Every finding on record at Kerr Lake Nursing and Rehabilitation Center

Based on observations and staff interviews, the facility failed to keep food service equipment clean, free of grease buildup, and/or dried spills by failing to clean the convection oven during two kitchen observations. This practice had the potential to affect food served to the residents who resided in the facility.The findings included:Review of the undated /blank Weekly Deep Cleaning Schedule, sixth line down, indicated/listed Convection Ovens were included to be cleaned.Review of the Dietary Sanitation Checklist dated 12/23/25 completed by the Dietitian documented the kitchen equipment had been cleaned.Review of the Dietary Sanitation Checklist dated 1/28/26 completed by the Dietitian showed no documentation the kitchen equipment had been cleaned.During a kitchen tour on 2/09/26 at 11:03 AM, the following observations were made with the Dietary Manager:The double stacked convection ovens had a large volume of grease buildup inside of the oven, inside the door and on the seals. The bottom shelf of the top convection oven was noted with charred food particles.A second observation of the convection ovens on 2/12/26 at 8:45 AM revealed the convections ovens were in the same condition.In an interview on 2/12/26 at 9:00 AM the Dietary Manager indicated they usually cleaned the convection ovens once a week, and it looked like they had not been cleaned in a while. She stated she would make a cleaning schedule and have staff clean the ovens that day. The Administrator was interviewed on 2/12/26 at 9:10 AM. She revealed she would make sure there was a cleaning schedule and she would now monitor the kitchen to ensure the convection ovens were clean.

Based on observations, record reviews, staff and Pharmacist interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication (Oxycodone) for 1 of 4 residents reviewed for misappropriation of property (Resident #76). The findings included:Resident #76 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic pain and osteoarthritis. Resident #76's physician's orders revealed an order dated 2/25/25 for Oxycodone 10 milligrams (mg) (two 5 mg tablets) by mouth every 4 hours as needed for moderate pain; take 15 mg (three 5 mg tablets) by mouth every 4 hours as needed for severe pain. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact. A Pharmacy Narcotic Delivery Slip dated 5/6/25 revealed 3 medication cards (blister packs) each containing 30 pills of Oxycodone 5 mg were delivered by the pharmacy and signed in as being received by Nurse #3 and Nurse 4. Resident #76 was discharged from the facility on 6/20/25.Attempts were made to contact Nurse #3 and Nurse #4 on 2/10/26 at 3:10 p.m., and on 2/11/26 at 7:20 a.m. Both nurses were unable to be reached. An initial report dated 5/12/25 completed by the Administrator for an allegation of drug diversion indicated one medication card of 30 Oxycodone for Resident #76 was missing. Resident #76 had additional medication cards of Oxycodone and had not missed any medication.An interview was completed on 2/11/26 at 8:26 a.m. with Medication Aide #1. Medication Aide #1 stated she worked on the dayshift on 5/11/25 and handed over the medication cart to Nurse #1 at the end of the shift. Medication Aide #1 stated that her and Nurse #1 counted the controlled medication cards for all residents on their hall (the hall Resident #76 resided on) and there were 27 cards counted during shift to shift change. Medication Aide #1 stated that she could not explain how the Oxycodone medication card for Resident #76 went missing. Medication Aide #1 stated that she regularly worked on the medication cart on hall 1 and had not noticed narcotic medications missing in the past. Medication Aide #1 stated that she was suspended pending the investigation into the missing medication. During an interview with Nurse #1 on 2/11/26 at 7:25 a.m. she stated when she completed her shift-to-shift narcotic medication count with Medication Aide #1 on 5/11/25 at 11:00 p.m. the narcotic medication count was correct, and the number of narcotic count sheets matched the total number of narcotic medication cards. Nurse #1 stated that during shift change on 5/12/26 at 7:00 a.m. she did a narcotic medication count with oncoming Nurse #2 when they noticed that one card of Oxycodone was missing. Nurse #1 stated that she was supposed to hand over 27 medication cards and records sheets but instead had 27 record sheets and 26 medication cards of controlled substance medications. Nurse #1 stated that she did not know how she ended up missing one card of Oxycodone for Resident #76. Nurse #1 stated that a mistake occurred and she was not sure how one card went missing. Nurse #1 stated that she informed the Unit Manager who counted the medications and found a total of 26 medication cards instead of 27. Nurse #1 revealed that she was suspended pending investigations. An interview with Nurse #2 on 2/11/26 at 8:04 a.m. revealed that during shift change on 5/12/25 at 7:00 a.m. she counted controlled medications with Nurse #1, and that they identified a missing medication card for Oxycodone. Nurse #2 stated that she informed the Unit Manager of the missing controlled medication for Resident #76. Nurse #2 stated that she had completed her shift-to-shift narcotic medication count with Nurse #1 many times in the past and it was the first time that medications cards were short. Nurse #2 revealed that she was suspended pending the investigation.An interview was completed on 2/11/26 at 8:16 a.m. with the Unit Manager. The Unit Manager stated that Nurse #2 reported to the missing Oxycodone card for Resident #76 on 5/12/25. The Unit Manager stated that she counted the medication in the cart and one card of Oxycodone was missing when comparing medication cards and the controlled substance count sheets. The Unit Manager revealed an investigation was initiated. The Unit Manager stated that a 100% audit was completed by her and the prior Director of Nursing (DON) of all medication carts and medication storage rooms, and the missing Oxycodone was unable to be located. The Unit Manager further stated that the investigation could not identify how the medication was lost. During an interview with the Social Work Director on 2/11/26 at 9:30 a.m. she revealed that she interviewed Resident #76 who disclosed to her that he got his medications for pain when he needed it. The Social Work Director stated that the missing medication did not have any effect on Resident #76. An attempt to contact the investigating officer on 2/11/26 was made, however it was unsuccessful. An interview with the Administrator on 2/11/26 at 11:12 a.m. revealed that on 5/12/25 she was notified by the Unit Manager and the prior DON that there was a discrepancy with the narcotic count during shift change in the 100 hall medication cart (the hall Resident #76 resided on). She revealed that one narcotic card for Resident #76's Oxycodone 5 mg tablets containing 30 pills was missing from the medication cart. The Administrator revealed that before suspension, Nurse #1, Nurse #2 and Medication Aide #1 completed a drug screen on 5/13/25 and the results were negative. The Administrator revealed they did not have camera surveillance in the facility and Nurse #1, Nurse #2, and Medication Aide #1 were suspended pending investigation. The Administrator further revealed that a report was made on 5/12/25 to the Division of Health Service Regulation, the police, Adult Protective services and Drug Enforcement Agency. The Administrator revealed that upon completion of the facility investigation, they were unable to determine how the narcotic medication card was lost. She revealed the facility contacted the pharmacy who replaced the medication at the cost of the facility to ensure there was no interruption to Resident #76's medications. A telephone interview was conducted on 2/12/26 at 2:36 p.m. with the facility's Pharmacist. The Pharmacist verified that there was no Oxycodone 5 mg for Resident #76 returned to the pharmacy on or around the month of May of 2025. Multiple attempts made to contact the prior DON were unsuccessful. The facility provided a corrective action plan that was not acceptable to the State Agency. The plan did not include a systemic approach to prevent future incidents of misappropriation of residents' property. Education was completed on processes that were already in place and the monitoring plan would identify misappropriation of property after it already occurred.

Based on record review, staff interview and Consultant Pharmacist interview, the Consultant Pharmacist failed to identify and report a medication irregularity on 7 Monthly Medication Reviews when Dyskinesia Identification System Condensed User Scale (DISCUS) assessments (used for medication monitoring of side effects of antipsychotic medication) were not completed for a resident who received Risperdal, Haloperidol and Olanzapine (antipsychotic medications). The Consultant Pharmacist also failed to identify and address an order for as needed (PRN) Haloperidol that extended beyond the 14-day limit for 1 of 6 residents reviewed for unnecessary medications. (Resident #57) The findings included: 1. Resident #57 was admitted on [DATE] with diagnoses that included vascular dementia with agitation, generalized anxiety disorder, and manic episode. a. Review of the medical record revealed a DISCUS assessment was conducted on 1/25/24 when Resident #57 was admitted . A physician's order dated 3/7/24 indicated Risperdal (an antipsychotic medication) 0.5 milligrams (mg) one tablet twice daily for anxiety/dementia with behavioral disturbance. Risperdal was discontinued on 3/24/24. A physician's order dated 3/18/24 indicated Olanzapine (an antipsychotic medication) 5 mg by mouth one time only for agitation for 1 Day. A physician's order dated 3/19/24 indicated Haloperidol (an antipsychotic medication) 0.5 mg one time only for agitation. A physician's order dated 3/19/24 indicated Olanzapine 5 mg at bedtime for agitation related to vascular dementia and manic episode. The Olanzapine 5 mg order remains active. A physician's order dated 3/20/24 indicated Haloperidol 0.5 mg every eight hours as needed for anxiety and dementia with other behavioral disturbances. The Haloperidol order was discontinued on 4/3/24. Review of the Medication Administration Record (MAR) revealed Resident #57 received Haloperidol on 3/28/24 and 3/29/24. A physician ' s order dated 4/3/24 indicated Haloperidol 0.5 mg every eight hours as needed for anxiety and dementia with other behavioral disturbances. The Haloperidol order was discontinued on 6/3/24. Review of the Medication Administration Record (MAR) revealed Resident #57 received Haloperidol on 4/7/24 and 5/12/24. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 4/4/24 revealed no recommendations for completion of a DISCUS assessment. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 5/3/24 revealed no recommendations for completion of a DISCUS assessment. A physician's order dated 6/7/24 and revised 6/8/24 indicated Olanzapine 2.5 mg every Tuesday, Thursday, and Saturday for anxiety, agitation. Administer at 11:00 AM prior to dialysis every Tuesday, Thursday, and Saturday. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 6/10/24 revealed no recommendations for completion of a DISCUS assessment. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 7/8/24 revealed no recommendations for completion of a DISCUS assessment. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 8/2/24 revealed no recommendations for completion of a DISCUS assessment. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 9/11/24 revealed no recommendations for completion of a DISCUS assessment. Review of the Monthly Medication Regimen (MRR) for Resident #57 completed on 10/4/24 revealed no recommendations for completion of a DISCUS assessment. Review of the most recent Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had severe cognitive impairment and was administered antipsychotic medications during the assessment lookback period. Further review of Resident #57's medical record revealed no other discus assessments were completed since admission. A telephone interview was conducted on 11/06/24 at 11:10 AM with the Consultant Pharmacist who revealed the facility was required to complete a DISCUS assessment on all residents that were prescribed an antipsychotic medication upon initiation of the medication and periodically if the medication changes. The Consultant Pharmacist stated the DISCUS assessment was used to monitor residents on antipsychotic medications for abnormal involuntary movements associated with the long-term use of antipsychotic agents. The Consultant Pharmacist stated Resident #57 had been overlooked and confirmed that she would have recommended that Resident #57 had another DISCUS assessment completed. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 03:12 PM. She stated the DISCUS assessment was to be conducted upon admission, every six months and when there was a change in the medication to monitor for abnormal involuntary movement disorders. The DON stated she expected the pharmacist to identify irregularities of antipsychotic medications by ensuring DISCUS assessments were completed for residents on antipsychotic medications. During an interview on 11/06/24 at 03:17 PM, the Administrator stated she expected the Consultant Pharmacist to review residents on antipsychotic medications during the Monthly Medication Regimen (MRR) for medication side effects and make recommendations for the completion of the DISCUS assessment to identify abnormal involuntary movements. b. A physician's order dated 4/3/24 indicated Haloperidol 0.5 mg every eight hours as needed for anxiety and dementia with other behavioral disturbances. The Haloperidol order was discontinued on 6/3/24. Review of the Medication Administration Record (MAR) revealed Resident #57 received PRN Haloperidol on 4/7/24 and 5/12/24. Pharmacy consultant monthly medication regimen reviews dated 4/4/24 and 5/3/24. revealed no recommendations related to the duration of Resident #57's PRN Haloperidol prescribed on 4/3/24 with a 6/7/24 stop date. A phone interview was conducted with the Medical Director on 11/6/24 at 8:36 AM. She stated orders for PRN antipsychotic medication should have a 14 day stop date. The Medical Director stated the order should be reevaluated after 14 days to see if the medication was still needed. The Medical Director further stated if the medication was still needed a new order had to be written. A telephone interview was conducted on 11/06/24 at 11:10 AM with the Consultant Pharmacist. She stated PRN antipsychotic medications are required to be reevaluated every 14 days. The pharmacist stated if the provider wished to continue the antipsychotic medication a new order had to be written. Review of Resident's #57's medical record with the Consultant Pharmacist confirmed there was no reevaluation of Resident #56 and that the 4/3/24 Haloperidol order extended past the 14-day duration. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 03:12 PM. The DON stated she expected the pharmacist to review PRN antipsychotic medications for stop dates or rationales for continued use.

Based on record review, staff interview, Consultant Pharmacist interview and Medical Director interview, the facility failed to complete a Dyskinesia Identification System Condensed User Scale (DISCUS) assessment (used for monitoring side effects of antipsychotic medication) for a resident who received multiple antipsychotic medications (Resident #57), ensure an as needed (PRN) antipsychotic order was limited to a 14-day duration (Resident #57), and ensure orders for PRN antianxiety medication were time limited in duration (Resident #23) for 2 of 6 residents reviewed for unnecessary medications. The findings included: 1. Resident #57 was admitted on [DATE] with diagnoses that included vascular dementia with agitation, generalized anxiety disorder, and manic episode. 1a. Review of the medical record revealed a DISCUS assessment was conducted on 1/25/24 when Resident #57 was admitted . A physician's order dated 3/7/24 indicated Risperdal (an antipsychotic medication) 0.5 milligrams (mg) one tablet twice daily for anxiety/dementia with behavioral disturbance. A physician's order dated 3/18/24 indicated Zyprexa (an antipsychotic medication) 5mg by mouth one time only for agitation for 1 Day. A physician's order dated 3/19/24 indicated Haloperidol (an antipsychotic medication) 0.5 mg one time only for agitation. A physician's order dated 3/19/24 indicated Zyprexa 5mg at bedtime for agitation related to vascular dementia and manic episode. A physician's order dated 3/20/24 indicated Haloperidol 0.5 mg every eight hours as needed for anxiety and dementia with other behavioral disturbances. A physician's order dated 4/3/24 indicated Haloperidol 0.5 mg every eight hours as needed for anxiety and dementia with other behavioral disturbances. A physician's order dated 6/7/24 and revised 6/8/24 indicated Zyprexa 2.5 MG every Tuesday, Thursday, and Saturday for anxiety, agitation. Administer at 11:00 AM prior to dialysis every Tuesday, Thursday, and Saturday. Review of Resident # 57's electronic medical record from 3/7/24 to 11/5/24 revealed no documentation regarding the completion of a DISCUS assessment. Review of the most recent Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had severe cognitive impairment and no behaviors during the lookback period. Resident #57 was further coded as change in behavior improved. Resident #57 was coded as received antipsychotic medications during the assessment lookback period. Review of the care plan last reviewed on 5/16/2024 revealed Resident #57 used psychotropic medications with the potential or characterized by side effects of cardiac, neuromuscular, gastrointestinal systems as evidenced by or/due to diagnosis of antipsychotic use anxiety, depression, psychophysiological insomnia, manic episode, vascular dementia with mood disorder and agitation. The goal was for Resident #57 to receive the lowest therapeutic dose through the next review. The interventions included administer medications per physician's orders, monitor resident's mood/behaviors with documentation per facility policy and notify physician of any significant changes. A telephone interview was conducted on 11/06/24 at 11:10 AM with the Consultant Pharmacist who revealed the facility was required to complete a DISCUS assessment on all residents that were prescribed an antipsychotic medication upon initiation of the medication and periodically if the medication changes. The Consultant Pharmacist stated Resident #57 had been overlooked and confirmed that she would have recommended that Resident #57 had another DISCUS assessment completed. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 03:12 PM. The DON stated the admission nurse was responsible for initiating the admission DISCUS. She further stated the DISCUS assessment was to be conducted upon admission, every six months and then there was a change in the medication. During an interview on 11/06/24 at 03:17 PM the Administrator stated the DISCUS assessment was missed due to a breakdown in their process and communication. She further stated expected the DISCUS assessment would be completed per the schedule. 1b. A physician's order dated 4/3/24 indicated Haloperidol 0.5 mg every eight hours as needed for anxiety and dementia with other behavioral disturbances. The Haloperidol order was discontinued on 6/3/24. Review of the Medication Administration Record (MAR) revealed Resident #57 received PRN Haloperidol on 4/7/24 and 5/12/24. A phone interview was conducted with the Medical Director on 11/6/24 at 8:36 AM. She stated orders for PRN antipsychotic medication should have a 14 day stop date. The Medical Director stated the order should be reevaluated after 14 days to see if the medication was still needed. The Medical Director further stated if the medication was still needed a new order had to be written. A telephone interview was conducted on 11/06/24 at 11:10 AM with the Consultant Pharmacist. She stated PRN antipsychotic medications are required to be reevaluated every 14 days. The pharmacist stated if the provider wished to continue the antipsychotic medication a new order had to be written. Review of Resident's #57's medical record with the Consultant Pharmacist confirmed there was no reevaluation of Resident #56 and that the 4/3/24 Haloperidol order extended past the 14-day duration. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 03:12 PM. The DON stated she expected the pharmacist to review PRN antipsychotic medications for stop dates or rationales for continued use. 45044 2. Resident #23 was admitted to the facility on [DATE] with diagnoses that included anxiety. A Physician order dated 8/22/24 indicated Xanax 0.25 milligrams (mg) 1 tablet by mouth every 8 hours as needed (PRN) for anxiety was ordered without a stop date. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired. The MDS revealed the resident was coded for taking an antianxiety medication. An interview was conducted on 11/6/24 at 11:00 AM with the Director of Nursing (DON). She indicated she was aware all PRN psychotropic medications required an initial 14 day stop date, and the Physician then reevaluated the resident at the end of the medication regimen for continued use. A telephone interview was completed on 11/6/24 at 11:10 AM with the Pharmacy Consultant. She indicated PRN psychotropic medications required an initial 14 day stop date. The Pharmacy Consultant continued to state the Physician then reevaluated the Resident for continued use of the medication and documented the rationale for extending the medication. A telephone interview was completed on 11/6/24 at 11:56 AM with Physician #2. He revealed all PRN psychotropic medications that were ordered should have included a 14 day stop date. The Physician stated he then revaluated the resident and extended the medication for a time frame he felt was appropriate. Physician #2 stated he was unable to state why the medication order did not include a stop date. An interview was completed on 11/6/24 at 1:45 PM with the Administrator. She stated it was her expectation all PRN psychotropic medications have a stop date included in the order.

Based on record review and interviews with staff, Responsible Party (RP), Medical Director, Poison Control Center, and Hospital Physician, the facility failed to provide a safe environment to prevent an avoidable accident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 had severe cognitive impairment, was dependent on staff for assistance, and was allergic to ingredients that were commonly found in shampoos, skin care products, and soap. On [DATE] Resident #1 had access to a bar of soap (Soap #1), she ingested the soap, and had an allergic reaction which included mouth and lip swelling and was transferred to the Emergency Department (ED) for further treatment. Resident #1 required intubation (a tube placed down throat into the trachea to facilitate airflow) and mechanical ventilation (a form of life support that helps you breathe when you cannot breathe on your own) in the ED and continued to decline despite medical interventions. Resident #1 was placed on comfort measures and according to the death certificate expired on [DATE] from complications of anaphylactic shock (a severe, potentially fatal allergic reaction that is rapid in onset and requires immediate medical attention) due to accidental ingestion of soap. The findings included: Review of a hospital discharge summary dated [DATE] Resident #1 had no known drug allergies. Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia. Record review of the census data revealed Resident #1 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the hospital discharge summary dated [DATE] revealed Resident #1 had allergies to cocamidopropyl betaine (a product derived from raw coconut oil and is used in many personal care items to create a thick lather when combined with water often found in products such as shampoo, skin care products, and soaps), chloroxylenol (an antiseptic and disinfectant agent used for skin disinfection found in antibacterial soaps), and erythromycin (antibiotic). Record review of Resident #1's allergy list on revealed an allergy to erythromycin was entered on [DATE] and an intolerance to perfume was entered into the record on [DATE]. The cocamidopropyl betaine and the chloroxylenol were not listed on Resident #1's medical record as allergies. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, had adequate vision with corrective lenses, and was not coded for behaviors. Resident #1 was dependent upon staff for all activities of daily living (ADLs) which included eating and movement throughout the facility. Resident #1 was not coded for use of mobility devices. Resident #1's care plan last revised [DATE] revealed a care plan was in place for decline in intellectual functioning related to dementia and was at risk for unmet needs with an intervention to allow resident sufficient time to verbalize needs. Resident #1 had a care plan for risk for inability to focus on objects, discriminate color, and adjust to changes in light and dark related to impaired peripheral (side) vision with an intervention to ensure eyeglasses were clean and worn. The nursing progress note dated [DATE] at 8:03 pm by Nurse #1 revealed Resident #1 was observed with a large amount of chewed up tissue in her mouth. Nurse #1 removed all paper and small items from Resident #1's reach. The nursing progress note dated [DATE] at 10:16 pm by Nurse #1 revealed that at approximately 8:00 pm she was notified that Resident #1 ate soap and was observed with swollen lips and face. Nurse #1 assessed Resident #1 and administered a dose of epinephrine (an emergency medication used to decrease the body's allergic reaction by relaxing the muscles in airway to make breathing easier) by injection. Resident #1 was transferred to the emergency department (ED) via ambulance at 8:20 pm. A telephone interview was conducted on [DATE] at 1:27 pm with Nurse #1 who revealed she was notified by Nurse Aide (NA) #2 that Resident #1's face and lips were swollen. Nurse #1 stated when she entered the room, she did observe some small particles on Resident #1's lips and in her mouth but she was unable to determine what it was. She stated she did not know Resident #1 had eaten Soap #1 until NA #2 reported she had found the soap in Resident #1's hand. Nurse #1 reported she administered an epinephrine injection to Resident #1 because it was apparent that Resident #1 had an anaphylactic reaction (a severe, potentially fatal allergic reaction that is rapid in onset and requires immediate medical attention) after eating Soap #1. Nurse #1 stated she had previously witnessed Resident #1 place non-food items in her mouth, but it was not a frequent occurrence. Nurse #1 stated she was aware of Resident #1's allergies to erythromycin and perfume but she stated that she thought the perfume allergy was related to spray perfume and lotions, but she did not think it would include soap. A telephone interview was conducted on [DATE] at 11:47 am with NA #2 who revealed she was assigned to Resident #1 on the evening of [DATE] when Soap #1 was ingested. NA #2 stated she was providing care to Resident #1's roommate with the curtain pulled when Resident #1 began talking funny and was not sounding right so she pulled the curtain and observed Resident #1's face and lips were swollen. NA #2 stated she immediately went to Resident #1 and grabbed her hand and that was when she saw the bar of Soap #1 in Resident #1's hand. She stated she knew it was Soap #1 because of the strong smell of the soap. NA #2 stated once she realized what happened her heart dropped because she knew Resident #1 was allergic to Soap #1. NA #2 reported she yelled for Nurse #1 and stayed with Resident #1 until Nurse #1 arrived. NA #2 stated she knew Resident #1's roommate used Soap #1, but she did not use Soap #1 on her shift and did not observe it on the bedside table in the room prior to the incident. She stated she did not know how Resident #1 was able to get the soap because she was not able to move herself around the room. NA #2 stated she had recently returned to work at the facility, and this was the first time she had provided care to Resident #1 since her return which was about two months prior. NA #2 stated she knew Resident #1 well from her previous employment with the facility and was aware of the allergy to Soap #1 since her previous time of employment. NA #2 stated she had received education from the facility during her previous time of employment and prior to providing care to Resident #1 regarding the allergy to Soap #1. NA #2 stated she thought there was a sign posted in the room about Resident #1's soap allergy. A follow-up interview was conducted on [DATE] at 12:37 with NA #2 who reported she was now not sure if she was told or knew about Resident #1's allergy to Soap #1, but stated she was aware of Resident #1's allergy to perfume. An additional interview was conducted on [DATE] at 2:43 pm with NA #2 who reported when she saw Resident #1 had eaten Soap #1, she knew she had an allergic reaction because her lips and mouth were swollen so that may be why she previously reported that Resident #1 had an allergy to Soap #1. NA #2 stated she was aware Resident #1 was not allowed to have soap and that was why she stated in her earlier interview that Resident #1 had an allergy. NA #2 stated she knew of Resident #1's allergy to perfume and since Soap #1 had such a strong scent that may be what made her think she had an allergy and made her so upset when Resident #1 ate the soap. NA #2 stated that all the staff were aware to use only Soap #2 (a mild soap used for sensitive skin) for Resident #1 and she stated the facility had provided an in-service about it. She reported that when she was cleaning up after the incident, she did observe the empty clear plastic cup with soap residue on Resident #2's bedside table but did not see it prior to the incident. She stated she did not recall Resident #1 being close enough to the table to be able to reach the cup and Resident #1 was not able to move herself around the room, so she was not sure how she got the soap. NA #2 stated she gave incorrect information during the first interview because she had just woken up and was confused. The hospital record with an admitted [DATE] indicated Resident #1 presented to the emergency department from the facility after ingesting a bar of soap with associated lip swelling. While in the ED Resident #1's lip swelling continued to progress to angioedema (swelling under the skin associated with an allergic reaction) with respiratory difficulty and was intubated and placed on a ventilator. Resident #1 was admitted to the intensive care unit and listed as critically ill with acute respiratory failure and a high probability of sudden clinically life-threatening deterioration in condition. Resident #1 suffered a heart attack on [DATE] and was determined not to be a candidate for medical intervention. Resident #1 continued to decline despite medications to maintain blood pressure and mechanical ventilation for breathing and expired on [DATE]. The Certificate of Death revealed Resident #1 expired on [DATE] and the immediate cause of death was determined to be complications of anaphylactic shock due to accidental ingestion of soap. A telephone interview was conducted on [DATE] at 8:44 am with the Hospital Physician who revealed Resident #1 was admitted to intensive care under his services after the ingestion of soap and anaphylactic shock. The Hospital Physician reported although it was not common to see such a severe reaction to the ingestion of soap products to this extent, but it was possible. He stated Resident #1's reported allergy to perfumes could have been the initial trigger to cause the severe anaphylaxis reaction. The Hospital Physician stated the hospital was unable to determine how much of the soap Resident #1 ingested, but any amount of soap ingested could pose a concern for a fragile resident. The Hospital Physician stated the stress of the severe anaphylaxis due to the soap ingestion triggered the additional events, including intubation, need for mechanical ventilation, and the increased stress on the heart muscle which led to the heart attack, and ultimately Resident #1's death. During a telephone interview on [DATE] at 4:12 pm Resident #1's RP reported she had multiple conversations with facility staff, including nurses and NAs, regarding the allergy to soap and perfume. The RP stated the facility was aware soap and perfume was an allergy which caused Resident #1 to have swelling. She stated she specifically told the facility that soaps such as Soap #1 were not allowed to be used due to her history of skin cancer and her soap allergy. She stated when she visited the facility, she would often find other soap products in Resident #1's drawers or on her bedside table and she would throw them away. The RP reported that Resident #1's roommate had Soap #1 and she often observed the bar of Soap #1 left out by the staff within reach of Resident #1. The RP stated the staff were aware Resident #1 had an allergy to Soap #1 and was only to use Soap #2 for her personal care needs. The RP stated Soap #2 was a gentle soap specifically for sensitive skin. The RP stated that although Resident #1 did not remain in the same room throughout her time at the facility she remained in the same area, she had the same staff provide her care, and they were all aware of the soap allergy. She stated the facility had a sign posted on the wall in the room about not using soap due to allergy, but stated when she went to pick up Resident #1's personal items the sign was no longer on the wall. The RP stated that Resident #1 had vomited multiple times at the hospital, and she stated it was such a strong fragrance that she was able to smell Soap #1 from the hall. The RP stated Resident #1 continued to worsen and the RP was forced to make the decision to try no further life saving measures. A telephone interview was conducted on [DATE] at 3:50 pm with the Poison Control Center who revealed when someone had an allergy, each use or interaction with that allergen or biproduct could increase the risk for more severe and possibly an anaphylaxis reaction. The Poison Control Center stated that derivatives (substances created from chemical reaction from another component) from natural products, surfactants (chemical compounds created from natural products or synthetic chemical compounds), fragrance, [NAME], or components of the products used to create soap products had the potential to induce an allergic reaction when ingested. The Poison Control Center reported that if bar soap was ingested most often would cause gastrointestinal system issues such as nausea, vomiting, and diarrhea, but for some a more severe allergic reaction could occur based on the individual and their health condition. The Poison Control Center stated if a bar of soap was ingested there could be a potential for an allergic reaction which is why the soap products have warning labels that state the products are for external use only. A telephone interview was conducted on [DATE] at 12:00 pm with NA #1 who was assigned to Resident #1 during the 7:00 am-3:00 pm shift on [DATE]. NA #1 stated she provided Resident #1 and her roommate with a bed bath during her shift that day. She stated she used Soap #1 for the roommate and when she was finished bathing Resident #1's roommate she placed Soap #1 in a cup and put it back in the top drawer of the roommate's dresser. She stated Resident #1 was unable to move herself around the room in her geriatric chair (a large, padded chair with wheels that reclines for comfort and positioning), and she does not know how she would have been able to get Soap #1 from the drawer. NA #1 stated she was not sure if Resident #1 had any allergies, but she stated she was aware Resident #1 was only allowed to have Soap #2 when care was provided. NA #1 stated she had received information in the past from the facility about only using Soap #2 for Resident #1 and she stated there was a sign in the room to use only Soap #2, but she was not sure if it was because of an allergy. A telephone interview was conducted on [DATE] at 12:09 pm with NA #3 who worked on [DATE] during the 3:00 pm-11:00 pm shift. NA #3 stated she was not assigned to Resident #1 during the shift on [DATE] but had assisted NA #2 to provide care in the room. She stated she was alerted by NA #2 that Resident #1 had eaten Soap #1, but she reported she was not in the room when it occurred. NA #3 stated she had provided care to Resident #1 in the past and was aware of a perfume allergy but was not able to recall it being reported as an allergy to soap. NA #3 stated she was aware that Resident #1 was to use only Soap #2 and she was not to use other soap products when providing care. NA #3 stated she did observe a clear plastic cup with a bar of soap on Resident #1's roommate's bedside table when she was in the room prior to the incident. NA #3 stated Resident #1 was not able to move herself around the room, but she was unable to recall if Resident #1 was sitting close to the cup with the bar of Soap #1. During an interview on [DATE] at 12:24 pm with the Supply Clerk she revealed the facility did not supply residents with bar soap which included Soap #1, but she stated families did bring in items for resident use. The Supply Clerk stated she was familiar with Resident #1's perfume allergy and that she had Soap #2 which was for sensitive skin, available in the resident's room and store room for bathing needs. During an interview on [DATE] at 12:49 pm with NA #4 she revealed she had provided care to Resident #1 and was aware of an allergy to soaps because the nurse told them, but she could not recall what specific soap. NA #4 stated she used only Soap #2 for Resident #1, but she did not recall seeing a sign about an allergy to Soap #1 for Resident #1. NA #4 stated Resident #1's roommate used Soap #1 and it was put back in the top drawer of the dresser when staff were done using it. An interview was conducted on [DATE] at 1:09 pm with the Medical Director who revealed she was notified of Resident #1's ingestion of soap and her being sent to the ED due to an allergic reaction. She stated Resident #1 had very sensitive skin and used gentle skin products that she was aware of, but she stated she was not aware of an actual allergy to soap or perfume. The Medical Director stated she was not aware of Resident #1 having an allergic reaction of any kind related to soap or perfumes prior. The Medical Director stated generally an intolerance to perfume would not necessarily correspond to an actual allergy, but she would have to review the medical record before being able to state if Resident #1 had any allergies. During an interview with the Director of Nursing (DON) and Administrator on [DATE] at 2:49 pm the DON revealed she was not aware of Resident #1's allergy to soap and further stated that perfume was not a true allergy but an intolerance. She stated when the Nurse Aides saw perfume listed, they did not understand the difference between an allergy and an intolerance, so they were reporting they were aware of an allergy to perfume when it was not an allergy. The DON stated she was not aware of any education provided to staff regarding Resident #1's reported soap allergy. The DON stated she did not recall any conversation with Resident #1's RP regarding the use of specific soap or an allergy to soap and she did not recall a sign being posted in the Resident #1's room about a soap allergy. The Administrator revealed she was not aware Resident #1 had any prior behaviors of eating non-food items and would not have expected Resident #1 to ingest soap prior to the event. She stated she was unsure how the facility could have prevented the incident because to her knowledge Resident #1 had not demonstrated this type of behavior prior to this incident. The Administrator and DON stated they were unable to determine how Resident #1 obtained Soap #1 and what happened to make Resident #1 eat it. The Administrator was notified of immediate jeopardy on [DATE] at 5:10 pm. The facility provided the following corrective action plan with a completion date of [DATE]: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 has a diagnosis of dementia, and allergies include erythromycin, perfume, chloroxylenol (an antiseptic and disinfectant agent used for skin disinfection found in antibacterial soaps), and cocamidopropyl betaine (a product used in many personal care items to create a thick lather when combined with water often found in products such as shampoo, skin care products, and soaps). The chloroxylenol, cocamidopropyl betaine was not listed in the resident's clinical record. On [DATE], at 8:00 pm, the Certified Nursing Assistant (CNA) #2 entered Resident #1's room and observed Resident #1 with a swollen red face, swollen lips, and was difficult to understand. Resident #1 had a piece of her roommate's soap (Soap #1) in her hand. The resident refused to open her mouth for CNA #2. CNA #2 immediately notified the nurse, and upon assessment, a small particle of soap was observed in Resident #1's mouth. The nurse notified the physician, and orders were received to administer an Epi-pen (a pen used to treat life-threatening, allergic emergencies) and to call 911. The Epi-pen was administered, and Resident #1 was transferred to the local Emergency Department with a diagnosis of anaphylaxis (life-threatening allergic reaction). While in the emergency department, Resident #1's lip swelling continued to progress to angioedema (swelling under the skin associated with an allergic reaction) with respiratory difficulty and was intubated (a tube placed down the throat into the trachea to facilitate airflow) and placed on a ventilator (a machine that helps a person breath with when intubated). Resident # 1 expired in the hospital on [DATE]. Following the incident, the Administrator immediately initiated an investigation. The investigation was completed [DATE]. It could not be determined how the resident obtained the soap. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], the Administrator completed an audit of all resident's rooms utilizing a resident census to ensure all soaps, lotions, medications, and shampoos were stored in appropriate containers and not easily accessible to cognitively impaired residents with behaviors of ingesting non-edible items/ objects when not supervised and in use. All other items were stored in appropriate containers or in drawers. On [DATE], the Second Shift Patient Care Coordinator initiated interviews with all alert and oriented residents to ensure all identified allergies are reflected in the clinical records for staff reference, including the demographics, and resident care guide. The interviews were completed by [DATE]. There were no other concerns. On [DATE], the Second Shift Patient Care Coordinator initiated interviews with all resident representatives for all non-alert and oriented residents to ensure all identified allergies are reflected in the clinical records for staff reference, including the demographics, and resident care guide. The interviews were completed by [DATE] for all resident representatives who were able to be reached. Four additional concerns were identified during the audit. The Patient Care Coordinator updated the resident record for all newly identified allergies. After [DATE], the Registered Nurse (RN) Unit Managers tracked and followed up with the families who could not be reached. The RN Unit Managers updated the clinical records for all identified areas of concern during the interviews. The audit was completed on [DATE] with one resident representative (RR) not able to be reached. The facility continued attempts to reach the RR. The RR responded on [DATE] with no additional allergies reported. On [DATE], the Second Shift Patient Care Coordinator completed an audit of all residents identified with a soap allergy to ensure that the allergen was not present in the room. There were no identified areas of concern during the audit. On [DATE], the Administrator initiated an audit of all residents' admission and readmission records to ensure all identified preadmission allergies are reflected in the facility's clinical records for staff reference, including the demographics and resident care guide. There were no areas of concern identified during this audit. The audit was completed by [DATE]. On [DATE], the Staff Development Coordinator (SDC) initiated interviews with all staff regarding the following: Do you know any resident who has ingested a non-edible item/ object? If yes, resident name, date of event, actions taken? The SDC will immediately forward the interviews with identified behaviors to the Director of Nursing. The Director of Nursing (DON) upon receipt of the interview will ensure that all residents identified with behaviors of ingesting non-edible item/ object have been addressed, including an assessment of the resident, removal or proper storage of the object, implementation of intervention depending on the root cause, physician and resident representative notification, documentation in the clinical record, and the behavior is reflected on the care plan. The interviews will be completed by [DATE]. After [DATE], the SDC will monitor staff completion, and all staff that have not worked and received the interview will complete it upon their next scheduled shift. The Director of Nursing was notified of this responsibility by the Administrator on [DATE]. On [DATE], the Unit Managers reviewed all current residents' progress notes from [DATE]-[DATE]. The purpose of the audit is to ensure that all residents identified with behaviors of ingesting non-edible items/ objects have been addressed, including an assessment of the resident, removal or proper storage of the object, implementation of an intervention depending on the root cause, physician and resident representative notification, and the behavior is reflected on the care plan/care guide. There were no additional areas of concern noted during the audit. The audit was completed by [DATE]. On [DATE], a resident council meeting was conducted by the Activity Staff with alert and oriented residents with education on how to properly store soaps, lotions, shampoo, and chemicals when not in use. On [DATE], the Activity Staff provided individual education to all alert and oriented residents who did not attend the resident council meeting. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE], an in-service was initiated with all staff (from all departments) by the Director of Nursing regarding ensuring all soaps, lotions, medications, and shampoos are stored in appropriate containers and not easily accessible to cognitively impaired residents with behaviors of ingesting non-edible items/ objects when not supervised and in use. On [DATE], an in-service was initiated by the SDC with all staff (from all departments) regarding immediately reporting to the nurse resident's behaviors of ingesting non-edible items/ objects (which would include new behaviors and prior behaviors). On [DATE], the Director of Nursing initiated an in-service with all nurses regarding the following: 1.) what to do when a resident ingests non-edible items/ objects to include but not limited to assessment of the resident, notification of 911 as necessary, removal or proper storage of the object, implementation of an intervention depending on the root cause, physician and resident representative notification, documentation in the progress notes, ensuring the behavior is reflected on the resident care plan/care guide, and 2.) reviewing resident's admission and readmission records and speaking with the families on admission or readmission to identify all allergies and ensure the allergies are reflected in the clinical records including the demographics, and resident care guide. All in-services for staff that worked were completed by [DATE]. After [DATE], the SDC will monitor staff completion and all nursing staff that have not worked and received the in-services will complete it upon their next scheduled shift/prior to working. All newly hired staff will be educated during orientation by the SDC regarding the following: 1.) ensuring all soaps, lotions, medications, and shampoos are stored in appropriate containers and not easily accessible to cognitively impaired residents with behaviors of ingesting non-edible items/ objects when not supervised and in use and 2.) immediately reporting to the nurse resident's behaviors of ingesting non-edible items/ objects. Additionally, newly hired nurses will receive education during orientation by the SDC regarding the following: 1.) what to do when a resident ingest non-edible items/ objects to include but not limited to assessment of the resident, notification of 911 as necessary, removal or proper storage of the object, implementation of an intervention depending on the root cause, physician and resident representative notification, documentation in the progress notes, ensuring the behavior is reflected on the resident care plan/care guide, and 2.) reviewing resident's admission and readmission records and speaking with the families on admission or readmission to identify all allergies and ensure the allergies are reflected in the clinical records including the demographics, and resident care guide. The SDC was notified of this responsibility by the Administrator on [DATE]. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision to monitor the system for residents ingesting non-edible items/ objects and allergies was made on [DATE] by the Administrator and Director of Nursing and presented to the Quality Assurance (QA) Committee on [DATE]. The Unit Managers will review progress notes 5 x per week x 4 weeks, then weekly x 1 month to identify residents that ingest non-edible items/ objects and ensure completion of an assessment of the resident, notification to 911 as necessary, removal or proper storage of the object, implementation of an intervention depending on the root cause, physician and resident representative notification, documentation in the progress notes and the behavior is reflected on the care plan utilizing an audit tool. The audit will be discussed during the cardinal Interdisciplinary (IDT) meeting (clinical meeting) and written on the audit tool by the Activity Staff with oversite by the Administrator and/or Director of Nursing. The Director of Nursing will immediately implement corrective actions upon identification of areas of concern including retraining of staff. The Unit Managers were notified of this responsibility by the Director of Nursing on [DATE]. The Treatment Nurse will monitor resident rooms to ensure inedible materials including soaps are in appropriate containers and stored properly and identified allergens are not present in the resident's room daily x 1-week, biweekly x 3 weeks, and then weekly x 4 weeks and document on a resident census. The Administrator will immediately ensure all areas of concern are addressed during the audit. The Treatment Nurse was notified of this responsibility by the Administrator on [DATE]. The Minimum Data Set (MDS) Nurse will review all admission and readmission records weekly x 8 weeks to ensure all preadmission allergies are reflected in the facility's clinical records including the demographics, and resident care guide for staff reference. The MDS Nurse will update the records accordingly and the Director of Nursing will immediately retrain the nurse upon notification for all identified areas of concern. The MDS Nurse was notified of this responsibility on [DATE]. The Administrator and/or DON will present the findings of the audit tools to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 2 months for review to determine trends and/or issues that may need further interventions and the need for additional monitoring. Date of immediate jeopardy removal and corrective action completion: [DATE]. Onsite validation was completed on [DATE] through record review, staff interviews, resident interviews, and observations of resident rooms. Record review of the staff education logs was completed with no areas of concern identified. Staff were interviewed to validate the in-service was completed on putting away all personal care items including soaps, lotions, and shampoo when not in use. Staff interviews validated the completion of the education regarding identification and reporting resident behaviors of ingesting non-edible items or objects, and steps to take when the behavior was observed. Staff interviews were conducted and validated the education was completed regarding confirmation and documentation of resident allergies upon admission and readmission. Resident Council Meeting Minutes and signature log were reviewed. Record review of the facility audits of personal care items was conducted and validated by observations of random resident rooms for personal care items which included soap, lotions, and shampoo to be stored properly and not within reach of cognitively impaired residents. Interviews were conducted with those residents identified by the facility as alert and oriented and with documented allergies to confirm the allergies listed were correct. No concerns were identified. A review was completed of the resident progress note audit with no identified concerns noted. The Quality Assurance and Performance Improvement (QAPI) ad-hoc (special and immediate meeting held for a specific situation) meeting minutes from [DATE] were review [TRUNCATED]

Based on record review, staff interviews, Responsible Party (RP) interview, and Medical Director interview, the facility failed to identify and enter reported allergies into the medical record for 1 of 3 residents reviewed for allergies (Resident #1). The findings included: Review of a hospital discharge summary dated 11/15/20 Resident #1 had no known drug allergies. Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia. Record review of the census data revealed Resident #1 was transferred to the hospital on 2/09/22 and returned to the facility on [DATE]. Review of the hospital discharge summary dated 2/19/22 revealed Resident #1 had allergies to cocamidopropyl betaine (a product derived from raw coconut oil and is used in many personal care items to create a thick lather when combined with water often found in products such as shampoo, skin care products, and soaps), chloroxylenol (an antiseptic and disinfectant agent used for skin disinfection found in antibacterial soaps), and erythromycin (antibiotic). The hospital discharge summary reported the allergies to cocamidopropyl betaine and chloroxylenol were identified by a positive patch test (a skin allergen test when allergens were placed on the skin to identify allergies). Record review of Resident #1's allergy list revealed an allergy to erythromycin was entered on 2/19/22 and an intolerance to perfume was entered into the record on 5/31/22. The cocamidopropyl betaine, chloroxylenol were not listed on Resident #1's medical record as allergies. A telephone interview was conducted with Nurse #2 on 4/30/24 at 1:20 pm who revealed she entered the intolerance to perfume into the electronic medical record based on a report from Resident #1's Responsible Party (RP) and she did not recall any other allergies being reported. Nurse #2 was unable to recall if Resident #1 had any other allergies. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. During a telephone interview on 4/30/24 at 4:12 pm Resident #1's RP reported she had multiple conversations with facility staff, including nurses and Nurse Aides (NAs), regarding the allergy to soap and perfume. She stated the facility was aware soap and perfume was an allergy. The RP stated the staff were aware Resident #1 had an allergy to Soap #1 and the staff was only to use Soap #2 for her personal care needs. Resident #1's RP stated Soap #2 was a gentle liquid soap specifically for sensitive skin. A telephone interview was conducted on 4/30/24 at 12:00 pm with NA #1. She stated she was not sure if Resident #1 had any allergies, but she stated she was aware Resident #1 was only allowed to have Soap #2 when care was provided. NA #1 stated she had received information in the past from the facility about only using Soap #2 for Resident #1 and she stated there was a sign in the room to use only Soap #2, but she was not sure if it was because of an allergy. A telephone interview was conducted on 4/30/24 at 12:09 pm with NA #3 who had provided care to Resident #1 in the past and was aware of a perfume allergy but was not able to recall it being reported as an allergy to soap. NA #3 stated she was aware that Resident #1 was to use only Soap #2 and she was not to use other soap products. During an interview on 4/30/24 at 12:49 pm with NA #4 she revealed she had provided care to Resident #1 and was aware of an allergy to soaps because the nurse told them, but she could not recall what specific soap. An interview with the Medical Director was conducted on 4/30/24 at 1:09 pm who revealed she was notified of Resident #1's ingestion of soap and her being sent to the ED due to an allergic reaction. The Medical Director stated if Resident #1 had allergies listed on the hospital discharge record the facility staff should have documented them in the medical record, and if the staff was not sure of the allergy they should have attempted to confirm with the family. The Medical Director stated she would have to review the medical record before being able to state if Resident #1 had any allergies. During an interview on 5/01/24 at 2:49 pm with the Director of Nursing (DON) and the Administrator the DON stated the nurse that completed the admission was responsible for entering any allergies. The DON stated the normal process of admission review was that the next day an admission audit tool was checked by another nurse to confirm the admission was completed. The DON stated she was not aware of Resident #1's reported use of a specific soap or any allergy to soap products. The DON and Administrator were unable to state why Resident #1's allergies were not placed on the medical record as documented on the hospital discharge summary. The facility provided the following corrective action plan with a completion date of 4/25/24: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 has a diagnosis of dementia, and allergies include erythromycin, perfume, chloroxylenol (an antiseptic and disinfectant agent used for skin disinfection found in antibacterial soaps), and cocamidopropyl betaine (a product used in many personal care items to create a thick lather when combined with water often found in products such as shampoo, skin care products, and soaps). The chloroxylenol, cocamidopropyl betaine was not listed in the resident's clinical record 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 4/24/24, the Second Shift Patient Care Coordinator initiated interviews with all alert and oriented residents to ensure all identified allergies are reflected in the clinical records for staff reference, including the demographics, and resident care guide. The interviews were completed by 4/24/24. There were no other concerns. On 4/24/24, the Second Shift Patient Care Coordinator initiated interviews with all resident representatives for all non-alert and oriented residents to ensure all identified allergies are reflected in the clinical records for staff reference, including the demographics, and resident care guide. The interviews were completed by 4/24/24 for all resident representatives who were able to be reached. Four additional concerns were identified during the audit. The Patient Care Coordinator updated the resident record for all newly identified allergies. After 4/24/24, the Registered Nurse (RN) Unit Managers tracked and followed up with the families who could not be reached. The RN Unit Managers updated the clinical records for all identified areas of concern during the interviews. The audit was completed on 4/24/24 with one resident representative (RR) not able to be reached. The facility continued attempts to reach the RR. The RR responded on 4/30/24 with no additional allergies reported. On 4/24/24, the Second Shift Patient Care Coordinator completed an audit of all residents identified with a soap allergy to ensure that the allergen was not present in the room. There were no identified areas of concern during the audit. On 4/24/24, the Administrator initiated an audit of all residents' admission and readmission records to ensure all identified preadmission allergies are reflected in the facility's clinical records for staff reference, including the demographics and resident care guide. There were no areas of concern identified during this audit. The audit was completed by 4/24/24. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 4/24/24, the Director of Nursing initiated an in-service with all nurses regarding reviewing resident's admission and readmission records and speaking with the families on admission or readmission to identify all allergies and ensure the allergies are reflected in the clinical records including the demographics, and resident care guide. All in-services for staff that worked were completed by 4/24/24. After 4/24/24, the SDC will monitor staff completion and all nursing staff that have not worked and received the in-services will complete it upon their next scheduled shift/prior to working. All newly hired staff will be educated during orientation by the SDC regarding reviewing resident's admission and readmission records and speaking with the families on admission or readmission to identify all allergies and ensure the allergies are reflected in the clinical records including the demographics, and resident care guide. The SDC was notified of this responsibility by the Administrator on 4/24/24. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision to monitor the system for residents' allergies was made on 4/24/24 by the Administrator and Director of Nursing and presented to the Quality Assurance (QA) Committee on 4/24/24. The Treatment Nurse will monitor resident rooms to ensure identified allergens are not present in the resident's room daily x 1-week, biweekly x 3 weeks, and then weekly x 4 weeks and document on a resident census. The Administrator will immediately ensure all areas of concern are addressed during the audit. The Treatment Nurse was notified of this responsibility by the Administrator on 4/24/24. The Minimum Data Set (MDS) Nurse will review all admission and readmission records weekly x 8 weeks to ensure all preadmission allergies are reflected in the facility's clinical records including the demographics, and resident care guide for staff reference. The MDS Nurse will update the records accordingly and the Director of Nursing will immediately retrain the nurse upon notification for all identified areas of concern. The MDS Nurse was notified of this responsibility on 4/24/24. The Administrator and/or DON will present the findings of the audit tools to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 2 months for review to determine trends and/or issues that may need further interventions and the need for additional monitoring. Date of corrective action completion: 4/25/24. Onsite validation was completed on 5/01/24 through record review, staff interviews, resident interviews, and observations of resident rooms. Record review of the staff education logs was completed with no areas of concern identified. Staff were interviewed to validate the in-service was conducted and validated the education was completed regarding confirmation and documentation of resident allergies upon admission and readmission. Interviews were conducted with those residents identified by the facility as alert and oriented and with documented allergies to confirm the allergies listed were correct. No concerns were identified. The Quality Assurance and Performance Improvement (QAPI) ad-hoc (special and immediate meeting held for a specific situation) meeting minutes from 4/24/24 were reviewed. The facility's corrective action plan was validated to be completed as of 4/25/24.

Based on record review and interviews with staff, Responsible Party (RP), Medical Director, Poison Control Center, and Hospital Physician, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the [DATE] complaint investigation survey. This was for one recited deficiency on the current complaint investigation survey of [DATE] in the area of Provide Supervision to Prevent Accidents (F689). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F689: Based on record review and interviews with staff, Responsible Party (RP), Medical Director, Poison Control Center, and Hospital Physician, the facility failed to provide a safe environment to prevent an avoidable accident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 had severe cognitive impairment, was dependent on staff for assistance, and was allergic to ingredients that were commonly found in shampoos, skin care products, and soap. On [DATE] Resident #1 had access to a bar of soap (Soap #1), she ingested the soap, and had an allergic reaction which included mouth and lip swelling and was transferred to the Emergency Department (ED) for further treatment. Resident #1 required intubation (a tube placed down throat into the trachea to facilitate airflow) and mechanical ventilation (a form of life support that helps you breathe when you cannot breathe on your own) in the ED and continued to decline despite medical interventions. Resident #1 was placed on comfort measures and according to the death certificate expired on [DATE] from complications of anaphylactic shock (a severe, potentially fatal allergic reaction that is rapid in onset and requires immediate medical attention) due to accidental ingestion of soap. During the [DATE] complaint investigation survey the facility failed to provide incontinent care safely for a resident who required extensive staff assistance which resulted in bruises to all extremities and the left side of the face, a laceration on left forehead 0.5 centimeters (cm) in length, multiple skin tears to the upper right arm, fractures of the left and right distal femurs (fracture of the thigh bone that occur just above the knee joint), a right lateral tibia plateau fracture (a break of the larger lower leg bone below the knee), and suffered pain of the face and lower extremities. An interview was conducted on [DATE] at 2:49 pm with the Administrator who revealed the facility's QAA committee had completed the education and auditing and resolved the plan of correction for the previous deficient practice. The Administrator stated she was not aware Resident #1 had any prior behaviors of eating non-food items and would not have expected Resident #1 to ingest soap prior to the event.

Based on record review and staff interviews, the facility failed to determine upon readmission to the facility a resident's code status for 1 of 4 residents reviewed for advanced directives (Resident #55). The findings included: Resident # 55 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, diabetes, and stroke. Resident #55 was discharged to the hospital on 8/08/23 and was readmitted to the facility on [DATE]. Record review of the admission progress note dated 8/10/23 at 8:42 pm by the Admission Nurse revealed no information regarding Resident #55's code status. Record review of Resident #55's physician orders revealed no order for code status. Review of Resident #55's paper chart on 8/22/23 at 11:51 am with Unit Manager #2 revealed no physician order or documentation about Resident #55's code status. An interview was conducted with Unit Manager #2 on 8/22/23 at 11:53 am who confirmed she did not find a physician order for Resident #55's code status in his electronic health record or his paper chart. Unit Manager #2 stated she did review his paper hospital discharge record dated 8/10/23 and saw he was a full code at the time of discharge from the hospital. She reported Resident #55's code status was expected to be reassessed upon admission and a physician order was required. She stated she believed the Admission Nurse was responsible to enter the order but would have to confirm with the Director of Nursing. Unit Manager #2 was unable to state why Resident #55's code status order was not in place since his 8/10/23 readmission to the facility. During an interview with Nurse #3 on 8/22/23 at 12:39, who was assigned to Resident #55, revealed the Admission Nurse or the Unit Manager enters physician orders upon admission to the facility. An interview with the Admission Nurse was conducted on 8/22/23 at 3:16 pm who revealed a resident's code status was normally discussed with the resident or resident family by the Social Worker and they would enter the code status order. The Admission Nurse stated that admission orders were reviewed by the Unit Managers to confirm that all physician orders were in place, but she was unable to state why Resident #55 did not have a code status order. An interview was conducted with the Social Worker on 8/22/23 at 3:54 pm who revealed she was responsible to confirm code status orders for those residents readmitting to the facility. The Social Worker was unable to state how Resident #55's code status order was missed. During an interview on 8/23/23 at 9:52 am with the Director of Nursing (DON) she revealed the Admission Nurse, or the Social Worker were responsible to confirm and enter resident code status orders. The DON was unable to state how Resident #55's code status order was missed during the admission process. An interview on 8/23/23 at 1:16 pm the Administrator revealed the Social Worker was responsible to address the resident code status if she was present in the facility at the time of the admission and when she was not present the Admission Nurse was responsible to confirm the code status and enter the order.

Based on record review, staff interviews, Responsible Party interview, and Medical Director interview, the facility failed to notify the residents Responsible Party and failed to notify the physician of a change in condition for 1 of 1 resident reviewed for change in condition (Resident #69). Findings included: Resident #69 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #69 had severe cognitive impairment with unclear speech. During a telephone interview on 8/21/23 at 12:00 pm Resident #69's Responsible Party (RP) #2 revealed that on the morning of 8/01/23 Resident #69 experienced an episode of unresponsiveness at the facility and the facility had not notified either RP #1 or RP #2 of the change in condition until RP #1 arrived at the facility after 3:00 pm. Record review of Resident #69's nursing notes for 8/01/23 during the 7:00 am - 3:00 pm shift revealed no documentation regarding Resident #69's morning episode of unresponsiveness, no notification to the physician, and no notification to Resident #69's Responsible Party (RP) was documented in the medical record. An interview was conducted on 8/22/23 at 12:12 pm with Nurse Aide (NA) #1, who was assigned to Resident #69 during the 7:00 am - 3:00 pm shift on 8/01/23, revealed he put Resident #69 in her wheelchair at approximately 10:00 am and she was observed shortly thereafter, leaned over with her head down while sitting in the wheelchair and he was unable to wake her up. NA #1 stated he reported his observation to the nurse but was unable to recall which nurse he reported to, but he stated several nursing staff members came to check on Resident #69. NA #1 stated Resident #69 was put back to bed and remained in her bed the rest of his shift. An interview was conducted on 8/22/23 at 12:22 pm with Nurse #2 who was assigned to Resident #69 on 8/01/23 during the 7:00 am-3:00 pm shift revealed Resident #69 had an episode of unresponsiveness in the morning while sitting in her wheelchair in the dining room. Nurse #2 stated the staff placed Resident #69 back to bed and staff obtained vital signs and she was assessed, and she did not have any further episodes during her shift. Nurse #2 stated Unit Manager #2 was also notified by the Medication Aide of the episode, and she came to the unit to assess on Resident #69 around lunch time. Nurse #2 stated Resident #69 had similar episodes of unresponsiveness in the past and they would lay her down in bed, monitor her, and she would return to her baseline. Nurse #2 stated she was unable to remember if she notified the family and the physician of the episode in the morning but if she did it would be documented in the medical record. A telephone interview was conducted with the Medication Aide on 8/22/23 at 7:15 pm who revealed she was assigned to Resident #69 on 8/01/23 for the 7:00 am-3:00 pm shift. The Medication Aide stated that around 10:00 am Resident #69 was in her wheelchair and she was just different, she stated Resident #69 was in (responding to voices she knew) and out of it (no movement), and she was leaning more than her normal posture. She stated she wanted Resident #69 put back to bed to prevent a possible fall out of her wheelchair due to her leaning, so they put her in bed. Medication Aide notified Nurse #2, who was assigned to Resident #69, and she came to assess Resident #69. She stated she remembered vital signs were taken but did not recall if Nurse #2 notified the family or the physician of the episode. The Medication Aide stated that Resident #69 began to respond to staff more after being returned to bed and did not have any further episodes on her shift. During an interview on 8/23/23 at 9:55 am the Director of Nursing revealed Nurse #2 was responsible to notify the physician and RP for Resident #69's change in condition that occurred on 8/01/23 during the 7:00 am-3:00 pm shift. An interview was conducted on 8/23/23 at 8:19 am with the Medical Director who revealed Resident #69 had a history of similar episodes of unresponsiveness in the past, but she expected the facility to notify her of any new episodes as they occurred. The Medical Director stated she did not receive notification of Resident #69's morning episode of unresponsiveness on 8/01/23 from staff at the facility. The Medical Director stated the failure of the facility to notify her of the morning episode of unresponsiveness on 8/01/23 did not cause harm to Resident #69 and it would not have changed her plan of care for the facility to notify Resident #69's RP and allow for the RP to make the decision to monitor at the facility or send to hospital for further evaluation due to the previous history of Resident 69's episodes of unresponsiveness. An interview was conducted on 8/23/23 at 1:18 pm with the Administrator who revealed that Nurse #2 was responsible to notify the physician and the RP for Resident #69's change of condition on the morning of 8/01/23.

Based on observation, record review, staff interviews, and Medical Director interview, the facility failed to obtain a physician order for the use of an indwelling urinary catheter for 1 of 2 residents reviewed for catheter (Resident #56). Findings included: Resident #56 was admitted to the facility on [DATE] with diagnoses which included presence of urogenital implants (material injected into urethra to help control urine leakage) and urinary retention. Resident #56 was discharged from the facility on 8/07/23 and returned to the facility on [DATE]. The most recent Minimum Data Set (MDS) discharge assessment dated [DATE] revealed Resident #56 was coded for an indwelling urinary catheter. The admission progress note dated 8/11/23 at 6:40 pm by the Admission Nurse revealed Resident #56 had an indwelling urinary catheter in place upon admission to the facility. During an observation on 8/21/23 at 11:20 am Resident #56 was observed with an indwelling urinary catheter. Record review of Resident #56's physician active orders revealed no order for an indwelling urinary catheter. An interview was conducted on 8/22/23 at 3:12 pm with the Admission Nurse who revealed she completed Resident #56's admission assessment and stated Resident #56 required a physician order for the indwelling urinary catheter. The Admission Nurse stated when a resident was admitted with an indwelling urinary catheter either her or the Treatment Nurse were responsible to enter the physician order. The Admission Nurse stated miscommunication between her and the Treatment Nurse regarding who would enter the order may have caused Resident #56's indwelling urinary catheter physician order to be missed upon admission. During an interview on 8/22/23 at 3:38 pm the Treatment Nurse stated she normally entered the indwelling urinary catheter orders but was unable to remember if she was present when Resident #56 returned to the facility. She stated if she was not present at the time of Resident #56's admission, the Admission Nurse was responsible to enter the physician order. The Treatment Nurse reported a physician order was required for Resident #56's indwelling urinary catheter but she was unable to state how the order was missed. An interview was conducted with the Director of Nursing (DON) on 8/23/23 at 9:49 am who revealed Resident #56's indwelling urinary catheter order was just missed due to miscommunication between the Admission Nurse and Treatment Nurse. The DON stated admission orders were reviewed on new admission during the clinical meeting and stated the indwelling urinary catheter order for Resident #56 was overlooked when the order review was completed. An interview was conducted on 8/23/23 at 1:00 pm with Unit Manager #1 who revealed she completed a review of physician orders for all residents that were located on her unit daily, but she was unable to state how Resident #56's indwelling urinary catheter order was missed. During an interview on 8/23/23 at 8:22 am the Medical Director revealed Resident #56 required a physician order for an indwelling urinary catheter. The Medical Director stated Resident #56 had an indwelling urinary catheter in place prior to her discharge and she was followed by urology, but she stated a new order for the indwelling urinary catheter was required when she returned to the facility.

Based on staff interviews, Physician interview, observation, and record review, the facility failed to provide incontinent care safely for a resident who required extensive staff assistance for 1 (Resident #1) of 3 residents reviewed for accidents. On 3/22/23 during incontinent care provided by Nursing Assistant (NA) #1, Resident #1 rolled off of the bed hitting her face on the nightstand and landing on the floor. Resident #1 sustained bruises to all extremities and the left side of her face, a laceration on left forehead 0.5 centimeters (cm) in length, multiple skin tears to her upper right arm, fractures of the left and right distal femurs (fracture of the thigh bone that occur just above the knee joint), a right lateral tibia plateau fracture (a break of the larger lower leg bone below the knee), and she suffered pain in her face and lower extremities. The findings included: Resident #1 was admitted on [DATE] with cumulative diagnoses of osteoporosis and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 had moderate cognitive impairment, required extensive assistance of 1 with bed mobility, toileting, and personal hygiene. The MDS did not code the resident as having behavioral symptoms or refusal of care. The MDS indicated the resident was always incontinent of bladder and bowel. Resident #1's care plan revised on 03/16/2023 indicated Resident # 1 had a focus of urinary incontinence related to: Physical immobility. The intervention included peri care after each incontinent episode. The care plan also indicated a focus area of the resident requiring assistance to maintain maximum function of self-sufficiency for transferring from one position to another and personal hygiene related to physical limitation. The incident report completed by Director of Nursing (DON) dated 03/22/2023 revealed Resident #1 had a fall from bed while being changed by staff. The resident fell on to her side with eye pain and right knee pain. NA #1 stated while changing her, the resident began turning over onto the floor and she was unable to catch her. The resident's position on the floor was left lateral with her head resting on the floor with NA #1 by her side. Resident #1 had a moderate amount of bleeding from the laceration to her forehead and swelling to her left eye. Later during assessment, multiple skin tears were noted on resident's upper right arm and increased swelling to right knee. The investigation of the incident dated 03/22/2023 completed by Director of Nursing (DON) revealed Nursing Assistant (NA)#1 entered Resident #1's room to provide incontinent care. NA #1 had turned and positioned the resident from side to side to remove soil brief and placed a new brief and disposable pads under the resident without difficulty. NA #1 left the resident lying on the left side in the center of the bed. Resident #1 remained safely in the center of bed for approximately 5 minutes before NA #1 returned to complete care. NA #1 resumed incontinent care. Resident #1 was still lying on the left side in center of bed with right leg crossed over her left leg and slightly in front of the resident. While NA #1 was attempting to place a clean brief under the resident, she noted the resident's right leg slid forward and off the edge of the bed. NA #1 grabbed the resident's right upper arm/shoulder but was unable to stop the resident's forward motion. Resident #1 began to roll off the bed landing onto the floor. Resident#1 was noted lying on her left side almost on her stomach and lying on her left arm with her feet toward the foot of the bed and her head toward the head of the bed resulting in multiple injuries. Resident#1 was immediately assessed by nursing staff and 911 notified. Resident #1 was transferred to the local hospital emergency room for further evaluation and treatment. Resident #1 was alert to self and verbal with staff at time of transfer. Review of Nursing Assistant (NA)#1's statement dated 03/24/2023 revealed the NA #1 went in resident's room around 1:55 PM on 3/22/23 to check on Resident#1. The resident had stool present in her brief. She gathered supplies and moved the bed so she could stand between the bed and the wall to provide care. She rolled the resident from side to side to remove the brief. Resident#1 continued to have stool. NA #1 indicated she placed the resident in the center of the bed on her left side facing the door with an incontinent pad and brief underneath her. She lowered the bed and returned in 5-6 minutes. The resident was still on her left side. She raised the bed back up to about waist height. She had her left hand on the resident and cleaned her with her right hand and removed the dirty brief. She indicated as she was wiping, the resident said ouch when she wiped over the reddened area that had been there before. NA #1 looked up, the resident's right leg was crossed over her left leg and her leg had dipped off the bed a little and her whole body started to roll off the bed. She grabbed Resident #1's right shoulder where her hand had been placed on her shoulder. When Resident #1 rolled from bed, NA #1 ran around the bed and checked the resident. The resident was laying on her left side, almost on her stomach. There was blood on her face and mouth. She placed a pillow under Resident #1's head and towel on her forehead. She went to doorway and yelled code green (a fall with an injury). During the phone interview on 03/27/2023 at 12:44 PM, NA #1 reported that she was in the resident's room giving care on 03/22/2023. Resident#1 needed to be changed due to having a loose stool. NA #1stated the resident was lying on the left side facing the door and her left hand was holding the resident's shoulder. She indicated the resident's right leg was extended over the left leg. NA #1 stated when she positioned the incontinent pad under the resident, she observed the resident's right leg dipped off the bed then the resident slid down and fell to the floor. NA #1 indicated She was standing next to the wall when cleaning the resident, so she ran around the bed and went to the door and called code green which meant the resident fell with an injury. She indicated that the resident moved her leg when placing the incontinent pad underneath, her then she started rolling and she could not stop her from falling to the floor. She indicated she had been in serviced on how to properly turn and repositioned the residents at the facility. Review of Nurse #2's witness statement dated 03/23/2023 revealed the nurse was the first to respond to the code green called by NA #1 for Resident #1. The nurse entered the room, the resident was already on the floor on her left side, lying on her left arm. Her head was tilted to the left. NA #1 who was her nurse aide was kneeling in front of her with a washcloth to her head, covering a laceration. Resident #1's left eye was swollen and there was a laceration to forehead, bruising under her left eye and her mouth had a bloody top and bottom lip. The nurse was unable to tell if it was coming from inside her mouth or from the resident biting her lips. The nurse then went to NA #1 who stated she was giving care and the resident weight shifted. Nurse #2 was unavailable for an interview. During an interview on 03/27/2023 at 11:02 AM, Nurse #1 who was assigned to Resident#1 reported on 03/22/2023 at approximately 2:15PM, she heard NA #1 yelling code green meaning a fall with an injury and heard call 911. Nurse #1 reported that she got the paperwork together and called the resident's son. She then went to the resident's room and saw 2 staff members (Unit Manager (UM)#1 and UM#2) in the room applying a bandage to the resident's head. She saw the resident positioned on the floor on her back, right leg over her left, and a bruise under the left eye. Review of Unit Manager (UM)#1's witness statement dated 03/23/2023 indicated she was in the hall helping another resident when she heard the code green announced. When she got to the room the resident was lying on her left side and was complaining of eye pain. NA #1 was kneeling on the floor holding pressure with a washcloth to the resident's head. NA #1 stated while changing the resident, the resident began turning over onto the floor and she was unable to catch her. Resident #1's head was resting on the floor with NA #1 by her side. Resident #1 had moderate amount of bleeding from a laceration to her forehead and swelling to her left eye. During the assessment of Resident #1, multiple skin tears were noted on resident's upper right arm and increased swelling to her right knee. The resident was semi undressed, and brief was not fastened with noted stool. The bed was about waist height and the foot was raised 2-3 inches. The resident was able to state her name and that her eye hurt. The room had adequate lighting and the floor appeared dry and free of hazards. Nursing staff responded rapidly assessing the resident and obtaining vital signs of Blood Pressure (BP) 110/ Heart Rate (HR) 74, respiration 24, and Oxygen (O2) 89%. Resident #1 was placed on O2 via Nasal Cannula (NC) @ 2 Liters (L). The nursing staff completed the head-to-toe assessment and bandaged her head to stop the bleeding. Resident #1 was transferred into stretcher and care turned over to Emergency Medical Services (EMS). During an interview on 03/27/2023 at 11:34 AM, UM #1 stated that she responded to a code green with everyone else. When she got to the resident's room, she observed the resident was lying on her left side, NA #1 was kneeling on the floor holding pressure with a washcloth to the resident's head. UM #1 reported she performed an assessment on the resident's cognition and the resident was able to state her name but did not know where she was. UM #1 reported that she assessed the resident, and she noticed the bleeding from a laceration to her forehead and swelling to right knee. She reported the resident indicated her head was hurting. UM #1 also indicated NA #1 stated to her that while she was changing the resident, she started rolling over and she could not stop the resident from falling to the floor. Review of UM #2's witness statement dated 03/23/2023 indicated she entered Resident#1's room and noticed her lying on her left side with her right leg over her left leg. NA #1 was applying pressure to the resident's forehead using a washcloth. The resident had skin tears on her arm, but UM #1 indicated she could not remember which arm. After she assessed that the blood was coming from the deep laceration on her forehead, she took over from NA #1 and began applying pressure with the washcloth. She also cleaned the inside of the resident's mouth, but there was blood on her lips. She cleaned her forehead with additional gauze, then applied (elastic) wrap to the laceration and applied more pressure. She did not notice any abnormalities when assessing her pupils. She asked the resident her name, and she stated her name but stated she did not know where she was. She assessed her upper body while UM #1 assessed her bottom. She attempted to get a blood pressure reading on Resident #1's right arm unsuccessfully. She got a fluctuating pulse oximeter reading 86-89% while UM #1 was getting BP. Then EMS arrived in the room and asked EMS to confirm their oxygen saturation reading, which was 89-90%. During an interview on 03/27/2023 at 12:01 PM, UM #2 stated on 03/22/2023 she heard code green, and she ran to Resident#1's room. She then observed the resident lying on the left side in front of her bed. NA #1 was down on the floor using a washcloth to apply pressure on the resident's forehead. UM #2 reported that she took over from NA #1 and started applying pressure with the washcloth. She also assessed the resident's cognition. The resident stated her name but did not recall where she was. UM #2 reported that she applied the elastic band on the resident's laceration on her forehead to control the bleeding. Review of the emergency room report dated 03/22/2023 revealed the resident was given fentanyl (a narcotic medication) for pain and was given fluids because she was hypotensive (low blood pressure). The resident sustained bruises on all extremities and the left side of her face. She complained of pain in her face and her right and left leg. There was a laceration on her left forehead 0.5 centimeters in length. The report indicated left and right distal fracture and a right lateral tibia plateau fracture. Facial and head Computed Tomography (CT) scans did not show any acute except for laceration on the left forehead. During the phone interview with the Physician on 03/27/2023 at 2:10 PM, she stated the ER report indicated the resident had multiple fractures in lower extremities. The physician reported the resident had a history of a right tibia fracture and verified this was fractured again from the fall. The physician added the CT scan was done and it did not identify head injuries. During an interview on 03/27/2023 at 3:30PM, the Director of Nursing (DON) indicated that NA #1's turning and repositioning skill checks had been done when she was hired and annually. The DON indicated NA #1 had no history of not following instructions in reference to turning and repositioning residents at the facility. She stated when NA #1 was providing care to Resident#1, she rolled and fell from bed to floor due to the positioning of the resident's right leg which shifted during the care. The DON also added after the resident's fall incident, she educated all the NAs to ensure that residents were kept in center of bed and to maintain proper safety when turning and positioning residents at the facility. During an interview on 03/27/2023 at 3:35 PM, the Administrator revealed that they had completed an investigation on how the resident fell from bed to the floor and they determined that the resident rolled due to the position of the resident's leg that shifted when NA #1 was providing incontinent care. She added that the NAs at the facility had been in serviced in keeping the resident in center of bed. The administrator also added the NAs had been in serviced in paying attention to resident safety when turning and repositioning residents when providing care. She indicated they also informed the NAs to report to the unit managers if they need more than 1 person to assist with turning and repositioning residents. The Administrator indicated the NAs have also been in serviced that while providing care to residents they needed to monitor residents' leg movements to prevent the residents from rolling from bed to the floor. The Administrator and DON were notified of the Immediate Jeopardy on 03/27/2023 at 03:05 PM. The corrective action for the past non-compliance dated 03/24/2023 was as follows: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is alert and oriented to self with a brief interview for mental status (BIMs) of 9 of 15 indicating resident cognition as moderately impaired. Resident #1 can verbalize needs. Diagnoses include Osteoporosis, Dementia, Anxiety, Hypertensive Heart Disease, blindness right eye, Major Depressive Disorder, Convulsions, Cardiomegaly (enlarge heart), Hypokalemia (low potassium which affects heart health), Hypomagnesemia (low magnesium which affect bones and leads to osteoporosis and heart disease), Psychosis, diabetes, and Anemia. Resident #1 has a history of a right tibial fracture with delayed/nonunion healing requiring the use of a bone stimulator to electronically stimulate bone growth and help heal broken. Resident #1 is receiving cholecalciferol (Vitamin D3, used to treat bone disorders), Calcium Citrate, Magnesium and Vitamin D for Osteoporosis and bone health. Resident #1's seizures are controlled with Keppra. Last Keppra level 3/16/23 was 62. Resident #1's fall risk assessments determined Resident #1 not to be at risk/or low risk for falls. It had been over a year since Resident #1's last fall. No previous falls while being assisted during care. Per Minimum Data Set Nurse (MDS) assessment 3/10/23 for bed mobility and toileting was extensive assistance of one person. Resident #1's height/weight is appropriate for her bed. On 3/22/23 at approximately 1:55pm Nursing Assistant (NA) #1 went in to check on Resident #1. Resident #1 had stool present in brief. NA #1 gathered supplies and moved the bed so NA #1 could stand between the bed and the wall to provide care. NA #1 rolled Resident #1 from side to side to remove brief and provide incontinent care. Resident #1 was continuing to have bowel movement; it was very loose. NA #1 decided Resident #1 needed more time to have bowel movement and placed Resident #1 in the center of the bed. The resident was positioned on the left side facing the door with right leg positioned over the left leg and slightly forward with an incontinence pad and brief underneath the resident. NA #1 lowered the bed and left the room. The foot of the bed was slightly raised 2-3 inches. On 3/22/23 at approximately 2:00pm NA #1 entered Resident #1's room to complete incontinent care. The bed was close to the wall. Resident #1 continued to be lying on left side, brief and pad were underneath Resident #1, with right leg crossed over left leg and slightly forward. The foot of the bed was elevated 2-3 inches. NA #1 unlocked bed and angled away from wall (just enough to get behind bed), then locked bed. NA #1 raised bed to about waist height, then placed remote of bed close to the Resident #1's head on the right side. NA #1 placed left hand on Resident #1 just below her right shoulder and provided incontinent care to Resident #1 using the right hand. NA #1 pulled out and rolled soiled brief and placed a new rolled pad/brief under Resident #1 using right hand while left hand remained on right arm. NA #1 saw the movement of Resident #1's legs. NA #1 looked up and observed Resident #1's right leg dipped off the bed a little and the resident's whole body started to roll. Resident #1's right leg first went off the bed. NA #1 tried to grab Resident #1's right shoulder. Resident #1 continued to roll. Resident #1's side of her face hit her nightstand, then her right knee hit the ground first, then the left knee. Resident #1 landed on left side mostly on stomach. The bed remote, brief and incontinence pad had come off bed with Resident #1, and Resident #1 was lying on the remote. Her brief was unfastened. NA #1 immediately ran around the bed; Resident #1 was on the left side almost on her stomach. Resident #1 had blood on her face. NA #1 placed a pillow under Resident #1's head, then went to doorway and called code green. NA #1 returned to Resident #1's side and held a towel against her head over laceration. Nurse #1 responded and assessed Resident #1 and noted Resident #1 was lying on the left side of his left arm. Her head was toward the bedside table and feet toward bathroom door. Resident #1's head was tilted to the left. Resident #1's left eye was swollen with a laceration to the forehead, bruise under left eye, and bloody mouth (top and bottom lip). Nurse #1 was unable to tell if blood was coming from Resident #1's mouth or the resident biting her lips. NA #1 told Nurse #1 she was providing care and Resident #1's weight shifted. Nurse #1 then went to doorway and called to charge nurse to call 911. License Practical Nurse (LPN) notified 911 and then went to assist with incident. Therapy staff member responded to assist, retrieved blanket from bed and covered resident #1. Nurse #2 responded to the incident and assessed resident #1. Resident #1 had multiple skin tears noted on upper right arm and increased swelling to right knee. Resident #1 was semi undressed, and brief not fastened. Resident #1 was able to state her name and that her eye was hurting. The room had adequate lighting. Vital signs were obtained with no significant findings, except for O2 (oxygen) saturation (O2 sat) at 89%. Resident #1 was placed on O2 at 2 liters per minute (lpm), head to toe assessment was completed and a bandage placed on the resident's head to stop the bleeding. Nurse #3 came to assist. Nurse #3 took over to apply pressure to the head with washcloth and cleaned inside Resident #1's mouth with gauze. Nurse #3 then cleaned the resident's forehead with gauze and secure dressing and applied additional pressure. Her pupils were assessed with no abnormalities. Nurse #3 asked Resident #1 her name and resident #1 was able to state her name. Resident #1 was not able to state where she was but was able to say in [NAME]. Nurse #3 assisted with head-to-toe assessment. Nurse #2 attempted to get Blood Pressure (BP) reading on right arm unsuccessfully. Pulse oximeter fluctuating between 86-89%. Nurse #4 and Director of Nursing responded and assisted with preparation for transfer. On 3/22/23 at approximately 2:25pm Emergency Medical Services (EMS) arrived, took over care and assessed resident #1. EMS confirmed O2 sat 86-89%. EMS staff placed draw sheet under Resident #1. Incontinent care was provided by facility staff and EMS prior to lifting resident #1 onto the gurney. On 3/22/23 at approximately 2:30pm EMS left facility with resident #1. Resident was alert to self and verbal with staff at time of transfer. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 3/22/23, the Director of Nursing (DON) and unit managers completed an audit of all residents' positioning in bed. This audit was to identify any resident who was not positioned in the center of bed and away from the edge of bed following care. No concerns were identified during the audit. On 3/22/23, DON initiated a Resident Care Audit on turning and positioning in bed with return demonstration to include NA #1. This audit was to ensure staff used appropriate techniques with turning and positioning during care, to ensure that the resident is positioned in the center of bed during care and following care and that the NA monitored position in bed during care to include when placing brief/pad under resident to prevent falls. The Resident Care Audit with required return demonstration will be conducted with all nurses and nursing assistants by 3/24/2023. After 3/24/2023, any nurse or nursing assistant who has not completed the return demonstration will complete upon the next scheduled work shift. The DON and Unit Managers will immediately address all areas of concern identified during the audit to include education of staff and/or repositioning residents when indicated. On 3/22/2023, the Unit Managers completed an audit of all residents to ensure the bed is the appropriate size for weight and stature. No concerns were identified during the audit. On 3/23/2023, the Social Worker conducted interviews with all alert and oriented residents in the facility to identify any resident concerns related to turning and repositioning during care as well as appropriate bed size. No concerns were identified during the interviews. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 3/22/23, DON initiated an audit of all care guides for assistance required for bed mobility. This audit is to ensure care guides accurately reflect the number of staff required for turning and repositioning resident in bed for safety. Audit will be completed by 3/24/2023. Any areas of concern identified during the audit will be immediately addressed by DON to include revision of the care guide as needed and education of staff. On 3/23/2023, DON reviewed progress notes for the past 14 days. This audit is to identify any residents with acute change to ensure acute change was addressed and safety interventions were initiated when indicated. The DON addressed all concerns identified during the audit. Audit was completed by 3/24/23. On 3/23/23, the Facility Consultant completed an audit of all incident reports from 2/1/2023 to 3/23/23. This audit is to identify any falls during care. There were no additional concerns identified. On 3/22/2023, the DON and Staff Development Coordinator (SDC) initiated an in-service with all nurses and nursing assistants to include NA #1 regarding turning and re-positioning during care. Emphasis on procedure for turning and positioning resident when providing care, positioning resident in the center of the bed following care when turning and positioning to prevent falls/injury. In-service will be completed by 3/24/2023. After 3/24/2023, any nurse or nursing assistant that has not received the in-service will receive it prior to the next scheduled work shift. All newly hired nurses and nursing assistants will be in-service by the Staff Development Coordinator (SDC) during orientation regarding turning and positioning. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Resident care audits on turning and positioning will be completed by the Staff Development Coordinator (SDC) and Unit Managers with 10% of NAs to include NA #1 weekly x 2 weeks, then 5 % of NA's weekly x 2 weeks to ensure correct turning and positioning techniques are used during resident care, that the resident is positioned center of bed during care and following care and that the NA monitored position in bed during care to include when placing brief/pad under resident to prevent falls. Any areas of concern identified during the audits will be immediately addressed by the SDC and/or Unit Managers to include repositioning of residents and staff re-training. The DON will review and initiate the Resident Care Audit Tool weekly x 4 weeks to ensure all areas of concern have been addressed. The DON will forward the Resident Care Audit Tool to the Quality Assurance Performance Improvement (QAPI) Committee monthly x 1 month. The QAPI Committee will meet monthly x 1 month and review the Resident Care Audit Tools to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. The date of compliance was 03/25/2023. Onsite validation was completed on 03/27/2023 through staff interviews, observation, and record review. The review of the in-service training revealed the staff were educated on 03/22/2023 until 03/24/2023 to ensure that they kept residents in the center of bed when providing care. Also, staff were educated on turning and repositioning residents in bed to maintain safety. Staff were interviewed to validate in-services completed on education provided to ensure that they kept residents in center of bed when providing care. No issues were identified. Observation was conducted on 03/27/2023 of staff completing care on resident while lying in the bed. The staff positioned and repositioned the resident appropriately. A review of care audits for turning and repositioning for staff was reviewed and it was revealed it was complete on 03/24/2023. Review of the completed resident questionnaire related to being turned and repositioned appropriately by staff dated 03/23/2023 and no concerns were identified. The care guide was updated for the residents who require extensive assistance with bed mobility verified and no issues identified. Review of progress notes for the previous 14 days was completed on 3/24/23 which identified residents with acute change and safety interventions were identified was verified and no concerns identified. The validation process verified the facility's date of compliance of 03/25/2023.

Based on record review, observations and staff interviews the facility failed to maintain the dish machine in safe operating condition for 71 of 71 residents. The findings included: The Installation, Operation, and Service Manual for the dishwasher was reviewed. It stated the minimum water requirements were wash and rinse temperatures of 120 degrees Fahrenheit (F). An observation on 4/18/21 at 10:29 AM was made of the dish machine in the kitchen, the wash cycle gauge read 110 degrees F after 5 run cycles with the Dietary Manager (DM) present. He stated the gauge might have been broken, and most of the dishes were washed by hand in the 3-part sink. During a follow-up interview with the DM on 4/19/22 at 8:33 AM, he revealed the dishwasher was able to meet the minimum temperature but needed to be run constantly. He stated the dishwasher had not been serviced within the last 2 years because kitchen staff preferred to use the use the 3-part sink. All meals were served in styrofoam containers with plastic utensils. On 4/19/22 at 12:27 PM, an interview was conducted with the Administrator. She revealed the dishwasher needed to be run several times to meet minimum wash temperature, but some of the kitchen staff preferred to wash dishes by hand. The Administrator indicated the facility had discussed the styrofoam containers and plasticware with Resident Council several times, but they did not have any complaints. She stated she was not aware the dishwasher was not meeting minimum wash temperature even after 5 cycles. During a follow-up interview with the Administrator on 4/21/22 at 9:27 AM, she stated a plate thermometer had been ordered and was scheduled to be delivered on 4/25/22 to determine if the dishwasher gauge was broken.

Based on observation and staff interviews, the facility failed to discard expired milk, buttermilk, and heavy cream. This occurred for 1 of 1 walk-in refrigerators. The findings included: During the initial tour of the kitchen with the Dietary Manager (DM) on [DATE] at 10:41 AM, the following items were observed and available for use in the walk-in refrigerator: - Observations of 4 quarts of whole cultured buttermilk dated [DATE], 7 heavy cream quarts dated [DATE], and 49 cartons of 2% milk dated [DATE] in walk in fridge During a follow-up tour of the kitchen with the DM on [DATE] at 8:39 AM, the expired milk items remained in the walk-in refrigerator. During an interview with the DM on [DATE] at 8:39 AM, he revealed kitchen staff would have never used the expired milk items. They remained in the walk-in refrigerator because he was waiting for the milk delivery man to discard the expired milk for account credit. During an interview with the Administrator on [DATE] at 9:27 AM, she stated her expectation was that expired perishable items in the walk-in fridge would have been removed or separated immediately so that they were not used mistakenly.

Based on observation and staff interview the facility failed to store narcotics in a locked permanently affixed compartment for 1of 1 store rooms checked for medication storage and facility failed to discard expired medication for 1 of 3 medication carts (Island Creek cart) reviewed for medication storage. Findings included: 1.During an observation of the medication storage room labeled as Nutbush Hall on [DATE] at 02:57 PM, the narcotic lock box was inside a refrigerator that was unlocked. The narcotic locked was not permanently affixed to refrigerator, did not have a chain attached, and was removeable. An interview with Nurse #2 on [DATE] at 03:05 PM indicated that the refrigerators had recently been changed out and that the narcotic box had a chain in place to secure it. An interview with the Director of Nursing (DON) on [DATE] at 3:22 PM revealed that the refrigerators had recently been replaced. The DON stated that the narcotic box had been secured until that point. The DON stated she was not aware the chain had not been replaced. 2.During an observation of the Island Creek cart for medication storage on [DATE] at 09:36 AM, 2 opened and accessed vials of [MEDICATION NAME] R insulin were in the drawer. The manufacturer's label on the vial directed that the vial be discarded 31 days after opening. One vial had a handwritten sticker with an opened date of [DATE], the second vial had a hand-written date of [DATE]. An interview was conducted with Nurse #3 on [DATE] at 9:40 AM and she indicated that insulin was to be discarded after 28 days. The nurse stated that it was the nurse administering the medications responsibility to check the expiration dates. An interview was conducted with the DON on [DATE] at 9:50 PM. The DON stated that expired insulins were to be discarded after 28 days.

Based on record reviews and staff interviews the facility failed to complete a recapitulation of stay (discharge summary) for 1 of 1 residents discharged to another facility. (Resident #88). The findings include: Resident #88 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Discharge Return Not Anticipated Minimum (MDS) data set [DATE], Resident #88 had some cognitive deficits and she required limited to extensive assistance in most areas of activities of daily living and required total dependence with bathing. Resident #88 was discharged to another facility on 11/15/19. Review of a a nursing note dated 11/15/19 at 10:19 AM read in part, Resident left facility at approximately at 10:15 AM with transportation. Resident's skin intact and resident in stable condition upon discharge from facility. Resident in good spirits upon discharge. During an interview on 1/16/2020 at 1:05 PM, the facility Social Worker stated the nurse does the discharge summary. She revealed Resident #88 was involved in discharge planning. The Social Worker revealed Resident #88 was in an assisted living facility prior to going to the hospital and she wanted to go back to assisted living facility. During an interview on 1/16/2020 at 1:16 PM, the Nurse stated she had not included recapitulation of stay for the discharge summary. She revealed a reconciliation of the resident's medication was completed, but she did not complete a recapitulation of stay. During an interview on 1/16/20 at 2:29 PM, the Director of Nursing stated her expectation was to follow the regulation. During an interview on 1/16/20 at 3:37 PM, the Administrator stated her expectation was to follow the regulation.

Based on observations, record review and staff interviews, the facility failed to monitor the refrigerator temperatures for 1 of 3 medication refrigerators reviewed (Satterwhite Point and Island Creek medication room refrigerator). The findings included: On 3/27/2019 at 4:04 PM the Satterwhite Point and Island Creek medication room refrigerator was observed with Nurse #1. The refrigerator was observed with a temperature of 26 degrees Fahrenheit (F). The temperature log was located on top of the refrigerator and indicated the refrigerator temperature range should be 35 to 41 degrees F. There was no month or year indicated on the log. There were only 2 dates documented on the log for dates 2 and 4, with a range of 34 degrees F to 38 degrees F. The temperature log located directly beneath the current chart was dated 2/2019, and dates 2/1/2019 thru 2/4/2019 were documented with temperature ranges of 32 degrees F to 38 degrees F. Medications in the refrigerator included: [MEDICATION NAME] 30 milligrams (MG) - 3 vials. The medication packaging indicated to store at 36 to 46 degrees F. Influenza vaccine - 2 prefilled syringes. The medication packaging indicated to store at 35 to 46 degrees F. [MEDICATION NAME] insulin- 1 vial. A pharmacy label indicated to refrigerate. [MEDICATION NAME] - 2 vials. The medication packaging indicated to store at 35 to 46 degrees F. [MEDICATION NAME] - 1 opened vial. The medication packaging indicated to store at 35 to 46 degrees F, do not freeze. [MEDICATION NAME] R insulin -2 vials. A pharmacy label indicated to refrigerate. Detemir insulin -1 vial. The medication packaging indicated to store at 35 to 46 degrees F. [MEDICATION NAME] - 1 opened vial and 1 unopened vial. The medication packaging indicated to store at 68 to 77 degrees F. After opening store at 36 to 46 degrees F. [MEDICATION NAME] suppositories 650 MG - 7 suppositories. The medication packaging indicated to store at 59 to 86 degrees F. Cathflo [MEDICATION NAME] - 2 units. The medication packaging indicated to store at 36 to 46 degrees F. On 3/27/2019 at 4:13 PM, an interview was conducted with Nurse #1. The nurse stated she was not sure who was responsible to check the refrigerator temperature. The nurse stated the temperature log was not dated but she assumed it was for (MONTH) 2019. On 3/27/2019 at 4:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the refrigerator should be kept at 35 to 41 degrees as indicated on the temperature log sheet. The DON stated all nurses were responsible to check the refrigerator temperatures. The DON stated she assumed the log sheet that was undated was for (MONTH) 2019, but there was no date written on it.

Based on observations and staff interviews the facility failed to maintain the area surrounding the dumpster free of debris and close the lid for 1 of 2 dumpsters observed. The findings included: During an observation of the dumpster on 3/27/19 at 2:05 PM a clear plastic bag of trash was observed on the ground between the dumpster and dumpster deck. A second observation on 3/28/19 at 10:48 AM a clear plastic bag of incontinent trash, 3 disposable gloves, two plastic spoons and a 2oz. medication cup were observed on the ground beside the dumpster and dumpster deck. The lid to the first dumpster was observed open. In an interview on 3/28/19 at 10:51 AM the Assistant Dietary Manager stated all staff were expected to shut the dumpster lid after use and to pick up any trash around the dumpster area on every shift. In an interview on 3/28/19 at 11:02 AM the Housekeeping Supervisor stated housekeeping staff checked the dumpster area every day.

Based on document review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately for discharge for 1 of 1 residents reviewed. (Resident #87). The findings included: Resident #87 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Discharge-Return not anticipated MDS dated [DATE], Resident #87's cognition was intact and he required extensive assistance in most areas of activities of daily living. Review of Resident #87#s care plan dated 1/8/19, revealed Resident #87 desired to return home upon completion of rehabilitation therapy. Interventions included establish a pre-discharge plan with resident./family/ representative/caregiver. Make arrangement with required community resources such as home health to support independence post discharge. Review of the MDS, dated [DATE], under Section A, Discharge Status, revealed Resident #87 was coded on the MDS for discharge to Acute Hospital. Review of a Nursing note dated 1/16/19 at 12:14 PM, read in part, Resident discharged home with home health. Medication list, discharge instructions, and upcoming appointments reviewed with resident and responsible person. During an interview dated 3/28/19 at 9:00 AM, MDS Coordinator #1 stated she made a data entry error. During an interview on 16/19 at 12:14 PM, the Administrator stated her expectation was that the MDS should be coded correctly.

Based on observations and staff interviews the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean twelve of twelve baking sheets and failed clean the steam table under shelf for one of one steam tables observed. The findings included: During an observation on 3/14/18 at 2:52 PM the dish room drying rack was observed. Twelve baking sheets were observed stacked on the drying rack. The 12 baking sheets were observed to have 1/8 to ¼ inch of black dried food residue one inch wide under the rim. A second observation on 3/15/18 at 10:20 AM the dish room drying rack was observed twelve baking sheets were observed stacked on the drying rack. The 12 baking sheets were observed to have 1/8 to ¼ inch of black dried food residue one inch wide under the rim. During an observation of the kitchen on 3/14/18 at 2:58 PM the 6 well steam table was observed. The 6 foot underside of the steam table shelf was observed to be covered with dark dried food particles. A second observation on 3/15/18 at 10:16 AM the 6 well steam table was observed. The 6 foot underside of the steam table shelf was observed to be covered with dark dried food particles and was sticky to touch. In an interview with the Certified Dietary Manager (CDM) on 3/15/18 at 10:25 AM he revealed he expected staff to clean the whole steam table and the areas would be cleaned that day. In an interview with the Administrator on 3/15/18 at 10:27 AM she stated the steam table would be cleaned that day between lunch and dinner.

Based on record review, observations and interviews the facility failed to ensure a resident's urinary catheter bag was secured in a manner to keep it from lying on the floor and promoting the possibility of disease and infection for 1 of 6 residents observed with an indwelling urinary catheter (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 as severely impaired cognitively and having an indwelling urinary catheter. Review of the care plan, dated 12/28/17 had a documented Focus area as Resident #65 had an altered pattern of urinary elimination with an indwelling urinary catheter and was at risk for infection. The goal listed was to keep Resident #65 free from infection through the next review. During an observation on 3/13/18 at 12:52 PM the urinary catheter bag was hanging on the left side of the bed. The bed was low to the floor and the catheter bag was hanging on the bottom frame of the bed with approximately one third of the bag lying on the floor. During an observation on 3/13/18 at 3:21 PM the urinary catheter bag was hanging on the left side of the bed. The bed was low to the floor and the catheter bag was hanging on the bottom frame of the bed with approximately one third of the bag lying on the floor. During an observation on 3/14/18 at 8:38 AM the urinary catheter bag was hanging on the left side of the bed. The bed was low to the floor and the catheter bag was hanging on the bottom frame of the bed resting on the floor. During an observation on 3/14/18 at 9:57 AM the urinary catheter bag was hanging on the left side of the bed. The bed was low to the floor and the catheter bag was hanging on the bottom frame of the bed resting on the floor. During an observation on 3/14/18 at 12:27 PM the urinary catheter bag was hanging on the left side of the bed. The bed was low to the floor and the catheter bag was hanging on the bottom frame of the bed resting on the floor. During an observation on 3/14/18 at 1:19 PM the urinary catheter bag was hanging on the left side of the bed. The bed was low to the floor and the catheter bag was hanging on the bottom frame of the bed resting on the floor. During an interview on 3/14/18 at 2:23 PM with NA #1 she stated the bed stayed in a low position and the catheter bag was covered with a protective bag and that was the highest she could hang the catheter bag on the bed frame and the best she could do. During an interview on 3/14/18 2:27 PM with the Director of Nursing she observed the catheter bag and stated the bed was in a low position and there was not any other place to position the catheter bag resulting in the bag being on the floor. During an interview on 3/14/18 at 3:13 PM with the Administrator she stated she expected the catheter bag to be off the floor.

Based on record review, staff interviews, and observation, the facility failed to provide adequate supervision to 1 of 1 sampled residents (Resident #86) by leaving her unattended on an air mattress and this resulted in Resident #86 falling out of bed to the floor, and sustained a closed head injury (contusion with soft tissue swelling). Findings included: Resident #86 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the quarterly minimum Data Set ((MDS) dated [DATE] and 2/8/16 revealed Resident #86 was totally dependent on staff for all activities of daily living (ADLs) except eating, was not able to complete the brief interview for mental status (BIMS) which indicated severe cognitive impairment, was not able to perform surface to surface transfers without staff assistance, had no upper or lower limb impairment, and had 1 fall since admission on 1/16/2016. Active [DIAGNOSES REDACTED]. A review of the care plans dated 12/21/15 revealed Resident #86 required assistance to maintain maximum function of self-sufficiency for mobility characterized by positioning in bed related to (r/t) an inability to move independently. A review of the care guide for Resident #86 dated 1/18/16 included Hi-low bed: return to lowest position after giving care. A review of an incident report dated 1/18/16 revealed Resident #86 had an unwitnessed fall from the bed to the floor on 1/16/16 and was sent to the hospital r/t the fall. The incident report also revealed Resident #86 was confused and had decreased functional status, decreased safety awareness, and contractures. The incident report also included a statement from the nursing assistant (NA #2) who provided care to Resident #86 at the time of the fall. She stated she had left the resident ' s room to retrieved clean linens. When NA #2 returned to the room, Resident #86 was on the floor, positioned on her right side. A review of the emergency department discharge summary dated 1/16/2016 revealed Resident #86 sustained a closed head injury with soft tissue swelling. An interview was conducted on 4/27/16 at 4:25 PM with nursing assistant #2 (NA #2). She stated, I had just changed her roommate (the roommate of Resident #86). When I went to check her I noticed she wasn't positioned properly in the bed. She had slid down so I tried to pull her up and into the middle of the bed as best as I could. She was on an air mattress. I pulled the covers back and noticed her pad was wet. I moved her to the middle of the bed as best as I could, put pillows on each side of her, she already had pillows by her head, and left the room to get linens. When I got back she was on the floor. The side rails were up when I left the room, I don't know how she fell out of the bed. I called for assistance and waited with her for EMS (Emergency Medical Services). The resident is not able move on her own, but she would slide down in the bed. She is a 2+ person assist (needed the assistance of 2 persons) for all ADLs including bed mobility, and there are care cards in the closets to tell us about the resident needs. We are also told of changes at change of shift. When I saw she wasn't positioned properly I guess I could've called for help to re-position her in the middle of the bed, but I didn ' t. An observation was made on 4/28/16 at 9:03 AM of Resident #86 in bed with pillows propped under her left side, the side rails were up, no staff were present in the room, and the bed was observed to be elevated above its lowest position. The nurse assigned to care for Resident #86 (Nurse #1) was observed as she entered the room at 9:08 AM and used the pendant control to lower the bed to its lowest position. Nurse #1 stated the bed was not in the lowest position when she entered the room, and could not state why. An interview was conducted with NA #3 on 4/28/16 at 9:10 AM. She stated she did not know who left the bed up and not in the lowest position. She stated it should be in the lowest position. She also stated Resident #86 was repositioned every 2 hours. She further stated Resident #86 was totally dependent on staff for bed mobility r/t not being able to move independently. An interview was conducted with Nurse #1 on 4/27/16 at 2:25 PM. She stated she typically cared for Resident #86 who was totally dependent on staff for all ADLs. She also stated Resident #86 was unable to move at all independently for at least the past 2 years r/t lower limb contractures. She also stated her bed was supposed to be in the lowest position when no staff were present. An interview was conducted with the facility administrator on 4/27/16 at 3:00 PM. She stated Resident #86 had a fall on 1/16/16. She stated, As best as we can tell, she was lying on her back and her legs are contracted. Her knees fell to the side and she cannot control her movements and we think the momentum pulled her out of the bed. She is not able to turn and reposition herself in bed without staff assistance, and is totally dependent on staff for all her needs. She has no control of her body. She was on an air mattress when she fell , but we changed it to a winged mattress before she returned from the hospital. We also in-serviced all the staff on how to properly position Resident #86, and updated her care plan. We tried a high winged mattress, but her family member refused it, so we put a medium sized winged mattress and the family was agreeable to that. An interview was conducted with the Director of Nursing (DON) on 4/27/16 at 3:55 PM. She stated, When she's (Resident #86) lying flat on her back her knees are hyper-flexed and her head is up. She will start to roll to one side or the other. So we figured she started to roll and got some momentum going. If she just fell she would've landed on her back or left side. But she was on her right side so she had to have rolled. She didn't move herself intentionally. It's a center of gravity thing. We have her in a winged mattress now. She had not fallen out of bed before. She went to the emergency department and had a hematoma on her head. The DON also stated Resident #86 was on an air mattress at the time of the fall, was a falls risk since she was admitted , but not as of March 2014 r/t not being able to move independently. She stated resident #86 was not able to move in bed, or reposition herself without staff assistance since March 2014. She also stated Resident #86 was not able to climb over the side rails.

Based on facility medical record review, hospital record review, observations and staff interviews the facility failed to have adequate supervision for a resident (#1) who rolled over the lowered bedrail and onto the floor while staff was doing incontinent care. The resident sustained [REDACTED]. The facility failed to implement interventions to prevent falls. This was for 1 of 3 resident in the survey sample at risk for falls. (Resident #1) Findings include: Resident #1 was re-admitted on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed the resident was alert and orientated. She was incontinent of bladder and continent of bowel and needed help when bathing, extensive assistance (1 person) for bed mobility, transfers, walking, dressing, toilet use and personal hygiene. The resident had a wheel chair for mobility in the facility. A Review of the " care guide " ( tool used to inform the nursing assistant about the care required) located in Resident #1 room dated for 2/5/11 indicated Resident #1 was at risk for falls. A bed was to be at the lowest position after giving care. Additionally, a mat was to be placed on the floor beside the bed when resident was in bed.. On 3/24/2011 at 4:05 pm an interview with the MDS Care Plan Coordinator RN revealed after each incident of the resident having a fall, the care plan did not change as there was nothing to add as all interventions were in place. Side rails are not care planned for unless there is a physician order [REDACTED]. The MDS Care Plan Coordinator continued to state that there was no written policy for side rail use. On 3/24/11 at 10:30 am an observation of Resident #1 revealed she was in her wheel chair and complained of right shoulder pain. The resident was unable to be interviewed. A review of the nurses notes dated 3/17/11 at 7:18 am revealed the Resident #1 was receiving incontinent care from NA#1 when Resident #1 attempted to grab hold of the lowered bedrail and fell on to the floor. Resident #1 sustained a contusion and a 2-2.5 inch laceration to her left side of her forehead. The resident complained of left hip pain and right wrist pain. The Medical Doctor (MD) was notified and sent Resident #1 to the emergency room for evaluation. A review of the Hospital records dated 3/17/11 revealed x-rays of the head, wrist, and low back were done showing no fractures. The notes continued to reveal, " The patient is usually alert and orientated x4, but she is alert and orientated x3 at this time. The Resident#1 was admitted for 24 hours for neurology checks with observation. Pain control with IV morphine (no dose documented) and Tylenol (no dose documented) by mouth. Resident #1 was discharged back to the Nursing facility on 3/18/11. A review of the MD orders dated 3/22/11 revealed physical therapy and a splint for right wrist pain due to the sprain. A review of NA#1 statement dated 3/17/11 regarding the fall on 3/17/2011 revealed, " I was changing the patient ' s diaper and turned her onto her left side. I turned to get her diaper and turned back toward the patient and observed the patient going over the side of the bed. " On 3/24/11 an interview with the Administrator at 5:35 pm revealed; " We suspended NA#1 after the incident and an investigation took place. We then sat down and discussed how we can prevent this from happening again. We did in-services for the staff (92 total staff), 10 RNs, 20 - LPNs, and 60 - NAs, regarding the proper use of draw sheets, and re- positioning of residents while doing care. Na#1 did attend the in-service. When NA#1 returned after the suspension, NA#1 no longer worked with Resident #1 at the family ' s request. The Administrator continued, " We did care audits for draw sheets and repositioning the residents in bed. On 3/24/11 at11:00 am an interview with the Administrator revealed she would contact NA#1 as she worked another job. The Administrator also stated she left a message on NA#1 phone to contact the facility for an interview with the surveyor. At 12 noon a phone call was placed to NA#1 and a message was left. An interview with NA#1 was attempted and NA #1 was unable to be interviewed. On 3/24/11 at 3:30 pm an interview with the DON revealed; " I talked to (NA#1) who was assigned to (Resident #1) and was told she had turned (Resident#1) on her side, facing the wall and had brought the bed away from the wall as she stated she uses both sides of the bed when giving incontinent care. When (NA#1) turned to get the diaper from the table and turned back, the (Resident #1) was falling on the floor. (NA#1) stated the side rail was up, The DON came back at 4:00 pm with the Administrator and stated, " I had notes regarding the fall and I can't find them so I can't be sure if the side rails were up or down. " The DON and Administrator further stated there is no policy about side rails or an assessment done for residents for side rails. On 3/24/11 at 6:45 pm a review of the employee file for NA #1 revealed a disciplinary warning notice dated 3/22/11 was issued for " failure to monitor resident safety. " On 3/24/11 at 2:45 pm an interview with NA#2 that usually takes care of Resident#1 on the 7-3 shift revealed that Resident#1 cannot roll herself, due to her hand problem, and a boost is needed to roll her on her side. NA#2 stated since the fall on 3/17/11 Resident #1 cannot roll herself as she cannot use the side rail due to her hand splint. " NA #2 continued to state; " I pull the sheet towards me and then roll her. I have been here for almost a year and I do( Resident #1) first thing when I come in. I always keep (Resident ' s #1) side rails up when doing care for her. I bathe her first thing in the morning because she doesn't like to be in bed when eating breakfast. I then get her up in her wheel chair. " On 3/24/11 at 3:00 pm an interview with NA#3, (works 3-11 shift), stated when she first comes in she makes her rounds and looks at her assignment and their (resident ' s) care plans. She further stated that when she does incontinent care she uses the draw sheet to turn the resident toward herself and then roll the resident to the side, clean the area of skin and push ? of the diaper under the resident. Na#3 further stated she then rolls the resident a little way back and pulls the diaper under the resident. She continued to state that she keeps the side rails up all the time. On 3/24/11 at 3:10 pm an interview with NA#4, (works 3-11 shift), revealed that she raises the hi-low bed first. She then pulls the resident toward her with the draw sheet and rolls the resident towards herself. She stated that she always leaves the side rails up. "I heard about the fall for (Resident #1)and couldn't think how she rolled out of bed because the side rails are always up. (Resident #1) usually reaches for the side rail to hold herself after we turn her, but now with her wrist hurt, she can't help. " On 3/24/11, observations of resident #1 in bed were made at 2:00 pm, 2:30 pm, 3:30 pm and 3:45 pm revealed there was no mat on the floor while resident#1 was in bed. On 3/24/11 at 4:30 pm an observation was made revealed there was no floor mat next to the bed while Resident #1 was in bed.. On 3/24/11 at 4:45 PM an interview with the Administrator revealed that her expectation is that a floor mat be placed next to the resident's bed when the resident is in bed. The Administrator immediately told the ADON to get a floor mat in resident ' s #1 room. Observations and an interview with NA#4 was conducted on 3/24/11 at 7:20 pm. NA#4 revealed she received a mat from the SDC (Staff Development Coordinator) who told her the mat had been cleaned. Observations of the resident ' s room revealed a floor mat was placed behind resident ' s #1 headboard as resident #1 was up in her wheel chair.