fogging up her prescription eyeglasses. b. On 2/23/21 at 5:20 PM, NA #2 was observed putting on a gown and gloves while wearing a KN95 mask. She was not wearing a face shield or goggles. She entered room Resident #8's room. After a minute, she removed her gown and gloves, discarded them in the trash bin by the door and exited Resident #8's room. She rubbed hand sanitizer to both hands while in the hallway. She proceeded to Resident #9's room after putting on a gown and gloves at the door before entering. She was not wearing a face shield or goggles. After five minutes, NA #2 exited room Resident #9's room after discarding her gown and gloves inside the room. She was further observed using hand sanitizer. At 5:55 PM, NA #2 was observed inside room Resident #10's room wearing a gown, gloves and a KN95 mask while feeding Resident #10. NA #2 did not have any eye protective gear on. An interview was conducted with NA #2 on 2/23/21 at 6:00 PM. NA #2 stated she was aware that she was supposed to wear an eye protective gear when working inside the rooms on the COVID-19 unit but her goggles broke while she was giving a resident a shower during the earlier part of the shift. She said she got busy and had not gotten around to getting a new pair. An interview conducted on 2/24/21 at 12:41 PM with the DON revealed NA #2 had come to her on the evening of 2/23/21 to ask for another pair of goggles. The DON stated NA #2 told her that her goggles had broken after she dropped it in the shower room. The DON had not been aware that NA #2 did not immediately replace her goggles and that she went back to the COVID-19 unit without any eye protective gear on. The DON said both NA #1 and NA #2 should have asked her or any nurse for eye protective gear because they had plenty of supplies and they should not have gone into any of the rooms in the COVID-19 unit without eye protection. An interview with the Administrator on 2/24/21 at 4:20 PM revealed she expected her staff to wear eye protection when working on the COVID-19 unit.

Based on observations, staff, resident and physician interviews and record review, the facility failed to transfer a resident with the required level of staff assistance. As a result, the resident was unable to support her weight during the transfer and fell . The fall was not reported to the assigned nurse, the next shift nurse or administration; the resident was not thoroughly assessed after the fall and the fall was not documented in the medical record. A day after the fall the resident complained of pain and an x-ray revealed a [MEDICAL CONDITION] layer of the femur just above the knee joint on the right leg. This was for 1 of 3 sampled residents for provide supervision to prevent accidents (Resident #5). Findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact and she required extensive 2-person assistance with transfers. The MDS also specified the resident was not steady moving from seated to standing, used a wheelchair for locomotion and had not fallen since the previous assessment. A care plan was developed for Resident #5 to address her activity of daily living (ADL) deficit related to decreased functional mobility secondary to chronic illnesses. The care plan was reviewed and updated with the MDS dated [DATE]. The care plan's interventions specified Resident #5 required two-person assistance for transfers. A nurse practitioner (NP) progress note dated 09/08/20 specified Resident #5 was seen for follow-up to recent therapy. The NP documented Resident #5 had no complaints of pain and did not express new medical concerns. A progress note made by Nurse #1 dated 09/08/20 during second shift specified Resident #5 complained of right lower leg pain. The nurse documented that Resident's leg was [MEDICAL CONDITION] (swollen), slightly discolored and had a positive pulse. Resident #5's vital signs were obtained and there were no irregularities noted by the nurse. Nurse #1 contacted the physician and obtained orders for an x-ray. The findings for the x-ray report dated 09/08/20 revealed moderate to severe [MEDICAL CONDITION] (brittle bones) with a [MEDICAL CONDITION] layer of the femur just above the knee joint on the right leg. In the same note dated 09/08/20 made by Nurse #1, the physician was notified of the x-ray results and ordered an Orthopedic consult ASAP (As Soon As Possible). Resident #5's family was notified of the change in condition. On 09/09/20 at 3:53 AM a progress note made by Nurse #2 revealed Resident #5 had no complaint of pain or discomfort and rested quietly in bed. The nurse documented vitals for Resident #5 and there were no irregularities noted. On 09/09/20 at 8:54 AM a progress note made by Nurse #3 revealed Resident #5 was being transported to the Emergency Department for assessment of right leg due to pain from a fall (no date specified). The Emergency Department (ED) records dated 09/09/20 were obtained and reviewed. Resident #5 was diagnosed with [REDACTED]. The ED notes specified Resident #5 presented to the Emergency Department for evaluation after a fall onto her right knee approximately 3 days ago. While in the ED, an Orthopedic physician was consulted, placed Resident #5 in a long-leg splint and returned to the facility with an order to follow-up with the Orthopedic physician (no timeframe was specified). On 09/09/20 at 5:22 PM Nurse #4 documented Resident #5 returned from the ED with a splint to her right leg and new orders for pain medication. The note specified Resident #5 was not in distress. On 09/10/20 Resident #5 was seen by the NP and a progress note revealed Resident #5 reported that her right leg went out from under her and she landed on her knee. Resident #5 complained that medication was not helping her pain and the NP made changes to Resident #5's pain management. On 10/08/20 Resident #5 was seen for follow-up by the Orthopedist. The report dated 10/08/20 specified Resident #5 was seen for follow-up of non-displaced fracture of right femur near the knee cap. The physician recommended to wear the knee immobilizer brace for 2 weeks. On 10/23/20 at 11:48 AM Nurse #5 was interviewed and explained she was assigned to Resident #5 on 09/07/20 from 7 AM to 3 PM. The nurse stated Resident #5 attended [MEDICAL TREATMENT] Monday, Wednesday and Friday and left the facility usually round 8 AM and would not return until after the 3 PM shift ended. Nurse #5 revealed on 09/07/20 she administered insulin to the Resident prior to her shower. The nurse added that she did not have any other direct contact with Resident #5 that day and was never notified of a fall. Nurse #5 stated Resident #5 was non-ambulatory and required two-person assistance with transfers. In the same interview, Nurse #5 explained that she was made aware a day or two later Resident #5 had a fractured leg from a fall in the shower on 09/07/20. The nurse stated again that she was never notified of a fall during the shift on 09/07/20. On 10/23/20 at 11:58 AM nurse aide (NA) #1 was interviewed and explained she was the nurse aide assigned to Resident #5 on 09/07/20 on the 7 AM to 3 PM shift. However, NA#1 stated she traded showers with NA #2 and did not provide the shower for Resident #5 on 09/07/20. NA #1 stated Resident #5 was alert and oriented and required two-person extensive assistance with transfers. The NA added there had been times when she had transferred the resident with one-person assistance even though she was care planned to have two staff. She explained that on 09/07/20 she entered the shower room and observed Resident #5 on the shower room floor. The NA could not recall what position Resident #5 was in on the floor. She stated she and NA #2 assisted Resident #5 off the floor using a gait belt and Nurse #6 was in the room and held onto the wheelchair. NA #1 stated that she did not report the fall because she was not the NA caring for the resident when the fall occurred. NA #1 added that she was trained to report any fall to the assigned nurse. NA #1 also stated that Resident #5 did not complain of pain or an injury and left the facility for [MEDICAL TREATMENT] after the fall. NA #1 added she did not see Resident #5 the remainder of the shift on 09/07/20. NA #1 stated she worked the following day 09/08/20 and Resident #5 did not complain of pain from the fall. The NA could not remember if Resident #5 got out of bed on 09/08/20 or had to be transferred. On 10/26/20 at 3:38 PM nurse aide (NA) #2 was interviewed on the telephone and explained she was not assigned to Resident #5 on 09/07/20 but had agreed to shower the resident. NA #2 stated she had showered Resident #5 in the past, but it had been so long she could not recall when the last time was. The NA explained she used care plans provided to staff with care instructions about residents. She stated she did not refer to Resident #5's care plan and relied on a co-worker who informed her Resident #5 could transfer with one-person assistance. NA #2 could not recall the identity of the co-worker. She described that on 09/07/20 after showering Resident #5, she wheeled the resident toward the toilet area equipped with a grab bar on the wall. Resident #5 held on to the grab bar, stood up from the shower chair with little assistance, as the NA reached back to get the wheelchair. NA #2 stated Resident #5 said, I gotta sit down and the NA lowered her all the way to the floor without a hard impact onto her buttocks. NA #2 stated that on 09/07/20 she was not aware Resident #5 required two-person assistance with transfers. During the same interview, NA #2 explained that once Resident #5 was on the floor Nurse #6 entered the shower room, observed Resident #5 on the floor and asked her if she was okay. According to NA #2, the resident did not complain of pain or injury from the fall. She stated she and NA #1 (who had also entered the shower room) used a gait belt to assist Resident #5 off the floor while Nurse #6 pushed the wheelchair under the resident. Approximately a half an hour to an hour after the incident, Resident #5 left for [MEDICAL TREATMENT]. NA #2 stated she did not report the fall to Nurse #1 because Nurse #6 was in the room and aware of the fall. On 10/23/20 at 2:55 PM Nurse #6 was interviewed and described on 09/07/20 around 7:30 AM she was completing a treatment, entered the showered room to dispose of soiled linens and observed Resident #5 on the floor. Nurse #6 stated she did an assessment of Resident #5 by asking her if she was okay and looked for any obvious injury. The nurse added that Resident #5 did not complain of pain or report any injury. She explained that she held the wheelchair while NA #1 and NA #2 assisted Resident #5 off the floor. Nurse #6 reported she did not notify anyone of the fall and did not document her assessment of Resident #5 because she was not the hall nurse. Nurse #6 stated once Resident #5 was off the floor, she left the shower room and proceeded with treatments. On 10/23/20 at 4:50 PM Resident #5 was interviewed after returning from [MEDICAL TREATMENT]. Resident #5 explained she had been a resident in the facility for more than a year and felt the staff took good care of her. She added that she was blind and relied on staff to do a lot for her. She stated her legs had not been good for a while and it took two people to transfer her in and out of bed. Resident #5 added that everything had been going fine until last month she fell in the shower room and broke her right leg. Resident #5 recounted an incident that occurred on Monday prior to leaving for [MEDICAL TREATMENT], she was showered by a nurse aide that she could not recall her name. At the completion of the shower, she wanted to be moved closer to the toilet where the floor was dry to not get her socks wet. She explained she had used the wall bar many times to hold on to while staff pulled her pants up. Resident #5 stated that for whatever reason when she stood up her legs gave out and she went down on both knees. Resident #5 reported there was only one nurse aide in the shower room for the transfer but after the fall, another person entered to assist. The resident recalled she heard a pop in her knee but there was no immediate pain until the next day. Resident #5 stated that since her injury, she was now transferred with a mechanical lift for all transfers. On 10/26/20 at 12:30 PM NA #3 was interviewed on the telephone and explained Resident #5 was transferred with a mechanical lift on second shift. She went on to explain that during the evening of 09/08/20 while preparing Resident #5 to be transferred with the mechanical lift, Resident #5 started crying. The NA stated she asked Resident #5 what was wrong, and the resident reported she was dropped in the shower room on 09/07/20. NA #3 and another nurse used the mechanical total lift to transfer Resident #5 to the bed and notified Nurse #1. NA #3 stated Resident #5 had always been a mechanical total lift on second shift and she was shocked to learn the resident could use her legs to stand. On 10/26/20 at 12:24 PM the nurse practitioner (NP) was interviewed on the telephone and explained she was providing in-room assessments and on 09/08/20 when she assessed Resident #5 there was no mention of pain and/or a fall. The NP was unaware on 09/08/20 Resident #5 had fallen and stated that after a fall, she tried to make a note to document what she saw. The NP added that she assessed Resident #5's pain from a fracture (on 09/10/20). The NP stated she had no reason to think Resident #5 broke her leg in any other way than from the fall on 09/07/20 in the shower room. She explained the fall was a minor thing that didn't require surgery and the only intervention was an immobilizer. On 10/27/20 at 11:00 AM Nurse #1 was interviewed on the telephone and explained on 09/08/20 she was notified by NA #3 that Resident #5 was complaining of pain in her right leg. The nurse stated Resident #5 reported she had fall after a shower on the previous day. Nurse #1 added she did not see documentation of a fall in the medical record but notified the on-call and obtained orders for a mobile x-ray that revealed a [MEDICAL CONDITION] femur. The nurse also reported she had administered as needed pain medication that was effective as evidence by Resident #5 rested with her eyes closed the remainder of the shift. On 10/23/20 at 3:22 PM the Director of Nursing (DON) was interviewed and explained Resident #5 fell on [DATE] in the shower room when being transferred by NA #2. The DON stated she was not made aware of the fall until the morning of 09/09/10 through a note left under her door. The DON reported Resident #5 had complained of pain during the evening shift on 09/08/20 and an x-ray revealed a fractured right femur. The DON reported Resident #5 was sent to the Emergency Department on 09/09/20 at the request of the family. She started an investigation on 09/09/10 by going to Resident #5 and asking her what had occurred. The DON reported Resident #5 told her she was in the shower room with one nurse aide who attempted a transfer her, but she fell . The DON added she spoke with NA #2 who reported Resident #5 was in a hurry and needed to use the bathroom, so she transferred the resident but had to lower the resident to the floor. The DON explained that lowering a resident to the ground was considered a fall and NA #2 failed to have a second nurse aide assist with the transfer. The DON added that NA #2 did not report the fall to the assigned nurse and there was no documentation in the medical record about the fall on 09/07/20. The DON stated it was the responsibility of NA #2 to report the fall to Nurse #5. She added that nurses are expected to complete a head to toe assessment for injury when a fall occurred and document the assessment and incident in the medical record. The DON stated that unfortunately Resident #5's nurse had not been notified of a fall which resulted in lack of documentation in the medical record. On 10/27/20 at 4:30 PM the Administrator was interviewed on the telephone and explained that after learning about the incident on 09/07/20, the facility conducted staff in-servicing about reporting falls. She reported she felt the incident was isolated and handled by nursing administration to prevent reoccurrence. She stated she did not introduce the incident into the Quality Assurance Program but intended to follow staffs' actions to ensure falls were reported.

Based on observation, record review, staff interview, the facility failed to educate staff on the importance of preventing cross contamination by performing hand hygiene after touching a resident or an environmental surface on the New Admission Observation COVID-19 quarantine hall. The facility failed to don/doff appropriate Personal Protective Equipment (PPE) according the Center for Disease and Prevention Control (CDC) on quarantine hall for 6 of 9 sampled residents reviewed for infection control practices (Resident #9, #10, #12, #15, #11, and #17). These failures in infection control practices occurred during a COVID-19 pandemic. The findings included: According to guidelines published by the CDC on 04/30/20, all new admissions shall be placed on isolation observation and full PPE is required when providing care. This PPE included the use of a gown, gloves, face mask, and eye wear and indicated hand washing was needed for the first 14 days following admission for all residents who did not meet criteria to discontinue isolation in the hospital prior to admission. According to the undated facility document titled, Admissions and Readmissions indicated the facility will follow all CMS and CDC recommendations for admissions and readmissions. The document further indicated: This will include isolation with enhanced isolation precautions for a minimum of 14 days. Residents with compromised immune systems may remain in isolation for up to 20 days. At the end of the isolation period, if the resident does not present signs of COVID-19 and has not had a new positive test (based on facility testing guidelines. Residents who have tested positive in the last 3 months will not be retested and discontinuation of isolation will be based on the 14-day isolation period and asymptomatic status of COVID-19), the resident may be moved off the isolation unit to a non-isolated unit. All occupied rooms on the Isolation/COVID-19 unit will have an ENHANCED DROPLET isolation sign displayed outside the room, on the door or designated area for notification of precautions. This will be in effect for all residents on the designated unit, regardless of COVID-19 status. Notification of ISOLATION/COVID-19 unit will be designated with an ENHANCED ISOLATION posting outside the unit. The following observations were made on the 100 hall New Admission Observation COVID-19 quarantine hall on 10/23/20. 1 a. Resident #9 was admitted to the New Admission Observation COVID-19 quarantine hall on 10/20/20 with [DIAGNOSES REDACTED]. A continuous observation of the 100 hall New Admission Observation quarantine unit was made on 10/23/20 between at 07:50 AM and ended at 08:10 AM revealed Resident #9's sitting outside the door of her room in the hallway. Resident 9's door displayed signage that indicate Modified Droplet Contact Precautions which indicated gloves and hand hygiene were required when interaction occurred. Resident #9 was sitting in her wheelchair and had an overbed table placed directly in front of her. NA #4 was wearing a face mask and eye wear when she approached Resident #9 wearing a mask and eyewear then sat the meal tray on the overbed table that Resident #9 had been observed touching prior. NA #4 opened the tray items and sat the tray up for Resident #9. NA #4 was not observed performing hand hygiene before setting up of the tray or following contact with Resident #9 before she continued delivering additional trays to other residents on the unit. NA #4 proceeded to obtain an additional tray from the meal service cart. 1 b. Resident #10 was admitted to the New Admission Observation COVID-19 quarantine hall on 4/30/20 with [DIAGNOSES REDACTED]. A continuous observation of the 100 hall New Admission Observation quarantine unit was made on 10/23/20 between 07:50 AM and ended at 08:10 AM revealed NA #4 was observed wearing a face mask and eye wear when she left Resident #9 after setting up her tray and entered Resident #10's room. Resident #10's room displayed signage that indicated Modified Droplet Contact Precautions. NA #4 sat the tray up and exited the room to obtain 2 cups of beverage without performing hand hygiene and returned to Resident #10's room with the cups. NA #4 was not observed to perform hand hygiene prior to exiting Resident #10's room. 1 c. Resident #12 was admitted to the New Admission Observation COVID-19 quarantine hall on 07/09/20 with [DIAGNOSES REDACTED]. A continuous observation of the 100 hall New Admission Observation quarantine unit was made on 10/23/20 between 07:50 AM and ended at 08:10 AM revealed NA #4 was observed to wear a face mask and eye wear while delivering breakfast meal trays. NA #4 was observed to enter Resident #12's and sat the tray on the overbed table. Resident #12 asked NA #4 for an item which she turned to the bedside table to retrieve and handed it to Resident #12 before returning to the breakfast tray to set up the food items. NA #4 then exited the room without performing hand hygiene and approached the community beverage cart, poured a cup of coffee and then returned to Resident #12's room. NA # 4 then exited the room without performing hand hygiene. An interview on 10/23/20 at 11:12AM with NA #4 revealed she had worn a facemask and eye wear when she delivered breakfast trays on the 100 hall New Admission Observation COVID-19 quarantine unit but did not don a gown or gloves because she had been taught gloves or a gown were not needed during meal service delivery. NA #4 stated she did not think about the need to perform hand hygiene after setting up Resident #9 and before proceeding to set up Resident #10's tray that morning. NA #4 also revealed she should have performed hand hygiene after interacting with Resident #12 and the community beverage containers should be sanitized if touched after contact with a resident on the quarantine unit. NA #4 indicated she had been taught gowns and gloves were not necessary on the 100 hall New Admission Observation COVID-19 quarantine unit unless providing incontinence care or coming in contact with the resident's nose or mouth. An interview with the Infection Control Nurse/ ADON (IC) on 10/23/20 at 11:47 AM revealed the 100 hall was the New Admission Observation COVID-19 quarantine unit and all residents are on transmission-based precautions of Modified Droplet Contact Precautions. The IC nurse indicated a mask and eye wear were always to be worn when caring for residents on the unit. The IC nurse stated gloves and gowns were not needed unless performing incontinence care for the residents on this unit. The IC nurse acknowledge signage posted on the doors of each resident room on the 100 hall illustrated the use of gloves and hand hygiene were needed; however, stated she did not believe NA #4 needed gloves to deliver meal trays to residents in rooms of transmission-based precautions. The IC Nurse stated NA #4 should have performed hand hygiene between every resident interaction on the New Admission Observation COVID-19 quarantine unit. An additional interview on 11/19/20 at 9:52 AM with the IC Nurse revealed she was the facility's infection preventionist and was certified in infection control through the NC SPICE program in March 2020. The IC Nurse indicated she was responsible for the up-to-date IC policies and providing staff trainings in the updates in infection control practices. The IC Nurse explained she was following CMS and SPICE guidance. The interview also revealed the IC acknowledged she did not review or verify any additional guidance provided by the CDC website on PPE usage and appropriate isolation precautions. An interview on 10/23/20 at 3:20 PM with the Director of Nursing (DON) and Administrator revealed the 100 and 500 halls were designated for all new admissions and COVID-19 residents who were on transmission-based precautions. They both acknowledged signage on the doors of each room indicated precautions which included needed PPE to be a mask, eyewear, and gloves at all times as well as a gown for incontinence care and hand hygiene was to be performed. The DON stated gloves, or a gown were not required to deliver meal trays to residents on the 100 unit who were under transmission-based precautions because the staff were not performing incontinence care. An interview on 10/26/20 at 10:26 AM with the local Health Department (HD) Nurse revealed all new admissions were to be placed on transmission-based precautions for 14 days following admission that must include the use of full PPE. The local HD Nurse indicated full PPE included a gown, gloves, eyewear, and gloves were always to be worn when interacting with a new admission for the 14-day quarantine period. The local HD Nurse also indicated thorough hand hygiene was to be performed after interactions with residents on transmission-based precautions. The local HD nurse indicated NA #4 potentially spread infection by not wearing gloves and performing hand hygiene while delivering meal trays to residents on the quarantine unit. 2. Resident #15 was admitted to the New Admission Observation COVID-19 quarantine hall on 08/08/20 with [DIAGNOSES REDACTED]. An observation on 10/23/20 at 10:45 AM revealed Nurse #7 enter Resident #15's room with a cup of pills and a box containing nasal spray. Nurse #7 was wearing a face mask and eyewear. Nurse #7 was not observed to be wearing a gown when she entered Resident #15's room. Nurse #7 sat both items on Resident #15's bedside table and exited the room and returned to the medication cart parked outside the door without performing hand hygiene. Resident #15's door displayed signage that indicated Modified Droplet Contact Precautions which included PPE needs to be a mask, eyewear, gloves, and gown when providing incontinence care and that hand hygiene should be performed. Nurse #7 opened the medication cart and retrieved an insulin pen then returned to Resident #15's room and closed the door. Nurse #7 then opened Resident #15's door holding the insulin pen and the box of nasal spray with her ungloved hands. Nurse #7 was observed to unscrew the injection tip with her bare hands then discard the injection tip into the sharps box and place the syringe in the cart along with the box of nasal spray which was in contact with other resident's items in the cart then close the cart drawer. Nurse #7 was not observed to perform hand hygiene before beginning to push the medication cart in the hallway to complete the remainder of her mediation delivery. An interview on 10/23/20 at 11:10 AM revealed Nurse #7 was a new nurse to the facility and worked the New Admission Observation COVID-19 quarantine unit. Nurse #7 stated she did not think about hand hygiene when delivering the medications to a Resident #15 who was on transmission-based precautions of Modified Droplet Contact Precautions although acknowledged Resident #15 had signage displayed on her door that indicated precautions that illustrated hand hygiene was to be performed and the use of gloves were required when entering Resident #15's room. Nurse #7 indicated she had not been taught there was any potential for cross-contamination of germs when a resident had touched a medication package and the medication being placed back in the cart along-side other medications in the hall medication delivery cart. Nurse #7 further revealed Resident #15 self-administers her own mediations and she did not think to apply gloves to discard the syringe after administration. An interview with the Infection Control Nurse/ ADON (IC) on 10/23/20 at 11:47 AM revealed the 100 hall was the New Admission Observation COVID-19 quarantine unit and all residents are on transmission-based precautions of Modified Droplet Contact Precautions. The IC nurse indicated a mask and eye wear were always to be worn when caring for residents on the unit. The IC nurse stated gloves and gowns were not needed unless performing incontinence care for the residents on this unit. The IC nurse acknowledge signage posted on the doors of each resident room on the 100 hall illustrated the use of gloves and hand hygiene were needed; however, stated she did not believe gloves were needed to deliver medications to residents in rooms on transmission-based precautions. An additional interview on 11/19/20 at 9:52 AM with the IC Nurse revealed she was the facility's infection preventionist and was certified in infection control through the NC SPICE program in March 2020. The IC Nurse stated Nurse #7 would not have needed to wear gloves when touching the soiled medication cup, box containing nasal spray, or the insulin pen when she exited the room of Resident #15. Nurse #7 would only use a mask and eyewear and performed hand hygiene while she administered medications to Resident #15. An interview on 10/23/20 at 12:02 PM with the Director of Nursing (DON) the 100 hall was the New Admission Observation COVID-19 quarantine hall and all doors included signage that indicated residents were on Modified Droplet Contact Precautions. The DON stated she did not believe it was necessary to wear gloves to administer medications of residents on transmission based precautions but explained that the nurse should not have had the syringe in her bare hand and Nurse #7 should have performed hand hygiene after she exited the room and before opening the medication cart to retrieve the insulin pen. The DON indicated Nurse #7 should have performed hand hygiene again after administering the medications. The DON did not feel it to be cross contamination for medications to be touching one another in the medication cart of residents on transmission-based precautions who had self-administered medications. An interview on 10/23/20 at 3:20 PM with the DON and Administrator revealed the 100 hall were designated for all new admissions and COVID-19 residents who were on transmission-based precautions. They both acknowledged signage on the doors of each room indicated Modified Droplet Contact Precautions which included needed PPE to be a mask, eyewear, and gloves at all times as well as a gown for incontinence care and hand hygiene was to be performed. The DON stated gloves were not required for any interactions with residents on transmission-based precautions except performing incontinence care. An additional interview on 11/19/20 at 10:03 AM with the DON revealed the IC Preventionist role in the facility was assigned to the Assistant Director of Nursing (ADON) who had been trained in infection control through the NC SPICE program this year and was responsible for the most up-to-date guidelines and guidance in best practices. An interview on 10/26/20 at 10:26 AM with the local Health Department (HD) Nurse revealed all new admissions were to be placed on transmission-based precautions for 14 days following admission that must include the use of full PPE. The local HD Nurse indicated full PPE included a gown, gloves, eyewear, and gloves were always to be worn when interacting with a new admission for the 14-day quarantine period. The local HD Nurse also indicated thorough hand hygiene was to be performed after interactions with residents on transmission-based precautions. The local HD Nurse indicated Nurse #7 potentially spread infection by not wearing full PPE while administering medication and performing hand hygiene after administering medications to residents on the quarantine unit. 3. Resident #11 was admitted to the New Admission Observation COVID-19 quarantine hall on 10/9/20 with [DIAGNOSES REDACTED]. An observation on 10/23/20 at 10:47 AM revealed Therapy Staff #1 and Therapy Staff #2 were in the hallway on the 100 Hall New Admission Observation COVID-19 quarantine hall with Resident #11. Therapy Staff #1 and Therapy Staff #2 were observed to wear a face mask and eye wear when interacting with Resident #11. Resident #11's door displayed signage that indicated Modified Droplet Contact Precautions that included illustration for the need of hand hygiene and gloves to be worn when contact with Resident #11 and a gown during incontinence care. Therapy Staff #2 was assisting Resident #11 to perform sit to stand exercises with Resident #11 using the handrails attached to the wall. Therapy Staff #1 was typing on his computer that was located on a rolling desk in the hallway and approached Resident #11 and placed both hands on Resident #11's shoulders, leaned his head around to Resident #11's left side and spoke to Resident #11 whose face was 6-8 inches away. Therapy Staff #1 was not observed to perform hand hygiene before returning to his laptop and begin typing. Therapy Staff #2 pushed Resident #11 back into her room and exited into the hallway. Therapy Staff #1 and Therapy Staff #2 were wearing a face mask and eyewear but neither Therapy Staff #1 nor Therapy Staff #2 were observed to perform hand hygiene following interaction with the resident. An interview on 10/23/20 at 11:02 with Therapy Staff #1 and Therapy Staff #2 revealed they acknowledged they had both touched Resident #11 who was on Modified Droplet Contact Precautions and had not followed it by performing hand hygiene. Therapy Staff #1 stated he typically was good to clean his laptop frequently but had not during the observation. An interview on 10/23/20 at 11:47 AM with the Assistant Director of Nursing/ IC Nurse revealed the 100 hall was the New Admission Observation COVID-19 quarantine unit and all residents are on transmission-based precautions of Modified Droplet Contact Precautions. The IC Nurse indicated a mask and eye wear were always to be worn when caring for residents on the unit. The IC Nurse acknowledged signage posted on the doors of each resident room illustrated the use of gloves and hand hygiene were needed; however, the IC stated she did not believe gloves were needed to provide a therapy treatment in the hallway to a resident on transmission-based precautions. An additional interview on 11/19/20 at 9:52 AM with the IC Nurse revealed she was the facility's infection preventionist and was certified in infection control through the NC SPICE program in March 2020. The IC Nurse indicated she was responsible for the up-to-date IC policies and providing staff trainings in the updates in infection control practices. The IC Nurse explained she was following CMS and SPICE guidance. An interview on 10/23/20 at 12:02 AM with the DON revealed the 100 hall was the New Admission Observation COVID-19 quarantine unit and all residents on that unit were on transmission-based precautions of Modified Droplet Contact Precautions which illustrated hand hygiene was required and the use of gloves were required for contact with the resident. An additional interview on 11/19/20 at 10:03 AM with the DON revealed the IC Preventionist role in the facility was assigned to the Assistant Director of Nursing (ADON) who had been trained in infection control through the NC SPICE program this year and was responsible for the most up-to-date guidelines and guidance in best practices. An interview on 10/26/20 at 10:26 AM with the local Health Department (HD) Nurse revealed all new admissions were to be placed on transmission-based precautions for 14 days following admission that must include the use of full PPE. The local HD Nurse indicated full PPE included a gown, gloves, eyewear, and gloves were always to be worn when interacting with a new admission for the 14-day quarantine period. The local HD Nurse also indicated thorough hand hygiene was to be performed after interactions with residents on transmission-based precautions. The local HD Nurse indicated both Therapy Staff #1 and Therapy Staff #2 potentially spread infection by not wearing full PPE during care and performing hand hygiene after providing care for residents on the quarantine unit. 4. Resident #17 was admitted to the New Admission Observation COVID-19 quarantine hall on 10/22/20. An observation on 10/23/20 beginning at 10:56 AM and ended at 11:00 AM revealed NA #4 entered Resident # 17's room to answer a call light that was on. NA #4 was observed to be wearing a face mask and eye wear. When NA #4 entered the room, she turned off the call light and asked Resident #17 what he needed. Resident # 17 told NA #4 he wanted some fresh ice in his water pitcher. NA #4 picked up the water pitcher and exited the room carrying the pitcher. NA #4 carried the pitcher down the 100 hall to the community nourishment room located on the end of the hall across from the nurses' station. NA #4 opened the door to the nourishment room with her bare hand and entered the room with Resident # 17's water pitcher. NA #4 then approached the ice machine, opened the lid with her hand, retrieved a scoop of ice, and put the fresh ice in the Resident #17's water pitcher. NA #4 then placed the scoop back in its container, closed the ice maker lid, and left the nourishment room with Resident # 17's water pitcher of fresh ice. NA #4 then returned to Resident # 17's room with the water pitcher and entered the room. NA #4 was not observed to perform hand hygiene before exiting Resident #17's room. An interview on 10/23/20 at 11:12 AM with NA #4 revealed she worked the 100 hall New Admission Observation COVID-19 quarantine unit and had answered the call light for Resident #17 whom had requested fresh ice in his pitcher. NA #4 acknowledged Resident #17 was on Modified Droplet Contact Precautions and she had taken the water pitcher from a resident room whom was on isolation and filled it with ice in the nourishment room at the end of the hall instead of obtaining ice and bringing it to the room. NA #4 agreed that she potentially cross-contaminated surfaces when she removed the water pitcher from an isolation room and had touched multiple surfaces without performing hand hygiene which was a potential to spread infection. An interview on 10/23/20 at 11:47 PM with the ADON/IC Nurse revealed 100 hall was a designated New Admission Observation COVID-19 quarantine unit and all residents on this hall were on precautions of Modified Droplet Contact Precaution. The IC Nurse indicated a mask and eye wear were required at all times when caring for residents on this unit. The IC nurse stated gloves and a gown were not needed unless performing incontinence care for the resident on the unit. The IC nurse acknowledged the signage posted on the doors of each room on the 100 hall illustrated the use of gloves and hand hygiene were needed; however, she stated she did not believe gloves were needed to provide fresh ice to the resident. The IC nurse indicated NA #4 should not have removed the soiled pitcher from Resident #17's room and taken it to the nourishment room to refill it. The IC Nurse explained NA #4 should have obtained a new water pitcher of ice and taken it to Resident #17's room. The IC Nurse said NA #4 should have performed hand hygiene after she exited Resident #17's room. An interview on 10/23/20 at 12:02 PM with the DON revealed Resident #17 resided on the 100 hall New Admission Observation COVID-19 quarantine unit and was on Modified Droplet Contact Precautions. The DON indicated she did not believe gloves or a gown were needed when obtaining fresh ice for Resident #17; however, did say that NA #4 should have taken a fresh pitcher of ice to Resident #17's room instead of removing the contaminated water pitcher from the room and into the community nourishment room at the end of the hall. An interview on 10/26/20 at 10:26 AM with the local Health Department (HD) Nurse revealed all new admissions were to be placed on transmission-based precautions for 14 days following admission that must include the use of full PPE. The local HD Nurse indicated full PPE included a gown, gloves, eyewear, and gloves were always to be worn when interacting with a new admission for the 14-day quarantine period. The local HD Nurse also indicated thorough hand hygiene was to be performed after interactions with residents on transmission-based precautions. The local HD Nurse indicated NA #4 potentially spread infection by not wearing full PPE when in a resident room that displayed transmission-based precautions and touching surfaces with contaminated hands when NA #4 did not perform hand hygiene after providing fresh ice to a resident on the quarantine unit.

Based on observation, record review, and staff interview the facility failed to cover facial hair while serving the lunch meal for 1 of 1 meal observations. The practice of not covering hair had the potential to affect the food being served to the residents. The findings included: Review of a facility policy titled Food Preparation and Service with no date noted read in part, Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does note contact food. A brief tour of the kitchen was made on 05/06/19 at 11:15 AM with the Dietary Manager (DM). Cook #1 was observed preparing food for the upcoming lunch service. Cook #1 was observed open/closing and taking items out of the oven and placing them on the steam table. Cook #1 was observed to have a ball cap on his head but his beard, mustache, and goatee that were neatly trimmed were uncovered. A continuous observation of the lunch meal service was conducted on 05/06/19 from 11:58 AM to 12:54 PM. Cook #1 was observed plating meals for the residents in the facility. Cook #1 was observed to have a ball cap on his head but his beard, mustache, and goatee that were neatly trimmed were uncovered. An observation of Cook #1 was made on 05/07/19 at 11:47 AM. Cook #1 was in the food preparation area and had a ball cap on his head but his beard, mustache, and goatee that were neatly trimmed were uncovered. An interview with Cook #1 was conducted on 05/07/19 at 1:46 PM. Cook #1 stated he had been at the facility for [AGE] years in the dietary department. He stated that he always wore his base ball cap on his head and further stated that when his facial hair was grown out he wore a bread guard. Cook #1 confirmed that he did not have a beard guard on covering his facial hair on 05/06/19 during the meal preparation/service and on 05/07/19 because he had recently trimmed his facial hair and did not think he needed one. An interview was conducted with the DM on 05/08/19 at 3:10 PM. The DM stated Cook #1 has always worn a beard guard and she had been instructed that if he only had a little bit of facial hair than he did not have to wear the beard guard. She added that she has never had to speak to Cook #1 about the beard guard because he generally always had it in place. The DM stated that she expected Cook #1 to have a beard guard in place anytime he was in the food preparation area. An interview was conducted with the Registered Dietician (RD) on 05/08/19 at 4:43 PM. The RD stated that she visited the facility often and never had to remind Cook #1 about the beard guard because he was so complaint. The RD stated that anytime Cook #1 was in the food preparation area his facial hair should be covered. An interview was conducted with the Administrator on 05/10/19 at 12:24 PM. The Administrator stated that Cook #1 always wore a beard guard and this was an isolated event. She continued to say that she had never had an issue with Cook #1 or his wearing a beard guard. The Administrator stated, he always wears a cap and a beard guard.

Based on record review and staff interviews, the facility failed to accurately code behaviors on an annual Minimum Data Set assessment for 1 of 1 resident who exhibited behaviors and was reviewed for level II PASARR (Resident #30). Findings Included: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #30's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderately impaired cognition with episodes of hallucinations but no other behavioral symptoms. A review of Resident #30's care plan last reviewed on 03/15/19 revealed a care plan area for having had a history of [REDACTED]. Interventions included to administer medications as ordered while monitoring for effectiveness and to not argue with Resident #30 when she talked about seeing or hearing someone but reassure her she was safe. A review of Resident #30's progress notes revealed a note documented by Nurse #4 dated 03/11/19 at 10:58 PM which read in part: episodes of confusion increased with periods of yelling at roommate, of false accusations about men molesting roommate, will continue to monitor, up in w/c at this time, call light within reach at this time. During an interview with MDS Nurse #1 on 05/10/19 at 11:20 AM, she revealed she did not complete the behavior section of Resident #30's MDS assessment dated [DATE]. She reported it was the responsibility of the Social Worker to accurately complete that section. During an interview with the Social Worker on 05/10/19 at 12:43 PM she revealed she was responsible for completing the behavior section of Resident #30's MDS assessment dated [DATE]. She reported to complete that section she reviewed physician progress notes [REDACTED]. She reported since she could not determine what day or time the note indicated, she would not have coded the behavior on the Minimum Data Set assessment dated [DATE]. During an interview with the Administrator on 05/10/19 at 1:41 PM, she stated based on Nurse #4's progress note dated 03/11/19 at 10:58 PM, she would assume it was a behavior and indicated it should have been coded on Resident #30's Minimum Data Set assessment dated [DATE]. An interview with Nurse #4 on 05/11/19 at 4:37 PM revealed she did not write general statements in her notes. She stated she wrote the note dated 03/11/19 at 10:58 PM because she observed the behavior of Resident #30 yelling at her roommate.

Based on observations, record review and staff interview the facility failed to implement fall care plan interventions for 1 of 6 residents investigated for supervision to prevent accidents (Resident #20). The findings included: 1. Resident #20 initially admitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]., [MEDICAL CONDITION], anxiety, and major [MEDICAL CONDITION]. Review of a care plan dated 10/08/18 read in part, Resident #20 has a history of falling related to decreased functional mobility. Resident #20 was impulsive and often did not understand her functional limitations. The goal of the care plan read, Resident #20 would be free from injury until next review. The interventions included: anti-roll back device to wheelchair. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #20 was severely cognitively impaired for daily decision making. The MDS further revealed that Resident #20 required extensive assistance with activities of daily living and had 1 fall with no injury since the previous assessment and 1 fall with no major injury since the previous assessment. Resident #20 was recently readmitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]. An observation of Resident #20 was made on 05/06/19 at 10:45 AM. Resident #20 was sitting in her wheelchair in front of the sink in her room washing her hands. She was nonverbal but would smile and wave her hand. There were no anti-roll back device to the back of her wheelchair. The metal pieces of the anti-roll back device that would keep the wheelchair from rolling backwards were missing. An observation of Resident #20 was made on 05/06/19 at 3:30 PM. Resident #20 was up in her wheelchair at bedside. She was nonverbal but smiled and waved her hand. There were no anti-roll back device to the back of her wheelchair. The metal pieces of the anti-roll back device that would keep the wheelchair from rolling backwards were missing. An observation of Resident #20 was made on 05/07/19 at 10:45 AM. Resident #20 was propelling self around the unit in her wheelchair. She was nonverbal but smiled and waved her hand. There were no anti-roll back device to the back of her wheelchair. The metal pieces of the anti-roll back device that would keep the wheelchair from rolling backwards were missing. An observation of Resident #20 was made on 05/08/19 at 9:15 AM. Resident #20 was propelling herself to the beauty shop to have her hair done. She was nonverbal but smiled and waved her hand. There were no anti-roll back device to the back of her wheelchair. The metal pieces of the anti-roll back device that would keep the wheelchair from rolling backwards were missing. An observation and interview were conducted with the Maintenance Director (MD) on 05/08/19 at 1:58 PM. The MD was observed to be adjusting Resident #20's wheelchair brakes. He stated that he was walking around the facility and noticed that Resident #20's wheelchair was missing the metal anti-roll back device. The MD stated that he also found other residents that were missing theirs as well, so he was replacing all of them. The MD stated he was not sure if the metal pieces were getting broken off or what the issue with the missing metal pieces was but stated he was just replacing them all. An interview was conducted with Nursing Assistant (NA) #1 on 05/08/19 at 2:21 PM. NA #1 confirmed that she routinely cared for Resident #20 and was familiar with her care needs. She stated that Resident #20 liked to be independent and do things for herself. She added that they assisted her as needed and as Resident #20 would allow. NA #1 indicated that Resident #20 fell a lot and they tried to explain to her that she can not get up by herself. She added that the staff educate Resident #20 to lock her wheelchair brakes and ring the call light for assistance but most of the time she would not do those things. NA #1 referred to her care guide (guide of each resident needs) and stated that Resident #20 had fall mats to both sides of her bed and had non-skid strips to the floor in her room. NA #1 could not recall if Resident #20 had anti-roll backs to her wheelchair and referred to her care guide but did not see it listed there. An interview was conducted with Medication Aide (MA) #1 on 05/08/19 at 2:30 PM. MA #1 confirmed that she routinely cared for and was familiar with Resident #20. MA #1 stated that when the facility implemented new fall interventions the Administration team would let the MAs on the hall know and then they would report them to the NAs on the hall. MA #1 could not recall if Resident #20 had anti-roll back to her wheelchair or not but stated at one time she did. An interview was conducted with the Director of Nursing (DON) on 05/09/19 at 11:29 AM. The DON stated that it was the facility practice to implement a new fall intervention with each fall. Once the intervention had been implemented it was placed on the care plan and then weekly during the facility's focus meetings they discussed the implemented interventions and discussed if they were effective or not. A follow up interview was conducted with the DON on 05/10/19 at 11:34 AM. The DON stated that long term fall care plan interventions were verified on administration rounds. The staff member would take a care guide and compare what was on the guide to what was in place. The DON stated that if the anti-roll backs were missing she would expect the staff member to report it immediately and all ordered fall care plan interventions should be in place as ordered. An interview was conducted with the Administrator on 05/10/19 at 12:24 PM. The Administrator stated that she expected all care plan interventions to be in place as ordered.

Based on Record reviews and staff interviews the facility failed to notify the State Survey Agency within the required 5 working day timeframe of allegations of abuse investigations for 1 of 6 residents with abuse investigations (Resident #27) and failed to report an allegation of abuse immediately upon knowledge for 1 of 6 residents with abuse investigations (Resident #50). Findings included: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #27 was cognitively intact for daily decision making A review of the facility's abuse investigations revealed on 6/11/17 at an unknown time Resident #27 reported an allegation of abuse. The 24 hour report with a facsimile confirmation date of 6/12/17 at 6:19PM indicated Resident #27 reported an allegation of verbal abuse due to a staff member came in the room and spoke to him using foul language, being verbally abusive. Review of the investigation revealed documentation that reportedly the nurse stated to Resident #27 that he was a f****** preacher and he should practice what he preached and treat staff respectful (sp). Resident then stated that she said I hope you burn in hell. A document titled 5-Working Day Report with a facsimile confirmation date of 6/20/17 at 6:42AM revealed the facility faxed the completed investigation 7 working days after the allegation was made. During an interview on 4/6/18 with the Assistant Director of Nursing, she reported she was the facility's Abuse Coordinator and reported that the 5 working day reports should be faxed into the division within 5 working days from the day the incident is reported. She did not have a reason the previous ADON who was the abuse coordinator at the time sent in 5 working day reports in late. She also reported that administration first became aware of the incident at the time she completed the 24 Hour Report. During an interview with the Administrator on 4/6/17 she reported she expected the 24 hour and 5 working day reports to be completed and filed with the state agency timely. 2. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #50 was significantly impaired cognitively for daily decision making. A review of the facility's abuse investigations revealed on 3/13/18 at an unknown time, a staff nurse aide reported that a coworker became angry with a resident after the resident spit in her face and she grabbed the resident's ankle and squeezed. The report further stated there was no apparent injury to Resident #50. A document titled 24-Hour Initial Report with a facsimile confirmation date of 3/13/18 at 3:39PM revealed the date of the alleged incident occurring on 3/2/18 at 9:00PM and was not reported to administrative staff until 3/13/18. An interview with Nurse Aide #1 was attempted on 4/6/18 at 9:02 AM but was unsuccessful. During an interview with the Director of Nursing on 4/6/18 at 9:49 AM, she reported she has had to speak to the CNA multiple times about reporting incidents in a timely fashion. She stated the CNA should have reported the incident immediately to her supervisor, either the hall nurse or the charge nurse. DON reported she was unsure why the CNA waited so long to report the alleged incident. During an interview on 4/6/18 with the Assistant Director of Nursing, she reported she was the facility's Abuse Coordinator and reported that the 5 working day reports should be faxed into the division within 5 working days from the day the incident is reported. She did not have a reason the previous ADON who was the abuse coordinator at the time sent in 5 working day reports in late. She also reported that administration first became aware of the incident at the time she completed the 24 Hour Report. During an interview with Administrator on 4/6/17 she reported she expected the 24 hour and 5 working day reports to be completed and filed with the state agency timely.

Based on observations, record review, and staff interviews the facility left a resident with no balance for sitting on the side of the bed unattended for 1 of 3 sampled residents reviewed for accidents (Resident #87). The findings included: Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #87 was cognitively intact and capable of making daily decisions. Resident #87 was coded to need extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and totally dependent of staff for bathing. Further review of the MDS coded Resident #87 with an un-steady balance and only able to stabilize with staff assistance, and was always incontinent of bowel and bladder. A care plan dated 02/19/15 specified Resident #87 was at risk for falls related to an unsteady gait and unsteady balance, history of falls, which included decreased mobility, left sided hemiparesis, and incontinence. The care plan goal was for the resident to have no major injury related to falls through the next review. Care plan interventions included call light within easy reach, assist with safety awareness, keep pathway clear of clutter, keep bed at lowest position, and document all falls. Review of Resident #87's medical record revealed an unwitnessed fall on 01/13/15 at 8:03 AM. The nurse's entry specified the resident was found lying on the floor beside her bed and she had sustained no injuries. Further review of the medical record revealed an intervention of restorative therapy was currently in place for the resident. On 02/24/15 at 11:24 AM, an interview was conducted with Nurse #4 and Resident #87's falls were reviewed. She stated Resident #87 had poor safety awareness and was known to set on the edge of the bed which would result in a fall because if the resident soiled the bed she expected it to be changed immediately. She further stated she was unaware of injuries with her un-witnessed falls and that Resident #87 was capable of getting out of the bed on her own but was advised to use the call light for assistance related to her unsteadiness and difficulty with walking. On 02/24/15 at 5:38 PM, an interview was conducted with the Director of Nursing (DON). She stated the "fall team" would meet every morning Monday through Friday to discuss each resident's fall and the recommendations/interventions were written by the DON on the bottom of each incident/accident report. The DON indicated the falls that occurred on the weekends were discussed at the Monday morning meetings. She further stated after Resident #87's fall on 01/13/15 the team had met on the morning of 01/14/15 and agreed that no other intervention was to be implemented at the time. Further review of the medical record revealed a fall on 01/20/15 at 9:15 PM. The nurse's entry specified the fall was unwitnessed and the resident was in the floor beside her bed and she had sustained no injuries. An intervention was noted that the resident was re-educated to not sit on the side of the bed. On 02/24/15 at 5:38 PM, an interview was conducted with the DON. She stated the team had met on 01/21/15 and agreed to re-educate the resident as to not sit on the side of her bed and no other intervention was discussed to be implemented. Further review of the medical record revealed a fall on 01/24/15 at 5:15 PM. The nurse's entry specified an unwitnessed fall, she was found sitting on the floor in her room with the wheelchair behind her, and had sustained no injuries. The interventions indicated an alarm would be placed in the wheelchair, she was currently on restorative therapy's caseload, and that physical therapy would evaluate/screen the resident. On 02/24/15 at 5:38 PM, an interview was conducted with the DON. She stated the team had met on 01/26/15 and had agreed to have an alarm placed in Resident #87's wheelchair and to have the resident evaluated by physical therapy (PT). The medical record indicated Resident #87 had an unwitnessed fall on 02/19/15 at 8:50 AM. The nurse's entry specified the resident was found on the floor beside of her bed with no injuries. On 02/24/15 at 5:38 PM, an interview was conducted with the DON. She stated Resident #87 had poor safety awareness, was unsafe to transfer herself, and required 2 person assist with transfers and bed mobility. She indicated Resident #87's falls were mostly contributed to her not wanting to wait for her call light to be answered when her bed was soiled. She stated Resident #87 would twist and turn until she would get herself to an upright position and set on the side of the bed, and that was the reason she was more likely to slide off of the bed. She further stated Resident #87 was difficult to reason with, a challenge, and she was unsure of what other interventions they would have put into place as to prevent Resident #87's falls and/or to keep her safe. On 02/23/15 at 12:19 PM, Resident #87 was observed with a large bruise to her left arm. She indicated she had fallen from her bed into the floor and hit her arm. On 02/23/15 at 1:33 PM, Resident #87 was observed to be alert and oriented. She stated she was feeling very tired, wished to take a nap, and would like to participate in the resident to surveyor interview on Tuesday 02/24/15. Resident #87's medical record indicated she had an unwitnessed fall on 02/24/15 at 9:30 PM. The nurse's entry indicated Resident #87 was found in the floor with a head injury, a deep laceration above her right eye, and a skin tear to her right elbow. Resident #87 was sent to a local hospital by emergency medical services (EMS) ambulance for evaluation and treatment. A review of the EMS report dated 02/24/15 at 10:00 PM indicated Resident #87 had a traumatic injury with hemorrhage (bleeding) over the right eye and was transported to a local hospital. A review of the hospital records dated 02/24/15 indicated Resident #87 was transferred from the local hospital to a trauma hospital for an intracranial hemorrhage (a buildup of blood within the skull) and a subdural hematoma (a collection of blood outside the brain) for evaluation and treatment by a neurosurgeon. On 02/25/15 at 5:16 PM, an interview was conducted with nurse aide (NA) #1. She stated she was working the 3:00 PM to 11:00 PM shift on 02/24/15 when Resident #87 sustained an unwitnessed fall. She stated the resident was sitting on the right side of her bed with her feet dangling and the tips of her toes touching the floor when she went into Resident #87's room to inform her that she would be right back to change her bed after she had obtained clean bed linens. She demonstrated Resident #87's bed was not in the lowest position but was at upper thigh to crotch level, and Resident #87 insisted that her bed remain at that level. She further stated she left the resident unattended sitting on the side of the bed to retrieve linens from the linen cart. She stated when she returned to Resident #87's room she found the resident on the left side of the bed in the floor face down, and blood was in the floor. She indicated she called for help, NA #2 and Nurse #1 came to the resident's room immediately, and Nurse #1 assessed the resident before they assisted the resident from the floor back into her bed. She further stated she was aware Resident #87 was at risk for falls and was not thinking when she left the resident unattended. On 02/25/15 at 5:26 PM, an interview was conducted with NA #2. She stated she had informed NA #1 that there were no linens on linen cart and she would need to go off of the hall to obtain linens. She further stated NA #1 instructed her to go on her supper break, and NA #1 would get someone else to assist her to change the resident's bed linens. She indicated Resident #87 was lying in her bed when she went into the resident's room to answer the call light. She indicated she was gone off of the hall approximately 10 minutes and when she returned to the hall she heard NA #1 calling out for help at which time she observed blood in the floor and Resident #87 lying face down in the floor on the left side of her bed. She further stated Nurse #1 assessed the resident before they assisted Resident #87 from the floor back into her bed. On 02/25/15 at 5:34 PM, an interview was conducted with Nurse #1. He stated Resident #87 was not very strong and had very poor safety awareness. He further stated he would have expected the NA to have assisted Resident #87 back into the bed before she left the resident's room to obtain bed linens. On 02/26/15 at 12:44 PM, an interview was conducted with Physical Therapist (PT). She stated in the fall team's morning meetings the DON goes over all resident falls from the previous day and the interventions to be put into place were discussed and implemented accordingly. She further stated she had assessed Resident #87 on 02/20/15. The PT stated she had reminded the resident to use her call light, ask for assistance when getting out of bed on her own. The PT indicated the resident was under the services of restorative therapy and that was why Resident #87 was not placed back on the physical therapy workload. The PT stated she had observed restorative therapy to work with the resident and that the resident had appeared to be her normal self and had no need for any additional therapy. The PT further stated Resident #87 was unable to walk by herself and/or transfer without assistance and had poor safety awareness. On 02/27/15 at 7:32 AM, an interview was conducted with Nurse #2. She stated Resident #87 was encouraged to not attempt to get out of bed on her own but she had poor safety awareness and frequently attempted to get out of bed, especially when the bed was wet. She indicated she would have expected the NA to have assisted Resident #87 back into the bed before the NA left the room for bed linens. On 02/27/15 at 2:01 PM, an interview was conducted with the Director of Nursing (DON). She stated Resident #87 had poor safety awareness and was not to be positioned on the side of the bed. She further stated she would have expected 2 staff members to transfer the resident into her wheelchair while they changed her soiled bed linens. She indicated the resident should not have been setting on the side of the bed and/or left unattended.

Based on observations, staff and resident interviews and record review the facility failed to provide a wheelchair securement system that would prevent a resident from turning over in her wheelchair during transport for 1 of 4 residents reviewed for accidents. (Resident #85) Immediate Jeopardy began on 11/15/13 when it was reported to the Assistant Administrator that the straps securing wheelchairs in all three facility transportation vehicles were frayed and worn. Immediate Jeopardy was removed on 01/12/14 at 3:48 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at the lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place. The findings included: Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] specified Resident #85 had short and long term memory impairment and was moderately impaired in cognitive skills for daily decision making. Resident #85 required extensive assistance with transfers, used wheelchair for mobility and received dialysis three times per week. Nursing note dated 11/15/13 at 10:50 AM revealed that the facility was notified by Transporter #1 that while en route to dialysis with Resident #85 in the facility van, her wheelchair tipped over due to a strap securing her wheelchair coming loose. Transporter advised the facility that Resident #85 denied any injury. The facility instructed the transporter to have the dialysis nurse assess the resident for any injuries and to follow up with the hall nurse upon return to facility. The transporter verbalized understanding. Review of nurse's note dated 11/15/13 at 12:30 PM revealed a call was received from the dialysis nurse stating that Resident #85 did not appear to have any injuries related to the fall in the van but Resident #85 did not want to complete dialysis and wished to return to the facility. The hall nurse was notified and the Transporter #1 was advised to pick resident up at approximately 2:00 PM. Review of the Resident Incident Report dated 11/15/13 at 10:50 AM revealed that while en route to dialysis in the facility van Resident #85 tipped over in wheelchair due to a strap securing her wheelchair coming loose. There were no injuries reported. Review of Camelot Manor Nursing & Rehab Facility Employee Verbal Consultation report dated 11/15/13 revealed handwritten notations from the Assistant Administrator regarding an explanation of circumstances related to the van incident. The report indicated Resident #85 tipped over in Bus #3 (facility transportation vehicle) when she rocked the wheelchair back and forth and caused the straps securing the wheelchair to the bottom of the van to loosen. The action taken was to have the mechanic order a more suitable latching system for all facility transportation vehicles. The plan of correction was for an employee to ride along with the transporter to ensure straps were secure until new straps/latching systems were installed. This document was signed by Transporter #1 and the Assistant Administrator on 11/15/13. During an interview with Resident #85 on 01/09/14 at 4:45 PM she stated she was en route to dialysis with Transporter #1. She stated Transporter #1 took the turn a little too fast and she turned over in her wheelchair in the van. Resident #85 reported she did not receive any injuries from the fall. Interview with Transporter #1 on 01/10/14 at 8:30 AM revealed he transported Resident #85 to dialysis on 11/15/13 and while en route he made a left turn and the resident's wheelchair tipped over. He stated he had informed the Assistant Administrator that the straps securing the wheelchair to the bottom of all three facility transport vehicles would slip and loosen during transport in August 2013. Transporter #1 reported that after he informed the Assistant Administrator of the straps slipping in August 2013 the facility purchased new straps of the same type as the old frayed straps for the facility transportation vehicles. He stated there was no system put in place to monitor the wear of the replacement straps. Transporter #2 was interviewed on 01/10/14 at 10:00 AM. He stated he had informed the Assistant Administrator of straps securing wheelchairs in all 3 of the facility transportation vehicles were worn and frayed and would become loose during transport in August 2013. Transporter #2 stated the facility used the 4 Point Wheelchair Tie-Downs that connect to the wheelchair and secure them to the floor of the wheelchair van or bus. A total of 4 points are required; two in the front and two in the back, and are positioned to provide front-to-back and side-to-side stability. Transporter #2 reported the facility purchased new straps of the same type of material to replace the worn straps for all 3 facility transport vehicles. He stated there was no system put in place to monitor the wear of the new straps that he was aware of. During a follow up interview on 01/10/14 at 2:37 PM with Transporter #2, he stated that after the incident with Resident #85 on 11/15/13 a second staff member was assigned to ride along on all transports to observe for loosening straps that secured the wheelchair to the bottom of the van until a new latching system could be installed in all 3 facility transport vehicles. He explained if the straps became loose the second staff member should have the driver stop the van and readjust/tighten the straps to secure the wheelchair. Transporter #2 stated he was not aware of a time when the second staff rider had to have the van driver pull over to tighten the straps that secured the wheelchair to the bottom of the van. He stated the second staff member was assigned to ride in the facility transportation vehicles until White Bus #3 was installed with the new securement system on 11/21/13. He further stated all 3 facility transport vehicles remained in use after the incident on 11/15/13. Observation on 01/10/14 at 4:30 PM revealed Transporter # 3 had Gray Van #1 running in front of the facility and was getting ready to leave the facility to pick up a resident at the hospital. Gray Van #1 was observed to have two new securement latching systems in the back of the van and two old strap latching systems which were worn and frayed in the front of the van. Transporter #3 stated the old worn and frayed straps were used to secure the front of the wheelchair and the new securement latching system was used to secure the back of the wheelchair. Transporter #3 was observed on 01/10/14 at 4:45 PM as he demonstrated how to tighten and secure the old strap system in Gray Van #1 when the strap slipped as he tightened it to secure it to the bottom of the van causing him to stumble backwards in the van. On 01/10/14 at 4:50 PM it was determined by the surveyors to have Transporter #3 called by the Business Office Manager/Assistant Administrator to return to the facility and not pick up the resident in Gray Van #1 due to the van not being safe for resident transport. Observation of the facility transport vehicle on 01/10/14 at 5:05 PM with Transporter #2 and the Business Office Manager/Assistant Administrator revealed White Van #2 had two new securement straps/latching systems in the back and two old latching systems in the front which were worn and frayed. Observation of the facility transport vehicle on 01/10/14 at 5:15 PM with Transporter #2 and the Business Office Manager/Assistant Administrator revealed White Bus #3 had four new securement straps/latching systems. An interview with the Business Office Manager/Assistant Administrator on 01/11/14 at 10:10 AM revealed the facility transporters had no formal training on the proper use of the new securement latching system after it was installed in the White Bus #3 on 11/21/13 and the Gray Van #1 on 12/17/13. A follow up interview with the Business Office Manager/Assistant Administrator on 01/11/14 at 5:45 PM revealed she was informed on 08/23/13 by Transporter #1 the straps securing the wheelchairs in the facility transportation vehicles were becoming loose during transport due to being worn and frayed. She reported new straps of the same type as the straps that were worn and frayed were ordered to replace the old straps in the 3 facility transportation vehicles but she could not find the receipt or invoice for the order of the new straps. The Business Office Manager/Assistant Administrator stated no system was put in place to monitor the wear or safety of the new straps. She stated she had not checked to see if the old worn frayed straps had been changed out to the new straps and that she relied on the transporters to notify her of any problems they were having with facility transportation vehicles. The Business Office Manager/Assistant Administrator reported that after the van accident on 11/15/13 she contacted a local mechanic regarding the straps slipping in the van and the wheelchair turning over to get advice on what needed to be done to keep the resident safe. She stated he informed her facility transportation vehicles needed to have a more secure latching system installed to prevent wheelchairs from becoming loose and turning over. The Business Office Manager/Assistant Administrator stated she told the mechanic to order the new securement system for all 3 facility transportation vehicles. She reported she thought all 3 facility transportation vehicles had been fitted with the new securement latching system by 12/21/13 and was not aware that Van #1 and #2 was still equipped with two of the old strap latching systems. She further stated she had not inspected the transportation vehicles herself after the new securement systems were installed nor had she questioned the completion of the work. The Business Office Manager/Assistant Administrator and Director of Nursing were informed of Immediate Jeopardy on 01/10/14 at 5:50 PM for Resident #85. The facility provided a credible allegation of compliance on 01/12/14 at 12:05 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. CREDIBLE ALLEGATION OF COMPLIANCE RESIDENT #85 - IMMEDIATE JEOPARDY INTRODUCTION: Resident situation: On Friday November 15th, 2013 when resident #85 was en-route to dialysis in the facility's White Bus #3, the resident's wheelchair tipped over sideways due to a strap securing her wheelchair to the White Bus #3 coming loose. Transporter reported the fall occurred when he was making a left turn and the wheelchair tipped over side-ways. Transporter stopped White Bus #3 and assisted the resident by placing the wheelchair upright and resident repositioned in wheelchair; resident denied injury. Transporter re-secured wheelchair safety belt system and transported to the Dialysis Center and the Dialysis Nurse assessed Resident #85 for any injuries and recommended follow-up upon return to the facility. Hall Nurse reassessed Resident #85 upon return to the facility with no injury identified. The facility's policy states "in the event of an accident or personal injury, insurance and registration information be kept in the vehicle at all times and the Transporter should contact the facility as soon as possible." **The Transporter contacted the facility upon arrival at the Dialysis Center which was approximately 5 minutes after the incident and spoke to the Assistant Director of Nursing. Then the Assistant Director of Nursing reported to Assistant Administrator. Due to reported concerns about wheel chair safety straps loosening during transport in August 2013 on White Bus #3, replacement straps of the same type were installed in August 23, 2013. The replacement of straps occurred before the incident of 11/15/2013. Due to the incident on 11/15/2013 a Root Cause Analysis was completed on 11/18/2013 by the Quality Assurance/Performance Improvement Coordinator and review of safety recommendations for wheelchair transportation by Rehabilitation Engineering and Assistive Technology Society of North America and National Highway Traffic Safety Administration was done. The installation of the new latching/ratchet system for the white bus #3, was ordered on [DATE] and installation was completed on 11/21/2013 for safe resident transport. After the incident all three facility vans remained in service for resident transport. White bus #3 was in service except when it was in the auto repair shop from 11/19/2013 to 11/21/2013 1. On 1/10/14 all specialized transportation vehicles were taken out of service until training of all transporters is complete by January 12th, 2014. 2. At 5:45 p.m. on January 10th, 2014 all transporters were notified that specialized wheelchair transport vehicles which included Grey Van #1 and White Van #2 and white bus #3 were taken out of service. 3. On 1/10/14 a local Auto Services technician who was completing the work on the specialized transport vehicles strapping and latching/ratchet systems was contacted concerning completion of the work for the Grey Van #1 and White Van #2 specialized transport vehicles. 4. The Services Technician completed the installation of the strapping and latching/ratchet system for the White 2008 Ford Van #2 at 6:30 p.m. on January 10th, 2014. A Facility Administrative Services Staff was in attendance and observed the completion of the installation of the wheelchair safety seat belt system at 6:30 p.m., on January 10th, 2014. 5. Administrative Services Representative, Environmental/Safety Director and Lead Transporter will be using SURE-LOK "Doing it Right" Leader Preparation Guide to enable them to educate all transporters. To validate competency, educators will review each other for competency. 6. Transporters will be reeducated by Administrative Services Representative, on daily safety inspection requirements and proper usage of the wheelchair safety equipment system for secure resident transport for all specialized wheelchair transport vehicles prior to transporting residents. Transport staff reeducated on what to do when there is an accident/incident, including when to call 911. All transporters have cell phone availability. Completion by January 12th, 2014. 7. Components of education will include SURE-LOK Safe and Secure Work Sheet, Pre-trip SURE-LOK Check List, Glossary of Terms for SURE-LOK System, Return Demonstration of Competency, Securing a resident in each specialized transport vehicle, SURE-LOK Training Video, purchased 01/11/14, will be part of the training. Licensed Physical Therapy Assistant will inservice all transporters on safe resident transport and proper body mechanics by 1/12/2014. 8. Facility policies on van transport will be revised to include safety inspections and pre-trip SURE-LOK Check List of the specialized wheelchair transport vehicles. Revised policies will be completed by January 12th 2014. 9. Beginning on 1/12/14 the Environmental Safety Director or a designated maintenance staff member will monitor compliance with safety inspections of the specialized transport vehicles on a daily basis. 10. Annual training will be done with all facility transporters. Records will be kept in employee file to validate training competency yearly. Immediate Jeopardy was removed on 01/12/14 at 3:48 PM when the facility provided evidence of additional in-service training for all transportation staff. Interviews and observations of transportation staff securing wheelchair bound residents in the facility van by the Business Office Manager and Maintenance Director were completed. Interviews of transportation staff revealed each staff had been trained on securing wheelchair bound residents in the transportation vehicles appropriately.

Based on record reviews and staff interviews the facility failed to provide an effective securement system in the 3 facility transportation vehicles. Administrative staff failed to follow up on the purchase and installation of a securement system. Following an incident when Resident #85 tipped over in the wheel chair during transport, administration continued to use the same system and permitted another unsafe intervention by assigning an attendant to the resident during transport until the new system was installed. The administrator was not aware the vehicle securement straps were not effective and that there was a problem. (Resident #85). Immediate Jeopardy began on 11/15/13 when it was reported to the Business Office Manager/Assistant Administrator that the securement straps that secured wheelchairs in all 3 facility transportation vehicles were frayed and worn. The Administrator had not been informed the securement straps that secured wheelchairs to transport vans were slipping and no monitoring was implemented to ensure safety straps did not loosen during van transport. Immediate Jeopardy was removed on 01/12/14 at 3:48 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at the lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place. The findings included: Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #85 had short and long term memory problems and was moderately impaired in cognition for daily decision making. The MDS also indicated Resident #85 required extensive assistance with transfers, used wheelchair for mobility and received [MEDICAL TREATMENT] 3 times per week. A review of a nurse's note dated 11/15/13 at 10:50 AM revealed the facility was notified by Transporter #1 that while en route to [MEDICAL TREATMENT] with Resident #85 in the facility van, her wheelchair tipped over when a strap that secured her wheelchair to the floor of the van came loose. A review of a facility document titled Review of Camelot Manor Nursing & Rehab Facility Employee Verbal Consultation report dated 11/15/13 revealed handwritten notes from the Assistant Administrator regarding an explanation of circumstances related to the van incident. The report indicated Resident #85 tipped over in Bus #3 (facility transportation vehicle) when she rocked the wheelchair back and forth and caused the straps that secured the wheelchair to the bottom of the van to loosen. The action taken was to have the mechanic order a more suitable latching system for all facility transportation vehicles. The plan of correction was for an employee to ride along with the transporter to ensure straps were secure until new straps/latching systems were installed and the document was signed by Transporter #1 and the Business Office Manager/Assistant Administrator on 11/15/13. During an interview on 01/10/14 at 8:30 AM Transporter #1 stated he transported Resident #85 to [MEDICAL TREATMENT] on 11/15/13 and while en route he made a left turn and the resident's wheelchair tipped over. He stated he had informed the Business Office Manager/Assistant Administrator that the straps that secured the wheelchair to the bottom of all three facility transport vehicles slipped and loosened during transport in August 2013 and the straps were replaced with the same type as the old frayed straps for the facility transportation vehicles. During an interview on 01/10/14 at 10:00 AM Transporter #2 stated he had informed the Business Office Manager/Assistant Administrator the securement straps that secured wheelchairs in all 3 of the facility transportation vehicles were worn and frayed and became loose during transport in August 2013. He explained the worn straps were replaced with new straps of the same type of material for all 3 facility transport vehicles and confirmed there was no system put in place to monitor the wear or slippage of the new securement straps that he was aware of. During an interview with the Business Office Manager/Assistant Administrator on 01/11/14 at 5:45 PM she stated her primary responsibility was to run the business office and she was responsible for the finances and billing. She explained she reported directly to the Administrator and all decisions had to be approved by the Administrator. She stated the Administrator had given her the title of Assistant Administrator but stated she only had in-service training for billing and did not have any formal training to be an administrator or assistant administrator. She confirmed the Administrator had not been physically present in the facility since before December 19, 2013 and prior to that was only at the facility approximately 2 days a week for a couple of hours at a time. The Business Office Manager/Assistant Administrator stated she was informed on 08/23/13 by Transporter #1 the securement straps securing wheelchairs in the facility transportation vehicles were becoming loose during transport because they were worn and frayed so she ordered new securement straps that were the same type as the straps that were worn and frayed. She explained she thought all securement straps were replaced in the 3 facility transportation vehicles but she could not find the receipt or invoice for the order of the new straps. She confirmed she did not monitor the wear or safety of the new securement straps because when she purchased new straps she thought that fixed the problem and she relied on the transporters to notify her of any problems they were having with facility transportation vehicles. She stated she was not aware there was still a problem with the securement straps until the straps loosened and Resident #85 turned over in her wheelchair when she was transported to [MEDICAL TREATMENT] on 11/15/13. She stated she should have made sure the securement straps were fixed in all transportation vans after new straps were ordered in August 2013. The Business Office Manager/Assistant Administrator reported that after the van accident on 11/15/13 she contacted a local mechanic to get advice on what needed to be done to the securement straps and was told the transportation vans needed to have a more secure latching system installed to prevent wheelchairs from becoming loose and turning over. The Business Office Manager/Assistant Administrator stated she told the mechanic to order the new securement system for all 3 facility transportation vehicles and thought all 3 facility transportation vehicles had been fitted with the new securement latching system by 12/21/13. She further stated she was not aware until 01/10/14 that Van #1 and #2 still did not have the securement latching system and were still equipped with 2 of the old securement strap latching systems that were worn and loosened. She further stated she had not inspected the transportation vehicles herself nor had she questioned the completion of the work but she should have made sure the mechanic who replaced the securement straps in the vans understood what needed to be fixed and she should have kept the Administrator informed. During a telephone interview on 01/11/14 at 6:22 PM the facility Administrator confirmed she was not physically present in the facility on a daily basis and had not been in the facility for several weeks. She stated she had never heard that the securement straps that secured wheelchairs in the facility transportation vans were slipping and she did not know it was an issue until she was called about it yesterday on 01/10/14. She stated nobody had reported anything to her about any slippage or anything at all related to the securement straps loosening during transports but it was her expectation for staff to report safety concerns to her immediately. The Business Office Manager/Assistant Administrator and Director of Nursing were informed of Immediate Jeopardy on 01/10/14 at 5:50 PM for Resident #85. The facility provided a credible allegation of compliance on 01/12/14 at 12:05 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. CREDIBLE ALLEGATION OF COMPLIANCE ADMINISTRATION IMMEDIATE JEOPARDY 1/12/14 On 8/23/13 replacement straps that held the wheelchair in place during transport were purchased for White Bus #3 due to frayed straps that loosened during resident transport and did not hold the wheelchair securely in place. On 08/23/13 the facility's Assistant Administrator or administrator was made aware of the need to replace the wheel chair restraint straps in all of the facility vans and approved the purchase of the straps for White Bus #3. On Friday November 15th, 2013 when resident #85 was en-route to [MEDICAL TREATMENT] in the facility's White Bus #3, the resident's wheelchair tipped over sideways due to the straps securing her wheelchair to the White Bus #3 coming loose. Transporter reported the fall occurred while he was making a left turn and the wheelchair tipped over side-ways. Transporter stopped White Bus #3 and assisted the resident by placing the wheelchair upright. The resident was repositioned in wheelchair and denied injury. Transporter re-secured wheelchair safety belt system and transported the resident to the [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] Nurse assessed Resident #85 for any injuries and recommended follow-up upon return to the facility. The Hall Nurse reassessed Resident #85 upon return to the facility with no injury identified. The Assistant Director of Nursing (ADON) was notified who then notified Assistant Administrator. After the 11/15/13 incident all three facility vans remained in service for resident transport. White bus #3 was in service except when it was in the auto repair shop from 11/19/2013 to 11/21/2013 to replace the van's wheelchair restraint straps with SURE-LOK safety system. An attendant was designated to ride in the white bus #3 by the Assistant Administrator until the replacement SURE-LOK system was installed. On 01/11/14 the facility's Assistant Administrator verified that she had not made the Administrator aware that the wheelchair restraint straps in two of the facility's transport vans needed to be replaced and that all administrative decisions must be approved by the Administrator. On 01/11/14 the facility's Administrator verified that she had not been informed that the straps used to secure the wheelchairs in the vans had slipped or loosened during resident transport until 01/10/14. CORRECTIVE ACTION: 1. On 1/10/14 all specialized transportation vehicles were taken out of service until training of all transporters is complete by January 12th, 2014. 2. At 5:45 p.m. on January 10th, 2014 all transporters were notified that specialized wheelchair transport vehicles which included Grey Van #1 and White Van #2 and white bus #3 were taken out of service. 3. On 1/10/14 a local Auto Services technician who was completing the work on the specialized transport vehicles strapping and latching/ratchet systems was contacted concerning completion of the work for the Grey Van #1 and White Van #2 specialized transport vehicles. 4. The Services Technician completed the installation of the strapping and latching/ratchet system for the White 2008 Ford Van #2 at 6:30 p.m. on January 10th, 2014. A Facility Administrative Services Staff was in attendance and observed the completion of the installation of the wheelchair safety seat belt system at 6:30 p.m., on January 10th, 2014. 5. Administrative Services Representative, Environmental/Safety Director and Lead Transporter will be using SURE-LOK "Doing it Right" Leader Preparation Guide to enable them to educate all transporters. To validate competency, educators will review each other for competency. 6. Transporters will be reeducated by Administrative Services Representative, on daily safety inspection requirements and proper usage of the wheelchair safety equipment system for secure resident transport for all specialized wheelchair transport vehicles prior to transporting residents. Transport staff reeducated on what to do when there is an accident/incident, including when to call 911. All transporters have cell phone availability. Completion by January 12th, 2014. 7. Components of education will include SURE-LOK Safe and Secure Work Sheet, Pre-trip SURE-LOK Check List, Glossary of Terms for SURE-LOK System, Return Demonstration of Competency, Securing a resident in each specialized transport vehicle, SURE-LOK Training Video, purchased 01/11/14, will be part of the training. Licensed Physical Therapy Assistant will inservice all transporters on safe resident transport and proper body mechanics by 1/12/2014. 8. Facility policies on van transport will be revised to include safety inspections and pre-trip SURE-LOK Check List of the specialized wheelchair transport vehicles. Revised policies will be completed by January 12th 2014. 9. Beginning on 01/12/14 the Environmental Safety Director or a designated maintenance staff member will monitor compliance with safety inspections of the specialized transport vehicles on a daily basis. 10. Annual training will be done with all facility transporters. Records will be kept in employee file to validate training competency yearly. 11. Beginning on 01/12/14 the facility's Environmental Safety Director will conduct daily meetings with Transporters to review vehicle safety check lists and submit written report to Administration. The report will be scanned and e-mailed to all staff in Administration. Any problem identified will be immediately relayed to the Auto Mechanic. Any effected Vehicle will be taken out of service until problem resolved. 12. An incident report will be filed on any complaint and e-mailed to the Administrator, Administration Staff and pertinent Department Heads. Remedial actions will be determined and prior plans assessed for effectiveness in the daily stand-up meeting. 13. A copy of all incident reports will be e-mailed to Administrator and Administration Staff and reviewed in the daily stand-up meetings for any required interventions. 14. The Administrator and Administration staff will attend Daily Stand up meetings to discuss reports and determine action to resolve issues. Prior issues will be reviewed for effectiveness of action taken and revised as needed until problem resolved. If the Administrator does not attend, minutes of the meeting will be e-mailed and communication will occur via email and/or telephone conference call. 15. The Grey Van # 1 will remain out of service until the scheduled SURE-LOK system is installed on 1/16/14. Immediate jeopardy was removed on 01/12/14 at 3:48 PM when the facility provided evidence of additional in-service training for all transportation staff. Interviews with the Maintenance Director revealed he had implemented vehicle safety check lists and had performed safety checks of the securement straps in the facility vans except for the Grey Van #1 which was out of service. Interviews with the Director of Nursing and Business Office Manager/Assistant Administrator revealed understanding to keep the Administrator informed regarding concerns and safety issues so that administrative services would be provided.

Based on record reviews and staff interviews the facility failed to develop and implement plans of action or include safety securement of wheel chairs in the 3 facility transportation vehicles as part of the quality assurance review process. The facility administration continued to use the same safety securement system and Resident #85 tipped over in the wheel chair during transport. The facility also permitted another unsafe intervention by assigning an attendant to the resident during transport until the new securement system was installed. (Resident #85). Immediate Jeopardy began on 11/15/13 when it was reported to the Business Office Manager/Assistant Administrator and Director of Nursing that the securement straps that secured wheelchairs in all 3 facility transportation vehicles were frayed and worn. Immediate Jeopardy was removed on 01/12/14 at 3:48 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at the lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place. The findings included: Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #85 had short and long term memory problems and was moderately impaired in cognition for daily decision making. The MDS also indicated Resident #85 required extensive assistance with transfers, used wheelchair for mobility and received [MEDICAL TREATMENT] 3 times per week. A review of a nurse's note dated 11/15/13 at 10:50 AM revealed the facility was notified by Transporter #1 that while en route to [MEDICAL TREATMENT] with Resident #85 in the facility van, her wheelchair tipped over when a strap that secured her wheelchair to the floor of the van came loose. A review of a facility document titled Review of Camelot Manor Nursing & Rehab Facility Employee Verbal Consultation report dated 11/15/13 revealed handwritten notes from the Assistant Administrator regarding an explanation of circumstances related to the van incident. The report indicated Resident #85 tipped over in Bus #3 (facility transportation vehicle) when she rocked the wheelchair back and forth and caused the straps that secured the wheelchair to the bottom of the van to loosen. The action taken was to have the mechanic order a more suitable latching system for all facility transportation vehicles. The plan of correction was for an employee to ride along with the transporter to ensure straps were secure until new straps/latching systems were installed and the document was signed by Transporter #1 and the Business Office Manager/Assistant Administrator on 11/15/13. During an interview on 01/10/14 at 8:30 AM Transporter #1 stated he transported Resident #85 to [MEDICAL TREATMENT] on 11/15/13 and while en route he made a left turn and the resident's wheelchair tipped over. He stated he had informed the Business Office Manager/Assistant Administrator that the straps that secured the wheelchair to the bottom of all 3 facility transport vehicles slipped and loosened during transport in August 2013. He further stated the straps were replaced with the same type as the old frayed straps for the facility transportation vehicles and he was not aware of any monitoring of the safety straps to ensure they did not loosen during transport. During an interview on 01/10/14 at 10:00 AM Transporter #2 stated he had informed the Business Office Manager/Assistant Administrator the straps securing wheelchairs in all 3 of the facility transportation vehicles were worn and frayed and became loose during transport in August 2013. He explained the worn straps were replaced with new straps that were the same type of material for all 3 facility transport vehicles and confirmed there was no system put in place to monitor the wear of the new straps that he was aware of. During an interview on 01/11/14 at 5:44 PM the Director of Nursing (DON) explained the quality assurance (QA) committee met quarterly and membership included herself, the Medical Director and various department managers. She verified the Business Office Manager/Assistant Administrator attended some of the meetings but the facility Administrator was not usually present at the meetings. She explained the Medical Director conducted the meetings and any identified issues such as safety concerns should be brought to the committee for discussion of any trends or patterns and they evaluated different approaches to resolve concerns. The DON confirmed the last QA committee meeting was held on 10/24/13 and there was no discussion regarding replacement of worn or loose securement straps to attach wheelchairs in transportation vans that had been identified on August 23, 2013. She further stated there had been no monitoring of securement straps in the facility vans and there were no plans of action to ensure the securement straps remained secure during resident transport. During an interview with the Business Office Manager/Assistant Administrator on 01/11/14 at 5:45 PM she stated her primary responsibility was to run the business office and she was responsible for finances and billing. She explained the Administrator had given her the title of Assistant Administrator but stated she only had in-service training for billing and did not have any formal training to be an administrator or assistant administrator. She stated she attended the QA committee meetings most of the time because the Administrator did not attend the QA committee meetings. She further stated she had not presented any concerns to the QA committee about securement straps that secured wheelchairs to the vans that loosened during transport. She explained when it was reported to her that securement straps were loose and slipped because they were worn she ordered replacement straps of the same type and they were installed on August 23, 2013. She stated she did not present this information at the next Quality Assurance Committee that occurred on October 24, 2013 because she thought since the straps had been replaced that had resolved the problem. She further stated there was no evaluation or follow up to ensure the securement straps remained secure during resident transport in the transport vehicles or to evaluate other interventions which included training of staff, to ensure residents were secured in their wheelchairs during van transport. She stated she was not aware there was still a problem with the securement straps until the straps loosened and Resident #85 turned over in her wheelchair when she was transported to [MEDICAL TREATMENT] on 11/15/13. She stated after the van accident on 11/15/13 she contacted a local mechanic to get advice on what needed to be done to the safety straps and was told the transportation vans needed to have a more secure latching system installed to prevent wheelchairs from becoming loose and turning over. The Business Office Manager/Assistant Administrator stated she told the mechanic to order the securement system for all 3 facility transportation vehicles and thought all 3 facility transportation vehicles had been fitted with the new securement latching system by 12/21/13. She further stated she was not aware until 01/10/14 that Van #1 and #2 still did not have the securement latching system and were still equipped with 2 of the old strap latching systems that were worn and loosened. She further stated she had not inspected the transportation vehicles herself nor had she questioned the completion of the work but she should have made sure the mechanic who replaced the securement straps in the vans understood what needed to be fixed and she should have informed the QA committee about problems with the securement straps in the facility transportation vans. During a telephone interview on 01/11/14 at 6:22 PM the facility Administrator confirmed she had not attended QA committee meetings but she made recommendations for items to be put on the agenda before the meeting was held and facility staff sent her the minutes after the meetings. She stated she had never heard that the securement straps that secured wheelchairs in the facility transportation vans were slipping and she did not know it was an issue until she was called about it yesterday on 01/10/14. She stated nobody had reported anything to her about any slippage or anything at all related to the securement straps loosening during transports but it was her expectation for staff to report safety concerns to her immediately and they should have presented the problems related to the safety straps to the QA committee. The Business Office Manager/Assistant Administrator and Director of Nursing were informed of Immediate Jeopardy on 01/10/14 at 5:50 PM for Resident #85. The facility provided a credible allegation of compliance on 01/12/14 at 12:05 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Allegation of Compliance Quality Assurance 1/12/14 During August 2013 concerns were reported by transporters to Administration about wheel chair safety straps loosening during transport of residents in facility vans and White Bus #3. Replacement straps of the same type were installed on August 23, 2013 but this information was not reported within the Quality Improvement process and was not presented at the next Quality Assurance Committee that occurred on October 24, 2013. There was no evaluation or follow up by the Quality Assurance Committee to ensure the straps remained secure during resident transport in white bus #3 and in the other two transport vehicles or to evaluate other interventions, including training of staff, to ensure residents were secured in their wheelchairs during van transport. On Friday November 15th, 2013 when resident #85 was en-route to [MEDICAL TREATMENT] in the facility's White Bus #3, the resident's wheelchair tipped over sideways due to a strap securing her wheelchair to the White Bus #3 coming loose. Transporter reports the fall occurred when he was making a left turn and the wheelchair tipped over side-ways. Transporter stopped White Bus #3 and assisted the resident by placing the wheelchair upright and resident repositioned in wheelchair; resident denied injury. Transporter re-secured wheelchair safety belt system and transported to the [MEDICAL TREATMENT] Center and the [MEDICAL TREATMENT] Nurse assessed Resident #85 for any injuries and recommended follow-up upon return to the facility. Hall Nurse reassessed Resident #85 upon return to the facility with no injury identified. Transporter reported incident to ADON and ADON reported incident to Assistant Administrator. The Grey Van #1 is out of service until scheduled replacement of straps and the SURE-LOK system is installed on 1/16/14. The White Van #2 had new straps installed 1/10/14. The White Bus #3 had SURE-LOK system installed, which included new strap system on 11/21/14. Corrective Action: The facility will identify QA issues that are being brought to QA by review of incident and accident reports by Administration and any other issue that is brought to our attention in the daily morning meeting. 1. On 1/10/14 all specialized transportation vehicles were taken out of service until training of all transporters is complete by January 12th, 2014. 2. At 5:45 p.m. on January 10th, 2014 all transporters were notified that specialized wheelchair transport vehicles which included Grey Van #1 and White Van #2 and white bus #3 were taken out of service. 3. On 1/10/14 a local Auto Services technician who was completing the work on the specialized transport vehicles strapping and latching/ratchet systems was contacted concerning completion of the work for the Grey Van #1 and White Van #2 specialized transport vehicles. 4. The Services Technician completed the installation of the strapping and latching/ratchet system for the White 2008 Ford Van #2 at 6:30 p.m. on January 10th, 2014. A Facility Administrative Services Staff was in attendance and observed the completion of the installation of the wheelchair safety seat belt system at 6:30 p.m., on January 10th, 2014. 5. Administrative Services Representative, Environmental/Safety Director and Lead Transporter will be using SURE-LOK "Doing it Right" Leader Preparation Guide to enable them to educate all transporters. To validate competency, educators will review each other for competency. 6. Transporters will be reeducated by Administrative Services Representative, on daily safety inspection requirements and proper usage of the wheelchair safety equipment system for secure resident transport for all specialized wheelchair transport vehicles prior to transporting residents. Transport staff reeducated on what to do when there is an accident/incident, including when to call 911. All transporters have cell phone availability. Completion by January 12th, 2014. 7. Components of education will include SURE-LOK Safe and Secure Work Sheet, Pre-trip SURE-LOK Check List, Glossary of Terms for SURE-LOK System, Return Demonstration of Competency, Securing a resident in each specialized transport vehicle, SURE-LOK Training Video, purchased 01/11/14, will be part of the training. Licensed Physical Therapy Assistant will inservice all transporters on safe resident transport and proper body mechanics by 1/12/2014. 8. Facility policies on van transport will be revised to include safety inspections and pre-trip SURE-LOK Check List of the specialized wheelchair transport vehicles. Revised policies will be completed by January 12th 2014. 9. Beginning on 1/12/14 the Environmental Safety Director or a designated maintenance staff member will monitor compliance with safety inspections of the specialized transport vehicles on a daily basis. 10. Annual training will be done with all facility transporters. Records will be kept in employee file to validate training competency yearly. 11. An incident report will be filed on any complaint and e-mailed to Administrator, Administration Staff and pertinent Department Heads. Remedial actions will be determined and prior plans assessed for effectiveness in the daily stand-up meeting. 12. A copy of all incident reports will be e-mailed to Administrator and Administration Staff and reviewed in the daily stand-up meetings for any required interventions. 13. The Administrator and Administration staff will attend Quality Assurance meetings to discuss reports and determine action to resolve issues. Prior issues will be reviewed for effectiveness of action taken and revised needed until problem resolved. If the Administrator does not attend, minutes of the meeting will be e-mailed and communication will occur via email and/or telephone conference call. 14. Communication of issue(s) and plan of action will be sent to Administrative staff prior to QA Meeting with approval and clear understanding by all Administrative staff. Staff will refer issues to the QA committee by verbal and written communication on Stop and watch forms. 15. All issues will be presented to the quality assurance committee by written and verbal form to all QA members present. 16. Plan of Action need to be approved or modified following presentation to QA Team members. A plan of action will be developed for each issue presented to the QA Committee with follow up to ensure the interventions are effective. The issue will remain on the agenda of the QA committee for follow up until the committee determines the issue has been resolved. 17. Individuals will be designated as the responsible party to follow up with action plans, give progress reports and provide a target completion date. All incident reports will be reviewed in the Daily Administrative Team Meetings and be referred to the next scheduled Quality Assurance Committee if indicated. One indication would be any issue that has the capacity to cause harm or has caused harm. Daily meetings will be held to review QA issue follow up and progress. Administrator will be notified of all incident and grievances following daily meetings. Immediate Jeopardy was removed on 01/12/14 at 3:48 PM when the facility provided provided evidence of additional in-service training for all transportation staff. Interviews and observations of transportation staff securing wheelchair bound residents in the facility van by the Business Office Manager and Maintenance Director were completed. Interviews of transportation staff revealed each staff had been trained on securing wheelchair bound residents in the transportation vehicles appropriately. The Business Office Manager/Assistant Administrator and Director of Nursing also provided evidence of knowledge related to the QA system, function of the QA committee and how the QA system monitors for necessary follow up.

Based on record reviews and physician and staff interviews, the facility failed to identify and assess the need for medical intervention for a resident who was vomiting dark brown liquid, had a nosebleed and was on daily dosages of [MEDICATION NAME] (blood thinner) in 1 of 10 residents on [MEDICATION NAME] therapy. (Resident #1). Immediate Jeopardy began on [DATE] when Resident #1 vomited dark colored liquid. Immediate jeopardy was removed on [DATE] at 5:15 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective and completion of employee training. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact for daily decision making. The MDS further indicated Resident #1 required supervision with eating, limited assistance with transfers and hygiene and was totally dependent on staff for bathing. A review of a care plan with a review date of [DATE] indicated a potential for abnormal bleeding due to [MEDICATION NAME]. The approaches indicated in part to report abnormal lab values to physician, monitor for abnormal bleeding (tarry stools, bleeding gums, blood in urine) and report bruising. A review of physician's orders [REDACTED]. A review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the most recent laboratory results for a [MEDICATION NAME] time (PT)/ International Normalized ratio (INR) with a collect date of [DATE], received date of [DATE] and a reported date of [DATE] indicated (PT) 23.9 (High) with a reference range of 11.5 to 14.1 seconds and (INR) 2.33 (High) with a reference range of 0.89 -1.16. (The PT/INR blood test results provide information for the physician to titrate the dosage of [MEDICATION NAME]). A review of a MAR indicated [REDACTED]. A review of a nurse's note dated [DATE] at 10:12 AM and written by Nurse #4 indicated Resident #1 vomited small amount of dark liquid this morning. During an interview on [DATE] at 5:24 PM Nurse #3 who was also a charge nurse during the 7:00 AM to 7:00 PM shift explained he was told Resident #1 vomited a yellowish colored liquid but did not remember being told about dark colored vomiting. He stated he was aware Resident #1 had a history of [REDACTED]. A review of a treatment sheet from the [MEDICAL TREATMENT] center dated [DATE] in a section titled Pre - [MEDICAL TREATMENT] "other comments" revealed Resident #1's nurse from the facility called and stated Resident #1 vomited today and yesterday and vomit was dark but not coffee ground consistency and upon arrival at [MEDICAL TREATMENT] Resident #1 stated he had been vomiting for 3 days. A section titled "Treatment Data" indicated Resident #1 had [MEDICAL TREATMENT] started on [DATE] at 10:25 AM and completed it at 1:56 PM. The notes revealed Resident #1 was alert, denied complaints and had no nausea or vomiting. A section titled Post - [MEDICAL TREATMENT] indicated no new complaints or observations developed during [MEDICAL TREATMENT] and Resident #1 was discharged back to the facility. During a phone interview on [DATE] at 9:22 AM with a [MEDICAL TREATMENT] nurse she explained Resident #1 received [MEDICAL TREATMENT] treatments on Monday, Wednesday and Friday of each week. She further explained Resident #1 was seen in the [MEDICAL TREATMENT] center on Thursday [DATE] and received a treatment because he missed his [MEDICAL TREATMENT] treatment on Wednesday [DATE] because the facility had reported Resident #1 was vomiting a dark brown liquid. She stated Resident #1 stated he had been vomiting for 3 days and it was a dark brown cola color. She further stated a lab test for a hemoglobin was drawn on [DATE] and the results were 12.0 (Low) with a reference range 14XXX,[DATE].0 but there was no PT/INR drawn because he was not due for his monthly PT/INR until the end of [DATE] and he did not have symptoms at the [MEDICAL TREATMENT] center to cause them to question what his PT/INR results were. She explained he was sent back to the facility mid afternoon on [DATE] and confirmed Resident #1 did not have vomiting or a nosebleed while in the [MEDICAL TREATMENT] center. A review of a nurse's note dated [DATE] at 7:39 PM and written by Nurse #2 indicated Resident #1 continued on [MEDICATION NAME] 5 mg. by mouth. The notes further indicated Resident #1 went to [MEDICAL TREATMENT] and labs were drawn; Resident #1 was noted to have a nose bleed from right nostril; Nurse #2 packed nostril with rolled gauze and expressed to resident to leave in place till tomorrow. The notes also indicated to place ice pack to bridge of nose for 3 minutes; noted to stop bleeding. The notes revealed vital signs were temperature 98.6 degrees Fahrenheit, Pulse 98, Respirations 16, blood pressure ,[DATE] and oxygen saturation percentage was 97. During a phone interview on [DATE] at 9:56 AM Nurse #2 verified she worked from 7:00 AM to 7:00 PM and was assigned as Resident #1's nurse on [DATE]. She explained Resident #1 had vomited a dark brown liquid and she was concerned because she knew Resident #1 had a history of [REDACTED]. Nurse #2 explained Nurse Aide (NA) #4 called her to Resident #1's room and he was sitting in his wheelchair and was bleeding from his nose. She stated her first response was to stop the bleeding so she put ice on the top of his nose and rolled up gauze to pack in his nose. She further stated she told Resident #1 to leave the packing in place until the next day. She explained Resident #1 was very pale and she called the [MEDICAL TREATMENT] center to ask them if they checked Resident #1's PT/INR and was told they did not because he was not due for his monthly PT/INR. Nurse #2 stated she talked to Nurse #3 who was the charge nurse about Resident #1 and verified she did not call the facility physician because that was not her call to make since the charge nurse usually called the physician. She explained Resident #1 pulled the gauze out of his nose before she finished her shift at 7:00 PM. She stated she got another clean piece of gauze and rolled it up and put it in Resident #1's nose because she was concerned he would continue to have bleeding during the night. She explained she reported Resident #1's nosebleed during shift report at 7:00 PM to the night shift nurse. During an interview on [DATE] at 2:53 PM with NA #4 she verified she worked on the 3:00 PM to 11:00 PM shift on [DATE] and was assigned to Resident #1. She explained Resident #1 came back to the facility from [MEDICAL TREATMENT] between 3:30 and 4:00 PM on [DATE]. She stated she went to Resident #1's room about 10 minutes after he arrived at the facility because his call light was on and when she walked in his room she saw his nose was "gushing blood." She explained bright red blood was running out of his nose, was on his face and in his beard and was all over his fingertips. She stated Resident #1 was very pale and weak and she went and told Nurse #2 and the nurse came to Resident #1's room. During an interview on [DATE] at 3:14 PM with transport aide (TA #2) he explained Resident #1 went to the [MEDICAL TREATMENT] center on Monday, Wednesday and Friday of each week and they usually left the facility around 9:15 AM. He stated he took Resident #1 to [MEDICAL TREATMENT] on Thursday morning [DATE] because he had missed his appointment on [DATE] and picked him up that afternoon. He stated when he got Resident #1 back to the facility he took the resident to his room. He confirmed Resident #1 did not have any vomiting or nosebleed when he transported him on [DATE]. He further stated Resident #1 looked weak and pale and was very quiet during the transport back to the facility. During an interview on [DATE] at 5:24 PM with Nurse #3 he verified he worked 7:00 AM to 7:00 PM on [DATE] and was assigned as the charge nurse. He explained when Resident #1 returned from [MEDICAL TREATMENT] Nurse #2 reported he had bleeding from his nose and was vomiting dark brown liquid. Nurse #3 stated he looked at Resident #1 but did not assess him. He explained Resident #1 had a communication sheet from the [MEDICAL TREATMENT] center but it didn't have any notes about bleeding or labs. He stated he should have followed through and called the facility physician or physician's assistant to find out what they needed to do but he didn't recognize the seriousness of what was going on. A review of a nurse's note dated [DATE] at 12:29 AM indicated Resident #1 continued [MEDICATION NAME] 5 mg. as ordered. The notes also indicated nose had stopped bleeding at this time and right nostril was packed with gauze and there were no complaints of pain or discomfort and no acute distress. During an interview on [DATE] at 3:31 PM with NA #5 she explained she worked on Friday [DATE] on the 7:00 AM to 3:00 PM. She stated when she went in to get Resident #1 up she saw one nostril plugged up with gauze but the gauze was out of the other nostril and it was not bleeding. She further stated when she got Resident #1 up on Friday [DATE] he said he did not feel well, was having trouble standing and said he needed help and that wasn't normal for him because usually he stood and pivoted without assistance. She explained she told Nurse #2 that Resident #1 was not doing well and was told by Nurse #2 that Resident #1 was losing blood. She stated she cleaned and dressed Resident #1 and he went to [MEDICAL TREATMENT]. During an interview on [DATE] at 9:56 AM Nurse #2 stated when she returned to work on [DATE] Resident #1 looked worse and his skin color was paler but he was alert and responded to her. She further stated she talked with Nurse #1 who was also a charge nurse about Resident #1 and was told Nurse #1 had talked to the [MEDICAL TREATMENT] center. She explained Resident #1 went to the [MEDICAL TREATMENT] center again that morning and was sent to the hospital from the [MEDICAL TREATMENT] center. During a phone interview on [DATE] at 9:22 AM a [MEDICAL TREATMENT] nurse stated Resident #1 came to the [MEDICAL TREATMENT] center on Friday morning [DATE] but they did not put him on a [MEDICAL TREATMENT] machine because he was lethargic, had labored breathing and was slow to respond to [MEDICAL TREATMENT] staff 's questions. She explained Resident #1 requested to be sent to the ER and confirmed they did not draw any labs at the [MEDICAL TREATMENT] center because they knew labs would be drawn in the ER. During an interview on [DATE] at 4:35 PM the Director of Nursing (DON) stated she was not aware of Resident #1's changes in condition with dark colored vomiting or nosebleed. She stated it was her expectation for nursing staff to assess and monitor residents for changes in condition and obtain whatever medical intervention was needed for the resident. During an interview on [DATE] at 4:46 PM the facility physician stated it was his expectation for nursing staff to monitor and assess residents for changes in condition and to communicate with the medical providers. During an interview on [DATE] at 5:51 PM with Nurse #1 she verified she was the charge nurse on Friday [DATE]. She explained Nurse #2 told her that morning Resident #1 was vomiting a dark brown cola colored liquid and had a nose bleed the day before. She stated Resident #1 was sent to [MEDICAL TREATMENT] because she felt a physician would see the resident at the [MEDICAL TREATMENT] center but later that day the [MEDICAL TREATMENT] center called her and told her Resident #1 was sent to the hospital. A review of a nurse's note dated [DATE] at 10:45 AM indicated [MEDICAL TREATMENT] center called and reported Resident #1 had been sent to the hospital for evaluation and treatment. A review of a nurse's note dated [DATE] at 5:44 PM indicated a call was received from a physician at the hospital that Resident #1 had been admitted to the intensive care unit. A review of a nurse's note dated [DATE] at 6:44 PM titled "addendum" indicated a physician from the hospital called the facility and reported that Resident #1's blood was "too thin" and Resident #1 "was not in good shape." A review of a hospital history and physical dated [DATE] indicated Resident #1 was to have [MEDICAL TREATMENT] today but was vomiting dark brown material and was sent to the emergency room (ER) for evaluation. The notes indicated Resident #1 was chronically ill appearing, poorly unresponsive with respiratory distress and a PT/INR was drawn and the results revealed his blood was not coagulable (was not clotting). The notes revealed Resident #1 was admitted to the intensive care unit, received 2 units of fresh frozen plasma and intravenous Vitamin K. A review of a hospital discharge summary titled "Death Summary" dated [DATE] indicated Resident #1 was taken to the intensive care unit and given fresh frozen plasma and intravenous Vitamin K for severe coagulopathy (no blood clotting). The notes further indicated Resident #1 was grossly bleeding from his upper pharynx (throat) and possible gastrointestinal tract and fresh frozen plasma was of important nature and priority. The notes revealed Resident #1 became less and less responsive and had a respiratory arrest and was pronounced dead at 7:24 PM on [DATE]. The facility's Director of Nursing and Assistant Administrator were notified of Immediate Jeopardy for Resident #1 on [DATE] at 4:26 PM. The facility provided a credible allegation of compliance on [DATE] at 4:53 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Resident # 1 was admitted to facility on [DATE] as a [MEDICAL TREATMENT] patient with chronic kidney failure. On [DATE] Resident #1 vomited dark colored liquid . No orders were received to address nosebleed, PT/INR, or acute episode. Facility physician was not notified on [DATE] of nosebleed and [MEDICATION NAME] dose of 5 milligrams was not held by staff. On [DATE] the resident was admitted to the hospital Intensive Care Unit and expired on this date. On [DATE] the facility's Quality Assurance Nurse completed a [MEDICATION NAME] audit of all residents with orders for [MEDICATION NAME] to determine proper dosage administration of [MEDICATION NAME] and proper lab result dates. There was no indication of any acute episodes to address. No abnormalities or deficits with PT/INR lab results or [MEDICATION NAME] doses were discovered. Beginning on [DATE] skin assessments for signs and symptoms of bleeding will be completed daily on all residents on [MEDICATION NAME] therapy. The facility's QI nurse will monitor daily skin assessments on a weekly basis and report weekly to morning nursing team meeting on Thursdays. If the QI nurse discovers any abnormalities she would report to the charge nurse or Director of Nursing immediately for follow up and notification of physician for interventions. On [DATE] all residents with [MEDICATION NAME] orders were re-entered into the electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Parameters set for: nurses only to administer [MEDICATION NAME] doses; [MEDICATION NAME] doses to be held if INR value greater than 3.0. MD is to be notified for values greater than 3.0 unless otherwise specified per MD. On [DATE] all nursing staff was inserviced by the Administrative Nursing Staff on the administration of [MEDICATION NAME]. Content of this inservice included: new [MEDICATION NAME] log, PT/INR results and how [MEDICATION NAME] affects coagulation time and nurses only to give [MEDICATION NAME]. The eMAR alerts the medication aide that the nurse has to administer the [MEDICATION NAME]. Medication Aides were trained on the new procedure of only nurses administering [MEDICATION NAME]. New parameters set on e-mar software for [MEDICATION NAME] administration. Signs and Symptoms of bleeding, abnormal INR results and when to notify physician. New tool developed: Hall nurse Daily [MEDICATION NAME] Log reviewed. Nurses have been given the signs and symptoms of bleeding related to [MEDICATION NAME] dosing and have had the expectation set by the Director of Nursing that they will communicate any of the abnormal signs and symptoms to the Physician immediately. Expectations set with nurses to document full assessment by an RN and interventions initiated based on MD order. Charge Nurse to monitor PT/INRs on a daily basis and implement adjustment to [MEDICATION NAME] as ordered. Hall nurses to document daily in nursing notes the daily dose of [MEDICATION NAME], the last PT/INR result and the next date for the PT/INR and the [DIAGNOSES REDACTED]. Charge Nurses are to assess the resident with any report of acute symptoms and notify practitioner on call to obtain orders for intervention (s). Staff will not be permitted to work until they have received this inservice training. Starting on [DATE] the DON will review all new [MEDICATION NAME] orders in daily morning nursing team meetings to ensure accuracy. Charge Nurse will review [MEDICATION NAME] log in daily morning nursing team meetings to ensure new orders for [MEDICATION NAME] changes are implemented and new orders for labs are being processed. QI Nurse will complete weekly audits of [MEDICATION NAME] log which includes labs and dates, [DIAGNOSES REDACTED]. QI nurse will report weekly audits to morning nursing team meetings on Thursdays of each week. QI nurse will audit staff response time to abnormal labs and/or signs and symptoms of abnormal bleeding and report weekly. Results of the QI Nurse [MEDICATION NAME] Audit weekly which includes the staff's response to ensure well-being of each resident will be presented to the facility's Quality Improvement Committee by [DATE]. Immediate jeopardy was removed on [DATE] at 5:15 PM when interviews with nursing staff revealed awareness of expectations to assess residents who received [MEDICATION NAME] therapy for bruising or bleeding or changes in condition and to obtain medical interventions for the resident. The nursing staff confirmed they had received inservice training on [DATE]. Record reviews of residents in the facility that were on [MEDICATION NAME] revealed nurses notes and assessment documents regarding their current condition. There were no residents identified who had vomiting, bruising or bleeding.

Based on observations, record review, resident interview and staff interviews the facility failed to prevent 1 of 7 sampled cognitively impaired residents, who were assessed as being at risk for elopement, from exiting the facility and leaving the facility's grounds. Resident #13 eloped from the facility and left the facility's grounds on 07/14/13 and 07/15/13 while unsupervised. On 07/14/13 Resident #13 was found by staff at a private residence 0.3 miles away from the facility and on 07/15/13 Resident #13 was found by staff walking next to a roadway approximately 0.2 miles away from the facility. (Resident #13) Immediate Jeopardy began on 07/14/13 when Resident #13 eloped from the facility without staff's knowledge that he was outside without supervision. Immediate jeopardy was removed on 07/20/13 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, no actual arm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: Review of the facility's "Wandering and Elopement Residents" Policy and Procedure, which was revised on July 2011, specified the following: "A. Residents are assessed on admission for possible elopement potential. If considered a concern, the secure guard bracelet will be placed on the resident." "2. All residents wearing the secure guard bracelets will be routinely monitored as to location in the facility. Staff assigned to routinely monitor the resident will enter the activity in the Electronic Medical Record." Resident #13 was admitted to the facility on [DATE]. The resident's "Nursing Admission Assessment" completed on 07/09/13 specified problems with short term memory and severely impaired cognitive skills for daily decision making. Review of Resident #13's 07/09/13 "Elopement Risk Assessment" revealed he was an elopement risk due to being a new admission to the facility, having impaired cognition with poor decision making skills, being able to ambulate independently and having visual or auditory deficits. Review of Resident #13's nursing notes from 07/09/13 to 07/18/13 revealed the following entries: 07/09/13 at 7:07 PM: "Resident is alert but has confusion keeps stating that he can walk up the road and smoke and go to ______ (a fast food restaurant) ... Found 2 packs of cigs and lighter in pocket resident stated he did not have any but gave me permission to search, states he cannot stay here without cig." 07/14/13 at 4:38 AM: "He still makes attempts to leave whenever he can and goes outside to smoke up the hill." 07/15/13 4:48 AM: "Resident has has (sic) been in facility 5 days and is begining (sic) to adjust to surroundings. He still makes attempts to leave whenever he can and goes outside to smoke up the hill." 07/15/13 at 6:27 PM: "Resident noted to have left building was walking on side Sunset Blv CN (Charge Nurse) escorted resident back to facility wanderguard apllpied (sic) to ankle explained to resident this is an alarm to make the staff aware if resident attempted to exit the building without assist, resident tolerated well." 07/16/13 at 4:19 PM: "Resident ambulates, alert. He is one on one care now, wears wanderguard to protect from wandering off again." 07/18/13 at 6:11 PM: "Confiscated a lighter from resident while he was taking a shower. Resident placed lighter on shower ledge, sitter informed this nurse that resident had lighter. Re-educated resident that he was not allowed to have a lighter or cigarettes. Resident states that he understands. Will continue to monitor." Review of Resident #13's "Elopement Risk Assessment" completed 07/18/13 specified; "Resident has had two elopements since admission to facility. One on 07/14/2013 and one 07/15/2013. Both times resident left facility and walked to a house nearby, where he knows the people that live there. he (sic) gets a cigarette from them and smokes. Resident has been picked up both times. Resident has had several wanderguards placed and resident removes them. Resident has been placed on 1:1 care at all times due to high risk for elopement." Review of Resident #13's medical record revealed staff did not document any checks of the resident's Wander-guard from 07/13/13 at 10:00 PM to 07/15/13 at 11:00 PM. Interview with Nurse #1 on 07/18/13 at 2:30 PM revealed that Resident #13 did exit the facility and leave the facility's grounds while unsupervised on 07/14/13 and 07/15/13. Nurse #1 specified that on 07/14/13 the facility was notified by an outside phone call that Resident #13 was observed off the facility's grounds. Nurse #1 stated that she immediately drove to find Resident #13 and located him at a private residence. Nurse #1 stated when she located Resident #13 he was smoking on the porch of the private residence and did not have any visible signs of injury. Nurse #1 stated that she transported Resident #13 back to the facility on [DATE] at around 6:30 PM to 6:45 PM and observed that he did not have a Wander-guard in place. Nurse #1 stated that another Wander-guard should have been placed on Resident #13 following his 07/14/13 elopement, but staff could not locate a Wander-guard bracelet to place on Resident #13 when she returned him to the facility. Nurse #1 stated that she did not notify the facility's Director of Nurses (DON) or Administration of Resident #13's 07/14/13 elopement. Nurse #1 explained the only intervention that was implemented by staff on 07/14/13 to prevent Resident #13 from eloping again was to instruct the on duty nursing staff to monitor the resident closely. Nurse #1 stated that on 07/15/13 the facility was again notified that Resident #13 had eloped off of the facility's grounds. Nurse #1 stated that on 07/15/13 she and a transport aide went to locate the resident and they found him walking next to the side of the road smoking a cigarette. Nurse #1 stated that the resident had no visible signs of injury and was transported back to the facility in the facility's van at around 4:15 PM. Nurse #1 stated that when Resident #13 returned to the facility on [DATE] he did not have a Wander-guard in place. Nurse #1 stated that upon Resident #13's return to the facility on [DATE] staff placed a Wander-guard bracelet on the resident. Nurse #1 stated that the facility's DON was not notified of Resident #13's elopements on 07/14/13 and 07/15/13 until the morning of 07/16/13. Interview with the facility's DON on 07/18/13 at 2:40 PM revealed that Resident #13 was assessed on his admission date of [DATE] to be a high risk for elopements. On 07/09/13 a Wander-guard bracelet was placed on Resident #13 as a preventative measure to keep him from exiting the facility and eloping off the facility's property. The DON stated that staff were directed to check that the resident every thirty minutes to ensure that he was in the facility and that his Wander-guard was in place. The DON specified that staff was also directed to document these resident checks. The DON confirmed that on 07/14/13 and 07/15/13 Resident #13 did not have a Wander-guard in place when he successfully eloped off of the facility's grounds without staff's knowledge. The DON also stated that on 07/14/13 and 07/15/13 staff failed to check Resident #13's Wander-guard to ensure that it was in place and that staff did not notify her of these two elopements until the morning of 07/16/13. The DON specified that staff should have notified her immediately of both elopements to ensure that preventative measures were implemented to prevent further elopements by Resident #13. The DON further stated that if staff had informed her of Resident #13's elopement on 07/14/13 she would have came to the facility and located a Wander-guard to place on the resident and directed nursing staff to implement direct one on one supervision of Resident #13 to prevent another elopement. The DON stated that Wander-guard bracelets were available in the facility on 07/14/13, but staff working on this date did not know where to locate them within the facility. On 07/18/13 at 6:15 PM Resident #13 was interviewed. Resident #13 stated he had left the facility's grounds on two occasions to walk down the road to get cigarettes from a man he knew. The resident specified that when he left the faciity on the first occasion (on 07/14/13) he was almost run over by a car as he walked along the road which had no sidewalks. On 07/19/13 at 3:38 PM Nurse #1, who located Resident #13 off of the facility's grounds on 07/14/13 and 07/15/13, showed a surveyor where the resident found on both occasions. The location where Nurse #1 found Resident #13 on 07/14/13 was at a private residence approximately 0.3 miles away from the facility's front door. The location where Nurse #1 found Resident #13 on 07/15/13 was along the side of a two lane roadway which had no sidewalks, with a posted speed limit of thirty five (35) miles per hour, which was 0.2 miles away from the facility's front entrance. On 07/19/13 at 9:58 AM an interview was conducted with NA #3. NA #3 stated that she worked on the facility's D-Hall, where Resident #13 resided, on 07/14/13 from 6:00 AM to 7:00 PM. NA #3 reported that on 07/14/13 she was not informed that Resident #13 had eloped from the facility during the afternoon of 07/14/13. NA #3 did not recall if Resident #13 was wearing a Wander-guard on 07/14/13. NA #3 also specified that during her shift on 07/14/13 she was not informed to check on Resident #13 more frequently or to provide him with additional supervision to prevent him from eloping again. On 07/19/13 at 3:17 PM an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated that she worked on the facility's D Hall, where Resident #13 resided, on 07/14/13 and 07/15/13 during the 7:00 PM to 7:00 AM shift. NA #1 stated that on 07/14/13 she found cigarettes in resident Resident #13's room and took the cigarettes to the nurse. NA #1 explained that on 07/14/13 Resident #13 was on the go constantly, usually on the front porch or the facility's gazebo and she did not recall Resident #13 wearing a Wanderguard bracelet on this date. NA #1 reported that Resident #13 eloped from the facility on 07/14/13 and when he returned to the facility, she did not recall being informed to check on him more often or to provide any additional supervision to prevent further elopements. NA #1 reported that she did not recall Resident #13 having a Wander-guard in place until after he eloped from the facility for the second time on 07/15/13. NA #1 stated that nursing assistants are directed to check residents, wearing Wander-guards, every thirty minutes to make sure they are present and have their Wander-guard alarm bracelet in place, but she did not recall Resident #13 wearing a Wander-guard on either 07/14/13 or 07/15/13. On 07/19/13 at 2:49 PM an interview was conducted with NA #2. NA #2 stated that she worked on the facility's D-Hall, where Resident #13 resided, on 07/15/13 from 6:00 AM to 7:00 PM. NA #2 Stated that during the afternoon of 07/15/13 Resident #13 left the facility with a transport aide for a appointment. NA #2 reported that at around 5:00 PM she went to give Resident #13 his medications, but she did not think he had returned from his appointment because he was not in his room, but a nurse informed her that Resident #13 had returned from his appointment. NA #2 stated that when she went to find Resident #13 she was informed by a resident, who was seated on the facility's front porch, that he had seen Resident #13 walking toward the roadway. NA #2 stated that she reported to Nurse #1 that Resident #13 was missing. NA #2 explained that Nurse #1 went to find Resident #13 in the facility's van and returned with the resident in approximately ten minutes. NA #2 stated that Resident #13 did not have a Wander-guard in place when he returned to the facility, but staff placed another Wander-guard on the resident's ankle upon his return to the facility on [DATE]. Observations on 07/18/13 at 5:02 PM of the facility's A-Hallway exit door, which has a Wander-guard alarm, revealed the door's alarm did not activate when tested by the facility's maintenance staff. Staff had to adjust the door's Wander-guard alarm sensitively in order for the alarm to function properly. Interview with the facility's maintenance staff on 07/18/12 at 5:05 PM revealed the facility's Wander-guard door alarms were checked daily to ensure proper function, but these checks were not documented by staff. The facility's Director of Nurses and Assistant Administrator were notified of the Immediate Jeopardy for Resident #13 on 7/18/13 at 4:25 PM. The facility provided a credible allegation of compliance on 07/19/13 at 4:00 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Resident #13 was admitted to the facility on [DATE] and was assessed as having severely impaired skills for daily decision making and being an elopement risk. On 07/09/13 the facility placed a Wander-guard on Resident #13, as a safety measure, to keep him from exiting the facility without the staff's knowledge. On 07/14/13 Resident #13 left the facility and the facility's grounds, without staff's knowledge, and was located approximately 0.30 miles away from the facility. Resident #13 was brought back to the facility by the charge nurse and the staff determined that the resident had removed his Wander-guard which allowed him to exit the facility without staff's knowledge. On 07/15/13 Resident #13 again exited the facility and left the facility's grounds without staff's knowledge. Resident #13 was located approximately 0.20 miles away from the facility and was brought back to the facility by the charge nurse. Staff did not notify the Director of Nurses until 07/16/13 that Resident #13 had exited the facility and left the facility's grounds on 07/14/13 and 07/15/13. On 07/16/13 Resident #13 was placed on three to one resident to staff supervision and a Wander-guard was again placed on the resident to keep him from exiting the facility without staff's knowledge. The facility's investigation determined that Resident #13 removed his Wander-guard on 07/16/13 and was then placed on one to one direct staff supervision. On 07/18/13 the facility's Assistant Director of Nurses (ADON) completed an "Elopement Risk Assessment" for Resident #13 which identified him as being at high risk for elopement. Staff will keep Resident #13 on one to one direct staff supervision until he is discharged from the facility on 07/19/13 to an assisted living facility. On 07/18/13 facility maintenance and nursing staff checked all residents with Wander-guards for placement and operation. All resident Wander-guards were found to be functioning properly. On 07/18/13 all facility doors with a Wander-guard alarm were checked by maintenance staff. The Wander-guard on the facility's A-Hallway exit door was found not functioning. Facility maintenance staff adjusted the alarm to enable the alarm to function properly. On 07/18/13 all residents were reassessed for elopement risk by administrative nursing staff and changes were made accordingly to wander-guards. Resident care plans were reviewed and updated based on this assessment by the facility's care plan staff. On 07/18/13 the facility's ADON also updated the facility's Wander-guard list to include all residents with Wander-guards. On 07/18/13 all care plans, for residents identified as elopement risks were checked and updated as needed by the facility's staff to include a potential for elopement and the resident's need for a Wander-guard. On 07/18/13 Electronic care guides were updated by IT staff to trigger checks and documentation by Nursing Assistants every thirty minutes on each resident assessed for the need for Wander-guards ensuring that each resident is present in the facility and wearing a Wander-guard. On 07/18/13 a designated staff member as assigned by Human Resources will be responsible for checking every resident that was identified as high risk for elopement every thirty minutes to ensure that they are present in the facility. This designated staff member will also check and document resident Wander-guards every two hours for placement and proper function. This will be documented on the "Wandering and Elopement Risk Residents-Monitoring Check List." Any identified problems will be reported to the Charge Nurse. The charge nurses will be responsible for overseeing this process and will report any variances immediately to the Director of Nurses who will be responsible for appropriate intervention. This intervention will be continued for four weeks to determine if there have been no further resident elopements. On 07/18/13 In-services on the facility's existing wandering resident and elopement policy were presented to all staff by the facility's Staff Development/Quality Improvement nurse. Staff will be educated to immediately report any resident that can not be located to the charge nurse. The charge nurse is responsible for calling a code Orange to alert staff of a missing resident. The charge nurse is to report this to the Director of Nurses. Upon return of the missing resident staff will place the resident on one to one direct staff supervision until further assessment by the Interdisciplinary team, including the DON, and interventions will be implemented as needed to keep the resident safe. Staff will not be permitted to return to work until they have received this inservice training. On 07/19/13 Residents will be screened prior to admission by the Interdisciplinary team/Director of Nurses to ensure the resident is appropriately placed and can be cared for by facility staff. On 07/19/13 all facility doors with a Wander-guard alarm were checked by maintenance staff and all door alarms were found to be functioning properly. All doors with Wander-guard alarms will be tested two times a shift for fourteen days by a designated staff member as assigned by Human Resources. These checks will be documented on the "Wandering Residents - Monitoring Check List". Review of the facility's Wander-guard and Elopement system, including any variances, will be reviewed by the facility's Quality Improvement Committee every three months. Immediate Jeopardy was removed on 07/20/13 at 5:15 PM. Observation revealed all residents, who were identified as elopement risks, were inside the facility, all resident Wander-guards and Wander-guard door alarms were functioning properly. All resident elopement risk assessments were verified as being complete. Interviews conducted with staff in all departments and who worked on all shifts confirmed that they had received inservice training on the facility's elopement policy and procedures.

Based on record reviews and staff interviews, the facility failed to call the physician for orders for a laboratory test to check the clotting time of a resident's blood and failed to hold the daily dosage of [MEDICATION NAME] (blood thinner) in a resident with a nosebleed in 1 of 10 residents on [MEDICATION NAME] therapy. (Resident #1). Immediate Jeopardy began on [DATE] when Resident #1 vomited dark colored liquid. Immediate jeopardy was removed on [DATE] at 5:15 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place are effective and completion of employee training. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact for daily decision making. The MDS further indicated Resident #1 required supervision with eating, limited assistance with transfers and hygiene and was totally dependent on staff for bathing. A review of a care plan with a review date of [DATE] indicated a potential for abnormal bleeding due to [MEDICATION NAME]. The approaches indicated in part to report abnormal lab values to physician, monitor for abnormal bleeding (tarry stools, bleeding gums, blood in urine) and report bruising. A review of a physician's orders [REDACTED]. (The PT/INR blood test results provide information for the physician to increase or decrease the dosage of [MEDICATION NAME]). A review of physician's orders [REDACTED]. A review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. by mouth daily at 5:00 PM. A review of the most recent laboratory results for a PT/INR with a collect date of [DATE], received date of [DATE] and a reported date of [DATE] indicated (PT) 23.9 (High) with a reference range of 11.5 to 14.1 seconds and (INR) 2.33 (High) with a reference range of 0.89 -1.16. A review of a MAR indicated [REDACTED]. A review of a nurse's note dated [DATE] at 10:12 AM indicated Resident #1 vomited small amount of dark liquid this morning. A review of the MAR indicated [REDACTED]. A review of nurse's notes dated [DATE] at 6:03 AM indicated medications were held due to "nausea." A review of nurse's notes dated [DATE] at 11:38 AM indicated Resident #1 was at [MEDICAL TREATMENT]. A review of a treatment sheet from the [MEDICAL TREATMENT] center dated [DATE] in a section titled Pre -[MEDICAL TREATMENT] "other comments" indicated Resident #1's nurse from the facility called and stated Resident #1 was vomiting today and yesterday and vomit was dark but not coffee ground consistency. Upon arrival at [MEDICAL TREATMENT] Resident #1 stated he had been vomiting for 3 days. A section titled "Treatment Data" indicated Resident #1 had [MEDICAL TREATMENT] started on [DATE] at 10:25 AM and completed it at 1:56 PM. The notes also indicated Resident #1 was alert, denied complaints and had no nausea or vomiting. A section titled Post - [MEDICAL TREATMENT] indicated no new complaints or observations developed during [MEDICAL TREATMENT] and Resident #1 was discharged back to the facility. A review of the MAR indicated [REDACTED]. A review of a nurse's note dated [DATE] at 7:39 PM indicated Resident #1 continues on [MEDICATION NAME] 5 mg. by mouth. The notes further indicated Resident #1 was noted to have a nosebleed from right nostril. A review of a nurse's note dated [DATE] at 12:29 AM indicated Resident #1 continues [MEDICATION NAME] 5 mg. as ordered and nose had stopped bleeding at this time. A review of a nurse's note dated [DATE] at 10:45 AM indicated [MEDICAL TREATMENT] center called and reported Resident #1 had been sent to the hospital for evaluation and treatment. A review of a nurse's note dated [DATE] at 5:44 PM indicated a call was received from a physician at the hospital that Resident #1 had been admitted to the intensive care unit. A review of a nurse's note dated [DATE] at 6:44 PM titled "addendum" indicated a physician from the hospital called the facility and reported that Resident #1's blood was "too thin" and Resident #1 "was not in good shape." A review of a hospital laboratory report dated [DATE] titled "coagulation" indicated a statement next to PT "no coagulation" and there were no results or notes for INR. A review of a hospital history and physical dated [DATE] indicated Resident #1 was to have [MEDICAL TREATMENT] today but was vomiting dark brown material and was sent to the emergency room (ER) for evaluation. The notes indicated Resident #1 was chronically ill appearing, poorly unresponsive with respiratory distress and a PT/INR was drawn and the results revealed his blood was not coagulable (was not clotting). The notes revealed Resident #1 was admitted to the intensive care unit, received 2 units of fresh frozen plasma and intravenous Vitamin K. A review of a hospital discharge summary titled "Death Summary" dated [DATE] indicated Resident #1 was taken to the intensive care unit and given fresh frozen plasma and intravenous Vitamin K for severe coagulopathy (no blood clotting). The notes further indicated Resident #1 was grossly bleeding from his upper pharynx (throat) and possible gastrointestinal tract and fresh frozen plasma was of important nature and priority. The notes revealed Resident #1 became less and less responsive and had a respiratory arrest and was pronounced dead at 7:24 PM on [DATE]. During a phone interview on [DATE] at 9:22 AM with a [MEDICAL TREATMENT] nurse she explained Resident #1 received [MEDICAL TREATMENT] treatments on Monday, Wednesday and Friday of each week. She further explained Resident #1 was seen in the [MEDICAL TREATMENT] center on Thursday [DATE] and received a treatment because he missed his [MEDICAL TREATMENT] treatment on Wednesday [DATE] due to vomiting. She stated the facility had reported to them that Resident #1 had been vomiting for 3 days and it was a dark brown cola color. She further stated a lab test for a hemoglobin was drawn on [DATE] and the results were 12.0 (Low) with a reference range 14XXX,[DATE].0 gram per deciliter but there was no PT/INR drawn because he was not due for his monthly PT/INR until the end of [DATE] and he did not have symptoms at the [MEDICAL TREATMENT] center to cause them to question what his PT/INR results were. She explained he was sent back to the facility mid afternoon on [DATE] and confirmed Resident #1 did not have a nosebleed while in the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] nurse stated Resident #1 came to the [MEDICAL TREATMENT] center again on Friday [DATE] but they did not put him on a [MEDICAL TREATMENT] machine because he was lethargic, had labored breathing and was slow to respond to [MEDICAL TREATMENT] staff's questions. She explained Resident #1 requested to be sent to the ER and confirmed they did not draw any labs at the [MEDICAL TREATMENT] center because they knew labs would be drawn in the ER. During a phone interview on [DATE] at 9:56 AM Nurse #2 verified she worked from 7:00 AM to 7:00 PM and was assigned as Resident #1's nurse on [DATE] and he did not look right to her when she saw him that morning. She explained Resident #1 was coughing up a dark brown liquid and she was concerned because she knew Resident #1 had a history of [REDACTED]. Nurse #2 explained a Nurse Aide (NA) called her to Resident #1's room and he was sitting in his wheelchair and was bleeding from his nose. Nurse #2 verified Resident #1 received [MEDICATION NAME] 5 mg. by mouth at 5:00 PM because she thought Resident #1 had scratched at his nose and that caused the nosebleed. She confirmed she did not call the facility physician to ask if the [MEDICATION NAME] dosage should be held or to request laboratory testing for a PT/INR. Nurse #2 stated when she returned to work on [DATE] Resident #1 looked worse and his skin color was paler but he was alert and responded to her. She explained Resident #1 went to the [MEDICAL TREATMENT] center again that morning and was sent to the hospital from the [MEDICAL TREATMENT] center. During an interview on [DATE] at 4:35 PM the Director of Nursing (DON) stated it was her expectation for nurses to call the facility physician to report Resident #1's nosebleed. She further stated they should have questioned whether to give the daily [MEDICATION NAME] dosage since Resident #1 was bleeding and should have gotten orders to have a PT/INR drawn. During an interview on [DATE] at 4:46 PM the facility physician stated if a resident on [MEDICATION NAME] therapy had significant bleeding a PT/INR should be obtained. The facility physician verified he was not notified of Resident #1's nosebleed on [DATE]. During an interview on [DATE] at 5:24 PM with Nurse #3 he verified he worked 7:00 AM to 7:00 PM on [DATE] and was assigned as the charge nurse. He explained when Resident #1 returned from the [MEDICAL TREATMENT] center Nurse #2 reported he had bleeding from his nose and was vomiting dark brown liquid. He explained Resident #1 had a communication sheet from the [MEDICAL TREATMENT] center but it didn't have any notes about bleeding or labs. He stated he should have followed through and called the facility physician or physician's assistant to find out what they needed to do but he didn't recognize the seriousness of what was going on. He stated he did not recall looking at previous PT/INRs lab results but probably didn't. He confirmed Resident #1 received [MEDICATION NAME] 5 mg. by mouth at 5:00 PM on [DATE] and they should have questioned whether to give the [MEDICATION NAME] since Resident #1 was bleeding from his nose. Nurse #3 stated they should have notified the facility physician at the point Resident #1 had the nosebleed, should have requested a PT/INR be drawn, held the [MEDICATION NAME] dosage and considered Vitamin K. He further stated he was slow to pick up on the fact that [MEDICAL TREATMENT] had not done a PT/INR During an interview on [DATE] at 5:51 PM with Nurse #1 she verified she was the charge nurse on Friday [DATE]. She explained Nurse #2 told her that morning Resident #1 had a nose bleed the day before and he was vomiting a dark brown cola colored liquid. She stated Resident #1 went to the [MEDICAL TREATMENT] center between 9:30 AM and 10:00 AM and later that day the [MEDICAL TREATMENT] center called her and told her Resident #1 was sent to the hospital. During an interview on [DATE] at 5:59 PM the DON verified there was no notification to the facility physician or physician's assistant of Resident #1's nosebleed. She also verified there was no request for a PT/INR to be drawn or for the [MEDICATION NAME] to be held on [DATE]. The facility's Director of Nursing and Assistant Administrator were notified of Immediate Jeopardy for Resident #1 on [DATE] at 4:26 PM. The facility provided a credible allegation of compliance on [DATE] at 4:53 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Resident #1 admitted to facility on [DATE] as a [MEDICAL TREATMENT] patient with chronic kidney failure. On [DATE] Resident #1 vomited dark brown liquid. No orders were received to address nosebleed, PT/INR, or acute episode. Facility physician was not notified on [DATE] of nosebleed and [MEDICATION NAME] dose of 5 milligrams was not held by staff. On [DATE] the resident was admitted to the hospital Intensive Care Unit and expired on this date. On [DATE] an audit of [MEDICATION NAME] logs and ordered labs for all residents on [MEDICATION NAME] therapy was completed by facility's QI nurse. No concerns were identified. As of [DATE] a change to our medication administration system was implemented. Medication Aides will not longer administer [MEDICATION NAME] doses. Only licensed nurses will be allowed to administer [MEDICATION NAME]. This change has been made to assure that each resident has been assessed for signs/symptoms of overt bleeding. On [DATE] the eMAR program was utilized to allow for the addition of parameters being set to include the acceptable INR range and documentation of the current INR prior to allowing the nurse to administer the 5pm [MEDICATION NAME] doses. The eMAR will then direct the nurse to call the MD if the value is greater than 3.0 unless otherwise ordered. The program will not allow the nurse to give the [MEDICATION NAME] until the doctor has been notified and orders received. On [DATE] the Staff Development Coordinator/Quality Improvement Nurse began inservicing all nurses prior to giving a [MEDICATION NAME] dose and content of this inservice included: a new [MEDICATION NAME] log; PT/INR results and how [MEDICATION NAME] affects coagulation time and nurses only to give [MEDICATION NAME]. The inservice also included documentation on the nurse's daily [MEDICATION NAME] logs and nurse's documentation in the nurse's notes to include diagnosis, current [MEDICATION NAME] dose, next INR date, acknowledge lack of / presence of signs/symptoms of overt bleeding and on the functioning of the facility's e-MAR system. Nurses will not be permitted to work until they have received this inservice training. On [DATE] all medication aides were inseviced by Administrative nursing staff on changes to [MEDICATION NAME] administration: Medication Aides were trained on the new procedure of only nurses administering [MEDICATION NAME]. Medication aides will not be permitted to work until they have received this inservice training. The process change will be evaluated for compliance on a daily basis in the morning nursing meetings by review of order entry on new orders and review of documentation of nurse's [MEDICATION NAME] administration. The facility's QI nurse will audit charts of resident on [MEDICATION NAME] weekly and report finding on Thursdays in morning nursing team meeting. The Director of Nursing will report weekly audits related to [MEDICATION NAME] quarterly to the facility's Quality Improvement Committee with plans to correct any deficits. Immediate jeopardy was removed on [DATE] at 5:15 PM. Observations of a [MEDICATION NAME] log was in place for each resident who received [MEDICATION NAME] and had spaces for the documentation of the current [MEDICATION NAME] dosage, the date and results of the last PT/INR and when the next PT/INR was due to be drawn. Interviews with nursing staff revealed they had received in-service training on [DATE] regarding the administration of [MEDICATION NAME]. They explained a new daily [MEDICATION NAME] log had to be filled out every shift, skin assessments were to be done every shift, and a nurses note was to be written with the resident's diagnosis, PT/INR results, next due date for PT/INR, and [MEDICATION NAME] dosage. They further stated they were expected to call the facility physician if PT/INR results were abnormal or when a resident had bleeding or bruising. They explained only nurses could give the [MEDICATION NAME] and medication aides could no longer give [MEDICATION NAME]. They explained the INR results had to be put in the e-MAR before they could give the [MEDICATION NAME] and the e-MAR would not allow the nurse to give the [MEDICATION NAME] until the physician had been notified and orders received.