Every finding on record at Lillington Health and Rehabilitation Center

Based on observation, record review, and staff interviews, the facility failed to: maintain a clean and sanitary kitchen floor, food prep table, serving carts, steam table, plate holder, deep fryer, and handwashing sink; ensure baking trays were undented and free of burn-on food; utilize oven mitts that were clean and free of dried food remnants; ensure garlic bread on baking trays was covered; remove a scoop from a dry storage bin; maintain a coffee/tea urn in good repair and free of leakage; and label/date/seal food items stored in 1 of 1 walk-in refrigerator and 1 of 1 walk-in freezer. In addition, the facility failed to label and date outside food items placed in the nourishment room refrigerators and discard outside food items that were not labeled and dated in 2 of 2 nourishment refrigerators observed (Nourishment Refrigerator #1 and Nourishment Refrigerator #2), The facility also failed to maintain a functioning water temperature gauge used to monitor the manufacturer's recommended water temperatures for the rinse and wash cycles of a low temperature dish machine. These issues had the potential to affect food served to residents. The findings included:1a. An initial tour of the kitchen and an interview with the Assistant Dietary Manager on 8/9/26 at 10:40 am revealed the floor on the right side of the spice rack and under the handwashing sink was observed as brown in color and appeared shiny/glossy. The Assistant Dietary Manager stated that the floors were supposed to be mopped every evening by the second shift dietary aides before they left the kitchen. She further stated that she had never seen the floors power washed, and that environmental services had not been there to clean in several weeks. Also observed under the handwashing sink was a metal box with areas that were rough in texture with a reddish-brown coloring, areas that were shiny/glossy, and areas that appeared white and chalky. The Assistant Dietary Manager did not know what the box was and stated it had always been there.An interview with the Environmental Services Manager on 8/12/26 at 3:00 pm stated that the staff had been in the kitchen 2 weeks ago with an electric floor cleaner. A degreaser was used to clean the kitchen floors, moving the equipment that they were allowed to move, to cover as much space as possible. She also stated that she had talked to the Dietary Manager during a previous visit regarding the soiled mops being used that caused grease build- up. She indicated she asked the Dietary Manager to throw the soiled mops away and gave her 5 new mopheads.An interview with the Dietary Manager on 8/12/26 at 4:46 pm stated that Environmental Services did not come to clean the floors two weeks ago and did not give her 5 new mopheads. She then stated that she bought her own mopheads. b. An observation of the walk-in refrigerator on 8/9/26 at 10:42 am revealed the following:- Half of a turkey sandwich wrapped in plastic wrap with an individual package of mayonnaise on top. The sandwich was not labeled with a date to indicate when it was made.- A pack of sliced yellow cheese (8 slices) wrapped in plastic wrap that was not labeled with an opened date.An interview with Dietary Aide #4 on 8/9/26 at 10:45 am revealed that all opened food items should be dated before putting them in the refrigerator. Dietary Aide #4 did not know how long the food could stay refrigerated after it was dated.c. An observation of the walk-in freezer on 8/9/26 at 10:48am revealed:- An open cardboard box of popcorn shrimp inside an open plastic bag without a received date or expiration date.- A bag of frozen, chopped green peppers on the shelf (unboxed) without a received date or expiration date.An interview with Dietary Aide #3 on 8/9/26 at 10:52 am indicated he identified the open box of popcorn shrimp, and he would let the Dietary Manager know that the box was open. Dietary Aide #3 stated it should be secured before being placed in the freezer and that the green peppers should have been labeled with a receive date.An interview with the Assistant Dietary Manager on 8/9/26 10:54 am stated that the dietary staff were all trained to place dates on open-food items before putting the items in the refrigerator and/or freezer.d. An observation on 8/9/26 at 10:52 am revealed the wheels on the food prep table located in front of the steamer encrusted with a reddish-brown coloring. The bottom shelf of the prep table was observed with loose food particles, used paper towels, and a soiled wet cloth lying next to a red container with white cloudy liquid in it. An interview with Dietary Aide #1 on 8/9/26 at 10:56 am indicated that all staff were responsible for cleaning all surfaces throughout the day and throwing away dirty paper products immediately. Dietary Aide #1 indicated that the red container had water with sanitizer in it for cleaning.An interview with the Assistant Dietary Manager on 8/9/26 at 10:57 am stated that the Corporate Dietary Manager had been asked for replacements for tables this month and months prior, especially the food prep table located in front of the steamer due to the encrusted reddish-brown wheels. She further indicated that the staff were to wipe the surfaces after each preparation, or when having raw food on the table. She then stated that all used paper products should be discarded after use. She further indicated there was not any paperwork to indicate the request had been made to corporate to replace the prep table. An interview with the Dietary Manager and the Corporate Dietary Manager on 8/10/26 at 11:03 am indicated that they had reached out to the Corporate Office to get a replacement food prep table but had not received confirmation that it would be replaced. The Corporate Dietary Manager indicated that he would get copies of the e-mails and request forms for a replacement prep table that were sent to the Corporate Office.The copies of the emails and request forms for a replacement food prep table were not provided during the survey.e. An observation and interview on 8/9/26 at 11:02 am with Dietary Aide #1 and the Assistant Dietary Manager revealed 2 black 3-tiered serving carts with food particles and brown water on all three tiers. Dietary Aide #1 and the Assistant Dietary Manager stated that the carts should be cleaned after each use and should not be left with dirty water puddled in the center and food particles.f. An observation on 8/9/26 at 11:05 am of the outside lower edging of the food carts revealed food particles and a shiny substance that smeared when touched with a gloved hand. The wheels of the carts were also encrusted with reddish-brown raised material. An interview on 8/9/26 at 11:05 am with the Assistant Dietary Manager indicated that there were a lot of new staff that needed to be re-in serviced on cleaning the equipment after use every day. She also stated that she and the Dietary Manager needed to follow up on cleaning more effectively. She indicated that there was a cleaning schedule posted and should be followed each day. She also stated that the carts should be wiped down of visible dirt and food particles after each meal.An interview with Dietary Aide #2 on 8/9/26 11:06 am stated that he did not clean the food carts after each use or after his shift, because he had not been told to do so, but would start making sure it was cleaned after use at the end of the day. Dietary Aide #2 indicated he had only worked at the facility for about 2 weeks.g. An observation on 8/9/26 at 11:08 am of the back of the steam table revealed it was brownish-red coated, and shiny in appearance. The substances coated the piping from the back of the steamer to the drain in the floor.An interview with the Assistant Dietary Manager on 8/9/26 at 11:11 am indicated that the cook was supposed to clean the steam table after each meal or at least once each day.h. An observation and interview on 8/9/26 at 11:15 am revealed Dietary Aide #1 utilizing oven mitts (4) that were shiny and had dried, crusty food stuck to them. Dietary Aide #1 indicated that she should not use the dirty oven mitts. She further stated that the mitts were not laundered but thrown out when they got dirty. Dietary Aide #1 stated that she should have replaced them with clean ones before she started the food prep this am.An interview with the Assistant Dietary Manager on 8/9/26 at 11:17 am indicated that the oven mitts were dirty and should have been replaced. She verified that the mitts were thrown out instead of being laundered.i. An observation on 8/9/26 at 11:22 am of the stackable 12-tier rack revealed it was loaded with flat baking trays of garlic bread that were uncovered. An interview conducted with the Assistant Dietary Manager on 8/9/26 at 11:22 am revealed that the dietary aide responsible for placing the sliced garlic bread on the trays should have covered the bread to prevent contaminationDuring an interview with Dietary Aide #3 on 8/9/26 at 11:25 am when asked about the exposed bread indicated that the bread should have been covered, but he had been told by another dietary aide, unable to recall who, to place the bread in the pans then place them on the rack. Dietary Aide #3 indicated he was a new employee at the facility.j. An observation of the coffee and tea machine on 8/9/26 at 11:30 am and interview with the Assistant Dietary Manager revealed that there was one (1) urn being used for coffee and tea. The dietary staff were making coffee then washing out the urn and making tea. The urn was leaking from the spout saturating two rolled up towels placed in front of the machine and brown liquid streaming down the back of the table. The Assistant Dietary Manager stated that the machine had not worked properly for at least a month and needed to be replaced. She further indicated that the Dietary Manager was responsible for ordering new equipment and that replacement urns had already been discussed between them several times.An interview with the Dietary Manager and the Corporate Dietary Manager was conducted on 8/11/26 at 9:50 am. When informed of the observation on 8/9/26 that only one urn was used for coffee and tea and that the spout was leaking, the Dietary Manager called over to the Assistant Dietary Manager to confirm the information. The Assistant Dietary Manager confirmed that a single urn had been used for both beverages and that it had been leaking. The Dietary Manager stated she would contact the company to have the urn replaced.k. An observation with the Assistant Dietary Manager on 8/9/26 at 11:37 am revealed a white bin with a clear plastic lid labeled sugar containing a white, grainy substance. [NAME] liquid splashes were observed on the top exterior surface of the bin, on one exterior panel, and on one interior panel. The clear plastic lid had dust and a bluish white grainy residue around its edges. Inside the covered bin, a metal scoop and a small piece of gray plastic was lying on top of the white, grainy substance. During an interview at the time of the observation, the Assistant Dietary Manager stated that the bin contained sugar and that the scoop should be removed after each use and the lid secured to prevent contamination.An interview with the Dietary Manager on 8/11/26 at 9:45 am regarding the white bin labeled as sugar indicated that the staff knew that they were not supposed to leave the scoop in the sugar. The Dietary Manager did not indicate where the scoop was to be stored.l. An observation on 8/9/26 at 11:45 am of 8 stacked baking trays revealed 4 of them had heavily baked on black substance around the edges, and multiple dents.An interview with the Assistant Dietary Manager on 8/9/26 at 11:45 am stated that they had a lot of pans that needed replacement because of dents and cooked on grease. She then stated that the Dietary Manager had to order new ones.During an interview with the Dietary Manager and the Corporate Dietary Manager on 8/11/26 at 11:03 am they agreed that there were a lot of the pans that needed replacement due to the heavy burnt on food and grease, and the pans would be removed immediately and replaced upon approval of a new order that same week. During an interview on 8/9/26 11:47 am Dietary Aide #3 was asked if he saw any issues with the plate holder and he responded that the plates were supposed to be upside down. He could not name any other issues with the plate holder. The food particles and debris were pointed out to Dietary Aide #3. Dietary Aide #3 then indicated the plate holder needed to be cleaned.An interview and observation of the handwashing sink with the Assistant Dietary Manager on 8/9/26 at 2:00 pm revealed that it had brownish-black stain along the caulk line seal of the sink. There were also dried brown drops of liquid on the exterior sides of the sink. The Assistant Dietary Manager stated the sealant was old and stained. She stated it had been cleaned but the stain would not come off.m. An observation on 8/9/26 11:47 am of the plate holder revealed the plates were turned right side up, and the top of the plate holder had food particles and debris.n. An observation on 8/9/26 at 11:55 am of the back of the deep fryer was coated with a brownish shiny substance that had dripped down in multiple areas.During an interview with the Dietary Manager on 8/11/26 at 9:40 am she stated that there was a cleaning schedule posted for the Dietary Aides to follow as far as cleaning, but some of the staff were very new and needed to be reminded to look at the schedule to see what needed to be cleaned.During an interview with the Dietary Manager on 8/9/26 at 11:55 am she stated that the deep fryer was dirty and splattered with grease. She then stated that there was a cleaning schedule that the staff was supposed follow. She further indicated that she needed to do a better job following up with the cleaning to ensure the schedule was being followed.An interview was conducted with the Administrator on 8/12/26 at 5:40 pm. The Administrator stated that kitchen cleaning was expected to be completed regularly by all dietary staff and that all equipment should be routinely cleaned and maintained in proper working order. She reported that the cleaning staff had been scheduled to clean the kitchen floors two weeks prior and expressed surprise that the floors had not been cleaned. She further stated that leftover food should be labeled and dated, and any opened food should be properly closed, labeled, and dated. 2. A review of the Patient/ Resident Personal Food Policy on 8/11/26 indicated labeling, and storage of outside food must be clearly labeled with the resident's name and date and stored in a designated, separate area to keep it distinguishable from facility-procured food. The staff are trained to assist residents with heating and consuming outside food safely, and facility refrigerators are to be checked weekly to discard expired personal item after 3 days. The staff are prohibited from keeping personal food items in patient-designated food refrigerators. a. During an observation of nourishment refrigerator #1 with the Dietary Manager on 8/10/26 at 9:50 am there were two (2) large bottles of flavored coffee in the side door of the refrigerator without names or dates, and an unlabeled half empty bottle of cola. The Dietary Manager removed the items from the refrigerator and threw them away. b. During observation of nourishment refrigerator #2 with the Dietary Manager on 8/10/26 at 10:04 am there were seven (7) containers of onion dip in three (3) separate plastic bags with a resident's name but no date, and two full unlabeled bottles of flavored coffee in the side door of the refrigerator. The Dietary Manager threw them away and stated that the nursing staff was to label these items before placing them in the refrigerator, and when the dietary staff bring in snacks each day, they should be checking refrigerated items for dates. She further indicated that she would talk to the dietary staff about checking the resident personal food items along with the others food items for expiration dates. The Dietary Manager further stated residents' personal food items should be stored in the nourishment room refrigerator for only three (3) days and then discarded. On 08/10/26 at 11:50 am Nursing Assistant (NA) #2 stated any food from outside for any residents at the facility, was to be labeled and placed in the nourishment room refrigerator. She added the food should only be in the refrigerator for 3 days if not eaten, then discarded. NA #2 indicated the NAs and the Dietary Staff were responsible for checking the nourishment refrigerators for names and dates daily on resident food items. An interview with Dietary Aide #4 on 8/11/26 at 2:30 pm stated that food placed in the nourishment room refrigerators should have names and dates and removed in 3-4 days. He stated that he was given the information on labeling and discarding food during orientation but could not remember if it was 3 or 4 days. An interview with the Administrator on 8/12/26 at 5:40 pm indicated that the personal food policy was updated each year and changes were made at that time. She further stated that the staff during orientation were instructed about labeling food when the resident's food items were placed in any kitchen or nourishment room refrigerators. The Administrator indicated it was her expectation that nursing and dietary work together to get these tasks done, and to make sure the food items were discarded after the 3-day timeframe, that have been placed in the nourishment room. 3. On 8/11/26 at 12:15 pm, an observation of the low-temperature dish machine in use revealed that the temperature gauge remained at 70 degrees Fahrenheit (F) during the wash and rinse cycles. The manufacturer instructions on the dish machine specified operating temperature range for a low temperature machine was 120-140 degrees F. Observations of the dish machine in use revealed a large amount of steam present coming from the machine. At the completion of the rinse cycles, plates and silverware appeared free of food particles and residueDietary Aide #3 and Dietary Aide #4 on 8/11/26 at 12:24 pm reported they did not know the correct temperature range for the dishwasher and did not check the water temperatures; the Assistant Dietary Manager (ADM) was responsible for documenting temperatures. Both aides stated they had not been educated on dishwasher temperatures during orientation. Interviews with the Dietary Manager (DM) and Regional Dietary Manager (RDM) on 8/11/26 at 12:43pm revealed the ADM was responsible for checking and recording temperatures of the dish machine. Review of the August dishwasher temperature log showed rinse and wash temperatures of 100-150 degrees F documented daily. The DM stated she had not been aware the gauge remained at 70 degrees F when in use. The RDM used a chemical strip to test the water temperature and chemical solution of the dish machine; the temperature sensitive chemical that changes color based on heat, turned orange, signifying at least 180 degrees F. The DM reported the dishwasher was old, not serviced by the in house maintenance team, and that the former service provider no longer serviced this model.An interview with the ADM On 8/11/26 1:27pm stated she had recorded the dishwasher temperature earlier that day because it was working at that time.A telephone interview with the Dish Machine Chemical Supplier at 1:58 PM on 8/11/26 indicated he did not service dishwashers but checked chemical concentrations and temperatures. He stated he did not normally replace temperature gauges but had one available and would stop by later that afternoon. An observation and interview at 4:30 PM on 8/11/26 with the Dish Machine Chemical Supplier confirmed he had replaced the dishwasher temperature gauge, and the machine was functioning properly. Dishes were run through the machine, and the gauge registered 131 degrees F.On 9/12/26 at 5:00 PM, an interview with the Administrator revealed she had not been aware the dish machine gauge was broken. She expressed disappointment that these issues had not been communicated to her.

Based on observations, record review, resident and staff interviews, the facility failed to maintain resident dignity when a staff member used the term feeder to describe a resident who needed assistance with eating. The term was used in front of the resident when lunch trays were delivered to the resident's room for 1 of 1 resident reviewed for dignity (Resident #126). A reasonable person would not want to be referred to as a feeder. The findings included:Resident #126 was admitted to the facility on [DATE] with diagnoses that included dementia, and dysphagia (difficulty swallowing).A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #126 was assessed with severe cognitive impairment, unclear speech, and required set-up assistance with eating. During a continuous lunch observation on 8/11/26 from 1:30 PM to 1:39 PM Nurse Aide (NA) #2 was observed in Resident #126's room and referring to the resident as a feeder during lunch time tray pass when speaking to another Nurse Aide. Resident #126 was present in the room and could hear what NA #2 called him. Resident #126 was not interviewable.An interview was conducted with NA #2 on 8/11/26 at 1:50 PM he reported he should not have used the term, feeder to describe a resident because it was a dignity issue. He stated he was a new employee who came from another setting which the term, feeder was acceptable. NA #2 stated he had been instructed during training to not use the term feeder, it was a dignity violation.During an interview with Unit Manager #1 on 8/11/26 at 2:00 PM she reported using the term feeder to describe a resident, was not acceptable and was a dignity issue.An interview was conducted with the Administrator on 8/11/26 at 3:15 PM she stated the term, feeder, should not be used when referring to residents who required assistance with eating because it reduced the resident to a task.

Based on record review, resident, and staff interviews, the facility failed to document and provide written information to residents/representatives regarding their right to refuse medical/surgical treatment or to formulate an advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) for 9 of 13 residents reviewed for advance directives (Residents #6, #8, #16, #21, #48, #74, #88, #118, and #133).Findings included: a. Resident #21 was admitted to the facility on [DATE]. Resident #21 had a Full Code physician order dated 7/4/26. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. An interview was conducted with Resident #21 on 8/12/26 at 12:03 PM. Resident #21 stated that she recalled discussing advance directives but did not receive written education regarding advance directives. There was no documentation in Resident #21's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. b. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48 had a Full Code Physician order dated 7/15/26. An admission MDS assessment dated [DATE] check date revealed Resident #48 was cognitively intact. During an interview with Resident #48 on 8/12/26 at 4:42 PM he recalled discussing advance directives but did not receive any written documentation regarding advance directives. There was no documentation in Resident #48's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. c. Resident #133 was admitted to the facility on [DATE]. Resident #133 had a Full Code Physician order dated 8/5/26. An admission MDS assessment dated [DATE] revealed Resident #133 was cognitively intact. Resident #133 was discharged to the hospital on 8/10/26. Resident #133 was unavailable for an interview due to her hospitalization. There was no documentation in Resident #133's medical record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Resident #88 was admitted to the facility on [DATE]. Resident #88 had a Full Code physician order dated 7/10/26. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact. An interview was conducted with Resident #88 on 8/12/26 at 12:09 PM. Resident #88 stated he did not recall discussing or receiving written education regarding advance directives. There was no documentation in Resident #88's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. e. Resident #16 was admitted to the facility on [DATE]. Resident #16 had a Full Code physician order dated 5/25/26. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact. An interview was conducted with Resident #16 on 8/12/26 at 12:18 PM. Resident #16 stated that he did not recall discussing or receiving written education regarding advance directives. There was no documentation in Resident #16's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. f. Resident #118 was admitted to the facility on [DATE]. Resident #118 had a Full Code physician order dated 7/30/26. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 was cognitively intact. An interview was conducted with Resident #118 on 8/12/26 at 12:05 PM. Resident #118 stated that he recalled he had a discussion regarding advance directives; however, he did not receive any written documentation regarding advanced directives. There was no documentation in Resident #118's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. g. Resident #6 was admitted to the facility on [DATE]. Resident #6 had a Full Code physician order dated 4/16/26. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was assessed as having moderate cognitive impairment. During an interview with Resident #6 on 8/12/26 at 5:00 PM he stated that he did not recall receiving written education regarding advance directives. There was no documentation in Resident #6's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. h. Resident #8 was admitted to the facility on [DATE]. Resident #8 had a Full Code physician order dated 5/1/25. A quarterly MDS assessment dated [DATE] revealed Resident #8 was assessed as having severe cognitive impairment. During a telephone interview with Resident #8's Responsible Party on 8/12/26 at 11:26 AM she stated that she did not recall receiving written education regarding advance directives or a discussion of Resident #8's code status. There was no documentation in Resident #8's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. i. Resident #74 was admitted to the facility on [DATE]. Resident #74 had a Full Code physician order dated 6/24/25. A quarterly MDS assessment dated [DATE] revealed Resident #74 was assessed as having moderate cognitive impairment. During an interview with Resident #74 on 8/12/26 at 5:15 PM she stated that she did not recall receiving written education regarding advance directives. There was no documentation in Resident #74's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. During an interview with the Admissions Director on 8/12/26 at 10:31 AM she stated upon admission the admission agreement pertaining to advance directives was verbally reviewed with the resident and/or resident representative and any additional information requested was referred to the Social Worker (SW). An interview was conducted with the Social Worker (SW) on 8/12/26 at 2:03 PM. She stated advance directives were reviewed with a resident and/or resident representative on admission during a meeting with the care planning team which included staff from the therapy department, nursing department, business office, medical records department, the activity department, and the Social Worker. During the meeting verbal explanation of advance directives including code status was provided, the resident's code status (a formal medical instruction in a patient's chart that tells the healthcare team what life-saving treatments to use, or not use, if the patient's heart stops or they stop breathing) was confirmed, and if the resident had an existing Power of Attorney (a legal document that allows someone else to act on your behalf) or Living Will (a legal document that states your choices for medical care if you become very sick and cannot speak or make decisions for yourself), they were asked to provide a copy to the facility. The SW further stated if the resident and/or resident representative asked for additional information they were provided with a written copy of the North Carolina State information concerning advanced directives. The SW stated if the resident and/or resident representative did not ask for a written document only the verbal explanation of advance directives was provided. She stated she was not aware that written documentation was required to be given to all residents and/or their representative. An interview was conducted on 8/12/26 at 3:16 PM with the Director of Nursing (DON). The DON stated residents came to the facility from the hospital/acute care setting with an established code status, verbal explanation of code status was provided by staff to the resident and/or resident representative, and the code status was entered into the resident's electronic medical record (EMR). The DON further stated it was her understanding and expectation that written documentation regarding advanced directives was provided to the resident and/or resident representative at the end of the care meeting. During an interview on 8/12/26 at 4:44 PM with the Administrator, she stated she was not aware that written documentation concerning advance directives needed to include instructions on what to do if a resident and/or resident representative changed their mind about their current advance directive. The Administrator stated her expectation was that all residents and/or resident representatives were given written education on advanced directives upon admission and during care plan meetings. An interview was completed on 8/12/26 at 5:03 PM with the Regional Director of Clinical Services. She stated wasn't aware that written education regarding advance directives, including instructions on what to do if a resident and/or resident representative changed their mind about their current advance directive, needed to be provided to all residents/resident representatives. The Regional Director of Clinical Services stated advance directive discussions were already taking place during care plan meetings, however the facility needed to do a better job of documenting those discussions.

Based on observation and interviews with staff, an employee at the local public health department and a commercial equipment service provider, the facility failed to ensure their kitchen dishwashing machine had the cleaning and sanitation chemical agents connected correctly into the dishwashing machine and also failed to ensure water leaks from the dishwashing machine were repaired to prevent water leaking multiple feet throughout the kitchen floor on multiple days. During the time the dishwasher was not functioning correctly, the facility continued to use the machine to wash reusable meal trays. This was for one of one dishwashing machines utilized by the facility to provide clean dishes for all halls of the facility.The findings included:On 8/5/25 at 12:45 PM an initial observation of the kitchen was made. At that time there was water on the floor spanning approximately 15 feet from the dishwasher. The Certified Dietary Manager (CDM) was interviewed at this time and reported the following information. They were currently using the dishwasher only to wash reusable trays (used to hold the disposable plates and utensils they were currently using to serve residents' meals). The facility had experienced problems with the dishwasher for several weeks. The dishwasher had two motors that lifted a mechanism to drain the contents of the dishwasher after each cycle. One of the motors was broken and on order. Therefore, when the dishwasher emptied, water would overflow onto the floor from the drain that did not work, and the staff would have to mop up the water.During a second observation of the kitchen on 8/6/25 at 10:40 AM the floor was observed to be wet again from the dishwasher. The wet area spanned approximately 15 feet away from the dishwasher. The CDM, who began facility employment on 6/23/25, was interviewed again and reported the following information. Since being employed at the facility, he thought the dishwasher was under a rental agreement, which he also thought entailed the rental company performing monthly service and maintenance checks. Since he had begun, the dishwasher had leaked numerous places. There were two areas at the top that had been squirting water towards the walls. A [NAME] eventually came and welded the holes. Part of the feed line had also separated from the dishwasher and was leaking. Therefore, it had been hard to tell how long the current problem with the motor being broken and causing water leakage had been occurring because there had been so many problems with the machine leaking. He (the CDM) thought at the current time it was only leaking during the rinse cycle because he noticed the problem when the machine showed it was going into the rinse cycle, and therefore he thought the water on the floor was only rinse water. The CDM further reported the following. The local health department had performed an inspection on 7/1/25 and reported that the machine was not sanitizing and the facility was instructed to use single service items for food service to residents. Since 7/1/25 he had used single service items except for reusable trays because of the malfunctioning dish washer. The local health department had instructed them to use the three compartment sink for sanitation if needed. They had tried using the three compartment sink for the reusable trays but found that the trays did not air dry quickly enough to be available for the next meal delivery time. He was not able to order single service trays because he worked for a contracting company which required him to get supplies from a specific supply company. That supply company did not have single service trays. Therefore, since it had been identified by the local health department that the dishwashing machine was not sanitizing, he would manually open the machine and insert the sanitizer. When the machine leaked then the kitchen staff would mop the floor. According to the CDM, a service provider came in on 7/18/25 and identified that the lines from the soap, rinse, and sanitizing agents were not correctly fed into the machine which had led to the machine not sanitizing the trays. The chemical agents usually lasted for about 1 1/2 to 2 weeks before they needed to be changed. He did not know when the chemical agents had last been changed prior to the error of the crossed lines being detected on 7/18/25. Therefore, he could not say how many days the trays had been going through the machine and out to residents without being sanitized. He did know that there had been multiple days of problems with the machine leaking water.A local Health Department Employee was interviewed on 8/6/25 at 9:23 AM and reported the following information. An inspection occurred on 7/1/25 by a colleague from the health department. The facility's dishwashing machine was not sanitizing on 7/1/25 at that visit. At that time the facility was directed to not use the dishwasher, use single service items for food service, and the three-compartment sink was to be used if needed for sanitation. She returned on 7/17/25 and the dishwasher was still broken and not sanitizing when checked. There was no evidence that the facility was using disposable meal service items at that time. There was also water on the floor. The CDM had reported to her that they were waiting for the health department's report to fix the dishwashing machine. She did not understand why the facility needed the report to fix the dishwashing machine. Since 7/17/25 the health department had received information from the facility that a service provider had found that the hoses were not tied into the cleaning agents correctly on 7/18/25 and that issue had been repaired but the facility had also submitted to the health department that the dishwashing machine needed further repairs.On 8/8/25 at 8:52 AM the commercial service provider, who was at the facility on 7/18/25, was interviewed and reported the following information. Their role was to supply the chemical agents but they were not under contract to repair or maintain the machine. When he arrived on 7/18/25 he checked the chemical agents and the lines from the chemical agents that fed into the machine were crossed. The detergent line was feeding into where the sanitizer should have been fed into the machine, and the detergent was feeding into where the sanitizer should have been feeding into the machine. The machine had water coming out of the backside also and the motor to the drain was making a loud chatter. The drain line making the chatter seemed to be locking up and therefore it would not drain correctly. This service provider was interviewed regarding whether it would always be rinse water that was not draining since the CDM noticed that the water would overflow the drain when the machine turned to the rinse cycle. The service provider reported that it could be either dirty water or rinse water. This was because once the wash cycle was completed, the machine then would show as being in the rinse cycle, but it would be emptying dirty water before beginning the rinse cycle. The malfunctioning motor could hang up at anytime during the process.The Administrator and the CDM were interviewed together on 8/8/25 at 11:00 AM and reported the following. When the health department employee arrived on 7/1/25 it was her understanding that they would give her a written report of the problem and provide some education. She thought education would be a good idea. They wanted to cooperate and were waiting on the actual report from the health department to have the machine fixed. In the interim, excluding the reusable trays, they were using disposable single use food service items to serve food to residents.Review of a facility invoice revealed the dishwasher holes, which had been identified as leaking water on the floor when the CDM was hired in June 2025, were repaired on 7/23/25 by a [NAME] company.During an interview on 8/8/25 at 8:19 AM with the Health Department Employee, who visited the facility on 7/17/25, the Health Department employee reported the following. Dirty water overflowing from the dishwasher was a sanitation issue. The health department also considered overflowing rinse water onto the floor as a sanitation issue because the water could attract pests into the kitchen. The dishwasher should not be used if it was leaking water on the floor and/or was not sanitizing.

Based on record review, and interviews with staff, resident, family, and home health agency staff members, the facility failed to have an effective discharge planning process that ensured a referral with all required documentation was submitted to the home health agency Resident # 5 selected resulting in a delay of planned services when the resident was discharged . This was for one (Resident # 5) of one resident reviewed for discharge services.The findings included:Resident # 5's hospital Discharge summary, dated [DATE], revealed Resident # 5 had undergone a total left hip replacement surgery.Resident #5 was admitted to the facility on [DATE].Resident # 5's care plan, dated 7/28/25, noted Resident # 5 was expected to be at the facility for short term rehabilitation and return to the community setting. An intervention on the care plan noted upon discharge the resident was to be referred to community resources as indicated and per the resident or the resident's representative's preference.On 7/28/25 at 3:32 PM the Social Worker documented a discharge planning note which indicated the following information. The resident's family was involved in his care, and the resident planned to return home where he resided alone.Resident # 5's admission Minimum Data Set assessment, dated 7/31/25, revealed the resident was cognitively intact.On 8/5/25 (Tuesday) at 5:06 PM the Social Worker documented the following information. Resident # 5 was discharging home alone on 8/7/25 (Thursday). The family was aware and all equipment had been ordered. Home Health Agency # 2 was scheduled to begin services on 8/8/25 (Friday).On 8/7/25 (Thursday) at 5:02 PM the Social Worker documented the following information. The family had called and requested for the home health agency to be changed. They spoke to Home Health Agency # 1 and they would start care on 8/12/25 (which corresponded to the Tuesday following the resident's discharge the previous Thursday).According to the record, Resident # 5 was discharged home on 8/7/25 per order with home health services to be provided.Resident # 5's family member was interviewed on 8/7/25 at 3:53 PM and reported the following information. Other family members had utilized Home Health Agency # 1 in previous times and had been pleased. Therefore, Resident # 5 had wanted his home health services also provided by Home Health Agency # 1 when he was discharged . She (the family member) was helping Resident # 5 by making sure things were in place for him to go home. She (the family member) had spoken to the Social Worker on 8/4/25 (Monday) and requested that the home health referral be made to Home Health Agency # 1, and she thought this was to be set up for Resident # 5. On 8/6/25 she had left a message on the voice mail for the Social Worker to make sure everything was arranged and did not hear anything back. On the day of discharge, she learned that the referral had been sent to Home Health Agency # 2. She talked to the Social Worker who said they did not hear back from Home Health Agency # 1. She in turn called Home Health Agency # 1 and found they had not received any orders from the facility but were willing to accept him (Resident # 5) and provide services. She again let the facility know Resident # 5 wanted Home Health Agency # 1 and orders were sent to them on the day of discharge. The resident was safe and at home on the day of discharge but because the referral had not been sent in timely, Resident # 5 was having to wait on services until 8/12/25. The family member thought there should have been better communication.Resident # 5 was interviewed on 8/8/25 at 10:20 AM and reported the following information. He and his family member had talked to the Social Worker and conveyed that he wanted Home Health Agency # 1 to provide services when he went home. That had not been initially arranged and now he was having to wait until 8/12/25 for services to begin. In the interim, he was safe and had family to help until home health began.On 8/11/25 at 9:30 AM the Social Worker was interviewed and reported the following information. On 8/4/25 Resident # 5's family member did let her know that the resident preferred Home Health Agency # 1. She emailed the agency to see if they would accept the referral and did not hear back. She waited a few hours, emailed again, and did not hear back. She then made the referral to Home Health Agency # 2. She did not recall telling the resident or family about the change and she did not try to call Home Health Agency # 1 before switching the referral to another home health agency.A Scheduler at Home Health Agency # 1 was interviewed on 8/11/25 at 10:40 AM and reported the following information. They had a Healthcare Liaison who could take referrals, or the facility could call their general intake line and the information could be given to them. As the Scheduler she did not get any information related to Resident # 5 until 8/7/25 (the day of Resident # 5's discharge) and they let the facility know they could not be out until 8/12/25. Services were scheduled to begin on 8/12/25. The Scheduler was interviewed regarding if they could have started services by 8/8/25 (the day following discharge) if the facility had sent the referral information on 8/4/24 (Monday) when the family had requested services through them. The Scheduler reported that their home health agency could have done so.A Clinical Manager for Home Health Agency # 1 was interviewed on 8/11/25 at 10:50 AM and reported the services their company were to provide for Resident # 5 included physical therapy, a nurse, and an aide. They did not receive the referral information until 8/7/25 and notified the facility it would be 8/12/25 before they could start, and the facility reported that was acceptable to the resident. Home Health Agency # 1's Healthcare Liaison was interviewed on 8/11/25 at 1:30 PM and reported the following information. The facility had been given instructions on how to submit information about a referral. They (Home Health Agency # 1) initially needed to have information where the resident resided, insurance information, and date of discharge. They (Home Health Agency # 1) can then let the facility know what date they can start services. They also need other items as well which included the order for services, the resident's hospital discharge summary if the resident had been hospitalized prior to the facility residency, and the last facility provider's note. She received an initial email on 8/4/25 at 10:55 AM and all the information was not sent. She thought that they were going to send the rest of the information and then she received an email just a few short hours later saying the resident was referred to another home health agency. She did not receive a call. At times she was busy, but she tried to quickly return emails and phone calls and if the facility was not able to reach her, then their home health agency had a main office that took referrals. The main office referral line information was on their website and easily accessible.Home Health Agency # 1's main office was contacted on 8/11/25 at 11:46 AM and the intake employee reported that the intake office answered the phone every day, and if the facility had not been able to reach the Healthcare Liaison, then they should have been called.On 8/11/25 the facility provided the email correspondence between their Social Worker and Home Health Agency # 1 for the date of 8/4/25. The correspondence was as follows.On 8/4/25 at 10:55 AM the Social Worker emailed Home Health Agency # 1's Healthcare Liaison and wrote, I have [Resident # 5] that will be discharging home on Friday, he mentioned [Home Health Agency # 1]. I believe he has been a patient before, can you accept? The email did not show any attachments or further information provided to Home Health Agency #1.Four hours later on 8/4/25 at 2:55 PM the Social Worker emailed Home Health Agency # 1's Healthcare Liaison, I have found another company to accept, thank you.Interview with the Administrator on 8/11/25 at 1:23 PM revealed the Social Worker should have attempted to reach out again to Resident # 1's preferred home health agency when she did not hear back from the initial email on 8/4/25 and prior to making other arrangements.

Based on record review and interviews with resident and staff the facility failed to ensure an accurate accounting and administration of a controlled pain medication. This was for one (Resident # 5) of three residents whose controlled pain medication records were reviewed. The findings include:Record review revealed Resident # 5 was admitted to the facility on [DATE] after being hospitalized for hip replacement surgery.Review of Resident # 5's admission Minimum Data Set assessment, dated 7/31/25, revealed the resident was cognitively intact.Review of physician orders revealed an order, dated 7/30/25, for Tramadol 50 mg (milligrams) two times a day for pain for 14 days. (Tramadol is a controlled pain medication and must be signed out of storage when removed with a notation of when the medication was removed and by whom.)Review of Resident # 5's August MAR (Medication Administration Record) revealed the resident's Tramadol was scheduled for 8:00 AM and 8:00 PM. According to the MAR Nurse # 1 placed a check mark by Resident # 5's 8:00 PM dose on 8/5/25 and the electronic MAR showed Nurse # 1 signed in the electronic record she did so at 9:49 PM. Review of Resident # 5's Controlled Drug receipt/ Record/ Disposition Form revealed Nurse # 5 had written she removed Tramadol on 8/5/25 at 9:00 PM and then she placed a line through the entry noting mistake. According to this Controlled Drug receipt/Record/ Disposition Form there was no Tramadol removed on 8/5/25 from Resident # 5's supply.Resident # 5 was interviewed on 8/8/25 at 10:20 AM and reported on the evening of 8/5/25 he needed his pain medication, and it was very late before it was administered. Resident # 5 reported he received the pain medication around 11:00 PM on 8/5/25.Nurse # 5 was interviewed on 8/8/25 at 11:56 AM and reported that she had administered Resident # 5's Tramadol on 8/5/25 around 8:30 PM or 9:00 PM. Nurse # 1 was further interviewed regarding where she had obtained the Tramadol given that there had been no Tramadol signed out from Resident # 5's supply. Nurse # 1 reported the following information. She had inadvertently removed the Tramadol from Resident #6's supply. Resident # 6 was also on Tramadol and received it on an as needed basis. She discovered the error around 7:00 AM on 8/6/25 at the end of her night-time shift. At that point she signed on Resident # 6's Controlled Drug receipt/ Record/ Disposition Form that she had removed a Tramadol dose from Resident # 6's supply but did not note she had signed it out for another resident. Nurse # 1 further reported when she administered the pain medication around 8:00 PM or 9:00 PM, Resident # 5 had not indicated he had needed anything for pain earlier than his scheduled dose.A review of Resident # 6's Tramadol Controlled Drug receipt/ Record/ Disposition Form revealed the form included Resident # 6's order at the top of the form. The order was for Tramadol 50 mg every eight hours as needed. Doses were signed out on 8/5/25 at 6:01 PM and again at 10:00 PM which indicated a span of 3 hours and 59 minutes between doses. There was no notation that this was an error or that the 10:00 PM dose was signed out for another resident.During the interview with Nurse # 1 on 8/8/25 at 11:56 AM, Nurse # 1 was interviewed regarding why she did not put 8:30 PM or 9:00 PM as the time on Resident # 6's Tramadol Controlled Drug receipt/ Record/ Disposition Form since this was the time she was reporting she had inadvertently made the mistake. Nurse # 1 reported the time between 6:01 PM (Resident # 6's last removed dose) and 8:30 PM would have been close in time so she put 10:00 PM instead.The DON (Director of Nursing) was interviewed on 8/8/25 at 12:20 PM and reported the following information. When an inadvertent mistake is made in controlled pain medications, then the nurse should call a supervisor and there should be two signatures noted on the Controlled Drug receipt/ Record/ Disposition Forms what had occurred so that the records were clear and accurate.The facility's Nurse Consultant was interviewed on 8/8/25 at 3:25 PM regarding the discrepancies regarding the differing times of administration being reported by Resident # 5 and Nurse # 1 when compared to the documentation on the MAR and the removal of the Tramadol from storage. According to the Nurse Consultant nurses should document the times controlled pain medications are administered and they should match the MAR and the Controlled Drug receipt/ Record/ Disposition Forms.

Based on observation and interviews with staff, an employee at the local public health department and a commercial equipment service provider, the facility failed to ensure a mechanical dishwashing machine was operating correctly to prevent water leaking multiple feet throughout the kitchen floor on multiple days. This was for one of one dishwashing machines utilized by the facility to service dishes and trays for the entire facility. The findings included:On 8/5/25 at 12:45 PM an initial observation of the kitchen was made. At that time there was water on the floor spanning approximately 15 feet from the dishwasher. The Certified Dietary Manager (CDM) was interviewed at this time and reported the following information. They were currently using the dishwasher only to wash reusable trays (used to hold the disposable plates and utensils they were currently using to serve residents' meals). The facility had experienced mechanical problems with the dishwasher for several weeks. The dishwasher had two motors that lifted a mechanism to drain the contents of the dishwasher after each cycle. One of the motors was broken and on order. Therefore, when the dishwasher emptied, water would overflow onto the floor from the drain that did not work, and the staff would have to mop up the water.During a second observation of the kitchen on 8/6/25 at 10:40 AM the floor was observed to be wet again from the dishwasher. The wet area spanned approximately 15 feet away from the dishwasher. The CDM, who began facility employment on 6/23/25, was interviewed again and reported the following information. Since being employed at the facility, he thought the dishwasher was under a rental agreement, which he also thought entailed the rental company performing monthly service and maintenance checks. Since he had begun, the dishwasher had leaked numerous places. There were two areas at the top that had been squirting water towards the walls. A [NAME] eventually came and welded the holes. Part of the feed line had also separated from the dishwasher and was leaking. Therefore, it had been hard to tell how long the current problem with the motor being broken and causing water leakage had been occurring because there had been so many problems with the machine leaking. He did know that there had been multiple days of problems with the machine leaking water.A local Health Department Employee was interviewed on 8/6/25 at 9:23 AM and reported the following information. An inspection occurred on 7/1/25 by a colleague from the health department. The facility's dishwashing machine was not sanitizing on 7/1/25 at that visit. At that time the facility was directed to not use the dishwasher, use single service items for food service, and the three-compartment sink was to be used if needed for sanitation. She returned on 7/17/25 and the dishwasher was still broken and not sanitizing when checked. There was also water on the floor. The CDM had reported to her that they were waiting for the health department's report to fix the dishwashing machine. She did not understand why the facility needed the report to fix the dishwashing machine. Since 7/17/25 the health department had received information from the facility that a service provider had found that the hoses were not tied into the cleaning agents correctly on 7/18/25 and that issue had been repaired but the facility had also submitted to the health department that the dishwashing machine needed further repairs.On 8/8/25 at 8:52 AM the commercial service provider, who was at the facility on 7/18/25, was interviewed and reported the following information. The facility owned the machine, and it was not rented. They (the service provider) did not do any routine service for machines that were not under contract with them. Also, their company did not do repairs for the facility. Their role was to supply the chemical agents for the machine. When he arrived on 7/18/25 he checked the chemical agents. He also observed while there that the machine had water coming out of the backside also and the motor to the drain was making a loud chatter. The drain line making the chatter seemed to be locking up and therefore it would not drain correctly. The Administrator and the CDM were interviewed together on 8/8/25 at 11:00 AM and reported the following. The Administrator reported it had not been conveyed to her that the dishwashing machine was not rented and rather was owned by the facility. That week (the week of the survey) she had learned at one time the machine had been rented and during a corporate buyout the previous year, the dishwashing machine had somehow become the property of the facility. When the health department employee arrived on 7/1/25 it was her understanding that they would give her a written report of the problem and provide some education. She thought education would be a good idea and they wanted to cooperate and were waiting on the actual report from the health department to have the machine fixed. In the interim, excluding the reusable trays, they were using disposable single use food service items to serve food to residents. The CDM was interviewed again about dates when the dishwashing machine had been leaking and repaired and reported that when he arrived in June it was spurting water and needed to be welded and the feed line was broken and leaking at some point as well. He further reported that the service provider for the chemical agents who discovered the lines were crossed on 7/18/25 was the person who ordered the motor part for the malfunctioning drain. The CDM was interviewed regarding whether he was aware of the date the motor was ordered and who was supposed to actually replace the broken motor when it arrived. The CDM was not sure who the repair person was intended to be when the part was ordered.Review of a facility invoice revealed the dishwasher holes, which had been identified as needing repaired when the CDM was hired in June 2025, were repaired on 7/23/25 by a [NAME] company.

Based on observation, staff interview, and record review the facility failed to have sufficient dietary staff to serve the breakfast meal on time on 5/22/2025 for 7 of 7 halls. The findings included: Based on review of the meal serving times for the facility, breakfast was scheduled between 7:00 AM and 8:00 AM. On 05/22/2025 observations between 9:00 AM and 9:40 AM revealed breakfast carts arriving on the halls. On 5/23/2025 at 11:02 AM An interview was conducted with [NAME] #1. [NAME] #1's name was not on the schedule for 5/22/2025. [NAME] #1 (who prepared breakfast on 5/22/2025) revealed she usually did not work at the facility in the dietary department and only helped to fill the needs in the dietary department. She explained the facility called her on 5/22/2025 at 6:00 am to help because the facility did not have a cook on the morning of 5/22/2025. She explained she lived two hours away from the facility and arrived at 7:30 am on 5/22/2025 to help prepare the breakfast menu. On 5/22/2025 at 11:04 AM an interview with the Dietary Manager revealed the cook was scheduled to arrive at 5:30 am to start preparing breakfast meals. He stated on 5/22/2025 there were 3 dietary staff that included 1 cook and 2 dietary aides scheduled for 5/22/2025. The scheduled cook did not report to work, and he had to call in a cook from a sister facility in [NAME] to help cover the dietary department on 5/22/2025. He explained due to the cook not reporting to work and the cook from the sister facility not arriving at the facility until 7:34 am, the breakfast meal on 5/22/2025 did not arrive to the resident halls as scheduled. On 5/23/2025 at 2:11 pm an interview with the Administrator revealed her concerns with the dietary department and the elimination of some dietary staff. Due to the staff turnover in the dietary department and having to re-educate new dietary staff, the facility has been unable to obtain a consistent improvement in resident satisfaction with the dietary services.

Based on record review, observations, and resident interviews and staff interviews, the facility failed to provide the breakfast meal on 5/22/2025 at times comparable to normal, scheduled mealtimes at the facility. This affected all residents that received food by mouth on 7 of 7 halls (Halls, 100,200, 300, 400, 500, 600 and 700). The facility had a census of 141. The findings included: Based on review of the meal serving times for the facility, breakfast was scheduled as follows: -the 700-hall breakfast time was 07:20 AM -the 200-hall breakfast time was 07:40 AM -the 300-hall breakfast time was 07:50 AM - the 400-hall breakfast time was 08:00 AM - the 100-hall breakfast time was 07:35 AM -the 500-hall breakfast time was 07:00 AM On 05/22/2025 at 09:00 AM an observation was made that 100 hall breakfast trays had not arrived at the 100 hall. Further observation revealed that the only trays that had arrived on any halls were 500 hall trays. Nursing staff were observed offering cereal and milk to residents due to the delay in receiving breakfast meal trays and there were no issues identified with diabetic residents receiving breakfast meal trays later than regularly scheduled The following carts arrived on the halls as follows: -700 hall breakfast cart arrived on the hall at 09:10 AM on 5/22/2025 -200 hall breakfast cart arrived on the hall at 09:19 AM on 5/22/2025 -the second breakfast cart for the 200-hall arrived at 0923 AM on 5/22/2025 -the 300/400 hall breakfast cart arrived at 09:27 AM on 5/22/2025 -the 400-hall breakfast cart arrived at 09:33 AM on 5/22/2025 -the 100-hall breakfast cart arrived at 09:40 AM on 5/22/2025 On 5/22/2025 at 09:13 AM a brief interview with the Dietary Manager revealed that two cooks had called out from work to the Dietary Manager. 05/22/25 at 09:06 AM an interview with Nurse Aide (NA) staff NA #1 revealed that breakfast trays normally were delivered to the hall between 08:00 AM and 08:15 AM. On 5/22/2025 at 11:52 AM an interview with the Dietary Manager revealed the reason the breakfast meal was late today was because two scheduled cooks called out and there was not enough time to schedule another staff. The Dietary Manager stated he was made aware at 7:00 AM. The Dietary Manager revealed that another team from a sister facility arrived and they were able to get started at 800 AM. On 5/23/2025 10:31 AM an interview with the Director of Nursing (DON) revealed that every staff understood when the trays were supposed to be on the hall. If trays are not seen and are late, staff would use the group chat on their phones to text management to communicate if trays were late as well as ask if snacks were available, for instance cereal and milk for breakfast. On 5/22/2025 02:09 AM An interview with the Administrator revealed that food trays are expected to be delivered on time. If the food trays are late, a snack should be offered to the residents.

Based on observations and staff interviews, the facility failed to close doors on the dumpsters to prevent possible pest and rodents entry for 4 of 4 dumpsters reviewed. The findings included: On 5/19/25 at 09:50 AM during an observation with the Dietary Manager of the dumpster area, all doors to the four dumpsters were open. Debris was observed on the ground to the left of dumpster #4 consisting of paper and blue plastic gloves. On 5/19/25 at 10:38 AM, an observation of the dumpster area revealed the doors were still open on 4 of the 4 dumpsters. On 5/20/25 at 8:51 AM, an observation from the facility breezeway revealed the doors of dumpster #4 were open. On 5/20/25 at 8:53 AM, an interview with the Dietary Manager revealed he had not had any issues with pests, rodents or roaches, but had seen cats in the area. He stated that dietary and housekeeping were responsible for cleanliness and door closure of the dumpster area. On 05/21/25 at 9:21 AM, an interview with the Housekeeping Manager revealed that dietary and housekeeping were responsible for cleanliness and door closure of the dumpster area. On 5/22/2025 at 2:09 PM, an interview with the Administrator revealed her expectation that staff needed to maintain cleanliness around the dumpster area and close the doors of the dumpsters. The dietary staff and housekeeping staff were responsible for the dumpster areas. Dietary was mostly responsible for the dumpster areas since they are located closest to the dumpster area.

Based on observations, record review, and staff interviews the facility failed to maintain a medication error rate of less than 5% as evidenced by 4 errors out of 33 opportunities observed. The medication error rate was 12.12%. Findings included: 1. Resident #101 had a doctor's order dated 4/18/25 for omeprazole oral suspension 10 milliliter via Gastrotomy (G) -tube two times a day for gastroesophageal reflux disease (GERD) and scheduled to be administered at 9:00 AM and 9:00 PM. On 5/20/25 at 9:33 AM, Resident #101 was observed during the medication administration. Nurse #4 was observed preparing and administering Resident #101's scheduled 9:00 AM medications. During this medication administration, Nurse #4 did not administer omeprazole oral suspension which was scheduled for 9:00 AM. On 5/20/25 at 10:01 AM, Nurse #4 was interviewed. He stated that he had not realized that Resident #101's omeprazole was out and needed to be refilled/reordered and he was going to call the provider about it after this interview. According to the manufacturers' instructions insulin lispro should be injected under the skin within 15 minutes before or right after a meal and a meal should be consumed within 10-20 minutes after insulin aspart is administered. 2a. Resident #59 had a doctor's order dated 2/28/25 for Humalog Kwik Pen subcutaneous solution pen injector 100 unit/milliliter (Insulin Lispro) inject as per sliding scale: 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 12 Units; 351 - 400 = 16 Units subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. On 5/21/25 at 11:20 AM, Nurse #5 was observed checking Resident #59's blood sugar which was noted to be 244. Nurse #5 administered 5 units of insulin lispro to Resident # 59 at 11:24 AM. Resident #59 was observed receiving his lunch tray at 12:54 PM which was 1 hour 30 minutes after insulin was administered. Resident #59 sat up in bed and ate his lunch when he received his tray. 2b. Resident #21 had a doctor's order dated 2/25/25 for Insulin Lispro Injection Solution (Insulin Lispro) inject as per sliding scale: 150 - 169 = 1 unit; 170 - 189 = 2 units; 190 - 209 = 3 units; 210 - 229 = 4 units; 230 - 249 = 5 units; 250 - 269 = 6 units; 270 - 289 = 7 units; 290 - 300 = 8 units; 301+ = 9 units & notify provider, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with other specified complication. On 5/21/25 at 11:30 AM, Nurse #5 was observed checking Resident #21's blood sugar which was noted to be 180. Nurse #5 administered 2 units of insulin lispro to Resident #21 at 11:35 AM. Resident #21 was observed receiving her lunch tray at 1:03 PM which was 1 hour 28 minutes after insulin was administered. Resident #21 sat up in bed and ate her lunch when she received her tray. 2c. Resident #76 had a doctor's order dated 12/12/24 for Novolog Injection Solution 100 unit/milliliter (Insulin aspart) Inject as per sliding scale: 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 12 units; 351 - 400 = 16 units subcutaneously before meals and at bedtime for diabetes mellitus. On 5/21/25 at 11:42 AM, Nurse #5 was observed checking Resident #76's blood sugar which was noted to be 335. Nurse #5 administered 12 units of insulin aspart to Resident #76 at 11:48 AM. Resident #76 was observed receiving her lunch tray at 1:11 PM which was 1 hour 23 minutes after the insulin was administered. Resident #76 sat up in bed and ate her lunch when she received her tray. During an interview on 5/21/25 at 1:22 PM, Nurse #5 stated that since the blood sugar checks were scheduled for 11:00 AM she went ahead and checked the blood sugars and administered insulin at that time thinking the trays would be out shortly, but she was not sure of the exact time when the trays would be delivered to the residents. Nurse #5 indicated that now that she had thought about it, she should not have administered the insulin more than 30 minutes before the meal was served to the residents. During an interview on 5/21/25 at 1:32 PM with the facility Director of Nursing (DON), she indicated Nurse #5 should not have administered Resident #21, Resident #59 and Resident #76 insulins before she saw trays in the hallway because it was indicated to be administered before meals. The DON stated she expected fast acting insulin to be administered 15 - 30 minutes before the meal and that Nurse #5 needed to be reeducated regarding insulin timeframes. The DON verbalized Nurse #4 should have ensured Resident #101 had all her 9:00 AM scheduled medications and if there was an issue with reordering the medication the expectation was for nurses to reach out to the physician. During an interview on 5/22/25 at 2:13 PM with the facility Administrator, she indicated Nurse #5 should not have administered Resident #21, Resident #59 and Resident #76 insulins until the meal trays were within vicinity. The Administrator indicated she expected nurses to request medication refills from pharmacy ahead of time so that the residents did not run out of medications. She also indicated that if there was an issue obtaining the medication from the pharmacy, nurses should reach out to the physician for guidance ahead of time.

Based on observations and staff interviews, the facility failed to remove leftover food stored past the use by date in 1 of 2 refrigerators observed (reach-in refrigerator). This practice had the potential to affect food served to residents. The findings included: On 5/19/25 at 09:50 AM during the observation of the kitchen area with the Dietary Manager (DM) revealed leftover prepared food in the reach in refrigerator. The Dietary Manager reported leftover food was good for 48 hours after being prepared. The following leftover items observed were: - chicken soup in a stainless-steel container covered with plastic wrap dated 5/10/25 - diced ham in a stainless-steel container covered with plastic wrap dated 5/13/25 - spinach in a stainless-steel container covered with plastic wrap dated 5/13/25 - cauliflower puree in a stainless-steel container covered with plastic wrap dated 5/15/25 - sliced turkey in a stainless-steel container covered with plastic wrap dated 5/15/25 On 05/20/25 08:53 AM an interview with the Dietary Manager (DM) revealed that if there were leftovers, the leftovers were cooled down, wrapped and dated for the day the leftovers were prepared. The DM reported the leftovers were dated using a date dot label, that included the item name, date of prep, date of holding time (how long it was to be kept) and name of the staff who dated the item. The leftovers were kept no more than 48 hours per the DM. The DM indicated the cooks were responsible for checking the refrigerators daily and disposing of the leftover food after 48 hours. On 05/22/25 02:09 PM Interview with the Administrator revealed food storage should be done according to the facility's policy and food safety guidelines were followed.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to assure the facility was free of significant medication errors when fast acting insulin (insulin lispro and insulin aspart) that starts to work approximately 15 minutes after injection to lower blood sugar levels was administered to 3 residents more than 1 hour before their meal tray was delivered. The significant medication errors could have resulted in adverse side effects for 3 of 8 residents observed for medication administration (Resident #59, Resident #21 and Resident #76). Findings included: According to the manufacturers' instructions insulin lispro should be injected under the skin within 15 minutes before or right after a meal and a meal should be consumed within 10-20 minutes after insulin aspart is administered. 1a. Resident #59 had a doctor's order dated 2/28/25 for Humalog Kwik Pen subcutaneous solution pen injector 100 unit/milliliter (Insulin Lispro) inject as per sliding scale: 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 12 Units; 351 - 400 = 16 Units subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic neuropathy. On 5/21/25 at 11:20 AM, Nurse #5 was observed checking Resident #59's blood sugar which was noted to be 244. Nurse #5 administered 5 units of insulin lispro to Resident # 59 at 11:24 AM. Resident #59 was observed receiving his lunch tray at 12:54 PM which was 1 hour 30 minutes after insulin was administered. Resident #59 sat up in bed and ate his lunch when he received his tray. 1b. Resident #21 had a doctor's order dated 2/25/25 for Insulin Lispro Injection Solution (Insulin Lispro) inject as per sliding scale: 150 - 169 = 1 unit; 170 - 189 = 2 units; 190 - 209 = 3 units; 210 - 229 = 4 units; 230 - 249 = 5 units; 250 - 269 = 6 units; 270 - 289 = 7 units; 290 - 300 = 8 units; 301+ = 9 units & notify provider, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with other specified complication. On 5/21/25 at 11:30 AM, Nurse #5 was observed checking Resident #21's blood sugar which was noted to be 180. Nurse #5 administered 2 units of insulin lispro to Resident #21 at 11:35 AM. Resident #21 was observed receiving her lunch tray at 1:03 PM which was 1 hour 28 minutes after insulin was administered. Resident #21 sat up in bed and ate her lunch when she received her tray. 1c. Resident #76 had a doctor's order dated 12/12/24 for Novolog Injection Solution 100 unit/milliliter (Insulin aspart) Inject as per sliding scale: 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 12 units; 351 - 400 = 16 units subcutaneously before meals and at bedtime for diabetes mellitus. On 5/21/25 at 11:42 AM, Nurse #5 was observed checking Resident #76's blood sugar which was noted to be 335. Nurse #5 administered 12 units of insulin aspart to Resident #76 at 11:48 AM. Resident #76 was observed receiving her lunch tray at 1:11 PM which was 1 hour 23 minutes after the insulin was administered. Resident #76 sat up in bed and ate her lunch when she received her tray. During an interview on 5/21/25 at 1:22 PM, Nurse #5 stated that since the blood sugar checks were scheduled for 11:00 AM she went ahead and checked the blood sugars and administered insulin at that time thinking the trays would be out shortly, but she was not sure of the exact time when the trays would be delivered to the residents. Nurse #5 indicated that now that she had thought about it, she should not have administered the insulin more than 30 minutes before the meal was served to the residents. During an interview on 5/21/25 at 1:32 PM with the facility Director of Nursing (DON), she indicated Nurse #5 should not have administered Resident #21, Resident #59 and Resident #76 insulins before she saw trays in the hallway because it was indicated to be administered before meals. The DON stated she expected fast acting insulin to be administered 15 - 30 minutes before the meal and that Nurse #5 needed to be reeducated regarding insulin timeframes. An interview was conducted on 5/22/25 at 8:46 AM with the facility Medical Director. The Medical Director stated that nurses should not be administering insulin before residents' meals are ready. He indicated that the window for administering fast acting insulin should be 15-30 minutes before meals. The Medical Director explained that if the residents' blood sugar was well controlled and insulin was administered before the resident is ready to eat there was potential for the blood sugar to get really low, the resident to develop hypoglycemia, become unconscious and develop associated complications. During an interview on 5/22/25 at 2:13 PM with the facility Administrator, she indicated Nurse #5 should not have administered Resident #21, Resident #59 and Resident #76 insulins until the meal trays were within vicinity.

Based on record review, observations, and staff interviews and Nurse Practitioner interview, the facility failed to change a chronic wound dressing as ordered by the provider for 1 of 1 resident reviewed for venous wound care (Resident # 40). Findings included: Resident #40 was admitted to the facility on [DATE] with diagnoses including chronic idiopathic (arising spontaneously with unknown cause) venous hypertension with ulcer to the left lower extremity and pyoderma gangrenosum (a rare condition that causes large painful sores on the skin). Resident's #40's revised care plan dated 1/7/2025 included a focus for a chronic left lower leg vascular wound. Interventions included treatments per the Treatment Administration Record (TAR). The care plan also included a focus for behaviors due to Resident #40 refusing care that included wound care. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was moderately cognitively impaired. The MDS was coded for one venous/arterial ulcer and treatments included application of ointments, medications and nonsurgical dressings. A review of physician orders indicated on 3/20/2025 Resident #40 was ordered daily wound care that included to cleanse the left lower extremity wound with wound cleanser, pat dry, apply collagen soaked gauze followed by calcium alginate with silver to the open area, cover with ABD pads (highly absorbent pads for large wounds) and apply Kerlix (crinkle-weave bandage used for wound care). Physician orders dated 5/9/2025 included a change in the wound care order to cleanse the left lower extremity wound with Vashe (a pure hypochlorous acid solution used to fight bacteria and infection), pat dry, apply collagen particles (provides support for cell organization and faster tissue formation, helps maintain a moist environment and stimulated new tissue growth), cover with Xeroform (sterile, non-adherent wound dressing that prevent air for reaching the wound) and infections), apply ABD pads and wrap the wound with Kerlix every day shift. The Nurse Practitioner's wound documentation dated 5/14/2025 reported the left lower ulcer wound was improving without complications and measurements were recorded as 14.5 centimeters (cm) by 25 cm by 0.30cm with moderate odorless serosanguineous drainage. The frequency of dressing changes was recorded for daily dressing changes. A review of Resident #40's May 2025 TAR recorded the following order for wound care: Cleanse left lower extremity wound with Vashe, pat day, apply collagen particles, cover with Xeroform, apply ABD pads then wrap with kerlix every day shift for wound care and the order date was recorded as 5/9/2025 at 10:20 am. There was no wound care recorded provided to Resident #40's left lower leg wound for the following dates on Resident #40's May 2025 TAR: 5/10/2025, 5/11/2025, 5/17/2025 and 5/18/2025. There was no documentation in the electronic medical record (EMR) that wound care was provided to Resident #40 or Resident #40 refused wound care on 5/10/2025, 5/11/2025, 5/17/2025 and 5/18/2025. On 5/22/2025 at 8:54 am in a phone interview with Nurse #3, she explained she served as the nurse supervisor for nursing station #2 that included Resident #40's room. Nurse #3 explained on weekends there were medication aides assigned to Resident #40 to administer medications and as nurse supervisor she was responsible for Resident #40's wound care. Nurse #3 stated on 5/10/2025, 5/11/2025, 5/17/2025 and 5/18/2025 she did not provide or offer to provide wound care to Resident #40 because she thought Resident #40 received wound care on Monday, Wednesday and Friday. Nurse #3 stated she was not aware of the new order for left lower extremity wound care written on 5/9/2025 and explained the resident would communicate when there were new orders for wound care and nurses reviewed Resident #40's EMR for new wound care orders. Nurse #3 stated she had not checked Resident #40's EMR for wound care orders. On 5/23/2025 at 9:20 am in an interview with Nurse #2, she stated she had been the unit manager for nurse's station #2 that included Resident #40's room since the end of March 2025. Nurse #2 stated Resident #40's left lower extremity wound care had been ordered daily since March 2025 and could not recall a change in the frequency of Resident #40's wound care. On 5/19/2025 at 12:52pm, Resident #40's left lower extremity wound dressing was observed with moderate amount of dried light brown drainage to the outer wound dressing and moderate amount of dried yellowish brown stains to the under pad on the bed underneath the left lower extremity. There was no date or initials on the dressing indicating when the dressing was last changed. On 5/19/2025 at 12:52 pm, Resident #40's Representative stated the dressing to the left lower extremity was not changed on the weekend. Resident #40 confirmed that the left lower wound dressing was not changed on the weekend (5/17/2025 and 5/18/2025). On 5/20/2025 at 11:26 am, Nurse #6 and Nurse #7 were observed educating Resident #40 on the importance of daily wound care before Resident #40 consenting to treatment. Nurse #7 was observed assisting Resident #40 in participating in the wound care and wound care was conducted as ordered by the provider. The large open wound area to the left lower leg was observed with dark burgundy-red color tissue covered with a thin clear to white slough in areas. There was no odor noted. On 5/20/2025 at 12:02 pm in a interview with Nurse #7, she stated when she changed Resident #40's left lower extremity wound dressing on 5/19/2025, there was no date or initials on the old dressing and the wound dressing appeared to not have been changed on the weekend. On 5/22/2025 at 9:03 am in a phone interview with the Wound Nurse Practitioner, she stated Resident #40's refused wound care at times and had refused debridement of the left lower extremity wound to remove the slough. She explained Resident #40 was scheduled wound care three times a week (Monday, Wednesday and Friday) at one time and because Resident #40 would refuse wound care, she had changed the frequency of Resident #40's left lower extremity wound dressing from three times a week (Monday. Wednesday and Friday) to daily. She explained when Resident #40 was receiving wound care three times a week and refused wound care, the dressing to the left lower extremity wound would go three to four days without treatment. Therefore, to ensure Resident #40 was receiving lower extremity wound care more consistently, the wound nurse practitioner increased the wound care to daily to capture the performance of wound care more routinely. She explained the resident had been more cooperative and there was less time in between wound care dressing changes even when Resident #40 refused wound care with daily wound care. The Nurse Practitioner stated Nurse #3 should have attempted to perform wound care as ordered for Resident #40 on 5/10/2025, 5/11/2025, 5/17/2025 and 5/18/2025. On 5/23/2025 at 9:03 am in an interview with the Director of Nursing, she stated the nurse assigned to nursing station #2 was responsible for performing wound care to the assigned area on weekends. She stated Nurse #3 should have verified Resident #40 wound care orders and offered Resident #40 wound care as ordered on 5/10/2025, 5/11/2025, 5/17/2025 and 5/18/2025.

Based on observations, record review, and resident, family and staff interviews, the facility failed to serve food in a form that met the resident's needs for 1 of 1 resident (Resident #84) reviewed. Resident #84 had been ordered food that was pureed texture and was observed eating a mechanically chopped breakfast meal. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses which included Progressive Supranuclear Palsy (a neurodegenerative disease involving the gradual deterioration of the brain), secondary Parkinsonism, and dysphagia (difficulty swallowing). Record review indicated Resident #84 had a Physician's Order, dated 1/16/25, for a Regular Diet, pureed texture, thin liquids consistency, double protein for all meals. A review of Resident #84's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident to have the ability to understand others and to make himself understood. The MDS indicated he was severely cognitively impaired. He had no impairment in his upper extremities and required setup or clean-up assistance when eating. The MDS indicated Resident #84 had a swallowing disorder and was on a mechanically altered diet. A review of Resident #84's Care Plan, last revised on 4/16/25, indicated the following focuses: 1) at risk for injury related to his medical diagnoses and stated he pockets food at times (holding food in the mouth without swallowing it); 2) refuses to allow staff to assist with meals and eating; and 3) requires assistance with his Activities of Daily Living. Interventions included, in part, a therapeutic diet as ordered, staff assistance with meal setup, encouragement by staff to allow with assistance with his meals, cues and reminders to improve his meal intake, assurance that he is safe and if he became distressed to listen to him and try to calm him. An interview was conducted with Resident #84's Responsible Party (RP) on 5/19/25 at 1:34 PM. The RP stated he and another family member visit the resident at the facility almost daily and while there, assist him with his lunch and supper meals. He explained the resident ate a pureed diet and took a long time to eat. The RP expressed concern that the resident had been brought solid food for a couple of his meals in January 2025. An observation of and interview with Resident #84 was conducted on 5/20/25 at 11:38 AM. He was observed sitting up in his wheelchair, in his room beside his bed. He was awake, alert and able to respond to yes and no questions by giving a thumbs-up for a yes answer and a thumbs-down for a no answer. When he was asked if he had ever been served food that was not in pureed form, he gave a thumbs up. When asked if that had happened often, he gave a thumbs down. When asked if the staff who had brought that regular consistency food to him in the past had realized the error and replaced it with the pureed version of that food, he gave a thumbs up. An observation of Resident #84 was conducted on 5/23/25 at 8:36 AM. He was sitting up in his bed and was observed eating. A small bowl that contained grits, scrambled eggs and sausage had been placed on his overbed table which was positioned across his lap. The eggs and sausage appeared to have a mechanically chopped texture (foods that are ground into very small pieces making it easier for people who have difficulty chewing or swallowing eat) instead of a pureed texture (foods that are smooth and pudding-like texture). He was observed using an adaptive spoon (a utensil with an easy-grip handle) to eat the grits. There was no tray or meal ticket on the table or in his room. Resident #84's nursing assistant (NA), NA #1, entered the room, introduced herself as the NA assigned to his care that day, and asked him if he was done eating and the resident indicated he was. An interview was conducted with NA #1 on 5/23/25 at 12:05 PM. NA #1 stated Resident #84 had orders for a pureed diet with double portions. When asked about his breakfast, NA #1 claimed she knew the resident's likes and dislikes very well and because she had fed him most of his breakfast, she had asked if he would like to eat some more, by himself, and said he indicated he would like to do that. Instead of leaving everything, she had taken some of the remaining eggs and sausage from his plate and put them into his bowl of grits, placed the bowl on his overbed table and gave him his spoon. She then removed the tray and left him to eat on his own. When asked about the texture of the foods in the bowl, NA #1 explained that grits and eggs always had that consistency, but the sausage appeared to have been a mechanically chopped texture. NA #1 further explained she realized the sausage had not been pureed when she sat down to feed him and removed the dome from his plate. She stated she had planned on going to the kitchen to get him the pureed version of sausage, but said the resident told her that he did not want any sausage that morning, so she did not go to the kitchen. NA #1 could not explain why she put the sausage into the bowl of grits that she had left with the resident except for saying that because he had said he did not want to eat any sausage that morning she knew he would not eat it. When asked if she had reported Resident #84 received a mechanically chopped diet that morning, she initially said she had reported it to the Resource Nurse on the hall and then admitted she had not. An interview was conducted with the Resource Nurse, Nurse #4, on 5/23/25 at 11:15 AM. Nurse #4 explained Resident #84 had orders for a pureed diet and could feed himself, but it took a long time for him to eat. He explained that nursing staff would assist him, if he allowed it, and said the resident would sometimes push away staff who are trying to feed him. Nurse #4 stated when the resident wants to feed himself, staff will make frequent checks on his progress and offer him verbal cues and encouragement to eat. Nurse #4 stated he was unaware Resident #84 had received a mechanically chopped breakfast meal that morning and stated he would talk with the dietary department about the error. An interview was conducted with the Dietary Manager (DM) on 5/23/25 at 11:27 AM. The DM explained the difference between a mechanically chopped food item and a pureed one. He stated that for mechanically chopped food, they have a machine that grinds the food into very small pieces. For pureed food, the food is blended to the consistency of applesauce and is smooth. The DM stated a resident's diet order is entered into their computer system and tray tickets that contain the order are printed out for each meal. He explained at mealtimes, one staff member calls out the diet order from the ticket and another staff member puts the correct consistency foods on the trays. The DM stated he had prepared all the breakfast trays that morning and could not offer an explanation as to how Resident #84 received a mechanically chopped diet that morning. The DM stated he had thought the pureed food appeared grainy instead of smooth that morning but did not question [NAME] #1 who had prepared the food that morning. An interview was conducted with [NAME] #1 on 5/23/25 at 11:34 AM. [NAME] #1 stated that you could see the difference between the different types of textures of the foods she prepared, explaining that mechanically chopped food was ground up food that had a bumpy texture while pureed food looked smooth, like baby food. She stated she was unaware Resident #84 had received a mechanically chopped breakfast that morning. [NAME] #1 said she had placed the pureed sausage right beside the mechanically chopped sausage in the steam table and that they definitely looked different. An interview was conducted with the Director of Nursing (DON) on 5/23/25 at 11:50 AM. The DON stated it was her expectation that residents receive the food that had been ordered for them. An interview was conducted with the Administrator on 5/23/25 at 11:51 AM. The Administrator stated it was her expectation that residents receive the correct food consistency as ordered.

Based on observations and staff interviews, the facility failed to secure medications on an unattended wound care cart that stored topical medications. The facility also failed to secure an unattended blood glucose cart that stored insulin. The blood glucose cart was not only observed to be unsecured and unattended but also had the key inserted into the lock. This deficient practice was found for 2 of 8 medication storage carts (wound cart and blood glucose cart). Findings included: 1. On 5/20/2025 at 11:25 am, Nurse #7 was observed gathering supplies from the wound care cart in preparation for Resident #40's wound care, proceeded to enter Resident #40's room, and allowed the door to remain open. The wound care cart was observed with the lock extended outward with tattered medical tape wrapped around the extended lock. The wound care cart was positioned in the hallway with the drawers and tape covered lock facing toward Resident #40's open door. Self-propelling residents in wheelchairs were observed around the nursing station located approximately twenty-two feet from the wound care cart. On 5/20/2025 at 11:25 am Nurse #6 (the designated Wound Nurse who was assisting Nurse #7 with Resident #40's wound care) was observed entering Resident #40's room behind Nurse #7 and closing Resident #40's door. On 5/20/2025 at 11:25 am in an interview with Nurse #6, she explained topical medications were stored in the wound care cart and the wound care cart would not lock. She stated in the last three weeks as the wound nurse she had been leaving the wound care cart unlocked in the hallway when providing residents' wound care in the room, and at times the resident door would be closed. She stated she did not have a key to the wound care cart and the Director of Nursing had the only key to the wound care cart. Nurse #6 could not explain why the medical tape was wrapped around the extended outward lock on the wound care cart. On 5/20/2025 continuous observation was conducted from 11:26 AM through 12:05 PM, Nurse #6 and Nurse #7 were observed to go into Resident #40's room while the wound care cart was left in the hallway and unlocked. Resident #40's door was observed closed while Nurse #6 and Nurse #7 were in Resident #40's room and the wound care cart was out of their sight while they were in Resident #40's room. Nurse #6 and Nurse #7 were observed providing Resident #40 wound care. At 12:05 pm, Nurse #6 and Nurse #7 opened the resident door and exited Resident #40's room. The wound care cart remained in the same position, in front of the resident room door, and remained unlocked. Self-propelling residents in wheelchairs were observed approximately twenty-two feet from the wound care cart at the nurse's station. On 5/20/2025 at 12:06 pm an observation was conducted of the wound care cart in the presence of Nurse #7. The following medications were observed in the unlocked wound care cart: Nystatin powder (antifungal medication), topical fungal and bacterial creams, topical bacterial ointments, wound cleanser (solution used to clean wounds and promote healing), betadine solution (antiseptic solution to disinfect wounds), Dakin's solution (topical antiseptic to clean infected wounds) and topical anesthetic spray. On 5/20/2025 at 12:25 pm in an interview with Nurse #7, she stated there was no key to lock the wound care cart when left unattended to perform wound care in residents' room and explained the wound care cart was kept in a locked medication room when not in use. She explained during the 2-3 times she had been assigned wound care in the last couple of weeks; the medical tape was wrapped around the extended outward lock which prevented the lock on the wound care cart to be pressed inward to lock and she was not able to lock the wound care cart when leaving the wound care cart unattended. Nurse #7 stated she had not mentioned to anyone the wound care cart would not lock when left unattended. Nurse #7 stated when the wound care cart was left unattended and not in sight, the wound care cart should have been locked due to storage of medications on the wound care cart. On 5/202/2025 at 12:41pm in an interview with the Director of Nursing, she explained the wound care cart should have been locked when left unattended and stated she did not know why or who placed the medical tape around the lock on the wound care cart. She stated the wound care nurse should have a key to the wound care cart and she had an extra key to unlock the wound care cart as needed. 2. On 5/21/2025 at 7:55 am, the blood glucose cart was observed on the 400 hall outside room [ROOM NUMBER] unattended with the lock extended outward (unlocked) with a key inserted into the lock. Self-propelling residents in wheelchairs were observed in the 400 hall. Nurse #5 was observed exiting room [ROOM NUMBER] and approaching the blood glucose cart. On 5/21/2025 at 7:57 am, Nurse #5 was observed exiting room [ROOM NUMBER] and approaching the blood glucose cart. In an interview with Nurse #5, she explained residents' insulin was stored on the blood glucose cart. Sixteen residents' insulin flex pens were observed on the blood glucose cart. There were no vials of insulin or syringes observed on the blood glucose cart. Nurse #5 stated the blood glucose cart should have been locked when unattended. Nurse #5 was unable to provide a reason why the blood glucose cart was left unlocked with the key in the lock. On 5/21/2025 at 8:50 am in an interview with the Director of Nursing (DON), she stated residents' insulin pens were stored on the blood glucose cart. The DON stated the blood glucose cart should have been locked and the key to the blood glucose cart should have been with Nurse #5 any time the blood glucose cart was left unattended.

Based on observations, record review, and staff interviews, the facility failed to ensure a severely impaired resident with a diagnosis of dysphagia (difficulty swallowing) and a physician order for a pureed diet (foods that are smooth and pudding-like texture) did not have access to mechanically chopped food. A nursing assistant realized the resident had received mechanically chopped breakfast sausage on a meal tray and left it with the resident who was able to feed himself independently. This deficient practice occurred for 1 of 3 residents reviewed for accidents. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses which included Progressive Supranuclear Palsy (a neurodegenerative disease involving the gradual deterioration of the brain), secondary Parkinsonism, and dysphagia (difficulty swallowing). Record review indicated Resident #84 had a Physician's Order, dated 1/16/25, for a Regular Diet, pureed texture, thin liquids consistency, and double protein for all meals. A review of Resident #84's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident to have the ability to understand others and to make himself understood. The MDS indicated he was severely cognitively impaired. He had no impairment in his upper extremities and required set up or clean-up assistance when eating. The MDS indicated Resident #84 had a swallowing disorder and was on a mechanically altered diet. A review of Resident #84's Care Plan, last revised on 4/16/25, indicated the following focuses: 1) at risk for injury related to his medical diagnoses and stated he pockets food at times (holding food in the mouth without swallowing it); 2) refuses to allow staff to assist with meals and eating; and 3) requires assistance with his Activities of Daily Living. Interventions included, in part, a therapeutic diet as ordered, staff assistance with meal setup, encouragement by staff to allow with assistance with his meals, cues and reminders to improve his meal intake, assurance that he is safe and if he became distressed to listen to him and try to calm him. An observation of Resident #84 was conducted on 5/23/25 at 8:36 AM. He was sitting up in his bed and was observed eating. A small bowl that contained grits, scrambled eggs and sausage had been placed on his overbed table which was positioned across his lap. The eggs and sausage appeared to have a mechanically chopped texture (foods that are ground into very small pieces making it easier for people who have difficulty chewing or swallowing eat) instead of pureed texture (foods that are smooth and pudding-like texture). He was observed using an adaptive spoon (a utensil with an easy-grip handle) to eat the grits. There was no tray or meal ticket on the table or in his room. Resident #84's nursing assistant (NA), NA #1, entered the room, introduced herself as the NA assigned to his care that day, and asked him if he was done eating and the resident indicated he was. An interview was conducted with NA #1 on 5/23/25 at 12:05 PM. NA #1 stated Resident #84 had orders for a pureed diet with double portions. When asked about his breakfast, NA #1 claimed she knew the resident's likes and dislikes very well and because she had fed him most of his breakfast, she had asked if he would like to eat some more, by himself and said he indicated he would like to do that. Instead of leaving everything, she had taken some of the remaining eggs and sausage from his plate and put them into his bowl of grits, placed the bowl on his overbed table and gave him his spoon. She then removed the tray and left him to eat on his own. When asked about the texture of the foods in the bowl, NA #1 explained that grits and eggs always had that consistency, but the sausage appeared to have been a mechanically chopped texture. NA #1 further explained she realized the sausage had not been pureed when she sat down to feed him and removed the dome from his plate. She stated she had planned on going to the kitchen to get him the pureed version of sausage, but said the resident told her that he did not want any sausage that morning, so she did not go to the kitchen. NA #1 could not explain why she put the sausage into the bowl of grits that she had left with the resident except for saying that because he had said he did not want to eat any sausage that morning she knew he would not eat it. When asked if she had reported Resident #84 received a mechanically chopped diet that morning, she initially said she had reported it to the Resource Nurse on the hall and then admitted she had not. An interview was conducted with the Resource Nurse, Nurse #4, on 5/23/25 at 11:15 AM. Nurse #4 explained Resident #84 had orders for a pureed diet and could feed himself, but it took a long time for him to eat. Nurse #4 stated he was unaware Resident #84 had received a mechanically chopped breakfast meal that morning and stated he would talk with the dietary department about the error. She stated she was unaware Resident #84 had received a mechanically chopped breakfast that morning. [NAME] #1 said she had placed the pureed sausage right beside the mechanically chopped sausage in the steam table and that they definitely looked different. An interview was conducted with the Director of Nursing (DON) on 5/23/25 at 11:50 AM. The DON stated it was her expectation that residents receive the food that had been ordered for them. An interview was conducted with the Administrator on 5/23/25 at 11:51 AM. The Administrator stated it was her expectation that residents receive the correct food consistency as ordered. The Administrator also stated a resident's safety should always be a priority for staff.

Based on record review, observations and staff interviews, the facility failed to implement care planned interventions by not placing fall mats at the bedside of a resident with a history of falls with major injuries. This occurred for 1 of 5 residents reviewed with care plan interventions for accidents (Resident #98). Findings included: Resident #98 was admitted to the facility on [DATE] with diagnoses of non-Alzheimer's dementia and Parkinson's disease (a movement disorder of the nervous system that worsens over time). A post fall report dated 3/24/2025 at 3:53 pm indicated Resident #98 had an unwitnessed fall and was found sitting on the floor next to the bed complaining of right hip pain on 9/23/2025 at 9:34 am. X-rays were obtained, and Resident #98 was transferred to the hospital on 3/24/2025. A care plan revised on 3/27/2025 indicated Resident #98 was a risk for falls related to the cognitive impairment. An intervention dated 3/23/2025 included fall mats upon return to the facility. Nursing documentation dated 3/27/2025 recorded Resident #98 returned to the facility from the hospital after having surgery for repair of a right hip fracture. The significant change Minimum Data Set assessment dated [DATE] indicated Resident #98 was severely cognitively impaired and was coded for recent surgery for repair of a fracture to the pelvis, hip, leg, knee or ankle. There was no documentation in the electronic medical record of any falls since re-admission on [DATE]. On 5/22/2025 at 6:35 am, Resident #98 was observed resting in the center of the bed with the bed positioned in the lowest position. There were no fall mats on the floor to either side of Resident #98's bed. On 5/22/2025 at 8:33 am, Resident #98 was observed still resting in the bed with no fall mats positioned on the floor on either side of Resident #98's bed. Fall mats were observed folded up in the left corner of the room. Medication Aide #1 was observed outside Resident #98's room at the medication cart. On 5/22/2025 at 8:33 am in an interview with the day shift (7:00 am to 7:00 pm) Medication Aide #1, she stated she had not been into Resident #98's room since receiving her assignment at 7:00 am and the fall mats should have been positioned down on the floor beside Resident #98's bed. Medication Aide #1 was observed entering Resident #98's room, gathering the folded fall mats from the left corner of the room and placing the fall mats to each side of Resident #98's bed. On 5/22/2025 at 8:35 am in an interview with Nurse #2, she stated Resident #98 was care planned for the use of fall mats at the side of the bed and she was not sure why the fall mats were not beside Resident #98's bed. She stated it was the responsibility of the nursing staff to ensure fall mats were positioned beside the bed when Resident #98 was in bed. On 5/22/2025 at 8:40 am in an interview with the Director of Nursing, she stated fall mats should have been beside the bed when Resident #98 was in the bed and it was the responsibility of all nursing staff to ensure fall mats were on the floor beside the bed.

Based on record review, and Physician and staff interviews, the facility failed to protect a resident's right to be free from abuse when a cognitively intact resident (Resident #326) hit a moderately cognitively impaired resident (Resident #325) on his arms with an ashtray holder. Resident #325 sustained 3 small skin tears on his left forearm, left elbow, left posterior arm, and right ring finger. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #325). The findings included: Resident #326 was admitted to the facility on [DATE] and was discharged on [DATE]. His diagnoses included osteomyelitis, anxiety disorder, depression, and hallucinations. Resident #326's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He was independent with upper body dressing, rolling left and right, sitting to lying, lying to sitting on side of bed, picking up an object, wheeling 50 feet with 2 turns, and wheeling 150 feet. He required partial/moderate assistance with toileting hygiene, showering/bathing himself, lower body dressing, putting on/taking off footwear, and personal hygiene. He needed supervision/touch assistance to sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident #326's revised care plan dated 10/7/24 revealed he exhibited behaviors that included throwing items at staff, cursing at staff, cursing at other residents, destroying others personal property, manipulative behaviors/ fabrication of stories, hitting staff and other residents. Interventions included 1:1 supervision, administering medications as ordered, diverting Resident #326 by giving him an alternative object or activity, listening and calming him. Resident #325 was admitted to the facility on [DATE] and was discharged on [DATE]. His diagnoses included epidural hemorrhage with loss of consciousness, dementia, muscle weakness, abnormalities of gait and mobility, major depressive disorder, seizures, schizophrenia, and chronic pain syndrome. Resident #325's Minimum Data Set (MDS) dated [DATE] revealed he was moderately cognitively impaired. He was independent in the areas of eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting on side of bed, toilet transfer, wheeling 50 feet with 2 turns, and wheeling 150 feet. He required set up/clean up assistance for tub/shower transfer. He needed supervision/touch assistance with shower/bathing himself, sitting to standing, chair/bed to chair transfer, walking 10 feet, and walking 50 feet with 2 turns. He required partial/moderate assistance to walk 150 feet. Resident #325's revised care plan dated 9/4/24 included the focus area of behaviors such as spitting on the floor and throwing briefs on the floor. Review of Resident #326's nursing progress note dated 9/30/24 at 10:40 AM entered by the Director of Nursing (DON) revealed Resident #326 was agitated and challenging with redirection. Resident #326 was medicated for pain and monitored closely for aggression. An emergency mental health tele-visit for Resident #326 was requested. Review of a Physician medical progress note dated 9/30/24 at 11:37 AM indicated during this visit Resident #326 was upset about his pain medication, used profanity and attempted to hit and throw things at the Physician. The Physician's progress note stated Resident #326 was asking for more anxiety medications. The Physician indicated psychiatry was seeing him and reportedly did not change his anxiety medications. The physician further indicated Resident #326 was upset his Physician would not increase his pain medication and started hitting, throwing things, and cursing at the Physician. An interview was conducted with Physician #1 on 5/22/25 at 11:31 AM. He stated Resident #326 always requested to have his pain medication increased. Physician #1 stated as he exited the room Resident #326 told him not to shut the door and then came after him in the hallway. Physician #1 stated Resident #326 attempted to hit him but instead punched his laptop twice. Physician #1 stated Resident #326 continued to follow him, and Physician #1 went into another resident room. Resident #326 came into the room and took one of the drawers out of a dresser and tried to hit Physician #1 with it. Physician #1 stated a physical therapist was near the room and attempted to intervene. Physician #1 indicated he was told later Resident #326 had an altercation in the courtyard. Regarding emergency mental health tele-visits, Physician #1 stated if a resident was experiencing a serious mental health emergency, that resident would be sent directly to the emergency room (ER). Otherwise, he stated, it was his expectation that a practitioner would see a resident within 24 hours. An interview with the Rehabilitation Director was conducted on 5/22/25 at 1:51 PM. He stated he and his Physical Therapy Assistant (PTA) saw Resident #326 yelling and belligerent. The Rehabilitation Director stated Resident #326 had cornered the provider in a resident room and was verbally abusive. He stated he removed Resident #326 from the room by pulling on the handles of his wheelchair. On 5/22/25 at 2:00 PM an interview was conducted with the Physical Therapy Assistant (PTA). He stated he heard a commotion, saw a provider (Physician #1) backing out of a room, and Resident #326 followed him and was verbally abusive and pushing the provider. The PTA stated he and the Rehabilitation Director walked to meet them. The provider backed into another resident's room and Resident #326 followed him and attempted to hit the provider. The PTA stated there was a resident in that room near the window. He stated the provider was positioned in the middle of the room in front of the resident in the bed by the window. He further stated it appeared that Resident #326 pulled on dresser drawers, while he was being backed out of the room. The PTA stated the Rehabilitation Director grabbed the back of Resident #326's wheelchair and backed him out of the room. The PTA stated it all happened very fast, in less than a minute. He added the provider was able to get out of the room and go down the hall. The PTA recalled that the Rehabilitation Director released the wheelchair and Resident #326 began pursuing the provider again. The PTA tried to talk to Resident #326 and distract him, however Resident #326 punched the PTA in the stomach and chest to continue to pursue the provider. The PTA talked to Resident #326 to calm him down. Both Resident #326 and the PTA went out to the courtyard and talked while Resident #326 smoked. The PTA stated the Social Worker came out to talk to Resident #326 and the police showed up. A review of the facility's Initial Allegation Report dated 9/30/24 revealed on 9/30/24 at 12:00 PM there was a resident-to-resident altercation. Resident #326 hit Resident #325 with a small table stand during an argument in the courtyard. The residents were separated immediately, and Resident #326 was placed on one-to-one supervision. Law enforcement was notified. Review of the witness statement from Medication Aide #1 dated 9/30/24 indicated she was outside with Resident #326 while he was smoking. Resident #326 and Resident #325 started to argue. Resident #326 picked up the ashtray stand and started hitting Resident #325. Medication Aide #1 attempted to grab the ashtray stand but a male housekeeper grabbed it. Medication Aide #1 brought Resident #326 inside and informed the nurse that Resident # 325 needed help. An interview was conducted on 5/22/25 at 9:15 AM with Medication Aide #1 who completed one to one observation of Resident #326 on 9/30/24. She stated she did not recall the incident between Resident #326 and Resident #325. A follow up interview was conducted with Medication Aide #1 on 5/23/25 at 10:34 AM. She stated she performed 15-minute checks on Resident #326 the morning of 9/30/24 after he had requested medications. She stated she was unsure what time he was placed on one-to-one observation. An interview with Housekeeping Staff #1 who witnessed the incident 9/30/24 was conducted on 5/21/25 at 7:03 PM. Housekeeping Staff #1 stated he was on the 500-hall taking out the garbage and was looking out the window toward the courtyard and saw a resident hit another resident with an ashtray holder. Housekeeping staff #1 stated he ran out and grabbed the ashtray holder out of the resident's hand, separated the residents, and went inside to report it to a staff member immediately. He was unsure which staff member he reported it to and did not recall seeing anyone else outside. An interview was conducted on 5/23/25 at 12:05 PM with Nurse #9 who was assigned to both Resident #326 and Resident #325 on 9/30/24. Nurse #9 stated she recalled there was an altercation because a housekeeper had reported the incident to her on 9/30/24. Nurse #9 was unsure if Resident #326 was on one-on-one observation prior to the incident, but stated he was supervised after the incident. Nurse #9 indicated when she was informed of the incident she assessed both residents for injuries. Resident #325 had skin tears on one arm. An interview was conducted with the Director of Nursing (DON) on 5/22/25 at 6:45 AM. She stated on 9/30/24 Resident #326 was checked on continuously and was kept at the nurse's station after he became agitated that morning. The DON indicated she was unsure how he could have left the nurse's station. Additional interventions included administering pain and antianxiety medications and 15-minute checks. The DON stated Resident #326's mental health practitioner saw him in person the next day on 10/1/24. She further stated that monitoring a resident closely entailed the resident was monitored every 15 minutes, and those logs were kept in a binder. She stated a safety attendant for one-to-one observations for Resident #326 were in effect until 11/7/24 for the duration of his stay. A review of Resident #326's one-to-one 15-minute monitoring logs 9/30/24 through 11/7/24. Resident #326's monitoring logs revealed he had 15-minute checks signed by staff. An interview was conducted with the Social Worker (SW) on 5/22/25 at 2:10 PM. He stated he saw Resident #326 after the incident with the provider (Physician #1) as well as after the incident with another resident. He stated they discussed his aggressive behavior in both instances. He stated he recalled Resident #326 was on one-to-one observation, however, was unsure of how long. The SW stated he could not recall anything further about the incidents that occurred on 9/30/24. Review of a psychiatry progress note dated 10/4/24 revealed Resident #326 was able to express insight into the altercation with Resident #325 and demonstrated emotional awareness and control. There were no changes made to Resident #326's medications. Recommendations included continued practice of calming techniques, redirection techniques, support, and redirection as needed. A review of the facility's investigation report dated 10/4/24 revealed in summary, Resident #325 sustained small skin tears on his left forearm, left elbow, left posterior arm, and right ring finger. Resident #325 declined to press charges. Resident #325 denied any lasting trauma because of the incident, stated he felt safe at the facility, and was not afraid of Resident #326. Resident #326 also denied a traumatic response to the incident, was placed on one-to-one observation, and received a mental health evaluation. This was completed by the Administrator. An interview was conducted with the Administrator on 5/22/25 at 3:47 PM. She stated interventions were put in place (15-minute observations and placing Resident #326 at the nurse's station) and was unsure why they did not prevent the incident.

Based on record review, observations and staff interviews, the facility failed to place a resident's adaptive flat call light device within reach to allow for the resident to request assistance if needed for 1 of 4 residents reviewed for accommodation of needs (Resident #81). Findings included: Resident #81 was admitted to the facility on [DATE] with diagnoses including legal blindness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #81 was moderately cognitively impaired, had no impairments with range of motion to both upper body extremities and was dependent on staff assistance for all mobility in and out of the bed. Resident #81's revised care plan dated 4/27/2025 indicated Resident #81 was legally blind. There was no intervention for keeping the call bell in the reach of Resident #81. On 5/19/2025 at 11:01 am, Resident #81 was observed lying in the bed with her head of the bed elevated and an adaptive flat call bell was observed attached to the upper right corner of the mattress cover with the call bell hanging toward the back side of the mattress. When Resident #81 was asked where the call ball was located, Resident #81 was observed moving her hands against the bed on each side of her body to search for the adaptive flat call bell. Resident #81 explained she was blind and stated she did not know where the call bell was located at that moment. When Resident #81 was informed where the adaptive call bell was located (hanging on the right corner of the mattress), Resident #81 stated she was unable to reach the adaptive flat call bell. Resident #81 needed assistance with incontinence care, and Nurse #2 was informed of the Resident #81 needs. On 5/20/2025 at 4:51 pm, Resident #81 was observed lying in the bed and the adaptive flat call bell was observed lying in a chair positioned four feet from the right side of the bed. Resident #81 was observed attempting to locate the call bell on the bed and stated she was unable to locate the adaptive flat call bell. Resident #81 stated they (nursing staff) put the call bell where they want to. On 5/20/2025 at 4:56 pm in an observation and interview with Nurse Aide (NA) #2 who was assigned Resident #81, she stated Resident #81 communicated her needs to staff when they were making rounds. NA #2 stated Resident #81 was checked every hour and when she was last in Resident #81's room thirty minutes ago, Resident #81's call bell was on the bed. NA #2 stated she had no idea Resident #81's call bell was in the chair and the call bell should be clipped to the bed in Resident #81's reach. NA #2 was observed moving the adaptive flat call bell to Resident #81's right side of the bed and informing Resident #81 where the adaptive flat call bell was located. NA #2 stated Resident #81 was unable to get out of bed independently to move the call bell into the chair beside the bed. On 5/21/2025 at 3:50 pm, Resident #81 was observed resting in the bed with a push button call bell positioned on the right side of the bed beside Resident #81. On 5/22/2025 at 8:38 am in an interview with Nurse #2, she stated Resident #81 was able to use the adaptive flat call bell to call for assistance as needed and had always known Resident #81 to use the adaptive flat call bell. She stated Resident #81's call bell was to be within reach for use and when the call bell was observed hanging from the right corner of the mattress (5/19/2025) and in the chair (5/20/2025), the call bell was not in the reach of Resident #81. On 5/22/2025 at 8:40 am in an interview with the Director of Nursing, she stated Resident #81 could use the adaptive flat call bell to call for assistance and Resident #81's adaptive flat call bell should be in the reach of Resident #8. The DON stated Resident #81's adaptive flat call bell should not have been changed to a push button call bell due to Resident #81's blindness and the possibility of Resident #81 missing the button to call for help. On 5/21/2025 at 8:49 am in an interview with Nurse #8, she stated Resident #81 required an adaptive flat call bell and the reason Resident #81 was observed with a push button call bell (5/22/2025) was because the adaptive flat call bell for Resident #81 and the push button call bell for Resident #81's roommate had been switched. On 5/23/2025 at 11:30 am in an interview with the Administrator, she stated Resident #81 adaptive flat call bell should be positioned within the reach of the resident

Based on record review, observations, Responsible Party interview, staff interviews, and a Physician interview, the facility failed to provide wound management to a skin tear that was recorded occurring initially on 3/12/2024 and reoccurring on 3/30/2024 for a resident. The resident's skin tear was reported infected on 4/3/2024 and was treated with antibiotics. There were no treatments for wound care ordered until 4/9/2024, and there were no weekly wound assessments (appearance and measurements of the wound) documented on the skin tear as of 4/26/2024 in the resident's medical record. This deficient practice occurred for 1 of 3 residents reviewed for skin conditions (Resident #118). Findings included: Resident #118 was admitted to the facility on [DATE] with diagnoses including a stroke. The care plan dated 2/23/2024 for Resident #118 included a focus for the risk for skin alterations and recorded there were scabbed wounds to the left lower extremity. Interventions included to assess the skin daily with routine care with baths and showers. Resident #118's care plan also included a focus for a potential in bleeding and bruising due to anticoagulation (receiving medications that prevent or break down blood clots) therapy. Interventions included gently handling the skin, observing for signs of bleeding that included changes in skin color, bruising and bleeding, and notifying the physician of bleeding or changes in skin condition. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #118 was severely cognitively impaired, and there was no limitation of mobility to her lower extremities. The MDS further indicated Resident #118 had no skin conditions. A facility's incident report dated 3/12/2024 completed by Nurse #1 recorded Resident #118 had a small skin tear to right shin after a fall. Nurse #1 recorded the area was cleaned with normal saline, and a dressing was applied. Resident #118's weekly skin assessment since 3/15/2024 reported skin was not intact. Nursing documentation on 3/15/2024 at 4:33 p.m. by unknown nurse reported a right lower leg skin tear was covered with an ABD pad (non-woven thick absorbent dressing) and wrapped with kerlix (a gauze bandage used to dress wounds or absorb fluids) at the request of Resident #118's Responsible Rarty, and Treatment Nurse #1 was notified. Nursing documentation on 3/30/2024 at 6:12 p.m. by Nurse #2 reported the scab of an old skin tear to the right lower leg was removed with some bleeding when Resident #118 slipped out of her wheelchair to the floor. Nurse #2 documented cleansing the right lower leg with wound cleanser and applying a bandage. Nursing documentation on 4/3/2024 at 5:40 p.m. by Nurse #3 reported Resident #118's Responsible Party reported to Nurse #3 the right lower dressing was coming off. Nurse #3 documented there was serosanguineous drainage observed on the right lower leg dressing, and there was odor from a small open, whitish/yellow area to the right lower leg. Nurse #3 recorded the right lower leg was cleansed with wound cleaner, covered with an ABD pad, and wrapped with kerlix. Nurse #3 documented an order for doxycycline, an antibiotic, was received from Physician #1 for an infected wound. There were no further nursing assessments of Resident #118's right lower leg skin tear wound documented in her medical record. There was no assessment of Resident #118's right lower leg skin tear wound located in the physician progress notes in the medical record. There were no wound treatments recorded for Resident #118's right lower leg on the March 2024 Treatment Administration Record (TAR). A physician order dated 4/3/2024 requested Resident #118 receive doxycycline hyclate (an antibiotic) 100 milligrams(mg) twice a day for ten days for a wound infection. On 4/9/2024, a physician order was written by Treatment Nurse #1 to cleanse skin tear to Resident #118's left (should be right) lower leg with normal saline or wound cleanser, apply xeroform and cover with a dry dressing every other day. Resident #118's April 2024 Medication Administration Record recorded doxycycline hyclate 100mg was administered twice a day from 4/4/24 to 4/13/2024. The April 2024 Treatment Administration Record (TAR) recorded Resident #118's left (should be right) lower leg skin tear was cleansed with normal saline or wound cleanser, xeroform was applied and covered with a dry dressing every other day. On 4/26/2024 at 4:10 p.m., Nurse #4 and NA #1 were observed changing Resident #118's right lower leg dressing. An outer right lower leg wound was observed as an oblong shaped superficial area measuring 2 by 1 centimeters (cm) with light pink granulation tissue. An inner right lower leg wound was observed as a linear shaped open area measuring 3 by 1 cm with red granulated tissue. Both areas were cleansed with wound cleaner and patted dry, and xeroform and a kerlix dressing was applied. In an interview with Resident #118's Responsible Party (who was present during the dressing change of the right lower leg) on 4/26/2024 at 4:10 p.m., she stated on 4/3/2024 it was the outer right lower leg wound that was covered with pus. She explained the inner right lower leg wound was there also on 4/3/2024 and became infected later. She explained both wounds were looking better than a couple weeks ago. In a phone interview with Nurse #2 on 4/26/2024 at 3:25 p.m., she explained Resident #118 was on a blood thinner (prevent blot clots) medication and had a dark blue discolored area the size of a baseball to her right lower leg on 3/30/2024. She stated on 3/30/2024, a scabbed area in the center of the dark blue area came off with some bleeding. She explained she cleansed the skin tear to the right lower leg with wound cleanser and applied a dressing. She stated she reported Resident #1's skin tear directly to Treatment Nurse #1 verbally. She explained Treatment Nurse #1 was responsible for wound management (assessing the wound, ordering and providing treatments, and evaluating wound care) once a skin tear or wound was communicated. In a phone interview of 4/26/2024 at 6:34 p.m. with Nurse #3, she explained on 4/3/2024 she was not aware of Resident #118's right leg wound until Resident #118's Responsible Party reported the dressing to the right lower leg was off. She described the right lower leg wound as infected with a white material covering the wound. She explained she cleansed the area, applied a dressing and texted the physician. She stated based on her assessment of the wound Physician #1 started Resident #118 on antibiotics and did not order any further wound care. She stated she also notified either Treatment Nurse #1 or Nurse Aide #1 (NA who assisted Treatment Nurse #1 with wound care) who was in the facility at the time, Nurse #1 and the Director of Nursing of the wound. She stated the nursing staff had standard orders for wound care but since Resident #118's right leg wound was infected, she needed more than the standard wound care. She explained it was Treatment Nurse #1's responsibility to assess the wound, determine the type of wound care and obtain a physician order for wound care. In an interview with Nurse #1 on 4/26/2024 at 10:03 a.m., she explained there was a treatment communication binder at the nurse's station to notify Treatment Nurse #1 of changes in a residents' skin, and Treatment Nurse #1 was to assess and order treatments. Nurse #1 stated there was no documentation in the treatment communication binder Treatment Nurse #1 was notified of Resident #118's right lower leg skin wound. In an interview with Nurse Aide #1 on 4/26/2024 at 2:37p.m, she explained she helped Treatment Nurse #1 in providing wound care, and Treatment Nurse #1 was responsible for assessing Resident #1 wounds and calling the physician to develop a plan of care. She stated she only provided and documented the wound care as ordered, and since 4/9/2024 when an order was written, she had performed Resident #118's wound care to the right lower leg. She stated she was not able to recall whether she was informed about Resident #118's right lower leg skin tears prior to 4/9/2024. In an interview with Treatment Nurse #1 on 4/26/2024 at 9:47 a.m., she explained nursing staff were to notify her of skin tears or wounds by recording the wounds in the treatment communication book at the nurse's station, and she couldn't recall the staff notifying her of Resident #118's right lower leg wound. She stated Resident #118's treatments to the right lower leg started (4/9/2024) after she assessed the wounds. Treatment Nurse #1 stated she was unable to recall the exact date of her assessment of Resident #118's right lower leg wound. She stated skin tear wound assessments were not documented in the electric medical record under wound assessments, and she did not have any records documenting the appearance or measurement of Resident #118's right lower leg wounds. She explained when Resident #118's wound became infected that changed the requirement for assessing and documenting of Resident #118's right lower leg wounds, and she should had assessed and documented Resident #118's right lower leg wounds for wound management weekly in the nurse notes or under wound assessments in the electrical medical record. She stated there were standing physician's orders to use for treatment of skin tears. She explained Resident #118 was not followed by the wound physician and could not say that Physician #1 had seen the wounds to her right lower leg. In an interview with the Director of Nursing (DON) on 4/26/2024 at 9:45 a.m., she explained the nursing staff were to assess skin tears, apply a dressing and notify Treatment Nurse #1 by recording the skin tear or wound in the treatment communication binder at the nurse's station. She stated Treatment Nurse #1 was to assess the skin tear or wound and initiate wound care as indicated. After reviewing Resident #118's electric medical record, the DON stated she was unable to locate nursing documentation of the weekly assessments (appearance and measurements) of Resident #118's right lower leg skin tear wound by Treatment Nurse #1. She stated there was not a physician order for wound care written until 4/9/2024, and wound care had been documented as provided since 4/9/2024. In a follow up interview with the Director of Nursing on 4/26/2024 at 5:10 p.m., she recalled discussing Resident #118's use of antibiotics in clinical morning meetings for a comprised skin condition and explained Treatment Nurse #1 missed managing Resident #118's skin tear wound because Nurse #2 did not report the skin injury on the treatment communication book for Treatment Nurse #1, and the skin injury was not visual to the staff due to Nurse #1 applying a dressing. She stated nursing staff were to report changes in skin conditions to Treatment Nurse #1 by using the treatment communication book and not verbally communicating the changes because Treatment Nurse #1 could forget about the skin change. She explained based on the facility's plan of correction for wound management Treatment Nurse #1 was monitoring the treatment communication book at the nurse stations for reported changes in residents' skin daily and the shower sheets were checked daily for any new skin conditions observed on residents. The Director of Nursing stated she had not conducted any wound care monitoring to ensure a resident's wound care was initiated and/or conducted as ordered. In a phone interview with Physician #1 on 4/26/2024 at 9:31 a.m., he explained the effects of not assessing and implementing wound care to a skin tear would depend on the appearance of the skin tear wound and said he could not say that Resident #118 not receiving wound care to the right lower leg skin tear caused the skin tear to become infected. He stated when Resident #118's right lower leg was reported infected, she was started on antibiotics. He explained the Treatment Nurse #1 should had assessed Resident #118's open wound initially to implement wound care and continued to assess and document the appearance of Resident #118's right lower leg that would have shown the progression of healing or signs of infection.

Based on record review, staff, Nurse Practitioner, Medical Director, and Radiologist interviews, the facility failed to protect a severely cognitively impaired resident from injury of unknown origin. On 3/18/23 nurse aide #1 observed bruising on Resident #22's left thigh and right fourth toe. On 3/20/23 Resident #22 was assessed by a nurse and found to have a bruise to her left thigh described as the size of a salad plate saucer and swollen knee. X-ray results revealed Resident #22 had a grossly displaced complex fracture of the left distal femur with angulation at the fracture site (the femur was broken in more than one place and the bone fragments were at an angle to each other). This was for one of one resident reviewed for an injury of unknown origin. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Tourette's disease (a nervous system disorder involving repetitive movements or unwanted sounds) cognitive communication deficit, abnormal posture, vascular dementia with behavioral disturbances, convulsions, and osteoporosis. The annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #22 was severely cognitively impaired, had unclear speech, and sometimes was able to understand others. The MDS showed Resident #22 required extensive assistance from two staff members for transfers and total assistance from one staff member for bathing. The MDS showed Resident #22 had not taken any anticoagulants, did not have any behaviors of refusing care, and did not have any physical/verbal behaviors directed at others. The MDS showed at the time of assessment, Resident #22 had not fallen in the previous six months. The care plan dated 1/8/23 showed Resident #22 had a focused area of socially inappropriate/disruptive behaviors of screaming out at times related to Tourette's disorder, a difficulty communicating, and at risk for falls with previous actual falls. Interventions included attempt to redirect as needed, use simple communications, assist with mobility at level resident requires, two persons assist with bathing, toileting, bed mobility, and transfers. A shower log and skin assessment sheet dated 3/18/23 (Saturday) showed Resident #22 had bruising on her left thigh and bruising on her right fourth toe. The shower sheet was signed by Nurse Aide #1 on 3/18/23 and the Unit Manager on 3/20/23. A nursing progress note written by Nurse #2 dated 3/20/23 read nurse aide was giving bath notice left knee was swollen. Physician was notified, order for left leg to be x-ray, writer called mobile x-ray mobile imagining. An x-ray dated 3/20/23 of Resident #22's left femur (thigh bone) showed osseous mineralization was decreased. This could reflect osteopenia (reduced bone mass lesser severity than osteoporosis) or osteoporosis (condition in which bones become brittle and fragile from a loss of tissue). The report also read Resident #22 had a grossly displaced complex fracture of the distal femur with angulation at the fracture site and soft tissue swelling. (the femur was broken in more than one place and the bone fragments were at an angle to each other). A Physician orders dated 3/20/23 showed an order to send Resident #22 to the emergency room for evaluation of a possible femur fracture. A nursing progress note written by the Unit Manager dated 3/20/23 read Resident sent to ER for further evaluation and treatment per MD for possible leg femur fracture. The emergency room physical assessment dated [DATE] read Left leg has obvious deformity. There is moderate swelling to left thigh with bruising. No additional obvious trauma on exam. Resident #22's vital signs were stable, and she was not in any distress. No known injury. Resident #22 showed signs of dementia, was alert, and moved her extremities spontaneously. The x-ray taken at the emergency roiagnom on [DATE] showed Resident #22 had a comminuted fracture (a fracture where the bone is broken in at least two places) that was reduced (a procedure used to set broken bones without cutting the skin open) in the emergency room and splinted after orthopedic surgery consultation. The facility was unable to provide the emergency room with information related to the cause of Resident #22's injuries. Resident #22 was admitted to the hospital on 3/20/23 with a diagnosis that included a closed fracture of the distal end of her left femur. (a fracture of the thigh bone above the knee). The resident was readmitted to the facility on [DATE]. An interview was conducted on 4/4/23 at 1:29 P.M. with Nurse Aide #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. NA #2 indicated she was familiar with Resident #22. Resident #22 was unable to communicate with staff and rarely made her needs known. During the interview, NA #2 indicated Resident #22 was able to move her legs to hanging off the bed and sit up in the bed without assistance from staff. During the interview, NA #2 indicated she was assigned to work with Resident #22 on 3/17/23 during the 7 A.M. to 7 P.M. shift and had not observed Resident #22 to have any bruising. NA #2 indicated when she went to work on 3/20/23, she had not received a report that stated Resident #22 had a fall or any injury and Resident #22 behaved at her baseline with no indication she was in pain. NA#2 indicated when she went to Resident #22's room to provide her with a bed bath she noticed bruising that was light in color on her left thigh approximately the size of a salad plate saucer. NA #2 indicated when she reached over the side of the bed, NA #2 observed Resident #22 to have a swollen knee. NA #2 reported the bruising to the assigned nurse. An interview was conducted on 4/4/23 at 2:02 P.M. with Nurse #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. Nurse #2 indicated she had not received a report Resident #22 had a fall or another incident with injury. Nurse #2 indicated Resident #22 was sleeping when she arrived for her shift on 3/20/23 with no signs of she was in pain. During the interview, Nurse #2 indicated NA #2 reported Resident #22 had a bruise on her thigh, a bruise under her left leg by her knee, and an indentation above the left knee. Nurse #2 assessed Resident #22 and described the bruise under her leg at the knee as being about the size of a softball. The bruise was dark purple, red, with a little bit of tint on her thigh. Nurse #2 indicated the indentation at the left knee was only observed when the leg was looked at from the side. During the interview, Nurse #2 indicated she felt Resident #22 had a broken leg and reported the injury to the Unit Manager. Nurse #2 further indicated the x-ray technician reported to her, when Resident #2's left thigh was x-rayed, Resident #22 did not call out when her leg was repositioned. An interview was conducted on 4/4/23 at 1:16 P.M. with the Unit Manager. The Unit Manager indicated she was unaware Resident #22 had any bruising on her left thigh until 3/20/23 when Nurse #2 made her aware. The Unit Manager indicated herself and Nurse #2 went and assessed Resident #22. During the interview, the Unit Manager indicated Resident #22 was unable to verbalize what caused the bruise, so a head-to-toe assessment was completed with the following results: a bruise the size of a softball on the top of Resident #22's left thigh that appeared to be a newer bruise because it was not yellow, a bruise behind Resident #22's left knee, and a bruise on a toe. The Unit Manager indicated she does not recall which toe had a bruise. During the interview, the Unit Manager indicated Resident #22 was unable to verbalize pain but did not show any nonverbal signs of being in pain when she assessed her on 3/20/23. The Physician was notified, and a mobile x-ray was ordered. The Physician gave orders to send Resident #22 to the emergency room when the x-ray results showed a fracture. The Unit Manager indicated after Resident #22 went to the emergency room an investigation was started by the Administrator. An interview was conducted on 4/4/23 at 3:42 P.M. with the Director of Nursing (DON). During the interview, the DON indicated the morning Resident #22 went to the emergency room , the Unit Manager reported a bruise of unknown origin to herself and the Administrator. An interview was conducted on 4/5/23 at 10:09 A.M. with the Administrator. During the interview, the Administrator indicated he was made aware Resident #22 had a bruise on 3/20/23. The Administrator stated he went to Resident #22's room and observed a bruise that was a significant size of approximately 10-15 centimeters. The Administrator indicated the doctor was contacted, an x-ray was taken that showed a fracture, and the resident was sent to the emergency room . A telephone interview was conducted on 4/6/23 at 3:25 P.M. with the Nurse Practitioner (NP). The NP indicated she was in the building on 3/20/23 when she was alerted by nursing staff Resident #22 needed to be assessed for a bruise. The NP observed a large bruise on Resident #22's top to the side of her left thigh that appeared to be under 24 hours old based on the coloration and her leg was a little swollen. During the interview the NP indicated she felt Resident #22 had a possible fracture. The NP indicated the facility completed an investigation and it was determined the injury occurred due to a mechanical lift, Resident #22's combativeness, and Resident #22's weak bones. A telephone interview was conducted on 4/5/23 at 8:22 A.M. with the Medical Director. During the interview, the Medical Director indicated he was familiar with Resident #22 and had given orders to send her to the emergency room for evaluation for a femur fracture. The Medical Director indicated Resident #22 had advanced dementia, seizure activity, contractures, and was unable to straighten her legs. The Medical Director further indicated when staff used a mechanical lift to transfer Resident #22, the pressure points on her body were in different locations compared to a person who was not contracted. The Medical Director further indicated with Resident #22's weakened bones, the movement with the mechanical lift, and rolling back and forth during a shower, the bone may have become grossly displaced. During the interview, the Medical Director indicated he was unaware of Resident #22 having a fall prior to being taken to the emergency roiagnom on [DATE] for an evaluation. A telephone interview was conducted on 4/11/23 at 9:24 A.M. with Radiologist #1. During the interview, Radiologist #1 accessed Resident #22's electronic medical record and reviewed the x-rays of Resident #22's left femur (thigh bone) taken while she was in the emergency room . Radiologist #1 indicated the left thigh fracture was a recent fracture and had occurred approximately within a day or less from her hospitalization . The radiologist indicated Resident #22 had diminished bone mineralization which made her more prone to fractures. During the interview, Radiologist #1 indicated based off the severity of the break on the femur (thigh bone), the multiple fractures on the femur, the location of the break above the knee, he would guess the resident had a fall. The radiologist further stated an aggressive amount of force from a fall, or a car accident was required for this type of fracture, and it was an unusual fracture to have occurred in a mechanical lift. The Administrator was notified of the Immediate Jeopardy on 4/6/23 at 5:00 P.M. The facility provided a corrective action plan on 4/8/23 which alleged a date of completion of 3/25/23. The corrective action plan indicated: The root cause analysis identified that the alleged noncompliance resulted from the failure of the facility to ensure each resident is free from injury of unknown origin for one resident #22. The RCA identified that an employee failed to use the mechanical lift properly per facility mechanical lift policy and procedures. Resident #22 have fragile bones resulting from decreased osseous mineralization that reflect osteopenia and osteoporosis. The RCA concluded that due to Resident #22 condition of osteopenia it is most likely that the sustained fractures resulted from an improper use of the mechanical lift by nursing aide #1 on 3/18/2023. The RCA concluded that the extent of resident #22 injuries is related to resident #22 medical condition and improper use of the mechanical lift. On 3/25/2023, Nursing assistant #1 was immediately suspended to allow further investigation of the allegation of abuse/neglect of Resident #22. Nurse #1 assessed Resident #22 on 03/20/2023 and notified the attending physician who ordered an X ray of the Resident #22 leg. Unit Coordinator #1 spoke to Xray technician who completed the Xray and received a preliminary result that resident had a fracture. Unit Coordinator contacted the Attending Physician who ordered resident to be sent to emergency room for evaluation and treatment. The Unit Coordinator #1 notified the resident's responsible party of the change in condition as well as transfer to the emergency roiagnom on [DATE]. On 03/25/2023, Director of Nursing completed a one-on-one re-education for Nursing Aide #1 on the importance of having assistance when using mechanical lift. The Director of Nursing also re-educated Nurse Aide #1 on 3/25/2023 on the abuse prohibition policy and procedures to include, but not limited to, ensuring each resident remains free from injuries of unknown sources. Resident #22 was readmitted on [DATE]. Resident #22 was reassessed by MDS Coordinator #1, and the care plan was revised to include measures for pain management and two person's assistance with ADLs, and the use of two persons assistance with mechanical lift. How the facility will identify other residents having the potential to be affected by the same deficient practice: 100% interview of all residents in the facility who are alert and oriented completed by assistant Director of Nursing, Staff Development Coordinator, Unit Coordinator #1 and/or MDS Coordinator on 3/25/23 to identify any other resident with an allegation of abuse/neglect. No other resident voiced any allegation of abuse/neglect. Findings of this audit are documented on a resident abuse interview tool located in the facility compliance binder. 100% audit of current resident's medical diagnosis completed by assistant director of Nursing, Staff Development Coordinator, MDS Coordinator #1, Unit Coordinator #1, and/or MDS Coordinator #2 on 03/25/2023, to identify any other resident with diagnosis of osteopenia and or osteoporosis and assure each resident has a care plan with intervention such as use two persons for transfer, to minimize risk for pathological and/or spontaneous fractures. Findings of this audit are documented on a care plan ADL audit tool located in the facility compliance binder. MDS Coordinator #1 and/or MDS Coordinator #2 on 03/25/2025, assure each resident has an Assistance of Daily Living (ADL) care plan that indicates the amount of assistance required during ADL care to include the use of mechanical lifts. Findings of this audit are documented on a care plan ADL audit tool located in the facility compliance binder. 100% audit of all incident reports written in the last 30 days completed on March 25, 2023, by Director of Nursing, Unit coordinator #1, and/or Unit manager #2 to identify any other incident of injury of unknown source. No other injuries of unknown sources identified. Findings of this audit are documented on an Incident report audit tool located in the facility compliance binder. 100% audit of all current resident's shower sheets for the last 30 days was completed on 03/25/2023 by Director of Nursing, MDS Coordinator #1, MDS coordinator #2, Unit coordinator #1, and/or Unit Manager #2 to identify any other documentation of an injury of unknown source further investigation. No other injuries of unknown sources were identified. Findings of this audit are documented on shower sheets audit tool located in the facility compliance binder. Measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Effective 03/25/2023, facility will ensure all remains free from abuse, neglect, misappropriation of resident property, and exploitation, to include be free from injuries of unknown source. Effective 03/25/2023 facility employees follow the company abuse prohibition policy and procedures, and policy and procedures when using mechanical lift to ensure each resident remains free from abuse to include injuries of unknown source. At least two employees are present when using a mechanical lift from 3/25/2023. Effective 03/25/2023, all new residents have a bed mobility assessment completed on admission, quarterly, and with any changes in their bed mobility status, by the nurse on duty. This is reviewed in the daily clinical meeting and be documented on the facility medical records under the comprehensive care plan. Any resident who requires mechanical lift has a care plan for two persons assistance with the mechanical lift. Effective 03/25/2023, the facility clinical team to include the Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1 and/or Unit Coordinator #2 revised the process of reviewing all new admits/readmits in a daily clinical meeting and include the provision for bed mobility assessment to ensure it is completed and documented in electronic medical records, presence of osteopenia and/or osteoporosis, and ensure appropriate care plan is in place. Any discrepancies identified are corrected promptly. Finding of this systemic change is documented on the daily clinical meeting report form located on the daily clinical meeting binder. 100% education of all current staff to include full-time, part-time, employees from contracted staffing agencies company, and as needed employees completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1, #2). The emphasis of this education includes but not limited to, the importance of completing bed mobility assessment on admission, quarterly and with changes of bed mobility status. Staff education also focused on facility abuse prohibition policy and procedures. and the requirements to use two persons assistance when using mechanical lifts at all times. This education was completed by 03/25/2023. Any staff members not educated 03/25/2023 is not allowed to work until educated. This education is now provided annually and has been added to the new hire orientation for all new employees including agency employees effective 03/25/2023. How the facility plans to monitor its performance to make sure that solutions are sustained: Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, MDS Coordinators (#1, #2), Unit Coordinators (#1, #2), and/or Weekend Supervisor complete abuse prohibition monitoring process. This monitoring process is accomplished by observing residents to ensure employees are providing services in the facility that assure each resident is free from abuse and neglect, and to provide an environment that is free from accidents and hazards. The monitoring process is accomplished by observing five randomly selected staff when using the mechanical lift to ensure two people are present when using the lift. This monitoring process will be completed daily for two weeks, weekly for two more weeks, then monthly for three months, or until the pattern of compliance is established. Any negative findings are addressed promptly. This monitoring process is documented on a Mechanical lift use monitoring tool located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, Unit Coordinators (#1, #2), and/or Weekend Supervisor review all new admissions for the last 24 hours or from last clinical meeting to ensure that a bed mobility assessment has been completed, a diagnosis or osteopenia/osteoporosis has been identified (if any) and plan or care developed to include intervention such as two people assistance with transfers when to minimize risk if injuries. Any negative findings are corrected promptly. This monitoring process is completed daily for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the bed mobility assessment tool for new residents located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, Unit Coordinators (#1, #2), and/or Weekend Supervisor complete incident/accident monitoring process. This monitoring process will be accomplished by reviewing all skin assessments and shower sheets completed for the last 24 hours or from last clinical meeting to ensure that any identified injuries of unknown source has been assessed by a nurse and being addressed promptly. Any negative findings are corrected promptly. This monitoring process is completed daily for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process are documented on the Skin assessments audit tool located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing and/or Assistant Director of Nursing report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Date of Completion: 3/25/23 The facility provided a corrective action plan for the incident that happened on 3/18/23 with a completion date of 3/25/23. The onsite validation was conducted on 4/10/23. Staff from different departments and who worked different shifts were interviewed and verified they had received training in using two people when transferring residents in a mechanical lift. Alert and oriented residents were interviewed who indicated they had been asked if they had been abused by staff and the residents had no concerns. A review was completed of the audit logs that included the educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were reviewed, staff names were randomly selected and verified to have received training. The audit of resident medical diagnoses, care plan to include two staff for transfer with a mechanical lift, the shower sheets and incident reports were verified to have been completed and no additional unreported injuries were identified. A review of the monitoring tool revealed staff had completed daily monitoring of shower sheets and incident reports. The QAPI plans to include this monitoring in their next meeting. The facility's compliance date was validated as 3/26/23.

Based on record review, staff interviews, nurse practitioner, and medical director interview, the facility failed to have a nurse assess a severely cognitively impaired resident (Resident #22) when an injury of unknown origin was discovered. On 3/18/23 nurse aide (NA) #1 did not report new bruising to Resident #22's left thigh and right fourth toe. On 3/20/23 Resident #22 was observed to have a bruise to her left thigh described as the size of a salad plate saucer and swollen knee. These findings were reported to Nurse #2 who assessed Resident #22. X-ray results revealed Resident #22 had a grossly displaced complex fracture of the left distal femur with angulation at the fracture site (the femur was broken in more than one place and the bone fragments were at an angle to each other). This was for 1 of 1 resident reviewed for an injury of unknown origin. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Tourette's disease (a nervous system disorder involving repetitive movements or unwanted sounds) cognitive communication deficit, abnormal posture, vascular dementia with behavioral disturbances, convulsions, and osteoporosis. The annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #22 was severely cognitively impaired, had unclear speech, and sometimes was able to understand others. The MDS showed Resident #22 required extensive assistance from two staff members for transfers and total assistance from one staff member for bathing. The MDS showed Resident #22 had not taken any anticoagulants, did not have any behaviors of refusing care, and did not have any physical/verbal behaviors directed at others. The care plan dated 1/8/23 showed Resident #22 had a focused area of socially inappropriate/disruptive behaviors of screaming out at times related to Tourette's disorder and a difficulty communicating. Interventions included attempt to redirect as needed and use simple communications. A shower log and skin assessment sheet dated 3/15/23 showed Resident #22 had no documented bruises on her skin. The shower sheet was signed by Nurse Aide #1 on 3/15/23 and the Unit Manager on 3/16/23. A shower log and skin assessment sheet dated 3/18/23 (Saturday) showed Resident #22 had bruising on her left thigh and bruising on her right fourth toe. The shower sheet was signed by Nurse Aide #1 on 3/18/23 and the Unit Manager on 3/20/23. Review of facility records showed no shift report sheet dated 3/18/23 from the 7 P.M. to 7 A.M. shift. The shift report listed each resident on an assignment. The shift report was used by staff to document changes in a resident's care reported from previous shifts and that occurred during their shift, in addition the sheet showed resident's glucose blood sugar results for sliding scale insulin to be administered. Review of a nursing progress note written by Nurse #2 dated 3/20/23 read nurse aide was giving bath notice left knee was swollen. Physician was notified, order for left leg to be x-ray, writer called mobile x-ray mobile imagining. Review of an x-ray dated 3/20/23 of Resident #22's left femur (thigh bone) showed osseous mineralization was decreased. This could reflect osteopenia (reduced bone mass lesser severity than osteoporosis) or osteoporosis (condition in which bones become brittle and fragile from a loss of tissue). The report also read Resident #22 had a grossly displaced complex fracture of the distal femur with angulation at the fracture site and soft tissue swelling. (the femur was broken in more than one place and the bone fragments were at an angle to each other). Review of physician orders dated 3/20/23 showed an order to send Resident #22 to the emergency department for evaluation of a possible femur fracture. Review of a nursing progress note written by the Unit Manager dated 3/20/23 read Resident sent to ER for further evaluation and treatment per MD for possible leg femur fracture. Review of the hospital physical assessment dated [DATE] read Left leg has obvious deformity. There is moderate swelling to left thigh with bruising. No additional obvious trauma on exam. Resident #22's vital signs were stable, and she was not in any distress. Resident #22 showed signs of dementia, was alert, and moved her extremities spontaneously. The x-ray taken at the hospital on 3/20/23 showed Resident #22 had a comminuted fracture (a fracture where the bone is broken in at least two places) that was reduced (a procedure used to set broken bones without cutting the skin open) in the emergency room and splinted after orthopedic surgery consultation. Resident #22 was admitted to the hospital on 3/20/23 with diagnosis that included closed fracture of distal end of left femur. (a fracture of the thigh bone above the knee). The resident was readmitted to the facility on [DATE]. A telephone interview was conducted on 4/4/23 at 2:32 P.M. with NA #1 who was assigned Resident #22 on 3/18/23 and 3/19/23 during the 7 P.M. to 7 A.M. shift. During the interview, NA #1 indicated when she gave Resident #22 a bed bath on 3/18/23, she observed bruising on Resident #22's left thigh, under her left knee, and on her fourth toe. NA #1 indicated Resident #22 did not appear to have a deformed leg. NA #1 stated she reported the bruising on Resident #22 to Medication Aide #2 and continued to provide Resident #22 with care throughout the rest of the shift. NA #1 indicated there was no change in Resident #22's behaviors from her baseline. During the interview, NA #1 indicated the previous shift had not reported any bruising on Resident #22. A follow up telephone interview was conducted with NA #1 on 4/6/23 at 11:19 A.M. During the interview, NA #1 indicated the skin conditions she observed on Resident #22 were immediately reported to Medication Aide #2 when she observed them. NA #1 described the bruise she observed on Resident #22's knee as a yellow bruise in the middle of Resident #22's knee, about the width of a number two pencil from the eraser to where it says two on the side of the pencil that curved with the natural curve of the knee. During the interview, NA #1 was unable to describe the length of the bruise on Resident #22's left knee. NA #1 indicated she completed the shower sheet and put the sheet in the shower book at the nurses' station for review. NA #1 indicated Resident #22's bruising was not reported to the assigned nurse on duty. During the interview, NA #1 indicated she had been educated prior to this date to report changes to both the medication aide and the assigned nurse. NA #1 did not indicate the appearance of Resident #22's bruise on 3/19/23. A telephone interview was conducted on 4/4/23 at 3:06 P.M. with Medication Aide #2 assigned Resident #22 on 3/18/23 and 3/19/23 during the 7 P.M. to 7 A.M. shift. During the interview, the Medication Aide indicated when nurse aide #1 went into Resident #22's room to provide incontinence care to Resident #22, she observed a bruise on Resident #22's fourth toe and the back of her left knee. Medication Aide #2 indicated NA #1 reported the bruises to her at that time. Medication Aide #2 indicated the bruising appeared purple and dark in color and she thought the bruises were old. During the interview, Medication Aide #2 stated she wrote down the location of the bruises on a piece of paper and gave the paper to Nurse #1. The Medication Aide #2 indicated she had not received a report Resident #22 had a fall or another incident and was unsure what had caused the bruising. A follow up telephone interview was conducted on 4/6/23 at 11:37 A.M. with Medication Aide #2. During the interview, the Medication Aide indicated when she observed the bruises on Resident #22, she wrote the information down on a 24-hour shift report. The Medication Aide was unsure what time she handed the report to Nurse #1. The Medication Aide observed Resident #22 to have two bruises, a bruise on the top of the right fourth toe and a bruise on the back of the knee. During the interview, Medication Aide #2 indicated Resident #22 had to be turned onto her side to observe the bruise on her left knee. Medication Aide #2 was unable to describe the size and appearance of the bruise and stated she was not sure how to measure bruises. Medication [NAME] #2 was unable to recall if she verbally told the nurse about Resident #22's bruising. A telephone interview was conducted on 4/5/23 at 4:21 P.M. with Nurse #1 who was the nurse overseeing the Medication Aide on 3/18/23. During the interview, Nurse #1 indicated when a nurse aide completed a resident's shower, the nurse aide used the shower sheet paperwork to document any changes in the resident's skin. The shower sheet was then provided to the assigned nurse with any changes in the resident's skin for the nurse to complete an assessment of the resident. Nurse #1 indicated she did not receive a report on 3/18/23 about any changes in Resident #22's skin. Nurse #1 further indicated had she received a report, she would have assessed Resident #22's skin. A follow up interview was conducted on 4/6/23 at 11:45 A.M. with Nurse #1. During the interview, Nurse #1 indicated at approximately 6:30 A.M. on 3/19/23, Medication Aide #2, assigned to Resident #22, gave her a scratch sheet of paper. The paper had the residents assigned to Medication Aide #2's blood glucose results, to include Resident #22's blood glucose results. Nurse #1 indicated she did not see any changes in Resident #22's skin written on the sheet. During the interview, Nurse #1 indicated no one during the shift verbally told her about any bruises on Resident #22's skin. An interview was conducted on 4/5/23 at 4:29 P.M. with NA #3 who was assigned Resident #22 on 3/19/23 for the 7 A.M. to 7 P.M. shift. During the interview NA #3 indicated she had not worked with Resident #22 long and she does not recall Resident #22 to have a bruise. NA #3 indicated nothing about Resident #22 having a bruise was given during the shift report and had she observed a bruise on Resident #22, she would have immediately reported the mark to her assigned nurse. An interview was conducted on 4/4/23 at 1:29 P.M. with Nurse Aide #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. NA #2 indicated she had not received a report Resident #22 had a fall or any injury. When she went to Resident #22's room to provide her with a bed bath she noticed bruising that was light in color on her left thigh approximately the size of a salad plate saucer. NA #2 indicated when she reached over the side of the bed, NA #2 observed Resident #22 to have a swollen knee. NA #2 reported the bruising to the assigned nurse. An interview was conducted on 4/4/23 at 2:02 P.M. with Nurse #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. Nurse #2 indicated she had not received a report Resident #22 had a fall or another incident with injury. Nurse #2 indicated Resident #22 was sleeping when she arrived for her shift on 3/20/23 with no calling out or moaning. During the interview, Nurse #2 indicated NA #2 reported Resident #22 had a bruise on her thigh, a bruise under her left leg by her knee, and an indentation above the left knee. Nurse #2 assessed Resident #22 and described the bruise under her leg at the knee as being about the size of a softball. The bruise was dark purple, red, with a little bit of tint on her thigh. Nurse #2 indicated the indentation at the left knee was only observed when the leg was looked at from the side. During the interview, Nurse #2 indicated she felt Resident #22 had a broken leg and reported the injury to the Unit Manager. Nurse #2 further indicated the x-ray technician reported to her, when Resident #2's left thigh was x-rayed, Resident #22 did not call out when her leg was repositioned. An interview was conducted on 4/4/23 at 1:16 P.M. with the Unit Manager. The Unit Manager indicated she was unaware Resident #22 had any bruising on her left thigh until 3/20/23 when Nurse #2 made her aware. The Unit Manger indicated herself and Nurse #2 went and assessed Resident #22. During the interview, the Unit Manger indicated Resident #22 was unable to verbalize what caused the bruise, so a head-to-toe assessment was completed with the following results: a bruise the size of a softball on the top of Resident #22's left thigh that appeared to be a newer bruise because it was not yellow, a bruise behind Resident #22's left knee, and a bruise on a toe. The Unit Manager indicated she does not recall which toe had a bruise. During the interview, the Unit Manager indicated Resident #22 was unable to verbalize pain but did not show any nonverbal signs of being in pain when she assessed her on 3/20/23. The physician was notified, and a mobile x-ray was ordered. The Physician gave orders to send Resident #22 to the hospital when the x-ray results showed a fracture. The Unit Manager indicated on 3/18/22 staff should have reported the bruise on Resident #22's thigh to the nurse that worked that shift. A telephone interview was conducted on 4/6/23 at 3:25 P.M. with the Nurse Practitioner (NP). The NP indicated she was in the building on 3/20/23 when she was alerted by nursing staff Resident #22 needed to be assessed for a bruise. The NP observed a large bruise on Resident #22's top to the side of her left thigh that appeared to be under 24 hours old based on the coloration and her leg was a little swollen. During the interview the NP indicated she felt Resident #22 had a possible fracture. The NP indicated the facility completed an investigation and it was determined the injury occurred due to a mechanical lift, Resident #22's combativeness, and Resident #22's weak bones. A telephone interview was conducted on 4/5/23 at 8:22 A.M. with the Medical Director. During the interview, the Medical Director indicated he was made aware Resident #22 had a bruise on her left thigh on 3/20/23. The Medical Director indicated an x-ray was ordered and it was discovered Resident #22 had a fracture. During the interview, the Medical Director indicated Resident #22 was severely demented and unable to express to staff the cause of her bruise. The facility completed an investigation and determined the improper use of a mechanical lift and the repositioning of the resident during her bath had caused the injury. An interview was conducted with the Director of Nursing (DON) on 4/4/23 at 3:42 P.M. During the interview, the DON indicated the Unit Manager reported the bruise on Resident #22's left thigh to herself and the Administrator. When the facility was made aware of the bruise, an investigation was immediately started. The DON indicated staff should have reported the bruise to herself or the Administrator when it was discovered over the weekend, and she is unsure why staff had not reported the injury when it was first discovered. The Administrator was notified of the Immediate Jeopardy on 4/6/23 at 5:00 P.M. The facility provided a corrective action plan on 4/8/23 which alleged a date of completion of 3/25/23. The corrective action plan indicated: The root cause analysis identified that the alleged noncompliance resulted from the failure of the facility staff (nurse aide #1) to report an injury of unknown source to a nurse on 3/18/2023 for further assessment and plan of care. Resident #22 injury was assessed by a nurse on 3/20/2023. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 3/25/2023, Nursing assistant #1 was immediately suspended to allow further investigation of the allegation of abuse/neglect of Resident #22. Nurse #1 assessed Resident #22 on 03/20/2023 and notified the attending physician who ordered an X ray of resident #22's leg. Unit coordinator #1 spoke to Xray technician who completed the Xray and received a preliminary result that resident had a fracture. Unit coordinator #1 contacted the Attending physician who ordered resident #22 to be sent to hospital for evaluation and treatment. The unit coordinator notified resident #22 responsible party of the change in condition as well as transfer to the hospital on 3/20/2023. On 03/25/2023, Director of nursing completed a one-on-one education with nursing assistant #1 on the importance of reporting any incident, accident, or any injuries to a nurse on duty for further evaluation and treatment. How the facility will identify other residents having the potential to be affected by the same deficient practice: 100% audit of all incident reports written in the last 30 days completed on March 25, 2023, by Director of Nursing, Unit coordinator #1, and/or Unit manager #2 to identify any other incident or injury not reported to a nurse on time. No other injuries and/or incidents/accidents identified as not reported to a nurse for proper follow ups. Findings of this audit are documented on an incident report audit tool located in the facility compliance binder. 100% audit of all current resident's shower sheets for the last 30 days was completed on 03/25/2023 by Director of Nursing, MDS Coordinator #1, MDS coordinator #2, Unit coordinator #1, and/or Unit manager #2 to identify any other documentation of an injury that was not reported to a nurse for proper assessment. No other injuries were identified as not reported to a nurse for proper follow-up. Findings of this audit are documented on shower sheets audit tool located in the facility compliance binder. Measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Effective 03/25/2023, facility ensures each residents receives quality of care and treatment based on the comprehensive assessment of a resident and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to ensuring any injury of a resident is reported to a nurse for proper assessment and follow ups. Effective 03/25/2023 facility employees follow the company policy and procedures, when observing/identifying any injury to a resident, by notifying the nurse on duty for proper assessment and follow ups. Effective 3/25/2023 and moving forward nurse on duty assess any reported injury and document findings on each resident's medical records. 100% education of all current staff to include full time, part time, employees from contracted staffing agencies company, and as needed nursing employees were completed by the Director of Nursing, Assistant Director of Nursing, Staff development coordinator, and/or Unit Coordinators (#1, #2). The emphasis of this education includes but is not limited to, the importance of reporting any incident/accident to a nurse on duty for proper assessment and follow-ups. This education was completed by 03/25/2023. Any staff members not educated on 03/25/2023, was not allowed to work until educated. This education will be provided annually and is added to the new hire orientation for all new employees effective 03/25/2023. How the facility plans to monitor its performance to make sure that solutions are sustained. Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, MDS coordinators (#1, #2) and/or Unit Coordinators (#1, #2) have been completing quality of care monitoring process. This monitoring process is accomplished by reviewing all skin assessments and shower sheets completed for the last 24 hours or from last clinical meeting to ensure that any identified injuries has been assessed by a nurse and being addressed promptly. Any negative findings are corrected promptly. This monitoring process has been completed daily Monday through Friday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process are documented on the Skin assessments audit tool located in the facility compliance binder. Effective 03/25/2023, the weekend nurse supervisor completes quality of care monitoring process. This monitoring process is accomplished by reviewing all skin assessments and shower sheets completed for the last 24 hours to ensure that any identified injuries have been assessed by a nurse and addressed promptly. Any negative findings are corrected promptly. This monitoring process is completed every Saturday, and Sunday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the Skin assessments audit tool located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing and/or Assistant Director of Nursing report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Date of Completion: 3/25/23 The facility provided a corrective action plan for the incident that happened on 3/18/23 with a completion date of 3/25/23. The onsite validation process was completed on 4/10/23. Staff from different departments and who worked different shifts were interviewed and verified they had received training to immediately report injuries to a nurse. A review was completed of the audit logs that included the educational information provided to staff during the in-service and a review of in-service staff sign in logs. The in-service logs were reviewed, staff names were randomly selected and verified to have received training. The audit of the shower sheets and incident reports were verified to have been completed and no additional unreported injuries were identified. A review of the monitoring tool revealed staff had completed daily monitoring of shower sheets and incident reports. The QAPI plans to include this monitoring in their next meeting. The facility's compliance date was validated as 3/26/23.

Based on observation, record review, and staff interview, for one (Resident # 1) of three sampled residents who had experienced accidents, the facility failed to assure a Nurse Aide safely assisted a resident with personal care. While Nurse Aide #1 was turning Resident# 1 for incontinence care, Resident # 1 rolled out of bed and sustained fractures to two toes and a fracture to her left orbital area (the area around the eyeball.) She also sustained a dislocated finger with possible fracture and a laceration to her forehead. The findings included: Resident # 1 was admitted to the facility on [DATE]. Although not all inclusive, the resident had diagnoses of muscle weakness, [CONDITION(S)], and [CONDITION(S)]. The resident's quarterly MDS (Minimum Data Set) assessment, dated 4/6/22, coded the resident as cognitively intact and as needing extensive assistance by one person for bed mobility and hygiene needs. Nurse # 1 made the following nursing entry on 4/8/22 at 6:31 PM. CNA (certified nursing assistant) notified me that she needed help because resident had fallen out/off of bed while she was being turned. Upon entering room resident was on floor bleeding from her forehead. I sent CNA to desk to call EMS and get cold compress while I assessed the resident. Resident was alert and oriented X 4. I applied her O2 (oxygen) mask, covered her and CNA and I turned her on her back. Told CNA to stay with resident and apply pressure (to) the wound while I got her paperwork ready for EMS (Emergency Medical Services) and called RP (Responsible Party). Nurse # 1 further noted Resident # 1's family arrived and the resident was transported to the hospital. Review of Resident # 1's discharge summary, orthopedic consults, progress notes, and diagnostic tests for the hospitalization dates of 4/8/22 to 4/12/22 revealed the following information. Resident # 1 had sustained a 2 ½ centimeter laceration above her eye, which was repaired in the emergency department. She had sustained a nondisplaced left orbital fracture and hairline fractures to her second and third left toes. She also had sustained a subluxation (dislocation) of the left middle finger. According to the radiologist readings of the left-hand x-ray, the radiologist noted there was a slight bone density at the level of the finger dislocation which might signify an accompanying fracture. Hospital notes reflected an attempt was made to treat the dislocated finger, but orthopedic treatment was not successful. The physician noted this was discussed with Resident # 1's family, and since the dislocated finger was on the nondominant hand, the decision was made to leave the injury without further treatment. According to orthopedic notes, since Resident # 1 was non-ambulatory, no long- term splint was needed for the hairline fractures of her toes. For pain control, the hospital records indicated upon arrival to the Emergency Department Resident # 1 was given Morphine; noting that she was in significant pain upon arrival to the emergency department. Review of the hospital discharge summary revealed Resident # 1 had been diagnosed with exacerbation of both her [CONDITION(S)] and chronic obstructive pulmonary and these conditions were also treated while she was hospitalized . On 4/12/22 she was discharged back to the facility in stable condition. Resident # 1 was interviewed on 4/19/22 at 2:30 PM and reported the following. She recalled on the day of the fall that she had told NA # 1 that she was too close to the edge of the bed. The resident stated the next thing she remembered, the NA let go of her and she went head first and hit the floor. Resident # 1 pointed to the area of her forehead directly above her eyes and stated she hit the floor there. Resident # 1 was observed to still have extensive bruising to the left side of her face and a small area also under her right eye. Half of the resident's left cheek was purple in color. Four of Resident # 1's left toes were purplish in color and her middle left finger was observed swollen. Resident # 1 stated the nurses were now giving her Tylenol to relieve pain. NA # 1 was interviewed on 4/19/22 12:30 PM and reported the following about the day of the incident. She was preparing to provide incontinence care to Resident #1 on 4/8/22. At the time of the incontinence care, the bed was at naval level. NA # 1 stated she always pulled residents close to her before turning them. According to NA # 1 she had pulled Resident # 1 towards her before turning her in the opposite direction away from her for care on 4/8/22. According to NA # 1, Resident # 1 was acting sleepy that day and, when she turned her, Resident # 1 rolled out of the bed. NA # 1 stated the nurse was right outside the door and she immediately called for the nurse to help. The nurse came immediately and checked Resident # 1. The resident had a cut on her head. NA # 1 stated she was directed to go get a washcloth to apply pressure to the resident's head. This was done. NA # 1 reported multiple staff members came in to check on the resident and she remained with Resident # 1 until EMS arrived in the parking lot and the resident said she was okay. After EMS arrival, she had to attend to a wandering resident. Nurse # 1 was interviewed on 4/21/22 at 10:40 AM via phone and reported the following. She was two doors down from Resident # 1's room on the evening of 4/6/22 when NA # 1 stepped to the door and alerted her Resident # 1 had fallen. She went to assess the resident. They rolled her over and found she had a cut to her head. She directed NA # 1 to obtain a washcloth. MA (Medication Aide) # 1 was also present, and MA # 1 was directed to call 911 for emergency services. By holding the washcloth to the resident's head, she was able to get the bleeding to stop. NA # 1 remained with Resident # 1 after Nurse # 1 assured the resident was no longer bleeding, and then Nurse # 1 went to prepare transfer paperwork for EMS. The resident was transferred to the hospital via EMS. The Administrator was interviewed on 4/19/22 at 11:40 AM and again at 3:00 PM. According to the Administrator, Resident # 1 had just undergone a quarterly MDS assessment on 4/6/22 prior to the accident. At that time the MDS nurse had assessed that Resident # 1 had enough upper body strength to help with positioning and thereby was deemed to need only one person's assistance for bed mobility. Following the incident, they had investigated the circumstances and talked to Resident # 1. Resident # 1 had indicated to the facility staff that NA # 1 had not pulled her closer to her before turning her on the day of the incident. Therefore, the facility had initiated a complete plan of correction for the incident. They had also updated Resident # 1's care plan to reflect she needed two staff members for bed mobility in future. The Administrator provided their written plan of correction. The facility provided the following corrective action plan with a compliance date of 4/15/22: Problem identified: Resident # 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Between the original admission and last readmission, she has multiple readmissions. The most recent readmission, she was readmitted with diagnoses that included (in parts) Acute respiratory failure, anxiety disorder, hypertension, heart failure, muscle weakness, needs assistance with personal care. Review of discharge summary form from a local hospital transcribed on 4/12/2022 indicted that Resident # 1 was diagnosed with left toe fracture, finger fracture, and left orbital fracture resulted from a fall, Resident # 1 was discharged back to the facility on [DATE] with medication including Acetaminophen 650 mg (milligrams) Q 6 hours (every 6 hours) for pain. Review of incident report completed on 4/8/2022, indicated that Resident # 1 fell out of bed when Nursing Assistant # 1 was providing activity of daily living care at around 5 PM. The report detailed that (in parts) on 4/8/22, Nursing Assistant # 1 was providing care to Resident # 1 while in bed. Review of Nursing Aide # 1 written stated dated April 14, 2022, indicated that; Nursing Assistant # 1 provided care to Resident # 1 roommate before proceeding to Resident # 1. When she approached Resident # 1, Resident # 1 was asleep. Nursing Aide # 1 woke up Resident # 1 to change her. Nursing Aide # 1 statement added that, Resident # 1 lowered her head of bed to allow her to proceed changing her. Nursing Aide # 1 indicated that she turned a resident away from her body, while Resident # 1 bed was in position appropriate for nursing aide to provide care. She indicated that the bed was around her Navel level (measured to be 40 inches from the floor). She added that when she rolled Resident # 1, Resident # 1 was close to her side of bed, however when she rolled her, resident moved slightly and rolled to the floor. Nurse aide # 1 proceeded to call for assistance of a licensed Nurse # 1 who provide first aide to Resident # 1. Review of Resident # 1 quarterly Minimum Data Set (MDS) assessment with Assessment Reference date (ARD) of 4/6/22 indicated that Resident # 1 had a Brief Interview of Mental Status (BIMS) score of 14 with no short term no long-term memory loss. Review of Section G (functional status) of MDS assessment indicated Resident # 1 requires one person assistance with bed mobility, two-person assistance with transfers, and/or set up assistance with eating. Review of care plan for Resident # 1 for activities of daily living dated 1/27/22 indicated (in parts); assist with perineal cleansing as needed, encourage resident to participate on small tasks of hygiene. Root Cause Analysis (RCA): The Governing body led by the facility Executive Director and Director of Nursing in collaboration with the selected members of the facility Quality Assurance and Performance Improvement (QAPI) committee conducted the root cause analysis on April 14,2022, to identify the causative factor for this alleged noncompliance and implemented appropriate measure to correct and prevent the reoccurrences. The root cause analysis identified that the alleged noncompliance resulted from the failure of an employee to pull the resident to the center of the bed before turning resident during ADL care on 4/8/22 that resulted onto a fall. The RCA further identified that facility staff remained with the resident in the room for most of the time until resident was settled and stabilized but departed briefly to redirect another resident who walked in Resident # 1's room before EMS arrived to pick up Resident # 1 following Resident # 1's fall with injuries on 4/8/22. Immediate Action Implemented: Resident # 1 first aid was provided by Nurse # 1 by applying pressure to an open area on Resident #1's forehead on 4/8/22. While resident was on the floor, 911 was contacted and arrived at the facility to transfer resident toER on [DATE]. On 4/14/2022, Director of Nursing completed a competence evaluation titled providing incontinence care for resident in bed for Nursing Aide # 1. The emphasis was on component # 5 that focus on ensuring resident is centered in bed when care is provided. Resident # 1 was readmitted on [DATE]. Resident # 1 was reassessed by MDS coordinator # 1 and care plan was revised to include measures for pain management and two person's assistance with ADLs. Identification of Other Residents who Might be Affected: 100% audit of current resident's care plans completed by MDS Coordinator # 1 and/or MDS Coordinator # 2 on April 13, 2022, to assure each resident has an ADL care plan that indicates the amount of assistance required during ADL care and ensure the care guide in kiosk is updated with such information. Findings of this audit is documented on a care plan ADL audit tool located in the facility compliance binder. 100% audit of all incident reports written in the last 30 days completed on Aril 12, 2022, by Director of Nursing, Unit coordinator # 1 and/or Unit manager # 2 to identify any other incident of fall or assisted fall in which resident was left unattended. No other incidents/ accidents identified with resident being left unattended. Findings of this audit is documented on an incident report audit tool located in the facility compliance binder. 100% audit of all current resident's medical records documented for the last 30 days was completed on April 13, 2022, by Director of Nursing, MDS Coordinator # 1, MDS Coordinator #2, Unit Coordinator # 1, and/or Unit Manager # 2 to identify any other documentation of a resident with an incident or accident and was left unattended. No other documentation of an incident/accidents identified with resident being left unattended. Findings of this audit is documented on clinical documentation audit tool located in the facility compliance binder. Systemic Changes and Modification: Effective April 14, 2022, all new residents will have a bed mobility assessment completed on admission, quarterly, and with any changes in their bed mobility status, by the licensed nurse on duty. This will be reviewed in the daily clinical meeting and be documented on the facility medical records under ADL care guide intervention module. Moving forward, residents, ADL assistance needs will be added on the care guide located electronically in the kiosks. Effective April 14, 2022, resident will be centered in bed before being turned from one side to side during care. Staff member will use appropriate number of staff based on resident's care plan. Effective April 14, 2022, no residents will be left unattended after being observed on the floor. Any staff member who observes a resident on the floor will ensure the resident is safe and then call for assistance by activating the call bell light. If no one comes immediately, staff will step outside of location and call for assistance (Staff member will remain with the resident at all times until 911 arrived. Effective April 14, 2022, the facility clinical team to include the Director of Nursing, Assistant Director of Nursing, Unit Manager # 1 and/or Unit Manager # 2 revised the process of reviewing all new admits/readmits in a daily clinical meeting and include the provision for bed mobility assessment to ensure it is completed and documented in electronic medical records. Any discrepancies identified is corrected promptly. Finding of this systemic change is documented on the daily clinical meeting report form located on the daily clinical meeting binder. 100% education of all current nursing staff to include full time, part time, and as needed nursing employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (# 1, #2). The emphasis of this education includes but not limited to, the importance of completing bed mobility assessment on admission, quarterly and with changes of bed mobility status. This education will be completed by April 15, 2022. Any nursing staff members (Registered nurses, Licensed practical nurses, Medication aides, Certified nurse aides and patient care aides) not educated by April 15, 2022, will not be allowed to work until educated. This education will be provided annually and will be added to new hire orientation for all new nursing employees effective April 15, 2022. Incident and accident process and safety of our residents. 100% education of all current nursing staff to include full time, part time, and as needed employees will be completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators. The emphasis of this education includes but not limited to the importance of ensuring resident is centered in bed during bed mobility. The education also emphasized the importance of ensuring resident is not left unattended while on the floor, until proper assessment and assistance arrived. This education will be completed by April 15, 2022. Any nursing staff members not educated by April 15, 2022 will not be allowed to work until educated. This education will be provided annually and will be added to new hire orientation for all new nursing employees effective April 15, 2022 incident and accident process and safety of our residents. Monitoring Process: Effective April 14, 2022, the Director of Nursing, Assistant Director of Nursing, MDS coordinators (#1, #2) and/or Unit Coordinators (#1, #2) will complete incident/accident monitoring process. This monitoring process will be accomplished by observing residents to ensure employees are providing services in the facility that assure an environment that is free from accidents and hazards. The monitoring process will be accomplished by observing five randomly selected staff members and residents. The observer will focus on observing ADL care specifically pertaining to bed mobility and ensure staff members keep resident at the center of the bed before turning from one side to another. The observer will also ensure appropriate number of staff based on individual residents' care plan is adhered. This monitoring process will be completed daily (Monday through Friday) for two weeks, weekly for two more weeks, then monthly for three months, or until the pattern of compliance is established. Any negative findings will be addressed by the Director of nursing promptly. This monitoring process will be documented on an accommodation of needs monitoring tool located in the facility compliance binder. Effective April 14, 2022, the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1, #2) will review all new admissions for the last 24 hours or from last clinical meeting to ensure that a bed mobility assessment has been completed. Any negative findings will be corrected promptly. This monitoring process will be completed daily Monday through Friday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the bed mobility assessment tool for new residents located on the facility compliance binder. Effective April 14, 2022, the Director of Nursing, and/or Unit Coordinators (# 1, #2) will review all incidents and accidents on daily clinical meeting to ensure that all residents were assisted promptly and not left unattended. This monitoring process will be completed daily Monday through Friday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the incidents and Accidents monitoring tool located in the facility compliance binder. Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is achieved. Person responsible to implement Corrective Plan of Care: Effective April 14, 2022, the Executive Director and the Director of Nursing will be ultimately responsible for the implementation of this plan of correction and ensure that the facility attains and maintains substantial compliance. The facility alleged compliance date: 4/15/22 The facility's credible allegation of compliance was validated on 4/19/22 by the following. Multiple residents were interviewed and reported they felt facility staff provided care in a safe manner. No resident reported any accidents in which a staff member was involved or whose care contributed to the accident. Review of Resident # 1's care plan revealed it had been updated to reflect two staff members were needed to provide bed mobility assistance for Resident # 1. On 4/19/22 at 2:15 PM Resident # 1 was observed as staff members provided incontinence care. There were two nurse aides present and they took appropriate measures to assure the resident was not near the edge of the bed before turning her to care for her. Resident # 1 was interviewed following the direct care and reported no further safety problems. Resident # 1 reported she was happy to be back at the facility. Review of in-service records revealed the DON and ADON presented a 30 minute education course for their direct care staff per their plan of correction on the topic of incidents, accidents and quality of care. There were accompanying sign in sheets where the facility staff members signed they attended. According to an interview with the Administrator, the in-services were begun on 4/11/22 and completed on 4/15/22. The signatures on the sign in sheets reflected this also. The facility provided documentation NA # 1 had undergone competency evaluation in providing incontinence care on 4/14/22 and was evaluated to meet current standards of practice by the DON. The facility provided evidence they had performed their audits per the plan of correction and documentation that their monitoring tools were begun on 4/14/22 and continuing per the planned schedule in their plan of correction. Nurses and Nurse Aides from different shifts were interviewed and verified they had attended the facility's in-service training on incidents, accidents and quality of care. Interviewed staff members reported they would assure a resident was safe in the middle of the bed before turning them. Nursing staff members also knew to check the kiosk care plan information to find the appropriate amount of needed assistance for each resident.

Based on record review and interviews with staff, paramedic and family, the facility failed to provide an accurate code status to Emergency Medical Services (EMS) for one of three residents reviewed for advanced directives. Resident #1, who chose a full code status, experienced [CONDITION(S)] on [DATE] and was not provided cardio-pulmonary resuscitation (CPR). Resident #1 expired at the facility on [DATE] and the certificate of death indicated a cause of death included cardiorespiratory arrest. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated [DATE] and completed by Nurse #1 revealed Resident #1 complained of chest pain to Nurse #1. Vital signs were listed as Blood Pressure ,d+[DATE]; pulse 67; respirations 18; temperature 97.5; oxygen saturation in low 80s. Resident #1 was started on oxygen. Resident #1 stated she thought she was having a [CONDITION(S)]. EMS was called and arrived in ten minutes. As EMS arrived and were taking over, they asked for the code status. According to the documents in Resident #1's folder, she was a DNR. From that time on nothing major was done to try to resuscitate her. She was pronounced dead at 10:40 PM. Review of Resident #1's certificate of death on [DATE] indicated the cause of death included cardiorespiratory arrest. In an interview on [DATE] at 3:17 PM, Nurse #1 stated after EMS was called, he was monitoring Resident #1's breathing conditions. Nurse #1 stated Resident #1 had a pulse, but it was not strong. Nurse #1 stated when EMS arrived and started to take over the care of Resident #1, they requested the code status and several of the staff were trying to establish that. Nurse #1 stated he was not aware of Resident #1's code status and knew it was in the filing cabinet in the nurse's station. Nurse #1 stated he was not sure who was looking for the code status, because he stayed with Resident #1, or who gave it to EMS, but Nurse #1 stated it was a Do Not Resuscitate form. On [DATE] at 8:00 AM, the Paramedic with EMS was interviewed and stated when he and other emergency personnel arrived at the facility on [DATE], Resident #1 was breathing and had a faint heartbeat. When code status was requested, facility staff said they did not know. The Paramedic stated he had applied a cardiac monitor with defibrillator pads on Resident #1, as well as electrocardiogram stickers in case they were needed. The Paramedic stated Resident #1 had a very slow pulse, and the external pacemaker was used to stimulate a stronger heartbeat and indicated after about ,d+[DATE] minutes Resident #1 lost her gag reflex and an endotracheal tube (a tube to maintain an airway) was put in and was breathing for the Resident. The Paramedic stated at that point Resident #1 was in [CONDITION(S)]. The staff brought in a DNR paper and a MOST (a form describing Medical Orders for Scope of Treatment) form indicating do not resuscitate, and EMS stopped their efforts. The Paramedic stated Resident #1's family member came to the facility when EMS was completing paperwork and stated Resident #1's code status had been changed to a full code. A review of the police report indicated the officer had arrived at the facility on [DATE] and was told the resident had a DNR order and EMS had stopped attempting to resuscitate. The report indicated the officer viewed the body and the family member of Resident #1 arrived and questioned why resuscitation measures were stopped. The officer explained the DNR form was given to EMS by facility staff. No charges were filed. An interview with Resident #1's family member was conducted on [DATE] at 11:46 AM. The family member stated she and Resident #1 had met with the facility Social Worker when Resident #1 returned from the hospital in October,2021 and informed him Resident #1 wanted to be a full code. Resident #1 was her own responsible party. The family member said the Social Worker told them the code status form would be changed. The family member indicated there seemed to be no reason to follow up on the code change. The family member was the Power of Attorney for Resident #1. In an interview on [DATE] at 4:35 PM, the facility Social Worker stated Resident #1 told him she wanted to be a full code in [DATE]. Resident #1 was her own responsible party. He indicated the normal protocol to change a code status from DNR to full code was to initiate a code status form, inform the physician, and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Worker noted he was re-educated on the process for changing a code status. On [DATE] at 1:33 PM in an interview, the facility Administrator confirmed the facility had failed to provide EMS with a correct code status for Resident #1. Therefore, the resident was not provided with CPR when she experienced [CONDITION(S)] on [DATE]. He stated the facility Social Worker had received the change in code status from Resident #1 and failed to follow through with the change. The Administrator stated the Social Worker had been reeducated. The facility provided the following corrective action plan with a completion date of [DATE]. Effective February 28, 2022, the Director of Nursing and/or Assistant Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. The facility's corrective action plan was validated to be completed as of [DATE]. Problem identified: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of discharge summary form from a local hospital signed on [DATE] indicated that Resident #1's daughter requested that Resident #1 code status to be changed from Do Not Resuscitate to Full Code. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On February 02, 2022, the Do Not Resuscitate order was re-entered in the system by MDS Coordinator #2 during a routine check when she identified that Resident #1 had an unexpired Golden rod without an order in the record. Review of the nursing notes dated [DATE] indicated; Resident #1 was readmitted on [DATE] at 6:00 PM from acute hospital. The note added resident #1 was alert and oriented x 3 with no complaints of pain or discomfort. Documentation added, no complaints voiced by family member. Review of social service documentation dated [DATE] indicates Resident #1's code status was changed from Do Not Resuscitate to Full code. Review of Resident #1 quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of [DATE] indicated that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14 with no short term no long-term memory loss. Review of Section G (functional status) of MDS assessment indicated Resident #1 requires extensive assistant with bed mobility, transfers, toileting, and independent with eating. Review of care plan for Resident #1 for advance directives dated [DATE] indicated resident was a DNR. Review of the nursing notes dated [DATE] at 4:28 AM revealed Resident #1 reported to have chest pain on [DATE] at 9:30pm, the nurse on duty checked the vital signs with oxygen saturation noted to be in the lower 80 ' s (no specific number documented). Oxygen therapy applied the notes added, resident then said she felt like she was having a [CONDITION(S)]. EMS was contacted and arrived within 10 minutes the notes added. Code status was communicated to EMS as Do Not Resuscitate as indicated on the Do not resuscitate order form (Golden rod) with date [DATE] and signed by MD on the same date [DATE]. Resident was pronounced dead on [DATE] at 10:40pm. Per staff on duty on [DATE], resident had a weak pulse until the time EMS arrived. Since resident had a weak pulse Cardiopulmonary Resuscitation (CPR) was not indicated. When EMS arrived the DNR form for Resident #1 was presented and resident was not provided CPR when she coded. The nurses note dated [DATE] at 4:28am added that resident's daughter arrived in the facility at 11:00pm and stated the code status had been changed to Full code. Attending physician contacted and order to release body to funeral home received. Licensed nurse on duty followed the process of identifying the code status for Resident #1 through resident electronic medical records and advanced Directive's information in file cabinets located on each nurse's station. Review of certificate of death from North Carolina Vital records indicated Resident #1 cause of death included Diabetes Mellitus, Hypertension, [CONDITION(S)] and Cardiorespiratory arrest. Root Cause Analysis (RCA): The Governing body led by the facility Executive Director and Director of Nursing in collaboration with the selected members of the facility Quality Assurance and Performance Improvement (QAPI) committee conducted the root cause analysis on February 16, 2022, to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences. The root cause analysis identified that the alleged noncompliance resulted from the failure of an employee to transcribe the full code status in resident's medical records and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCA further identified that on [DATE]; the facility social worker noted the change of code status from DNR to full code but did not remove the Do not resuscitate order form from the resident's records. The RCA also identified that the clinical leadership team failed to review the new admission/readmission resident records and ensure any changes in code status was transcribed correctly in each resident's electronic medical records. Immediate Action Implemented: Resident #1 is no longer in the facility. On February 16, 2022, the facility Executive Director educated Social Services Director #1 and social service director #2 on the importance of ensuring each residents ' code status is documented in the medical records and reflects the resident wishes. The education emphasized the importance of ensuring Do not resuscitate order forms are removed from the file Cabinet immediately following the change of code status and ensuring a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Identification of Other Residents who Might Be Affected: 100% audit of all current resident ' s medical records was completed on February 16, 2022, by Director of Nursing, MDS Coordinator #1, MDS coordinator #2, Unit coordinator #1, Social worker #1, Social worker #2 and/or Unit manager #2 to identify any other resident with a change of code status that was not transcribed in medical records and ensuring a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . No other code status changes were identified with discrepancies in resident ' s medical records. Findings of this audit is documented on a Code status audit tool located in the facility compliance binder. 100% audit of all deaths that occurred in the facility in the last 90 days was completed on February 16, 2022, by Director of Nursing, Unit coordinator #1, and/or Unit manager #2 to identify any deaths whose advance directive wishes were not followed. No other deaths were identified in which the code status was not honored. Findings of this audit is documented on a Death record audit tool located in the facility compliance binder. Systemic Changes and Modification: Effective February 16, 2022, the facility staff will provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This systemic modification will be accomplished by implementing the following changes: Effective February 16, 2022, the facility ' s Licensed nurses on duty will review hospital discharge summary for any resident admitted or readmitted to the facility and transcribe the code status to each resident ' s electronic medical records. Effective February 16, 2022, the facility ' s Licensed nurses on duty will remove Do not resuscitate order form from resident ' s active medical records as soon as the new order for full code is obtained. This will allow front line staff to only access one set of code status in resident ' s medical records. Effective February 16, 2022, the facility clinical team to include the Director of Nursing, assistant director of Nursing, Unit Manager #1 and/or Unit Manager #2 initiated the process of reviewing all new admits/readmits in a daily clinical meeting and review the code status to ensure it is transcribed correctly. Any discrepancies identified is corrected promptly. Finding of this systemic change is documented on the daily clinical meeting report form located on the daily clinical meeting binder. 100% education of all current Licensed nurses, to include full time, part time, and as needed employees completed by the Director of Nursing, Assistant Director of Nursing, Unit coordinator #1 and/or Unit coordinator #2. The emphasis of this education includes, but not limited to, the importance of ensuring code status changes is transcribed and documented on each resident ' s electronic medical record; and ensure each staff member provides basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This education will be completed by February 28, 2022, any Licensed nurses not educated by February 28, 2022, will not be allowed to work until educated. This education is added to new hire orientation for all Licensed nurses effective February 28, 2022. Monitoring Process: Effective February 28, 2022, Director of nursing, Assistant Director of Nursing, and/or Unit coordinator #1 and/or Unit coordinator #2, will monitor compliance by reviewing, admissions, and readmissions in the daily clinical meeting (Monday-Friday), to ensure any resident ' s code status change is transcribed and documented in electronic medical records. Any issues identified during this monitoring process will be addressed promptly. This monitoring process will be completed daily Monday through Friday for four weeks, weekly for four more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on clinical documentation monitoring form located in the facility compliance binder. Effective February 28, 2022, Director of nursing, Assistant Director of Nursing, and/or Unit coordinator #1 and/or Unit coordinator #2, will monitor compliance by reviewing any changed code status from Do Not Resuscitate to Full code obtained in the prior 24 hours or from last clinical meeting to ensure the Do not resuscitate order form is removed from resident record when a new code status is obtained. This monitoring process will be completed daily Monday through Friday for four weeks, weekly for four more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on clinical documentation monitoring form located in the facility compliance binder. Effective February 28, 2022, the Director of Nursing and/or Assistant Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Person(s) Responsible to implement Corrective Plan of Care: Effective February 28, 2022, the Executive Director and the Director of Nursing will be responsible for the implementation of this plan of correction and ensure that the facility attains and maintains substantial compliance. Onsite validation was completed on [DATE] through staff interviews and record review. Staff were interviewed to validate in-service completed on the importance of code status changes being transcribed and documented on residents ' electronic medical record and obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation of code status audit and file folder status being the same was reviewed. Monitoring of Do Not Resuscitate order forms were reviewed and matched to chart documentation; this monitoring was ongoing. QAPI meeting signatures were reviewed. The facility ' s corrective action plan was validated to be completed as of [DATE].

Based on observations, staff interviews, interview with the local public health department nurse practitioner and review of the facility ' s COVID -19 Pandemic Guidelines, infection control polices, and The Centers for Disease Control and Prevention (CDC) COVID 19 guidelines revealed these guidelines and policies were not implemented when the facility failed to; 1. assign dedicated staff to only work on the COVID positive isolation unit 2. supply required Personal Protective Equipment (PPE) to staff working in the designated isolated and quarantine units. 3. don required PPE before providing resident care and to remove PPE before leaving the resident ' s room and the COVID positive isolation unit. 4. use the correct precaution signage in the facility ' s New Admission and Person Under Investigation (PUI) quarantine units and on the COVID positive isolation unit. 5. Four of eight dietary workers were observed on the meal serving line with facial masks not covering the nose and mouth. These failures occurred during the COVID-19 pandemic and had the likelihood to affect all residents in the facility. A total of 10 residents tested positive for the COVID-19 virus as of September 14, 2020. Immediate Jeopardy began on 09/14/20 when observations revealed the same staff were assigned to work with residents who resided on the COVID positive unit and the adjoining quarantined Person Under investigation (PUI) unit, and staff were observed not wearing required personal protective equipment (PPE). Isolation gowns were not observed on the quarantine PUI unit and the COVID positive isolation unit for staff to use for resident care and eye wear was not available for use on the COVID positive isolation unit or the PUI and New Admission quarantine units. The staff were observed not removing PPE before leaving residents ' rooms on the COVID positive isolation unit and the PUI and the New Admission quarantine units and when leaving the COVID positive isolation unit to enter the PUI quarantine unit. The facility was posting Airborne/Contact Precaution signage on the New Admission and the PUI quarantine units rather than the Enhanced Droplet and Contact Precautions. Also, four of eight dietary staff were observed not wearing face masks covering the nose and mouth. The Immediate Jeopardy was removed on 9/19/20 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility ' s Personal Protective Equipment (PPE) policy dated January 2018 revealed the facility was responsible for ensuring that appropriate PPE was readily accessible, and PPE should be removed and discarded before leaving a resident ' s room or cubicle. The facility ' s Resident Placement COVID-19 Pandemic Guidelines dated effective on March 31, 2020 and revised May 26,2020 revealed the COVID positive isolation unit was a unit for residents who had tested positive for COVID-19, and the Person Under Investigation (PUI) unit was a unit for residents with a known exposure to COVID-19 or respiratory illness or infection symptoms were evident. The PPE requirements for the health care professionals on both of these units included disposable gowns, N95 mask, goggles or face shields and shoe coverings. Furthermore, the policy listed Special Airborne/Contact Precautions as the required signage for the units and to limit staff working between units as much as possible. The policy also revealed the New Admission unit was a unit for residents after an emergency room visit, readmission to the facility and new admissions to the facility. PPE requirements for the health care professionals in the New Admission quarantine unit included a Trio: disposable sleeves, plastic apron, cloth gown sleeves (the facility stated disposable gowns were used instead of a Trio as noted in the policy), N95 mask, goggles or face shields and shoe coverings. Special Airborne/Contact Precautions was listed as the required signage for the New Admission quarantine unit also. For health care professionals in unaffected areas, the policy revealed masks were the required PPE. The Centers for Disease Control and Prevention (CDC) Responding to Coronavirus (COVID-19) in Nursing Homes Responding to COVID-19 dated April 30, 2020 stated to place signage at the entrance to the CVOID-19 care unit that instructs healthcare personnel they must wear eye protection and an N95 or higher level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. Centers for Disease Control and Prevention (CDC) Preparing for COVID-19 in Nursing Homes dated June 25, 2020 stated the facility was to identify a dedicated space to care for residents confirmed with COVID-19 and identify health care personnel who will be assigned to work only on the COVID-19 care unit when in use. The CDC guidance further noted residents with known or suspected COVID-19 should be cared for using all recommended PPE, which included use of N95 or higher level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown, and the residents with known or suspect COVID-19 did not need to be placed into an airborne infection isolation room. CDC guidance stated for managing new admissions and readmissions whose COVID-19 status is unknown, healthcare personnel should wear an N95 or higher-level respirator, eye protection (googles or face shield that covers the front and sides of the face), gloves and gown when caring for these residents. Further CDC guidance for PPE stated healthcare personnel should wear a facemask at all times while they were in the facility and included the facility monitoring daily PPE use to identify when supplies would run low, making necessary PPE available in area where resident care was provided and staff discarding PPE prior to exiting the room or before providing care for another resident in the same room. The CDC COVID-19 Overview and Infection Prevention and Control Priorities in non-US Healthcare settings COVID-19 & IPC Overview dated August 12, 2020 stated the current World Health Organization (WHO) guidance for healthcare workers caring for suspected or confirmed COVID-19 patients recommends the use of contact and droplet precautions in addition to standard precautions (unless an generated procedure is being performed, in which airborne precautions are needed.) The Center of Disease Control and Prevention (CDC) Sequence for Putting on Personal Protective Equipment document provided by the facility revealed the mask ' s flexible band fitted to the nose bridge and the mask fitted snug to the face and below the chin. 1. On 9/14/20 at 1:10pm, Special Airborne/Contact isolation precaution signage was observed on the PUI unit entrance doors located on the 200 hallway. The posted signage stated a N95 mask, gloves, gown and protective eyewear were required PPE. Underneath eyewear in parentheses a statement read: goggles for aerosol generating procedures. Gowns, gloves, face shields and shoe coverings were observed outside the PUI unit to apply before entering the unit. On 9/14/20 at 1:21pm there were 6 residents on the PUI unit, and no gowns or eyewear were observed in the hallway of the PUI unit to apply before entering the resident ' s rooms on the PUI unit or the adjoining COVID positive isolation unit. Special Airborne/Contact Precautions signage was observed on the resident doors. Medication Aide (MA) #1 was observed on the PUI unit wearing a gown and a N95 mask, but no eyewear. On 9/14/20 at 1:23pm, MA #1 stated she and NA #1 were assigned to work both the PUI quarantine unit and the COVID positive isolation unit. She stated she wore the same gown between the PUI quarantine unit and COVID positive isolation unit. MA #1 was observed removing the gown before entering the employee ' s lounge on the PUI unit and washing her hands in the bathroom. A medication cart was observed in the employee lounge. On 9/14/20 at 1:25pm, MA #1 was observed exiting the employee lounge with medications in her hand. She was wearing a gown, N95 and gloves, and she entered the resident ' s room [ROOM NUMBER] to administer the medications wearing no protective eyewear. On 9/14/20 at 1:27pm, MA #1 was observed exiting resident ' s room [ROOM NUMBER] with gowns, gloves and N95 mask on. She stated while walking toward the employee lounge, I need my face shield in the COVID unit. MA#1 was observed entering the employee lounge without removing the gown, gloves or N95 to get a face shield. MA #1 exited momentarily the employee ' s lounge wearing gown, gloves, N95 mask and a face shield holding medications in her hand and entered the COVID positive isolation unit through a plastic zip wall barrier located in the hallway. On 9/14/20 at 1:29pm, MA #1 was observed exiting the COVID positive isolation unit without removing the gown before entering the PUI quarantine unit hallway and entering the employee lounge. In an interview with MA #1 on 9/14/20 at 1:29pm, MA #1 stated residents on the PUI quarantine unit were roommates of COVID positive residents or residents that were having signs or symptoms of COVID-19 that had tested negative last week. She stated the face shield was not required on the PUI quarantine unit. MA #1 stated she had received computerized education on COVID-19 and denied receiving specific instructions on using PPE between the PUI quarantine unit and the COVID positive isolation unit. On 9/14/20 at 1:30pm, an Enhanced Droplet and Contact Precaution signage was observed on the plastic zipped barrier in the 200 hallway beyond room [ROOM NUMBER] and 210 of the Person Under Investigation (PUI) quarantine unit before entering the COVID positive isolation unit. The Enhanced Droplet and Contact Precaution signage listed use of gloves, gowns, eye protection, a surgical mask and hand hygiene before entering the COVID positive resident ' s room. On 9/14/20 at 1:32pm upon entering the COVID positive isolation unit, Nurse Aide (NA) #1 was observed exiting Resident #1 ' s room with a meal tray. NA #1 was observed wearing an isolation gown, gloves, and a N95 mask and no protective eyewear. No isolation signage was noted on the door. On 9/14/20 at 1:33pm, NA #1 was observed wearing the same isolation gown and N95 mask, removing her gloves, performing hand hygiene, applying new gloves before entering Resident #2 ' s room on the COVID positive isolation unit. There was no isolation signage noted on the door. NA #1 was observed at the resident ' s bedside speaking with the resident and pulling the top covers up onto the resident without wearing protective eyewear. An interview was conducted on 9/14/20 at 1:36pm with NA #1. NA #1 stated gloves, mask, shoe covers, gowns, and face shields were required PPE on the COVID positive isolation unit. NA #1 stated she was passing out the meal trays and forgot to reapply the face shield. She stated unless patient care was being provided isolation gowns were not changed between residents. NA #1 explained she was assigned to work both the COVID positive isolation unit and the PUI quarantine unit. NA #1 stated she had received COVID-19 and PPE training, and PPE except for the face mask and face shields were removed before exiting the COVID positive isolation unit into the PUI quarantine unit. NA #1 stated she had used all the gowns brought into the COVID positive isolation unit that morning and obtained new gowns from the supply outside the PUI quarantine unit. On 9/14/20 at 1:45pm when the surveyor prepared to exit the COVID positive isolation unit, there were no instructions observed on the plastic zipped wall barrier, and no new isolation gowns were available on the COVID positive isolation unit to apply before re-entering the PUI quarantine unit. An interview was conducted with the Director of Nursing (DON) on 9/14/20 at 2:18pm. The DON stated the same staff were assigned to the COVID positive isolation unit and the PUI Quarantine unit. The DON stated the PPE requirement for the COVID positive isolation unit and the PUI quarantine unit was the same: gloves, gowns, N95 mask, face shields and shoe covering, and the PPE should be on the entire time on the COVID positive unit. The DON noted to prevent the spread of COVID-19 from the COVID positive unit to the PUI quarantine unit the staff were to remove PPE prior to exiting the COVID positive unit and perform hand hygiene. The DON stated PPE should not be worn into the employee lounge, and PPE supplies were to be on the unit for staff to use between resident care. The DON stated staff had completed a computerized COVID-19 training and a donning and doffing review was place at the nurse ' s station and the front desk over the weekend. The DON further stated there were no issues with the availability of PPE supplies for the staff. On 9/14/20 at 3:00pm, MA #1 was observed inside the COVID positive isolation unit with no gown or face shield on. MA #1 exited the COVID positive isolation unit without donning new PPE when entering the PUI quarantine unit. On 9/14/20 at 3:30pm, the Administrator of the facility deferred the interview to the Administrator- in- training while the Administrator remained present in the interview. The Administrator-in-training stated designated staff were assigned to work both the COVID positive isolation unit and the PUI quarantine unit, and the facility had a sufficient supply of PPE for staff to provide resident care. The Administrator- in- training stated when caring for residents on the PUI quarantine unit and the COVID positive isolation unit full PPE was required before entering the resident ' s room, and listed gowns, gloves, N95 mask and shoe coverings for full PPE. He stated gowns and face shields were not required in the hallways of the COVID positive isolation unit, and protective eyewear was not required for patient care except with aerosol nebulizer treatments. The Administrator-in-training further stated PPE should be changed before leaving the COVID positive isolation unit before entering the PUI quarantine unit. On 9/15/20 at 10:05am, MA #2 was observed through the fully unzipped plastic barrier wall walking throughout the COVID positive isolation unit wearing a N95 mask and not wearing a gown or face shield. MA #2 had a thermometer in her hand when she exited the COVID positive isolation unit into the PUI quarantine unit. On 9/15/20 at 10:13am, no gowns were observed on the PUI quarantine unit outside the resident ' s rooms for staff to use in between resident care. In an interview on 9/15/20 at 10:25am, MA #2 stated when she was on the COVID positive unit she was signing the Isolation Room Entry log sheets on the resident ' s doors and was not wearing PPE because she did not enter the resident ' s rooms. She stated she had received COVID-19 training but denied receiving any educational instructions related to working between the COVID positive isolation unit and the PUI quarantine unit. MA #2 stated there was not enough PPE on the two units, and she borrowed another staff member ' s face shield to work on the unit that day and had requested more gowns for the units. MA #2 stated the staff were saving gowns to use between resident care. On 9/15/20 at 2:46pm an interview with a Nurse Practitioner of the Harnett County Health Department, was conducted. She stated on 9/7/20 a resident on [MEDICAL TREATMENT] tested positive for COVID-19. The positive COVID-19 resident and the resident ' s roommate were quarantine. She stated the facility conducted a facility wide COVID-19 testing on all residents and staff on 9/8/20, and seven residents and one staff member tested positive for COVID-19. She stated the Harnett County Health Department declared a new outbreak for the facility on 9/10/20. She stated the facility created the PUI quarantine unit per the facility ' s former policy, and the Harnett County Health Department did not conduct on-site visits. She stated the Harnett County Health Department recommendation to facilities was to not share staff between the PUI quarantine and COVID-19 positive isolation unit. On 9/16/20 at 2:28pm, the Administrator stated the facility was working toward having separate staff for the PUI quarantine unit and the COVID-19 isolation unit and deferred the availability of staff to work the units to the Director of Nursing. On 9/16/20 at 4:16pm in an interview, the Director of Nursing stated staffing needs of the facility were met by using agency staff and staff volunteering to work extra shifts. When asked why the COVID positive unit and the PUI quarantine unit did not have separate staff, the DON stated she understood the same staff could work the COVID positive unit and the PUI quarantine unit. On 9/21/20 at 11:20am in an interview with the Director of Nursing, the DON stated a resident, who previously tested negative on 9/8/20 on the PUI quarantine unit, tested positive for COVID-19 on 9/16/20. 2. On 9/14/20 at 9:55am, the Administrator-in-training stated the required PPE throughout the facility was a N95 mask and the New Admission and PUI quarantine units and the COVID positive isolation units required specific PPE per the Airborne/Contact Isolation precautions. On 9/14/20 at 10:45am, an Airborne/Contact Isolation precautions signage was observed on some of the doors on the New Admission unit located on the 700-600 hallway. The Airborne/Contact Isolation precautions signage listed gowns, gloves, N95 mask and eyewear as required PPE before entering the room. Gowns, gloves and shoe covers were observed in over-the-door PPE [MEDICATION NAME] but not protective eyewear. Staff were observed on the hallway without protective eyewear to use for resident care. An interview with Nurse #1 was conducted on 9/14/20 at 10:48am. Nurse #1 stated she gathered the required PPE: gown, gloves, and shoe covers to enter a resident ' s room on Airborne/Contact Isolation from an over-the-door PPE [MEDICATION NAME]. When Nurse #1 was asked where she obtained protective eyewear as noted required on the Airborne/Contract Isolation precaution signage, Nurse #1 stated she was not aware that eyewear was required, or protective eyewear was available to the staff. In an interview with the Director of Nursing (DON) on 9/14/20 at 2:18pm, the DON stated new admissions or re-admissions were on the New Admissions unit and were quarantined for 14 days. She stated gowns, gloves and N95 mask were required before entering the resident ' s rooms but eye wear was not required on the New Admission unit. On 9/15/20 at 9:02am, NA #2 was observed exiting a resident ' s room with an Airborne/Contact isolation precautions signage posted on the door wearing the isolation gown in the hallway. NA #2 was observed placing the resident ' s meal tray on the meal cart and re-entering the resident ' s room, removing the PPE and sanitizing her hands. Nurse #2 stated during an interview on 9/15/20 at 9:06am that protective eyewear was necessary for residents per the Airborne/Contact Isolation precautions signage that were receiving aerosol nebulizer treatments. On 9/15/20 at 9:18am, NA #2 was observed on the New Admission unit wearing a N95 mask and only applying a gown in the hallway before entering a resident ' s room with Airborne/Contact Isolation precautions signage on the door. NA #2 was observed removing the meal tray from the resident ' s room wearing no gloves or eyewear as indicated on the Airborne/Contact Isolation signage posted on the door. The NA #2 placed the meal tray on the meal cart located in the hallway. NA #2 was observed removing the isolation gown outside the resident ' s room in the New Admission unit hallway and walking down the hallway with the isolation gown in her hand to discard in the soiled utility room. In an interview on 9/15/20 at 9:23am, NA #2 stated residents on the New Admission unit were on isolation for 14 days, and gown, gloves, mask, shoe covers, and eyewear were required before entering the resident ' s rooms. NA #2 stated she did not have any eyewear. NA #2 stated she had received COVID training, and PPE was to be removed inside the resident ' s room prior to leaving the room. NA #2 stated she did not put on gloves before entering the resident ' s room because the resident was not in the room and removing the gown outside the resident ' s room was a habit. On 9/15/20 at 10:27am, NA #1 was observed entering a resident ' s room on the PUI quarantine unit with a pack of adult briefs in her hand wearing a face shield, gown, gloves, shoe coverings and N95 mask. On 9/15/20 at 10:35am, NA #1 was observed exiting the resident ' s room on the PUI quarantine unit into the hallway wearing the isolation gown, face shield, shoe coverings and N95 mask. NA #1 removed the isolation gown in the PUI quarantine unit hallway and discarded the gown in the big trash bin. In an interview with NA#1 at 10:35am on 9/15/20, NA #1 stated PPE was to be applied before entering the resident ' s room and removed and discarded into the trash before leaving the room. NA #1 stated having the big trash bin in the hallway caused her to exit the resident ' s room to remove the gown in the hallway. NA #1 stated she had received PPE donning and doffing education and noted there were no gowns on the PUI quarantine unit. On 9/15/20 at 10:42am, an interview was conducted with Central Supply Coordinator. The Central Supply Coordinator stated she stocked the PPE [MEDICATION NAME] outside the PUI quarantine unit with gowns, shoe coverings, and face shields. She denied stocking gowns inside the COVID positive isolation unit or the PUI quarantine unit. She stated staff were to change gowns and gloves between resident care, and the facility ' s supply of isolation gowns, gloves, N95 mask and protective eyewear were plentiful. She stated she had over 200 protective eyewear between goggles and face shields, and protective eyewear had not been issued to the staff. She stated the staff of the COVID positive isolation unit and the PUI quarantine unit needed to notify her, the unit manager or the supervisor on weekends when PPE was not available on the units. . On 9/15/20 at 10:42pm during an interview with the Director of Nursing (DON), she stated PPE should be on the COVID positive isolation unit and the PUI quarantine unit for staff to change between resident care, and PPE was removed before exiting the resident ' s room. The DON denied any shortage of PPE in the facility and stated she would contact the Central Supply Coordinator about protective eyewear availability for the staff. 3. On 9/14/20 at 10:45am, Airborne/Contact Isolation precautions signage was observed on the resident ' s doors on the New Admission quarantine unit rather than Droplet and Contact precautions as recommended by the CDC. The admissions were dispersed throughout the 700 and 600 hallways. On 9/14/20 at 1:10pm, Airborne/Contact Isolation precautions signage was observed on the entrance of the PUI quarantine unit and on the resident ' s doors instead of the Droplet and Contact precautions recommended by the CDC. On 9/14/20 at 1:30pm, the entrance of the COVID positive isolation unit was observed with an Enhanced Droplet and Contact Precautions signage, and the Enhanced Droplet and Contact Precautions signage listed a surgical mask as the mask required on the COVID positive isolation unit. On 9/14/20 at 1:45pm when the surveyor prepared to exit the COVID positive isolation unit, there was no precaution signage identifying the PUI quarantine unit on the other side of the barrier or signage to stop and remove PPE observed on the plastic zipped wall barrier before re- entering the PUI quarantine unit. On 9/16/20 at 2:28pm, the Administrator stated in an interview she was unsure why the Enhanced Droplet and Contact isolation precaution signage was posted on the entrance of the COVID positive or why there was no signage posted on the plastic zipped barrier wall exiting from the COVID positive isolation unit to the PUI quarantine unit. The Administrator stated all of the designated units, which included the COVID positive isolation unit, required Airborne and Contact isolation based on the facility ' s policy. She further stated the plastic zipped barrier wall reminded staff of the PPE requirements when exiting the COVID positive isolation unit into the PUI quarantine unit. 4. On 9/14/20 at 12:22pm, four dietary aides of the eight dietary staff in the kitchen area were observed not wearing a face mask covering the nose and mouth. The four dietary aides were observed working on the serving line with the face mask positioned under the dietary aide ' s chin. Three of the four dietary aides immediately reapplied the face mask to cover the nose and mouth. A continuous observation was conducted on 9/14/20 from 12:22pm to 12:28pm. Dietary Aide #4 was serving food items from the serving line onto resident ' s plates with the face mask positioned under the chin and not covering the nose and mouth. On 9/14/20 at 12:28pm, the dietary manager was informed of the four dietary aides not wearing the face mask to cover the nose and mouth upon entering the kitchen area. The Dietary Manager instructed Dietary Aide #4 to cover the nose and mouth with the face mask, and Dietary Aide #4 reapplied the face mask to cover the nose and mouth as instructed. In an interview with the dietary manager on 9/14/20 at 12:28pm, she stated the dietary staff had received PPE training on wearing mask and mask were to be worn covering the nose and mouth at all times. The Dietary Manager further stated staff were allowed to take breaks outside where masks could be removed for fresh air. On 9/14/20 at 12:29pm, an interview was conducted with dietary aide #1. She stated the mask was to be worn at all times and had received PPE training. She stated the mask was pulled under the chin to fix it. An interview with dietary aide #2 was conducted on 9/14/20 at 12:31pm. She stated she was to keep the mask on, and the mask was to cover the nose and mouth. She stated she had received PPE training for handwashing and wearing a mask. She stated she had asthma, [MEDICAL CONDITION] and [MEDICAL CONDITION], and she couldn ' t breathe with the mask on. Dietary aide #3 stated in an interview on 9/14/20 at 12:33pm that she had received training on wearing a mask, and the mask was to be worn all day covering the nose and mouth. She stated she was not wearing her mask because she had [MEDICAL CONDITION] and hot flashes, and the mask caused her glasses to fog up. In an interview with dietary aide #4 on 9/14/20 at 12:36pm, she stated the mask was under her chin because it was hot. She stated she had received training for wearing a mask, and the mask was to be worn all day covering the nose and the mouth. An interview was conducted with Director of Nursing (DON) on 9/14/20 at 2:18pm. The DON stated everyone in the facility was to wear a mask at all times, and the dietary staff should have received training. On 9/17/20 at 5:05pm, the administrator and the administrator-in-training were notified of the immediate jeopardy by phone. On 9/18/20 at 6:39pm the facility submitted a credible allegation for removal of immediate jeopardy. The facility ' s credible allegation of immediate jeopardy removal for F-880 INFECTION PREVENTION AND CONTROL included the following: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance All residents are at risk of COVID 19 when infection control breaches occur. Alert and oriented residents will continue to be re-directed in importance of wearing mask while out of their room. Confused residents will be re-directed by staff. Staff will reapply/reposition masks as required to ensure residents are wearing mask while out of their rooms. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete A 100 % audit was completed on 9/15/2020 by Director of Nursing, Regional Clinical Consultant and Senior Corporate Clinical Consultant on the COVID Unit, PUI area, and the New admission area to ensure all rooms have correct signs posted. Precautions signs have been updated to reflect use of Enhanced Droplet/Contact precautions in all of these areas which would include gown, gloves, surgical mask (N-95 or KN-95 (if optimizing supply) and eye protection. Effective 9/18/2020, the facility policy was updated to reflect the use of Enhanced Droplet/Contact Precautions in the COVID Unit, PUI area, and the New Admission. On 9/15/2020, the facility Director of Nursing and Administrator were educated on COVID-19 Pandemic Guidelines by the Regional Clinical Consultant and Senior Corporate Clinical Consultant. This education included specific criteria/ proper function, PPE requirements and precaution signage of the COVID isolation unit and quarantined units (PUI unit and Admission unit). The following policy and procedures were also reviewed: Resident Placement, Infection Control, Handwashing, PPE, and Isolation practice inside isolation and quarantined units. Additionally, emphasis was placed on ensuring proper wear of PPE (mask covering nose and mouth) at all times while in the building. Lastly, education was provided to ensure dedicated staff on the COVID Unit with no cross-over to other quarantined areas and ensuring residents are wearing a mask while out of their room with re-direction and re-application, as necessary. On 9/15/2020, on All PPE stations were audited on all units to ensure equipment was available by Central Supply Clerk. On 9/18/2020, facility change staffing protocol to ensure dedicated staff on the COVID Unit. The facility staffing scheduler was educated by the Director of Nursing on expectation for dedicated staff on the COVID unit. On 9/15/2020, 100% of staff in facility were provided education by the Director of Nursing. This education included specific criteria/ proper function, PPE requirements and precaution signage of each isolation unit and/or quarantined areas and use of dedicated staff on the COVID unit with no cross-over to other quarantined areas. The following policy and procedures were also reviewed: Resident Placement, Infection Control, precaution signage, handwashing, PPE, and isolation practice inside quarantined areas and isolation units. Additionally, emphasis was placed on ensuring proper wear of PPE (mask covering nose and mouth) at all times while in the building and ensuring residents are wearing masks while out of their room with re-direction and re-application, as necessary. Lastly, all nursing staff in facility were educated on process to notify Central Supply/ DON when PPE needs restocking by Director of Nursing. Central Supply or Manager on Duty will check PPE availability at least daily. On 9/15/2020, 100% of Staff in facility completed the Hand Hygiene Competency with the Director of Nursing. On 9/15/2020, 100% of Staff in facility completed the PPE Competency with the Director of Nursing. Effective 9/17/2020, no staff will be allowed to work until education/competency is completed. Until a Staff Development Coordinator (SDC) is hired for the facility, the Director of Nursing (DON) will provide COVID-19 education updates to facility staff to ensure facility staff are abreast of any new guidance related to controlling the spread of COVID-19 and ensure all new hire staff (including agency staff) receives training on infection control and prevention prior to resident contact. This education will include specific criteria/ proper function, PPE requirements and precaution signage of each isolation unit and/or quarantined areas and use of dedicated staff on the COVID unit with no cross-over to other quarantined areas. The following policy and procedures will be (TRUNCATED)

Based on record review, staff interview, and physician interview, the facility failed to assure a wound physician assessed and treated a changing pressure ulcer as ordered by the resident's medical physician for 1 of 3 residents reviewed with pressure ulcer's (Resident #3). The findings included: Record review revealed Resident # 3 was initially admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. According to the record the resident was hospitalized from [DATE] to 12/23/18 for a [MEDICAL CONDITION]. The resident was readmitted to the facility on [DATE] and resided there until her discharge on 1/24/19. The resident was [AGE] years of age. Review of the admission Minimum Data Set (MDS) assessment, dated 12/30/18, revealed Resident #3 needed extensive assistance with her bed mobility, and total assistance with her hygiene and bathing needs. She was incontinent of bladder and bowel, and was assessed to have one Stage II pressure sore. Review of Resident #3's readmission care plan, dated 1/9/19, revealed she had a Stage II pressure sore to her Coccyx area, and was at risk for further skin problems. Interventions included: skin is checked daily with care and notify MD of abnormalities. Review of physician orders [REDACTED]. Review of nursing notes revealed an entry by the Wound Nurse on 12/28/18 at 4:58 PM that read the resident had a Stage II shearing area to her Coccyx area which measured 5.2 cm (centimeters) X 4.9 (centimeters). The area was described as 100 % granulation tissue (healing tissue) with diffuse edges and no exudate. Review of physician orders [REDACTED]. Review of Resident # 3's, nursing notes and December, (YEAR) and January, 2019 TARs (Treatment Administration Records) revealed documentation the resident received [MEDICATION NAME] dressing changes for the pressure ulcer following the 12/28/18 order. Review of nursing notes revealed an entry by the Wound Nurse on 1/10/19 at 4:29 PM that read Resident #3's Stage II Coccyx pressure sore was 4.0 cm X 0.9 cm and was 100% granulation tissue. There was scant exudate. Review of physician orders [REDACTED]. The new order was to clean the wound, apply Santyl and Calcium Alginate to the wound, and cover it with an ABD pad (a type of dressing cover). The dressing was to be changed daily. (Santyl is an ointment used to remove dead tissue on the wound surface and within the wound bed of a pressure sore while the ointment also preserves healthy tissue; Calcium Alginate helps to absorb wound exudate). Review of the (MONTH) nursing notes and January, 2019 TAR revealed documentation Resident # 3 received the Santyl and Calcium Alginate wound dressing as ordered on a daily basis to treat her pressure sore. Review of nursing notes and Wound Assessment Reports did not reveal a corresponding wound assessment on 1/14/19 when the order was changed. Interview with Resident #3's Physician on 2/8/19 at 12:35 PM revealed the 1/14/19 order was given because the resident's wound had some eschar (dead tissue) in the wound bed. The Physician stated the facility had a Wound Physician who consulted, evaluated, and treated facility resident's pressure sores. The Physician further stated a consult should have been initiated on 1/14/19 when the resident's wound showed eschar and the wound physician should have been involved in the resident's wound care thereafter. According to the physician he thought an order for [REDACTED]. Review of the record revealed no evidence of a Wound Physician referral for Resident #3 on 1/14/19. Review of the medical record revealed on 1/14/19 at 1:20 PM the Registered Dietician (RD) made an entry in the record noting that the resident was consuming zero percent of her meals on multiple occasions and had a significant weight loss. The RD recommended a vitamin supplement and Med Pass 2.0 (a protein supplement) twice per day. Record review revealed the Med pass was initiated on 1/14/19 and the vitamin supplement on 1/15/19. Review of the Wound Assessment Report dated 01/16/19 revealed the Wound Nurse noted Resident #3's Coccyx pressure sore was 100% necrotic tissue and measured 3.50 cm X 1.60 cm with .5 cm depth. The Wound Nurse also noted the resident would be evaluated and treated by the Wound Physician on the next visit. Review of physician orders [REDACTED].#3 her next visit. There was also a telephone order on 1/21/19 for [MEDICATION NAME] 500 mg (milligrams), an antibiotic, three times per day for 10 days to treat a wound infection. It was also noted on the physician's orders [REDACTED]. Review of Resident # 3's (MONTH) MAR (Medication Administration Record) revealed the resident started receiving [MEDICATION NAME] 500 mg at 1:00 PM on 1/21/19 and continued to receive this antibiotic as ordered through her date of discharge on 1/24/19. The Wound Nurse was interviewed on 2/7/19 at 11:10 AM and again on 2/12/19 at 1:20 PM, and reported the following. She stated she had obtained the order for the Wound Physician to see the resident on 1/14/19 from the physician when eschar first appeared in the pressure sore. On 1/14/19 she had also obtained the responsible party's consent for the Wound Physician to see the resident. She did not know what happened to the order, but validated the order was missing from the resident's record. She rewrote the order on 1/21/19, and did not want to back date the order. Therefore, she dated the 1/14/19 order as an order for [REDACTED].# 3's information on 1/17/19. She did not recall why the Wound Physician did not evaluate the resident's pressure sore on 1/16/19 when the Wound Physician was in the building. On 1/21/19 she noticed the pressure ulcer sore had a foul odor. She had called the resident's medical physician and obtained an order for [REDACTED]. She further stated Resident #3's pressure sore continued to have a foul odor on 1/22/19, and the Wound Physician had not seen the resident. The Wound Nurse stated she knew the Wound Physician often utilized [MEDICATION NAME], an antibiotic, in the wound bed in a pressure sore which had a foul odor, and she talked to the Nurse practitioner to obtain the order on 1/22/19 after she had completed the wound dressing on 1/22/19. Review of physician orders [REDACTED]. Review of the Resident's Treatment Administration Records revealed the resident started receiving the crushed [MEDICATION NAME] in her wound bed on her next daily dressing change; which was 1/23/19. An interview with the Wound Physician on 2/8/19 at 11:03 AM and again on 2/11/19 at 2:35 PM revealed she was at the facility on 1/16/19 and 1/17/19, but did not see Resident #3 on either of those dates. According to the Wound Physician, she was handed the resident's discharge summary and demographics at the end of her day on 1/17/19, but there had been no formal physician referral or family consent given for her to see the resident. According to the Wound Physician, the paperwork would have needed to have been in order for her to see the resident on 1/16/19 or 1/17/19, and she did not see the resident until 1/24/19. A follow up interview conducted with the Wound Physician on 2/12/19 at 1:20 PM revealed she saw Resident #3's pressure sore on 1/24/19 for the first time. The pressure sore was described by the Wound Physician to be heavily necrotic and extensive. The pressure sore was also described as draining. The Wound Physician stated she started to debride the pressure sore, but it became evident the resident's pressure sore was in need of further services than she could provide at the facility. Review of Resident #3's medical record revealed the Nurse Practitioner and the Wound Physician had evaluated the resident together on 1/24/19, and the decision was made to transfer the resident to the hospital for her to receive evaluation and treatment. Review of hospital records dated 1/24/19 revealed in the emergency room , Resident #3 was identified to have a very large, foul smelling necrotic Stage IV decubitus ulcer and was diagnosed as having an infection of the soft tissue below the pressure sore. Resident #3 was hospitalized for [REDACTED]. Interview with the emergency room physician on 2/11/19 at 2 PM revealed the soft tissue infection occurring underneath the pressure sore would not have been evident to the facility staff. An interview with the facility Wound Nurse on 2/12/19 at 1:20 PM revealed the following. The Wound Nurse stated the NP, physician, nor the Wound Physician looked at Resident #3's pressure sore with her prior to 1/24/19, but the changes prior to the date of 1/24/19 were changes she had visualized in other debilitated, elderly residents who had poor nutritional intake. The Wound Nurse stated the Wound Physician usually visited once per week. The Wound Nurse knew there had been a mistake in the referral not being done for 1/16/19, but she stated she was aware the resident was receiving the Santyl for the necrosis and both an oral antibiotic and antibiotic in the wound bed. She therefore thought it would be acceptable that the resident's wound be evaluated by the Wound Physician on the Wound Physician's next weekly scheduled date in the facility. According to the Wound Nurse the next time the Wound Physician was in the facility following 1/16/19 and 1/17/19 was the date of 1/24/19. According to the Wound Nurse, although a mistake had been made in assuring the Wound Physician referral was done, she had continued to communicate with the resident's physician and/or NP to assure treatment orders were updated and carried out as the wound changed. The Wound Nurse said the pressure sore seemed to change more from the time she viewed it on 1/23/19 than when she viewed it on 1/24/19. On the AM of 1/24/19, she was aware the Wound Physician would be in the facility on 1/24/19 and would evaluate the most recent changes. Interview with Resident #3's facility medical physician on 2/19/19 at 4:50 PM revealed there were contributing factors to the resident developing an infection beneath the pressure sore which included the resident's advanced age which compromised her ability to fight off infection, her refusal to eat, her dementia, and her recent hip surgery which led to decreased immobility. The physician stated he had not assessed Resident #3's pressure sore when it started becoming necrotic or odorous because he had ordered that the wound physician oversee the care of the wound.

Based on record reviews, staff and Medical Doctor interviews, the facility failed to evaluate a resident's condition by a licensed professional before moving a resident following a fall in the facility's transport van for 1 of 2 residents sampled for assessment after an accident (Resident #1). Resident #1 experienced a Cervical (C2-C3) fracture to the neck and expired at the hospital. The findings included: A review of the facility's undated Falls Procedures for Nursing Staff revealed to: evaluate resident's condition before moving, do not stand resident upright; lift to bed or chair, notify physician, and notified family or responsible party (RP). Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was mildly cognitively impaired and required extensive assistance of 1 staff member with bed mobility. The MDS further revealed that Resident #1 had received [MEDICAL TREATMENT]. A nursing note dated [DATE] at 7:46 PM revealed Resident #1 was sent to the emergency room (ER) for evaluation related to an accident in the facility van during transport. The medical director (MD) and responsible party (RP) were notified. Review of a facility document titled Resident Incident Report dated [DATE] at 5:45 PM read in part, Nursing Assistant (NA) #1 (Transportation Aide #1) was transporting Resident #1 from [MEDICAL TREATMENT] when another vehicle cut in front of him and he had to apply emergency braking and then observed the resident on the transportation van's floor. Emergency Medical Services (EMS) was notified and resident was transported to the emergency room (ER) for evaluation. An Emergency Medical Services (EMS) record dated [DATE] at 5:48 PM revealed Resident #1 was sitting on the bench with blood coming from forehead, mouth area as well as lower left leg. Resident #1 was sitting on passenger side of transport van. The driver of the van advised a vehicle pulled out in front of him causing the van to stop suddenly throwing patient into passenger side floor board. Resident #1's initial physical findings included: laceration to left forehead, blood coming from patient's mouth, laceration to left lower leg, mental status normal baseline for patient, and neurological normal basline for patient. An ER Report dated [DATE] revealed Resident #1 had a head/neck Computed Tomography (CT) scan which showed a Second Cervical vertebrae (C-2) neck fracture. A Hospital History and Physical (H&P) dated [DATE] at 10:42 PM revealed per Emergency Medical Services (EMS), the driver of the van said the patient was acting appropriately immediately following the incident. He was taken to their local hospital and by the time of his arrival he could not move any of his extremities. A neck cervical collar was applied. Resident #1 underwent a chest x-ray, head CT, neck CT, which showed a cervical vertebra #2 (C-2) fracture, and left 1st and 2nd rib fractures. He was then transferred to larger regional hospital for further care. A Hospital Course note dated [DATE] revealed Resident #1 had a very brief hospital course. The patient with severe C-2 fracture. He was seen by a Neuro Surgeon with the intent to operate, but patient had a poor clinical prognosis with pre-existing medical conditions, including dementia and [MEDICAL CONDITION], as well as being unable to transfuse secondary to his religious beliefs. The resident's family arrived to bedside and after explaining patient's poor prognosis as well as the likely hood that he would unlikely be able to be separated from the ventilator, family decided to make him a do not resuscitate (DNR) and do not intubate (DNI). The patient became acutely unresponsive and bradycardic while family discussion was happening, and patient expired quite quickly at 11:12 AM. A Hospital Discharge Summary dated [DATE] at 2:28 PM revealed Resident #1 with dementia and [MEDICAL CONDITION] who sustained C-2 fracture with resultant complete [MEDICAL CONDITION], extremely poor prognosis given underlying morbidities; family wished for patient to receive comfort care and he subsequently expired shortly thereafter. An interview was conducted with Transportation Aide (TA) #1 on [DATE] at 10:57 AM revealed on [DATE] around 5:20 PM The resident and I were on our way back from [MEDICAL TREATMENT] (the 4th time he transported the resident to [MEDICAL TREATMENT]) heading to the facility when a beige truck with trailer pulled right going into the gas station from the left lane, cutting us off. He said, I had to hit the brake, and when I did, I heard a thump behind me, and I observed Resident #1 had fallen out of his wheelchair and onto the floor. Earlier, when I picked the resident up from [MEDICAL TREATMENT] I had strapped his wheelchair with the floor straps on the van, and had secured the resident with the seatbelt, going across his chest and abdomen, hooking it in the seat buckle to his right. The TA said the resident's wheelchair was strapped closer to the back of the van above the last floor strap. He said, After the accident, I pulled into the gas station and called my supervisor, who instructed me to call 911, and to stay there. TA #1 said, She told me, she was coming up there with the Director of Nursing (DON). The TA said the resident told him he felt uncomfortable on the floor. TA then called 911, and stayed with the resident. TA #1 said the resident's wheelchair was still secured with the floor straps; but, that the seat belt was unbuckled and back to the left of the wheelchair. He said, I secured him in his chair, with the 4 point straps, and I put the seatbelt around his abdomen/shoulder, and pulled on it to make sure it was secure. The TA said, the resident with his left hand could have un-buckled the seat belt. The TA said he demonstrated to the DON at the scene on how he hooked up the resident's wheelchair and seatbelt. The TA said the resident fell on the floor of the van with his left arm under him, and the left side of his face on the floor. He said the resident had a scrape on the left side of his nose and forehead, and was bleeding from his mouth. The TA said the resident talked to him, and wanted to get up, and that his head hurt. The TA said he couldn't go against the resident's wishes; so, he helped the resident up to the nearest seat. An interview conducted with Transportation Aide (TA) #1 on [DATE] at 11:15 AM revealed on [DATE] Resident #1 was observed laying on his left arm with the left side of his face to the ground in the transportation van. TA #1 said, I didn't want to get the resident up; but, he wanted to get up, even when I said he should not get up. I helped him up to the passenger seat on the side of the van. The TA then said, Residents have a right to get up, even in emergencies, the resident has a right to get up, and I got him up. He said the EMS showed up in 5 to 10 minutes. TA #1 said he was trained to keep residents to the floor; but, if they say they want to get up, you cannot force them not to get up. An interview conducted with Transportation Aide (TA) #1 on [DATE] at 12:41 PM revealed on [DATE] around 5:20 PM after Resident #1 had fallen to the van floor, he was moving his left arm trying to get up, and was not able to get up on his knees. The resident was laying on his left arm, on his front. Resident #1 told him he didn't want to stay there, that he wanted to sit up. The TA said, if the resident wanted to get up, he couldn't leave him there. He said, to Resident #1, I am calling my manager, and the resident said, I don ' t want to lay down there; so, I rolled him onto his back, and he helped me sit him up. The TA #1 said the resident was then helped from a sitting position, onto a van seat, by pushing up with his legs and I helped by lifting him under his arms to the nearest van seat. Review of a Witness Interview Form dated [DATE] and signed by TA #1's Supervisor (who was over medical records and transportation scheduling) revealed a call came to her on [DATE] at 5:24 PM from TA #1 who said Resident #1 had fallen out of his wheelchair. He said a vehicle had cut him off and he had to slam on the brakes causing Resident #1 to hit the van floor. TA #1 said, the resident was strapped in, but not sure how it came loose. He said Resident #1 was bleeding around the head area. I told him to call 911. I called the DON and told him what had happened. The DON said, we have to go get the van because TA #1 cannot drive the van. When we (DON and I) arrived at the station, the paramedics were already there assessing Resident #1. The DON walked on the driver side of the van to see what was going on with Resident #1. I looked at Resident #1, knowing that he had just completed his [MEDICAL TREATMENT] treatment and saw that his eyes appeared weak/sleepy-like and blood covering his bottom teeth. He looked to me and was trying to say something, but his words were not clear. At approximately 6:00 PM, Resident #1 was transported to the local hospital. An interview with facility Medical Director (MD) #1 on [DATE] at 11:30 AM revealed on [DATE] Transportation Aide (TA) #1 should have called 911 first thing, and not put Resident #1 in the van seat before an assessment by a professional was conducted. MD #1 said TA #1 should have kept the resident still, until EMS stabilized his neck. You do not disturb the neck. He said the van stopped from going 45 miles per hour and the resident's neck hit the floor from the sudden stop. MD #1 said you also cannot hold a person down, if they say they want to get up. After saying it is not a good idea for them to get up, and they still want to get up, they will get up anyway. You cannot hold a person down, it could increase injury. An interview on [DATE] at 12:16 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed if a resident falls with an apparent head injury, she would not move the resident until an assessment was done on the resident. The ADON said she would encourage the resident to wait where they were, and wait for assistance. The DON said Resident #1 attempted to get himself up while in the van on [DATE], and to avoid possible further injury, TA #1 helped the resident up to the nearest van seat. She said the resident was already getting up (per what TA #1 told her at the van scene). She said, TA #1 also told her the resident was uncomfortable on the floor of the van and wanted to get up. She said the resident was moving and trying to get up by himself. The ADON said if a resident fell at the facility with a suspected head injury, she would call code green, would not move the resident, assess the resident fully, call the MD, and start neuro checks. The ADON said all facility NAs were instructed to get help when a fall occurs, remain with the resident, and don't move the resident. Review of a Certificate of Death with date of death of [DATE] revealed Resident #1's immediate cause of death was multiple [MEDICATION NAME] force injuries. Description of how injury occurred revealed motor vehicle stopped abruptly throwing unrestrained passenger forward. During an interview with the Administrator and the Executive Director on [DATE] at 12:32 PM they confirmed TA #1 should not have moved Resident #1 following the incident on [DATE] prior to being assessed by a licensed staff member or EMS. The administrator and Executive Director provided the following plan of correction with a compliance date of [DATE]. On [DATE] at 5:20 PM, Resident #1 fell from the wheel chair inside the facility van while transported from [MEDICAL TREATMENT] back to the facility. Facility Van Driver TA #1 indicated that he was travelling on the local road within the city speed limits. He was driving the facility's van, from [MEDICAL TREATMENT] center back to the facility. Resident #1 was on the wheel chair that was correctly secured. Both lap seat belt and main seat belts were both correctly secured. Resident #1 unbuckled the seat belt without the knowledge of the driver. While driving north on a beige colored vehicle cut off the path of TA #1 ' s way that necessitated driver (TA) #1 to apply the emergency breaking. Resident #1 fell forward off the wheel chair face forward and hit the floor that resulted onto facial injuries. Resident was able to move all extremities while on the van floor. Resident requested TA #1 to help him back to the seat as he was uncomfortable on the van floor. TA #1 assisted resident back to the van seat, following resident's requests, as well as multiple attempts by the resident to get off the floor, and lack of obvious signs of neurological injuries such as changes of mental status at that time. TA #1 contacted the facility and spoke to TA #1's Supervisor at 5:22 PM via her cell phone with no answer, then at 5:24 PM via the facility phone. TA #1's supervisor advised him to call 911. TA #1 called 911, who arrived at the scene of the accident and took over the care of the resident. The two medics assisted Resident #1 from a van chair to his wheel chair. Resident #1 was then wheeled outside the van via a rear van mechanical lift. While outside, two medics assisted Resident #1 from wheel chair to the stretcher before transporting resident to the emergency room (ER). Resident remained alert and oriented at the time he left the scene of an accident Director of nursing who was at the scene of the accident added. No obvious signs of neurological injuries noted. Driver (TA) # 1 went to Hospital for drug screening, toxicology results shows that employee was negative for [MEDICATION NAME], Barbiturates, Benzodiazepine, Cocaine, [MEDICATION NAME], Opiates, PCP as well as Marijuana. Driver #1 was suspended pending investigation and findings. Driver (TA) #1 driving privileges of the facility van has been revoked effective [DATE]. Resident #1 was transferred to another hospital on [DATE] for further evaluation and treatment. No other actions taken for Resident #1 as he is no longer in the facility. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. 100% of all drivers' education records were audited on [DATE] by the facility Administrator and/or Director of Nursing, to ensure each driver receive necessary education to drive the van safely. All drivers noted to have necessary training and qualification to drive the facility Van to include what to do in-case of an emergency. 100% of residents who has an incident or accident for the last 30 days starting on [DATE] through [DATE] were audited by the facility Director of Nursing on [DATE] to identify any other resident with an incident or accident who was moved without a licensed nurse's assessment. No other resident identified to be moved before licensed nurse assessed the resident. Findings of this audit is documented on the incident log audit maintained in the facility compliance binder. Measures will be put into place or what systematic changes will be made to ensure that the deficient practice will not occur. Effective [DATE] all non-licensed employees will not move any resident involved in an incident or accident, to include the incidents happened in the facility van when a resident experience any fall until the resident is assessed by the trained personnel. The Facility staff will ensure patient safety is maintained while to awaiting for help to arrive effective [DATE]. Executive Director, and/or Director of Nursing conducted re-education for current staff members on duty to include full time, part time and as needed employees on duty on [DATE]. This education included the importance of ensuring resident is not moved from the floor when resident incident or accident occurred until proper assessments are completed by the appropriate, trained personnel. This education will be completed by [DATE], any staff member not educated by [DATE] will not be allowed to work until educated on this requirement. Effective [DATE] this education will be added on new hires orientation education for all new facility staffs. This education will also be provided annually for all facility staff to include drivers. In-service form stated The resident should be kept safe in the location observed until help arrived. If a resident fell in an area that put resident at further risk for injuries, extreme precautions must be taken to ensure resident's injuries are not exacerbated, should the resident be moved. Executive Director, and/or Director of Nursing conducted re-education for current drivers and back up drivers' onsite on [DATE]. This education included the importance of ensuring resident is not moved from the floor of the van until proper assessments are completed by the appropriate, trained personnel. This education was completed by [DATE], any driver not educated by [DATE] will not be allowed to drive until educated on this requirement. Effective [DATE] this education will be added on new hires orientation education for all new facility drivers. This education will also be provided annually for all facility staff to include drivers. The facility plans to monitor its performance to make sure that solutions are sustained. Effective [DATE], Director of Nursing, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor compliance of staff not moving residents until a proper assessment is completed by a trained licensed employee by conducting clinical meeting daily (Monday through Friday). This meeting will allow the team to review all incidents or accidents that occurred from the prior clinical meeting to ensure that non licensed employee did not move a patient before a proper assessment is completed by the trained personnel. Any issues identified during this monitoring process will be addressed promptly. Findings from this meeting will be documented on a daily clinical report form and filed in the clinical meeting binder after proper follow up is done. This monitoring process will take place daily (Monday-Friday) for 2weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. This Effective [DATE], Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI) for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. QAPI committee members notified of this plan of action and its monitoring process on [DATE] by the facility Administrator. QAPI Committee adopted the established plan and will be the responsible body to modify any part of this plan effective [DATE]. The title of the person responsible for implementing the acceptable plan of correction. Effective [DATE] the facility Executive Director and the Director of Nursing will be ultimately responsible for the implementation of this plan of correction to ensure the facility attains and maintains substantial compliance. Validation of the above referenced plan of correction was completed on [DATE] during an extended survey. Validation included staff interviews regarding residents Fall Procedures. In-services regarding Fall Procedures were reviewed. In-services regarding not moving any resident involved in an incident or accident were reviewed. Staff were interviewed regarding in-service for residents not to be moved from the floor when resident incident or accident occurred until proper assessments are completed by the appropriate, trained personnel. Drivers' education records, as well as residents who had an incident or accident for the last 30 days starting on [DATE] through [DATE] were audited 100%. Compliance of staff not moving residents after an incident or accident audit tool were reviewed that will be and are used on a daily clinical report. This auditing process will take place daily (Monday-Friday) for 2 weeks, weekly x 2 more weeks, then monthly x 3 months as stated in the plan of correction. The date of [DATE] was validated as the facility's date of compliance.

Based on record review, staff, resident, physician, and Department of Social Services staff interviews, the facility failed to protect 1 of 3 residents (Resident #84) from physical abuse when Resident #84 was witnessed by facility staff being hit and kicked by his spouse in his facility room. Immediate jeopardy began on 6/4/18 when 2 witnesses observed Resident #84 seated in his room in a wheelchair speaking loudly and shaking both arms in front of his head. A female visitor, identified as his wife, was observed seated on the bed close to Resident #84 hitting, kicking and stomping on Resident #84. No physical injuries were assessed. Immediate jeopardy was removed on 6/7/18 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #84 was originally admitted to the facility 4/25/18 under an order of protection (known as a Petition for Ex Parte Order) provided by the Department of Social Services (DSS), Adult Protective Services (APS). The order read, in part, The undersigned petitioner (DSS Director of the county DSS) and through his representative (APS Social Worker-SW #1) having sufficient knowledge to believe the respondent (Resident #84) is in need of protective services alleges: 3. The respondent (Resident #84) is a disabled adult who is in need of protective services based on the following specific facts, j. without a protective order DSS is concerned the wife will remove respondent (Resident #84) from the hospital/rehab (rehabilitation). The hospital discharge summary dated 4/25/18 read, in part, Problems: (2) closed fracture of pubic ramus; (3) fracture of radius, distal right, closed (forearm); (4) nasal fracture; (5) assault; (7) neglected elder. Suspected abuse by pt.'s (Resident #84) wife. An incident report dated 6/4/18 revealed an allegation of visitor to resident abuse was witnessed by 2 staff members in the resident's room. A narrative of the incident read, Staff was walking past resident's room at 4:42 PM when they noted resident with his hands in the air and yelling. The resident's spouse was noted kicking him on the legs and stepping on his feet. Resident denied pain and no bruising was evident. Resident was supervised for safety and police were notified and responded. The resident's wife spouse was escorted from the building and is not to return until further notice. A nursing note dated 6/4/18 at 7:27 PM read, Staff was walking past resident's room at 4:42 PM when they noted resident with his hands in the air and yelling. The resident's spouse was noted kicking him on the legs and stepping on his feet. Resident denied pain and no bruising was evident. Resident was supervised for safety and police were notified and responded. The resident's wife spouse was escorted from the building and is not to return until further notice. A statement provided on 6/4/18 to the facility by Witness #1 read, in part, I witnessed (Resident #84) being physically abused by his wife. I was walking down (the hall Resident #84 resided on) when I noticed (Resident #84) yelling with his hands held high. (Resident #84's) wife was physically abusing him by kicking his legs and stomping on his feet. This incident happened approximately at 4:42 PM. An interview was conducted 6/5/18 at 11:50 AM with Witness #1. She stated as she walked down the hall Resident #84 resided on she heard him speaking loudly and saw his hands up and shaking. She stated he was in his wheelchair and his wife was observed kicking his legs and stomping his feet. She also stated, She was abusing him. She stated she intervened and asked Resident #84 if he was alright, but received no response. She stated she removed Resident #84 from the room and brought him to the common area where she and another staff member (Medical Records Director) stayed with him until police arrived. She also stated, This is his second or third admission here. I think he was here under a protective order the second time because his wife physically abused him. This is his third admission and I believe he's under protective custody now. She stated the wife visited frequently during the second admission, but had not visited as often this admission. She also stated she made a positive identification 6/4/18. A statement provided on 6/4/18 to the facility by Witness #2 read, in part, I, (Witness #2) walked by resident room (Resident #84) and saw him and his wife hitting each other. An interview was conducted on 6/5/18 at 1:10 PM with Witness #2. She stated she walked by Resident #84's room and observed Resident #84 and his wife hitting each other. She stated, I have seen his wife visit quite often but I had never seen a physical interaction before. When he was on the rehab (rehabilitation) hall she stayed with him all the time, but this admission she wasn't here so much. When we (Witness #1 and Witness #2) saw her hitting him we took him out of the room immediately. We put him in the TV room, she followed, and had (Medical Records Director) stay with them. An interview was conducted with Resident #84 on 6/5/18 at 1:30 PM. The resident stated he had known his wife for [AGE] years and she was not abusing him. He stated, All this talk about her hitting me is baloney. No care plan related to safety measures for Resident #84 was initiated until after the witnessed physical abuse. An interview was conducted on 6/5/18 at 3:00 PM with APS SW #1. She stated she was called to the hospital in (MONTH) related to (r/t) (Resident #84's) 3rd admission to the hospital since (MONTH) (YEAR) for multiple fractures and bruises. She also stated they (APS) suspected his wife was harming him. She stated, The facility was aware at the time of his admission in (MONTH) (4/25/18) of the potential for his wife to physically abuse him. I spoke with the Admission's Coordinator (AC #1) at the time of his admission. I signed him in because we had a protective order in place for him. This was his 3rd admission to (facility). His wife signed him out against medical advice in (MONTH) (YEAR) and tried to do the same thing in (MONTH) (his second admission) but she couldn't because of the protective order. So in the beginning of (MONTH) he improved tremendously and because we didn't have concrete evidence of abuse he went home with her. He was readmitted to the hospital with [REDACTED]. The facility and hospital speculated his wife was physically abusing him. I explained to the facility at the time of his last admission he was not to be left alone with her for his protection. (AC #1) told me they would only be allowed to meet in common areas, his door was to be kept open, he was put in a room up front near the Administrator's office (his room was approximately 100 feet from the Administrator's office) so it would be easy to hear if something was going on, and he was put in a semi-private room with an alert and oriented roommate. APS SW #1 also stated, (The AC #1) said to me, 'You know that woman is hurting him.' I told her I didn't disagree, but we needed proof of abuse. His room assignment and those protective measures were put into place before he was admitted last time. So the facility was well aware of the situation. When I asked them today what happened they told me they couldn't monitor him all the time. Now we are in the process of getting a Domestic Violence Protective Order, the (local) police are pressing assault charges, and she will be arrested this afternoon. An interview was conducted on 6/5/18 at 3:55 PM with AC #1. She stated she had no recall of any safety discussions with APS SW #1, just that he was under APS for some type of on-going investigation. She stated Resident #84 was admitted in (MONTH) (YEAR) and signed out against medical advice by his wife in (MONTH) of (YEAR). He was re-admitted [DATE] by APS SW #1 and discharged home 4/5/18. He was admitted a third time by APS SW #1 on 4/25/18. She said they had suspicions of domestic violence but both Resident #84 and his wife denied it. An additional interview was conducted with AC#1 on 6/6/18 at 9:05 AM. She stated there were no plans in place for Resident #84's safety when he was admitted because APS had not told the facility what to do. She stated she knew there was a suspicion of neglect and abuse, but it was just a suspicion and denied any recall of safety details being discussed with APS SW #1 at the time of his last admission. An additional interview was conducted on 6/6/18 at 3:35 PM with APS SW #1 and AC #1. APS SW #1 stated she had spoken to AC #1 on the day of admission (4/25/18) and explained why Resident #84 was admitted under a protective order and from whom he was being protected. It had always been a concern his wife was abusing him, but he had always been cognitively intact, until this admission, and had always denied abuse. He admitted to APS SW #1 his wife was the abuser on 6/5/18. APS SW #1 Stated, On the day of admission (AC #1) told me she had concerns the wife was abusing him, but we had never been able to substantiate the abuse. We discussed putting him in a semi-private room for safety, on the main hall for more traffic and (AC #1) and I agreed to keep his door open when the wife visited. We talked about keeping visits to the common area, but realized she could hit him just as easily in the common area as in his room. I told them not to allow visits with the wife behind closed doors. The protective order I gave them stated he was to be protected from his wife related to neglect, but I needed proof of physical abuse and I never had that until Monday. Now there's a Domestic Violence Order of Protection (DVPO) in place. A review of the DVPO revealed it was issued 6/5/28 at 3:05 PM and named Resident #84's wife the defendant. An interview was conducted with MDS Nurse #1 (Minimum Data Set) on 6/6/18 at 11:20 AM. She stated, I know APS was involved when (Resident #84) was placed here, but I didn't know there was a protective order in place until after the incident. I just did a care plan for safety today. No care plans related to the interventions APS SW #1 and AC #1 agreed to on 4/25/18 (the day of admission). An interview was conducted on 6/6/18 at 12:50 PM with the Administrator and Director of Nursing (DON). They stated their expectations were all residents would be protected at all times from harm and abuse, but behavior could not be predicted. The Administrator stated systems were in place which helped protect residents (rounds, wander guards). Staff were in serviced on abuse at the time of hire and annually, and after an incident. The Administrator stated, I don't feel our systems failed (Resident #84) because we couldn't predict the wife's behavior. There's a possibility she wasn't who he needed protection from. If I had concrete evidence it was her we would have had interventions in place. I had no suspicion he was being abused. An additional interview was conducted with the Administrator on 6/6/18 at 4:00 PM. He stated the Admission's Coordinator had not informed him of the APS protective order at the time of admission. An interview was conducted on 6/6/18 at 9:15 AM with the Medical Records Director. She stated the staff were in serviced on abuse annually and as needed. The 1st thing done was the resident in danger was removed and brought to safety. They stayed with resident until told by administration to do otherwise. She stated, at the time of Resident #84's admission the safety measures in place included to keep him in a room with high traffic, his door and curtains remained open when his wife visited, and they were kept in the common areas as often as possible. She stated there was 'hearsay' and suspicion he was being abused by his wife at admission. She also stated when she asked Resident #84 if he was alright he said yes and, She didn't mean to hurt me. The Medical Records Director also stated the facility had kept Resident #84's door and curtain open whenever his wife visited him in his room since his 2nd admission. An interview was conducted on 6/6/18 at 9:30 AM with the facility physician (MD). He stated he was not aware resident #84 was here under APS protective order, but he was notified of the resident's assault on Tuesday (6/5/18) morning. He also stated, If the facility was aware he was here under APS protection they never should have let the wife visit him alone under any circumstances. Today he is remarkably alert and oriented. He told me his wife in no way abused him, but the court order he came in with is very clear. He should not have been left alone with any visitors, except (the APS SW #1). It was the facility's responsibility to protect this man from being abused. Even if they could not prevent her from visiting him, they never should have left them alone. A staff member should have been present during all visits. I was notified Tuesday morning that his wife was seen abusing him. I was told the facility assessed him for injuries, and I saw him today. An interview was conducted with Resident #84's roommate on 6/6/18 at 11:30 AM. He stated, I was in the room when his wife was shoving and hitting him. I saw her hit him before too. When she hit him before I told the Nursing Assistants (NA's), but she still came in closed the door and curtain all the time. When she's in here, and I'm in here the door is supposed to be open. I don't like what she did to him. The roommate was not able to state which NA's he told or when he told them about what he saw. The Administrator, DON and Corporate Consultant were notified of the immediate jeopardy on 6/6/18 at 2:55 PM. On 6/7/18 at 10:48 PM the facility provided the following credible allegation of compliance and immediate jeopardy removal: This alleged noncompliance resulted from the center's failure to protect one resident with prior history of suspected domestic abuse from a spouse. On 4/25/2018 the facility admitted resident #84 for rehabilitation and long term care placement. Resident #84 had a protective order named Ex parte order filed in Harnett County Clerk of Superior Court on 4/24/2018. The protective order was presented to the facility at the time of admission on 4/25/2018 by the assigned Social worker from the Department of Social Services. The protective order included information that the department of Social services is concerned with the possibility of physical abuse and neglect, it also added that Without a protective order department of Social Services is concerned the wife will remove respondent from the hospital/rehab. The root cause analysis, concluded that, the systemic failure that resulted onto resident #84 incident on 6/4/2018 includes, broken communication process from admission for necessary information to include protective orders for resident #84. As a result the resident's alleged perpetrator visited resident #84 multiple times with no appropriate interventions to protect resident #84. The broken communication process resulted from a lack of a systemic process set forth on how protective orders was to be communicated by the admission Director to the rest of the IDT. Although the facility received the documentation on admission on 4/25/2018, and was notified by the DSS social worker of the protective orders of this resident, there is no indication that the facility put forth measures to protect Resident #84 from his wife. Admission Director failed to communicate the pertinent information to the interdisciplinary team necessary to insure resident #84 was protected while in the facility from his wife. On 6/4/2018 the resident's spouse was witnessed by the facility Activity Aide, & Central Supply Aide #1 in the room with the Resident #84. Activity Aide and Central Supply Aide stated they witnessed resident's spouse kicking resident's leg and stepping on his feet. Resident and the spouse were immediately separated by the Central Supply Aide. A Complete Head to toe body assessment was completed by the Registered nurse Supervisor #1. No injuries noted, resident denied any signs and symptoms of pain or discomforts. Initial report for the alleged abuse was completed and sent on 6/4/2018, DSS social worker and the attending Physician notified. IMMEDIATE ACTION TAKEN On 6/04/2018 at approximately 5:00PM the Central supplies aide separated resident #84 from his wife by pushing him out of the room to the hallway. The central supplies aide remained with resident #84 on the hallway, and notified Assistant Director of nursing who was standing in the proximity at the nurse's station #2. ADON walked towards the resident accompanied by the Unit Manager #1 who relieved the central supplies aide and took over supervision and protection of resident #84. Unit Manager #1 completed a head to toe assessment of the resident and noted no injuries. Resident denied pain or discomforts. Central supplies aide notified a Medical records supervisor who was standing at the nurse station #1. Medical records aide walked to the resident's room immediately and met Unit Manager #1 in the room. Medical records aide assisted Unit manager #1 while the Unit manager was assessing the patient. Unit Manager #1 and Medical Records supervisor transferred resident #84 to the wheel chair and moved the resident to the dining area. Medical Records supervisor remained with resident #84 until the police arrived with a brief period when she was relieved by the transportation aide who stayed with the resident when Medical Records supervisor departed. Likewise, the ADON who left Unit Manager #1 with resident#84 walked to the Executive Director's office for notification. On 06/04/2018 the 24 hour initial report was sent to the Department of Health and Human Services related to resident #84's witnessed abuse by the spouse. These reports were completed and submitted by the Director of Nursing. The Five day report was completed on 6/7/2018 after a detail investigation was conducted by the Center Executive Director, Director of Social Services and Director of Nursing. The incident on 6/4/2018 against resident #84 was substantiated based on findings of the investigation conducted by the Facility, Department of Social Services, and Harnett county Police Department. Resident #84's spouse is ordered by the court not to visit or be in contact with the resident effective 6/5/2018. Facility has yet to receive a confirmation of actions taken legally against the spouse. Facility will keep resident on 1 on 1 until confirmation is obtained of the spouse's inability to come to the facility. The photograph of the alleged perpetrator (resident#84 wife) is currently posted at the front desk, and at each nurse's station for easy identification and notification effective 6/6/18. The photograph is located on the pertinent location where all employees can identify resident #84's wife. Facility Executive Director, Director of Nursing, and Social worker from Department of Social Services met briefly on 6/5/2018 to discuss the incident that happened on 6/4/2018. The team discussed the possible actions necessary to protect the resident from the spouse. Multiple ideas were discussed, such as room change, identify the resident with a different name, or transfer resident #84 to another location that the spouse will not be aware of. On 6/5/2018, the facility as well as the DSS social worker reached a conclusion that, the best course of action that will protect resident #84 from his spouse, while maintaining his dignity, self-determination, and reduce risk for deterioration from this event is to relocate resident #84 to another part of the facility. Resident #84's name was changed on 6/5/2018 to an alias to ensure his protection by the facility Director of Nursing, Executive Director and Admission Director. Resident #84 was relocated to another room in the facility on 6/5/2018 and the posted name in the facility was changed. Resident #84 was placed on every 15 minutes watch from 7pm on 6/4/2018 to 9am. One on one supervision was initiated on 6/5/2018 in which an employee observe the resident at all times while in the facility. One on one care will continue until the facility receives confirmation that resident #84's wife is arrested. IDENTIFICATION OF OTHERS 100% audit of current residents financial files was completed by the Facility Admission Director and Business office manager on 6/6/2018 to identify any other resident with protective orders and validated the facility has measures in place to protect the resident from the alleged perpetrator. The audit revealed no other resident has protective orders related to abuse/neglect. Findings of this audit are documented on the financial files audit tool located in the facility compliance binder. On 06/06/2018, 100% interviews was completed by Director of Rehabilitation Center, Business office Manager, Activity Director, Medical Records Supervisor and MDS for all current alert and oriented residents in the facility to identify any other resident with an allegation of Abuse and/or Neglect. Two other residents, Resident #2, and Resident #3 voiced allegation of abuse and/or neglect. Alleged perpetrators identified were suspended while the investigation is conducted by the facility Executive director and/or Director of Nursing. 24 hour reports were submitted on 6/6/2018. A thorough investigation initiated. The resident's attending Physician and Responsible Party were notified of the allegation. Resident #2 and #3, will be informed of the findings and actions taken when the investigation is completed by the Center Executive Director and/or Director of Social Services. The Director of Social services, Assistant Director of Nursing, Unit manager, Admission Director and Director of Rehabilitation Services interviewed the responsible parties for residents who were not able to answer questions during this interview due to mental capacity. MONITORING PR[NAME]ESS Effective 6/7/2018, Director of Nursing, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor compliance with resident protection, thorough investigation, injuries of unknown sources and resident neglect by conducting clinical meeting daily. This meeting will allow the team to review all allegation of abuse, incidents or accidents that occurred from the prior clinical meeting. Any DSS protective orders and any documented information that indicate suspicion of abuse will be reviewed to ensure measures are in place to protect the resident. Any issues identified during this monitoring process will be addressed promptly. Findings from this meeting will be documented on a daily clinical report form and filed in the clinical meeting binder after proper follow up is done. This monitoring process will take place daily for 4weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 6/7/2018, Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. RESPONSIBLE PARTY Effective 6/7/2018, the center Executive Director and the Director of Nursing will be ultimately responsible to ensure implementation of this plan of correction for this alleged noncompliance to ensure the facility remains in substantial compliance. The credible allegation for immediate jeopardy removal was validated on 6/8/18, which removed the IJ on 06/07/18, as evidenced by staff interviews, in-service record reviews, and observations. The in service included information r/t Resident #84's new alias, new room number, and what action was to be taken if his wife was observed on the facility property. Other observations included one on one (1:1) staff with Resident #84, monitored entry and exits from the facility's main entrance, and a photograph of Resident #84's wife posted at every nursing station and ante room. A care plan was initiated 6/6/18 and focused on Safety: At risk for injury and social isolation r/t spousal abuse. The stated goals included maintained safety from his wife. Interventions included, but were not limited to, relocation to another room, identify by a different name, 1:1 supervision, staff education on name change, room change, safety interventions, monitoring for changes in mood or behavior, and an approved visitor list.

Based on record review and staff interviews, the facility failed implement the policy to screen the resident, prevent abuse and protect 1 of 3 residents (Resident #84) from visitor to resident physical abuse. The facility failed to implement measures specified by the Department of Social Services Adult Protective Services Social Worker prior to Resident #84's admission on 4/25/18 to protect him from being physically abused. Following the physical assault Resident #84 was assessed and did not have any physical injuries and did not require medical treatment. Immediate jeopardy began on 6/4/18 when 2 witnesses observed Resident #84 seated in his room in a wheelchair speaking loudly and shaking both arms in front of his head. A female visitor, identified as his wife, was observed seated on the bed close to Resident #84 hitting, kicking and stomping on Resident #84. No physical injuries were assessed. Immediate jeopardy was removed on 6/7/18 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: The facility's Abuse Prevention, intervention, Reporting and Investigation policy dated 11/2016 and revised (MONTH) (YEAR) read, in part, Purpose: The purpose of this policy is to ensure all residents have the right to be free from abuse. The facility will ensure the prevention, protection, in response to alleged, suspected, or witnessed abuse. The policy also read, in part, Definitions: 1. Abuse-willful infliction of injury, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, or visitor to resident. Physical Abuse-defined as non-accidental use of physical force that may result in bodily injury, physical pain, or impairment. Examples include, but are not limited to hitting, slapping, pinching, and kicking. The policy also read, in part, The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. The seven key components of an abuse prevention system can potentially detect, reduce, and prevent abuse from occurring. Overview of seven components: screening, training, prevention, identification, investigation, protection, reporting and response. The policy also read, in part, Protection: It is our policy that the resident(s) will be protected from the alleged offender(s). 4. Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation. If the alleged abuser is not an employee, measures are taken to provide a safe, secure environment for the patient. Actions may include: patient room change, patient daily schedule change, visitor restrictions, reporting to other agencies or law enforcement. Review of Resident #84's hospital discharge summary dated 4/25/18 read, in part, Problems: (2) closed fracture of pubic ramus; (3) fracture of radius, distal right, closed (forearm); (4) nasal fracture; (5) assault; (7) neglected elder. Suspected abuse by pt.'s (Resident #84) wife. Review of the order of protection (known as a Petition for Ex Parte Order) dated 4/24/18 provided to the facility on [DATE] by the Department of Social Services (DSS), Adult Protective Services (APS)read, in part, The undersigned petitioner (DSS Director of the county DSS) and through his representative (APS Social Worker-APS SW #1) having sufficient knowledge to believe the respondent (Resident #84) is in need of protective services alleges: 3. The respondent (Resident #84) is a disabled adult who is in need of protective services based on the following specific facts, j. without a protective order DSS is concerned the wife will remove respondent (Resident #84) from the hospital/rehab (rehabilitation). Review of Resident #84's medical record revealed he was admitted from the hospital to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. A 5 day MDS (Minimum Data Set-a tool used for resident assessment) dated 5/2/18 revealed Resident #84 was admitted [DATE] from an acute care hospital. He was cognitively intact and required extensive to total assistance for all activities of daily living. He had 1 upper limb (arm) impairment and active [DIAGNOSES REDACTED]. Review of Resident #84's medical record revealed a nursing note dated 6/4/18 at 7:27 PM which read, Staff was walking past resident's room at 4:42 PM when they noted resident with his hands in the air and yelling. The resident's spouse was noted kicking him on the legs and stepping on his feet. Resident denied pain and no bruising was evident. Resident was supervised for safety and police were notified and responded. The resident's wife spouse was escorted from the building and is not to return until further notice. An incident report dated 6/4/18 indicated the incident type was an allegation of abuse, which occurred in the resident's room. A narrative of the incident read, Staff was walking past resident's room at 4:42 PM when they noted resident with his hands in the air and yelling. The resident's spouse was noted kicking him on the legs and stepping on his feet. Resident denied pain and no bruising was evident. Resident was supervised for safety and police were notified and responded. The resident's wife spouse was escorted from the building and is not to return until further notice. A statement provided on 6/4/18 to the facility by Witness #1 read, I witnessed (Resident #84) being physically abused by his relative. I was walking down (the hall Resident #84 resided on) when I noticed (Resident #84) yelling with his hands held high. (Resident #84) relative whom is his wife was physically abusing him by kicking his legs and stomping on his feet. This incident happened approximately at 4:42 PM. An interview was conducted 6/5/18 at 11:50 AM with Witness #1 (Central Supply Clerk) She stated on 06/04/18 as she walked down the hall Resident #84 resided on she heard him speaking loudly and saw his hands up and shaking. She stated he was in his wheelchair and his wife was observed kicking his legs and stomping his feet. She also stated, She was abusing him. She stated she intervened and asked Resident #84 if he was alright, but received no response. She stated she removed Resident #84 from the room and brought him to the common area where she and another staff member (Medical Records Director) stayed with him until police arrived. She also stated, This is his second or third admission here. I think he was here under a protective order the second time because his wife physically abused him. This is his third admission and I believe he's under protective custody now. She stated the wife visited frequently during the second admission, but had not visited as often this admission. A statement provided on 6/4/18 to the facility by Witness #2 read, I, (Witness #2) walked by resident room (Resident #84) and saw him and his wife hitting each other. Ask her to step out and told (nurse) about it. An interview was conducted on 6/5/18 at 1:10 PM with Witness #2 (Activities Aide). She stated on 06/04/18 she walked by Resident #84's room and observed Resident #84 and his wife hitting each other. She stated, I have seen his wife visit quite often but I had never seen a physical interaction before. When he was on the rehab (rehabilitation) hall she stayed with him all the time, but this admission she wasn't here so much. When we (Witness #1 and Witness #2) saw her hitting him we took him out of the room immediately. We put him in the TV room, she followed, and had (Medical Records Director) stay with them. Witness #2 was not aware of any visitor restrictions for Resident #84. Review of Resident #84's care plans since the date of admission (4/25/18) revealed no care plan related to safety measures for Resident #84 was initiated until after the witnessed physical abuse on 06/04/18. An interview was conducted on 6/5/18 at 3:00 PM with APS SW#1. She stated she was called to the hospital in (MONTH) related to (r/t) (Resident #84's) 3rd admission to the hospital since (MONTH) (YEAR) for multiple fractures and bruises. She also stated they (APS) suspected his wife was harming him. She stated, The facility was aware at the time of his admission in (MONTH) (4/25/18) of the potential for his wife to physically abuse him. I spoke with the Admission's Coordinator (AC #1) at the time of his admission. I signed him in because we had a protective order in place for him. This was his 3rd admission to (facility). His wife signed him out against medical advice in (MONTH) (YEAR) and tried to do the same thing in (MONTH) (his second admission) but she couldn't because of the protective order. So in the beginning of (MONTH) he improved tremendously and because we didn't have concrete evidence of abuse he went home with her. He was readmitted to the hospital with [REDACTED]. The facility and hospital speculated his wife was physically abusing him. I explained to the facility at the time of his last admission he was not to be left alone with her for his protection. (AC #1) told me they would only be allowed to meet in common areas, his door was to be kept open, he was put in a room up front near the Administrator's office (his room was approximately 100 feet from the Administrator's office) so it would be easy to hear if something was going on, and he was put in a semi-private room with an alert and oriented roommate. APS SW #1 also stated, (The AC #1) said to me, 'You know that woman is hurting him.' I told her I didn't disagree, but we needed proof of abuse. His room assignment and those protective measures were put into place before he was admitted last time. So the facility was well aware of the situation. When I asked them today what happened they told me they couldn't monitor him all the time. Now we are in the process of getting a Domestic Violence Protective Order, the (local) police are pressing assault charges, and she will be arrested this afternoon. A copy of the DVPO was reviewed and revealed it was put in place, against Resident #84's wife, on 6/5/18 at 3:08 PM and read, in part, 4. The Defendant (wife) has attempted to cause or has intentionally caused me bodily injury, or has placed me in fear of imminent bodily injury. 4 (MONTH) (YEAR)- An aid at (facility name) heard a commotion coming from the Plaintiffs (Resident #84) room, then observed the Plaintiff seated I his wheelchair with his arms raised in an attempt to protect himself from the Defendant who was slapping him, punching him, kicking him about the kneecaps & (and) stomping on his feet. The facility had previously been instructed by HCDSS (Harnett County Department of Social Services) to not allow any supervised contact between Plaintiff & Defendant. The facility's Abuse Prevention, intervention, Reporting and Investigation policy dated 11/2016 and revised (MONTH) (YEAR) read, in part, The center has developed a system (Seven Key Components which included screening and protection) for identifying, preventing, and reporting any incident or suspected incident of any type of abuse. The Abuse Policy further read, in part, Protection- Patient protection actions include immediately removing the patient from contact with the alleged abuser. If the alleged abuser is not an employee, actions may include: patient room change, patient daily schedule change, visitor restrictions. An interview was conducted on 6/5/18 at 3:55 PM with AC #1. She stated she had no recall of any safety discussions with APS SW #1, just that he (Resident #84) was under APS for some type of on-going investigation. She stated Resident #84 was admitted in (MONTH) (YEAR) and signed out against medical advice by his wife in (MONTH) of (YEAR). He was re-admitted [DATE] by APS SW #1 and discharged home 4/5/18. He was admitted a third time by APS SW #1 on 4/25/18. She said they had suspicions of domestic violence but both Resident #84 and his wife denied it. An additional interview was conducted with AC #1 on 6/6/18 at 9:05 AM. She stated there were no plans in place for Resident #84's safety when he was admitted on [DATE] because APS had not told the facility what to do. She stated she knew there was a suspicion of neglect and abuse, but it was just a suspicion and denied any recall of safety details being discussed with APS SW #1 at the time of his last admission. An additional interview was conducted on 6/6/18 at 3:35 PM with APS SW #1 and AC #1. APS SW #1 stated she had spoken to AC #1 on the day of Resident #84's admission to the facility (4/25/18) and explained why Resident #84 was admitted under a protective order and from whom he was being protected. It had always been a concern his wife was abusing him, but he had always been cognitively intact until this admission and had always denied abuse. He admitted his wife was the abuser on 6/5/18. APS SW #1 Stated, On the day of admission (AC #1) told me she had concerns the wife was abusing him, but we had never been able to substantiate the abuse. We discussed putting him in a semi-private room for safety, on the main hall for more traffic and (AC #1) and I agreed to keep his door open when the wife visited. (This occurred) We talked about keeping visits to the common area, but realized she could hit him just as easily in the common area as in his room. I told them not to allow visits with the wife behind closed doors. The protective order I gave them stated he was to be protected from his wife related to neglect, but I needed proof of physical abuse and I never had that until Monday (6/4/18). Now there's a Domestic Violence Order of Protection (DVPO) in place. An interview was conducted with MDS Nurse #1 (Minimum Data Set) on 6/6/18 at 11:20 AM. She stated, I know APS was involved when (Resident #84) was placed here (4/25/18), but I didn't know there was a protective order in place until after the incident on 06/04/18. I just did a care plan for safety today. An interview was conducted on 6/6/18 at 12:50 PM with the Administrator and Director of Nursing (DON). They stated their expectations were all residents would be protected at all times from harm and abuse, but behavior could not be predicted. The Administrator stated systems were in place which helped protect residents (rounds, wander guards). Staff were in serviced on abuse at the time of hire and annually and after an incident. The Administrator stated, I don't feel our systems failed (Resident #84) because we couldn't predict the wife's behavior. There's a possibility she wasn't who he needed protection from. If I had concrete evidence it was her we would have had interventions in place. I had no suspicion he was being abused. An additional interview was conducted with the Administrator on 6/6/18 at 4:00 PM. He stated AC #1 had not informed him of the APS protective order at the time of admission on 4/25/18. An interview was conducted on 6/6/18 at 9:15 AM with the Medical Records Director. She stated the staff were in serviced on abuse annually and as needed. The first thing done was the resident in danger was removed and brought to safety. They stayed with resident until told by administration to do otherwise. She stated, at the time of Resident #84's admission to the facility on [DATE], the safety measures in place included to keep him in a room with high traffic (it was), his door and curtains remained open when his wife visited (they were), and they were kept in the common areas as often as possible. She stated there was 'hearsay' and suspicion he was being abused by his wife at admission. She also stated when she asked Resident #84 on the day of the assault (6/4/18) if he was alright he said yes and, She didn't mean to hurt me. The Medical Records Director also stated the facility had kept Resident #84's door and curtain open whenever his wife visited him since his 2nd admission. An interview was conducted on 6/6/18 at 9:30 AM with the facility physician (MD). He stated he was not aware resident #84 was here under APS protective order, but he was notified of the resident's assault on Tuesday (6/5/18) morning. He also stated, If the facility was aware he was here under APS protection they never should have let the wife visit him alone under any circumstances. Today he is remarkably alert and oriented. He told me his wife in no way abused him, but the court order he came in with is very clear. He should not have been left alone with any visitors, except (the APS SW #1). It was the facility's responsibility to protect this man from being abused. Even if they could not prevent her from visiting him, they never should have left them alone. A staff member should have been present during all visits. I was notified Tuesday morning that his wife was seen abusing him. I was told the facility assessed him for injuries, and I saw him today. An interview was conducted with Resident #84's roommate on 6/6/18 at 11:30 AM. He stated, I was in the room when his wife was shoving and hitting him. I saw her hit him before too. When she hit him before I told the Nursing Assistants (NA's), but she still came in closed the door and curtain all the time. When she's in here, and I'm in here the door is supposed to be open. I don't like what she did to him. The roommate was not able to state which NA's he told or when he told them about what he saw. The Administrator, Director of Nursing, and Corporate Consultant were notified of the immediate jeopardy on 6/6/18 at 2:55 PM. On 6/7/18 at 10:48 PM the facility provided the following credible allegation of compliance and immediate jeopardy removal: This alleged noncompliance resulted from the center's failure to follow the abuse policy and procedures that led to not protecting one resident with prior history of suspected domestic abuse from a spouse. On 4/25/2018 the facility admitted resident #84 for rehabilitation and long term care placement. Resident #84 had a protective order named Ex parte order filed in Harnett County Clerk of Superior Court on 4/24/2018. The protective order was presented to the facility at the time of admission on 4/25/2018 by the assigned Social worker from the Department of Social Services. The protective order included information that the department of Social services is concerned with the possibility of physical abuse and neglect, it also added that Without a protective order department of Social Services is concerned the wife will remove respondent from the hospital/rehab. This alleged noncompliance resulted from the facility failure to implement abuse policies and procedures on the area of proper screening, identification, protection and reporting that resulted from the broken communication process from resident's admission to the facility for necessary information to include protective orders for resident #84. As the result the resident's alleged perpetrator visited resident #84 multiple times with no appropriate interventions to protect resident #84. Root cause analysis also concluded that the facility miss-interpreted regulatory requirements that requires the facility to protect each resident while in the facility, and reporting any allegation of abuse immediately but no later than two hours after the allegation is made. The facility also failed to follow the policies and procedures to put measures in place to protect residents while in the facility even when they are under the custody of DSS. The root cause analysis, concluded that, the systemic failure that resulted onto resident #84 incident on 6/4/2018 includes, broken communication process from admission for necessary information to include protective orders for resident #84. As a result the resident's alleged perpetrator visited resident #84 multiple times with no appropriate interventions to protect resident #84. The broken communication process resulted from a lack of a systemic process set forth on how protective orders was to be communicated by the admission Director to the rest of the IDT. Although the facility received the documentation on admission on 4/25/2018, and was notified by the DSS social worker of the protective orders of this resident, there is no indication that the facility put forth measures to protect Resident #84 from his wife. Admission Director failed to communicate the pertinent information to the interdisciplinary team necessary to insure resident #84 was protected while in the facility from his wife. On 6/4/2018 the resident's spouse was witnessed by the facility Activity Aide, & Central Supply Aide #1 in the room with the Resident #84. Activity Aide and Central Supply Aide stated they witnessed resident's spouse kicking resident's leg and stepping on his feet. Resident and the spouse were immediately separated by the Central Supply Aide. A Complete Head to toe body assessment was completed by the Registered nurse Supervisor #1. No injuries noted, resident denied any signs and symptoms of pain or discomforts. Initial report for the alleged abuse was completed and sent on 6/4/2018, DSS social worker and the attending Physician notified. IMMEDIATE ACTION TAKEN The Chief Clinical officer from the Management and consulting company that manages the center, re-educated the Center Executive Director and the Director of Nursing 6/7/2018 on the center Abuse Prohibition and Investigation policies and procedures, and emphasized the importance of screening, identification, protecting and reporting to the regulatory required agencies immediately but no later than two hours from the time the allegation is made. The education also emphasized on the importance of ensuring residents are screened for potential abuse and measures are put forth to protect them while residing in the facility. The Chief Clinical officer from the Management and consulting company that manages the center, re-educated facility management team that consist of the department supervisors on the center's Abuse Prohibition and Investigation policies and procedures, and emphasized on the importance of screening patients and employees before hire, protecting resident(s), and reporting any allegation of abuse or Neglect to their Direct supervisor and the Executive Director in a timely manner as well as to the Regulatory required agencies immediately but no later than 2 hours after forming suspicion, witness the abuse and/or after a resident, another staff and/or family member alleged abuse. On 6/04/2018 at approximately 5:00PM the Central supplies aide separated resident #84 from his wife by pushing him out of the room to the hallway. The central supplies aide remained with resident #84 on the hallway, and notified Assistant Director of nursing who was standing in the proximity at the nurse's station #2. ADON walked towards the resident accompanied by the Unit Manager #1 who relieved the central supplies aide and took over supervision and protection, per facility abuse prohibition process of resident #84, per the facility abuse policy and procedures. Unit Manager #1 completed a head to toe assessment of the resident and noted no injuries. Resident denied pain or discomforts. Central supplies aide notified a Medical records supervisor who was standing at the nurse station #1. Medical records aide walked to the resident's room immediately and met Unit Manager #1 in the room. Medical records aide assisted Unit manager #1 while the Unit manager was assessing the patient. Unit Manager #1 and Medical Records supervisor transferred resident #84 to the wheel chair and moved the resident to the dining area. Medical Records supervisor remained with resident #84 until the police arrived with a brief period when she was relieved by the transportation aide who stayed with the resident when Medical Records supervisor departed. Likewise, the ADON who left Unit Manager #1 with resident#84 walked to the Executive Director's office for notification. On 06/04/2018 the 24 hour initial report was sent to the Department of Health and Human Services related to resident #84's witnessed abuse by the spouse. These reports were completed and submitted by the Director of Nursing. The Five day report was completed on 6/7/2018 after a detail investigation was conducted by the Center Executive Director, Director of Social Services and Director of Nursing. The incident on 6/4/2018 against resident #84 was substantiated based on findings of the investigation conducted by the Facility, Department of Social Services, and Harnett county Police Department. Resident #84's spouse is ordered by the court not to visit or be in contact with the resident effective 6/5/2018. Facility has yet to receive a confirmation of actions taken legally against the spouse. Facility will keep resident on 1 on 1 until confirmation is obtained of the spouse's inability to come to the facility. The photograph of the alleged perpetrator (resident#84 wife) is currently posted at the front desk, and at each nurse's station for easy identification and notification effective 6/6/18. The photograph is located on the pertinent location where all employees can identify resident #84's wife. Facility Executive Director, Director of Nursing, and Social worker from Department of Social Services met briefly on 6/5/2018 to discuss the incident that happened on 6/4/2018. The team discussed the possible actions necessary to protect the resident from the spouse. Multiple ideas were discussed, such as room change, identify the resident with a different name, or transfer resident #84 to another location that the spouse will not be aware of. On 6/5/2018, the facility as well as the DSS social worker reached a conclusion that, the best course of action that will protect resident #84 from his spouse, while maintaining his dignity, self-determination, and reduce risk for deterioration from this event is to relocate resident #84 to another part of the facility. Resident #84's name was changed on 6/5/2018 to an alias to ensure his protection, per facility abuse prohibition process by the facility Director of Nursing, Executive Director and Admission Director. This measure is in alignment with the facility abuse policy and procedure. Resident #84 was relocated to another room in the facility on 6/5/2018 and the posted name in the facility was changed. Resident #84 was placed on every 15 minutes watch from 7pm on 6/4/2018 to 9am. One on one supervision was initiated on 6/5/2018 in which an employee observe the resident at all times while in the facility. One on one care will continue until the facility receives confirmation that resident #84's wife is arrested. IDENTIFICATION OF OTHERS 100% audit of all residents clinical documentation within the last 30 days was completed by the Director of Nursing, Assistant Director of Nursing and/or Nurse Supervisor to determine if there is any documentation in any resident medical records that indicate allegation of abuse, neglect, or injury of unknown sources, if any, determine whether a 24 hours and 5 days investigation reports were completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. The audit revealed two other documented allegation of abuse, and/or neglect documented in resident medical records. This audit was completed on 6/6/18 & 6/7/18. Findings of this audit is documented on clinical records audit tool located at the facility compliance binder. 100% audit was completed by the Center executive Director for all allegation of abuse and/or neglect submitted in the past from 1/24/2018 to 6/7/2018 determine if the alleged perpetrator was suspended during investigation to protect the resident, 24 hours completed within 2 hours of the allegation and 5 days completed and submitted to the state agency as required by regulation and Elder Justice Act in a timely manner. The audit revealed 5 of 5 completed abuse/neglect reports indicated the alleged perpetrator was suspended pending investigation per abuse prohibition policy and procedure, however all 5 of 5 initial 24 hour reports were not submitted within two hours of the allegation. 2 months noted with detail investigation and the Alleged Perpetrator(s) were suspended. This audit was completed on 6/7/2018. On 06/06/2018, 100% interviews was completed by Director of Rehabilitation Center, Business office Manager, Activity Director, Medical Records Supervisor and MDS for all current alert and oriented residents in the facility to identify any other resident with an allegation of Abuse and/or Neglect. Two other residents, Resident #2, and Resident #3 voiced allegation of abuse and/or neglect. Alleged perpetrators identified were suspended while the investigation is conducted by the facility Executive director and/or Director of Nursing. 24 hour reports were submitted on 6/6/2018. A thorough investigation initiated. The resident's attending Physician and Responsible Party were notified of the allegation. Resident #2 and #3, will be informed of the findings and actions taken when the investigation is completed by the Center Executive Director and/or Director of Social Services. The Director of Social services, Assistant Director of Nursing, Unit manager, Admission Director and Director of Rehabilitation Services interviewed the responsible parties for residents who were not able to answer questions during this interview due to mental capacity deficit on 6/7/18. No family member voiced any allegation of abuse and/or neglect. SYSTEMIC CHANGES Effective 6/7/2018, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials to include; the State Survey Agency, adult protective services, the state Ombudsmen in accordance with State law through established facilities policies and procedures. Effective 6/7/2018, The facility will report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Effective 6/7/2018, the facility interdisciplinary team to include Executive Director, Director of Nursing, Director of Social services and at least three other department supervisors will attend a monthly mandatory training that will be conducted by contracted management and consulting company that oversees the facility. This training will put an emphasis on all seven components of abuse prohibition to include screening, training, prevention, identification, investigation, protection, reporting and responses. This training will take place monthly for next twelve months or until the pattern of compliance is maintained. Effective 6/7/2018, the Center Director of Human Services, and/or employee direct supervisor and/or designated staff member will conduct interviews for each current employee at least once a year. The interview will be intended to determine the employee understanding of the Center Abuse policies and Procedures. The interview process will be incorporated to the annual employee evaluating. Any staff member not interviewed by the anniversary date will not be allowed to work until educated. Effective 6/7/2018, interviews for alert and oriented residents will be completed by the Director of Social Services, Director of Recreational Services and/or designated staff me (TRUNCATED)

Based on record review, staff, physician and Department of Social Services interviews, and observations, the facility failed to provide oversight and leadership to the staff to ensure the facility was free from abuse and to prevent and protect 1 of 3 residents (Resident #84) from being physical abused by a visitor. Resident #84 was witnessed being physically abused by his spouse in the facility. The facility failed to implement measures specified by the Department of Social Services Adult Protective Services Social Worker prior to Resident #84's admission to the facility to protect him from being physically abused. Immediate jeopardy began on 6/4/18 when the facility administration failed to provide oversight and management to ensure the facility was free from abuse when 2 witnesses observed Resident #84 seated in his room in a wheelchair and a female visitor, identified as his wife, was observed hitting, kicking and stomping on Resident #84. Immediate jeopardy was removed 6/7/18 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Cross Refer Tag -600: Based on record review, staff, resident, physician, and Department of Social Services staff interviews, the facility failed to protect 1 of 3 residents (Resident #84) from physical abuse when Resident #84 was witnessed by facility staff being hit and kicked by his spouse in his facility room. Cross Refer Tag F-607: Based on record review and staff interviews, the facility failed implement the policy to screen the resident, prevent abuse and protect 1 of 3 residents (Resident #84) from visitor to resident physical abuse. The facility failed to implement measures specified by the Department of Social Services Adult Protective Services Social Worker prior to Resident #84's admission on 4/25/18 to protect him from being physically abused. Following the physical assault Resident #84 was assessed and did not have any physical injuries and did not require medical treatment. The Administrator, DON and Corporate Consultant were notified of the immediate jeopardy on 6/6/18 at 2:55 PM. On 6/7/18 at 10:48 PM the facility provided the following credible allegation of immediate jeopardy removal: This alleged noncompliance resulted from the center's failure to be administered in a manner that use the resources effectively, efficiently, and consistently to ensure the facility implemented the abuse prohibition policies and procedures to protect residents from abuse and/or neglect and ensure the facility attain and maintain regulatory compliance consistently to avoid repeated deficient practices. The analysis conducted also indicated that the facility failure is resulted from the high turnover in administrative staff that cause inconsistences on processes as the result quality outcome is diminished. The high turnover rate is concluded to be due to the poor work place culture. This alleged noncompliance resulted from the center's failure to follow the abuse policy and procedures that led to not protecting one resident with prior history of suspected domestic abuse from a spouse. On 4/25/2018 the facility admitted resident #84 for rehabilitation and long term care placement. Resident #84 had a protective order named Ex parte order filed in Harnett County Clerk of Superior Court on 4/24/2018. The protective order was presented to the facility at the time of admission on 4/25/2018 by the assigned Social worker from the Department of Social Services. The protective order included information that the department of Social services is concerned with the possibility of physical abuse and neglect, it also added that Without a protective order department of Social Services is concerned the wife will remove respondent from the hospital/rehab. This alleged noncompliance resulted from the facility failure to implement abuse policies and procedures on the area of proper screening, identification, protection and reporting that resulted from the broken communication process from resident's admission to the facility for necessary information to include protective orders for resident #84. As the result the resident's alleged perpetrator visited resident #84 multiple times with no appropriate interventions to protect resident #84. Root cause analysis also concluded that the facility misinterpreted regulatory requirements that requires the facility to protect each resident while in the facility, and reporting any allegation of abuse immediately but no later than two hours after the allegation is made. The facility also failed to follow the policies and procedures to put measures in place to protect residents while in the facility even when they are under the custody of DSS. The root cause analysis, concluded that, the systemic failure that resulted onto resident #84 incident on 6/4/2018 includes, broken communication process from admission for necessary information to include protective orders for resident #84. As a result the resident's alleged perpetrator visited resident #84 multiple times with no appropriate interventions to protect resident #84. The broken communication process resulted from a lack of a systemic process set forth on how protective orders was to be communicated by the Admission Director to the rest of the IDT. Although the facility received the documentation on admission on 4/25/2018, and was notified by the DSS social worker of the protective orders of this resident, there is no indication that the facility put forth measures to protect Resident #84 from his wife. Admission Director failed to communicate the pertinent information to the interdisciplinary team necessary to insure resident #84 was protected while in the facility from his wife. On 6/4/2018 the resident's spouse was witnessed by the facility Activity Aide, & Central Supply Aide #1 in the room with the Resident #84. Activity Aide and Central Supply Aide stated they witnessed resident's spouse kicking resident's leg and stepping on his feet. Resident and the spouse were immediately separated by the Central Supply Aide. A Complete Head to toe body assessment was completed by the Registered nurse Supervisor #1. No injuries noted, resident denied any signs and symptoms of pain or discomforts. Initial report for the alleged abuse was completed and sent on 6/4/2018, DSS social worker and the attending Physician notified. IMMEDIATE ACTION TAKEN The Executive Director counselled the facility Admission Director on 6/7/2018 to address the communication failure that caused the deficient practice. The New Executive director was hired on 2/15/2018 to manage and supervise the facility's operation. The Executive director is rebuilding the facility management staff by hiring qualified personnel to manage the departments in the facility to ensure and assure quality outcomes. The Executive Director has hired qualified Assistant Director of Nursing, Two Registered nurse Supervisors, Business Office Manager, and Director of Food Services. The Admistrator is leading the team towards systematically identifying and addressing quality deficits. He has put systems and processes in place to improve facility systems and processes. Chief Clinical officer from the Management and consulting company that manages the center, re-educated the Center Executive Director and the Director of Nursing 6/7/2018 on the center Abuse Prohibition and Investigation policies and procedures, and emphasized the importance of screening, identification, protecting and reporting to the regulatory required agencies immediately but no later than two hours from the time the allegation is made. The education also emphasized on the importance of ensuring residents are screened for potential abuse and measures are put forth to protect them while residing in the facility. The Chief Clinical officer from the Management and consulting company that manages the center, re-educated facility management team that consist of the department supervisors on the center's Abuse Prohibition and Investigation policies and procedures, and emphasized on the importance of screening patients and employees before hire, protecting resident(s), and reporting any allegation of abuse or Neglect to their Direct supervisor and the Executive Director in a timely manner as well as to the Regulatory required agencies immediately but no later than 2 hours after forming suspicion, witness the abuse and/or after a resident, another staff and/or family member alleged abuse. On 6/04/2018 at approximately 5:00PM the Central Supplies aide separated resident #84 from his wife by pushing him out of the room to the hallway. The central supplies aide remained with resident #84 on the hallway, and notified Assistant Director of Nursing (DON) who was standing in the proximity at the nurse's station #2. ADON walked towards the resident accompanied by the Unit Manager #1 who relieved the Central Supplies aide and took over supervision and protection, per facility abuse prohibition process of resident #84, per the facility abuse policy and procedures. Unit Manager #1 completed a head to toe assessment of the resident and noted no injuries. Resident denied pain or discomforts. Central Supplies aide notified a Medical Records supervisor who was standing at the nurse station #1. Medical Records aide walked to the resident's room immediately and met Unit Manager #1 in the room. Medical Records aide assisted Unit manager #1 while the Unit manager was assessing the patient. Unit Manager #1 and Medical Records supervisor transferred resident #84 to the wheel chair and moved the resident to the dining area. Medical Records supervisor remained with resident #84 until the police arrived with a brief period when she was relieved by the transportation aide who stayed with the resident when Medical Records supervisor departed. Likewise, the ADON who left Unit Manager #1 with resident#84 walked to the Executive Director's office for notification. On 06/04/2018 the 24 hour initial report was sent to the Department of Health and Human Services related to resident #84's witnessed abuse by the spouse. These reports were completed and submitted by the Director of Nursing. The Five day report was completed on 6/7/2018 after a detail investigation was conducted by the Center Executive Director, Director of Social Services and Director of Nursing. The incident on 6/4/2018 against resident #84 was substantiated based on findings of the investigation conducted by the Facility, Department of Social Services, and Harnett county Police Department. Resident #84's spouse is ordered by the court not to visit or be in contact with the resident effective 6/5/2018. Facility has yet to receive a confirmation of actions taken legally against the spouse. Facility will keep resident on 1 on 1 until confirmation is obtained of the spouse's inability to come to the facility. The photograph of the alleged perpetrator (resident#84 wife) is currently posted at the front desk, and at each nurse's station for easy identification and notification effective 6/6/18. The photograph is located on the pertinent location where all employees can identify resident #84's wife. Facility Executive Director, Director of Nursing, and Social Worker from Department of Social Services met briefly on 6/5/2018 to discuss the incident that happened on 6/4/2018. The team discussed the possible actions necessary to protect the resident from the spouse. Multiple ideas were discussed, such as room change, identify the resident with a different name, or transfer resident #84 to another location that the spouse will not be aware of. On 6/5/2018, the facility as well as the DSS social worker reached a conclusion that, the best course of action that will protect resident #84 from his spouse, while maintaining his dignity, self-determination, and reduce risk for deterioration from this event is to relocate resident #84 to another part of the facility. Resident #84's name was changed on 6/5/2018 to an alias to ensure his protection, per facility abuse prohibition process by the facility Director of Nursing, Executive Director and Admission Director. This measure is in alignment with the facility abuse policy and procedure. Resident #84 was relocated to another room in the facility on 6/5/2018 and the posted name in the facility was changed. Resident #84 was placed on every 15 minutes watch from 7pm on 6/4/2018 to 9am. One on one supervision was initiated on 6/5/2018 in which an employee observes the resident at all times while in the facility. One on one care will continue until the facility receives confirmation that resident #84's wife is arrested. IDENTIFICATION OF OTHERS 100% audit of all residents clinical documentation within the last 30 days was completed by the Director of Nursing, Assistant Director of Nursing and/or Nurse Supervisor to determine if there is any documentation in any resident medical records that indicate allegation of abuse, neglect, or injury of unknown sources, if any, determine whether a 24 hours and 5 days investigation reports were completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. The audit revealed two other documented allegation of abuse, and/or neglect documented in resident medical records. This audit was completed on 6/6/18 & 6/7/18. Findings of this audit is documented on clinical records audit tool located at the facility compliance binder. 100% audit was completed by the Center Executive Director for all allegation of abuse and/or neglect submitted in the last from 1/24/2018 to 6/7/2018 determine is the alleged perpetrator was suspended during investigation to protect the resident, 24 hours completed within 2 hours of the allegation, and 5 days completed and submitted to the state agency as required by regulation and Elder Justice Act in a timely manner. The audit revealed 5 of 5 completed abuse/neglect reports indicated the alleged perpetrator was suspended pending investigation per abuse prohibition policy and procedure, however all 5 of 5 initial 24 hour reports were not submitted within two hours of the allegation. Two months noted with detail investigation and the Alleged Perpetrator(s) were suspended. This audit was completed on 6/7/2018. On 06/06/2018, 100% interviews was completed by Director of Rehabilitation Center, Business Office Manager, Activity Director, Medical Records Supervisor and MDS for all current alert and oriented residents in the facility to identify any other resident with an allegation of Abuse and/or Neglect. Two other residents, Resident#2, and Resident #3 voiced allegation of abuse and/or neglect. Alleged perpetrators identified were suspended while the investigation is conducted by the facility Executive Director and/or Director of Nursing. 24 hour reports were submitted on 6/6/2018. A thorough investigation initiated. The resident's attending Physician and Responsible Party were notified of the allegation. Resident #2 and #3, will be informed of the findings and actions taken when the investigation is completed by the Center Executive Director and/or Director of Social Services. The Director of Social Services, Assistant Director of Nursing, Unit Manager, Admission Director and Director of Rehabilitation Services interviewed the responsible parties for residents who were not able to answer questions during this interview due to mental capacity deficit on 6/7/18. No family member voiced any allegation of abuse and/or neglect. SYSTEMIC CHANGES Effective 6/7/18 the facility will conduct an interdisciplinary weekly team building meeting that with the department supervisors to discuss culture change initiatives to be implemented in the facility. These meetings will be held without affecting resident care activities. Effective 6/7/2018 the facility established an Employee Appreciation Committee (EAC) chaired by the Director of Human Resources. Initial members of this committee were selected by the facility Executive Director and Director of Nursing Services. Members include the Activity Director, Director of Social Services, Nurse Aide #1, Dietary Aide #1 and Laundry aide #1. This committee will meet monthly to discuss ways to improve employees' morale in order to reduce staff turnover and improve work place culture effective 6/7/2018. Effective 6/7/2018, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and, are reported immediately, but not later than 2 hours after the allegation is made to the Administrator of the facility and to other officials to include; the State Survey Agency, adult protective services, the state Ombudsmen in accordance with State law through established facilities policies and procedures. Effective 6/7/2018, The facility will report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Effective 6/7/2018, the facility interdisciplinary team to include Executive Director, Director of Nursing, Director of Social services and at least three other department supervisors will attend a monthly mandatory training that will be conducted by contracted management and consulting company that oversees the facility. This training will put an emphasis on all seven components of abuse prohibition to include screening, training, prevention, identification, investigation, protection, reporting and responses. This training will take place monthly for next twelve months or until the pattern of compliance is maintained. Effective 6/7/2018, the Center Director of Human Services, and/or employee direct supervisor and/or designated staff member will conduct interviews for each current employee at least once a year. The interview will be intended to determine the employee understanding of the Center Abuse policies and Procedures. The interview process will be incorporated to the annual employee evaluating. Any staff member not interviewed by the anniversary date will not be allowed to work until educated. Effective 6/7/2018, interviews for alert and oriented residents will be completed by the Director of Social Services, Director of Recreational Services and/or designated staff member at least once every month to identify any allegation of Abuse and/or Neglect. This interview will be documented on the psychosocial assessment tool. Any voiced allegation of abuse, and/or neglect will be reported to the Center Executive Director promptly. Alleged perpetrators will be suspended pending investigation by the facility, and reported according to the regulatory requirements. The Director of Social services, Assistant Director of Nursing, Unit manager, Admission Director and Director of Rehabilitation Services will interview the responsible parties for residents who are not able to answer questions during the interview due to mental capacity deficit effective 6/7/18. This interview will be documented on the psychosocial assessment tool. Any voiced allegation of abuse, and/or neglect will be reported to the Center Executive Director promptly. Alleged perpetrators will be suspended pending investigation by the facility, and reported according to the regulatory requirements. Effective 6/7/2018 a copy of any resident's protective orders received on admission or readmission by the admission director or designated person during the admission process, will be placed in the medical file under the advance directive tab for easy identification and accessibility by the nursing staff. Effective 6/7/2018; received protective orders will be added to resident's care plan by the Admitting nurse and/or Nursing supervisor and nursing aide care guide for accessibility by both license nurses and nurse aides. If the protective order includes guidelines such as supervised visits, no visitation, or not allowed on the premises such measures will be added to resident's face sheet and appropriate information posted such as the perpetrator picture and/or description in a readily accessible location in the facility. Facility Director of Nursing (DON), Assistant Director of Nursing and/or Unit manager will complete 100% education on the location of protective orders in each resident's medical charts and the location of intervention necessary to protect the resident with protective orders. This education will also cover process to be taken if the protective order to include adding the protective order interventions to resident's care plan and to nursing aide care guide for accessibility by both license nurses and nurse aides. Guidelines such as supervised visits, no visitation, or not allowed on the premises will also be covered in this education. The education will also emphasize on the process that such information will be added to resident's face sheet and appropriate information posted such as the perpetrator picture and/or description to be a readily accessible location in the facility. This education will be provided for all licensed nurses, nursing assistant to include full time, part time and as needed licensed nursing staff. This education will be completed by 6/7/2018. Any employee not educated by 6/7/2018 will not be allowed to work until educated. This education will also be added on the new hire orientation process for all new licensed nurses and nursing aides effective 6/7/2018, and will also be provided annually. Effective 6/7/2018, the center nursing administrative team, which includes DON, Nurse supervisors, Unit Managers, and/or SDC, added reviewing of DSS protective orders to an existing process of reviewing clinical documentation for the last 24 hours, which includes completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. By adding the review of DSS protective orders to this process, it will ensure that any resident with prior history of allegation of abuse, neglect, and/or injuries of unknown sources has appropriate measures in place to protect the resident from the alleged perpetrator, effective 6/7/2018. This process with take place daily Monday through Fridays effective 6/7/2018. The result of this systemic process will be documented on the clinical meeting form maintained in the Daily Clinical meeting binder. Effective 6/7/2018, the week end Registered Nurse supervisor and/or designated licensed nurse will review clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. This process will also incorporate reviewing of any DSS protective orders to ensure the facility put measures in place to address such orders. This systemic process will take place every Saturday and Sunday. Any negative findings will be documented on the week end supervisor report form and maintained in the daily clinical meeting binder, effective 6/7/2018. Effective 6/7/2018 the Admission Director (AD) will print any protective order for any referral to the facility before bed is offered. The AD will then provide copies of the protective order to the facility Executive Director, Director of Nursing, Director of social services and/or designated licensed nurse. The IDT team will then review all referrals with DSS protective orders prior to admitting resident to the facility to ensure measures are put in place to protect the resident when admitted to the facility. Effective 6/7/2018 the facility Executive Director, Director of Nursing, and/or Director of social services will discuss new admits and re-admits to the facility during their daily department head meeting to validate that any admitted or readmitted resident with protective orders has measures in place to protect the resident against the alleged perpetrators. Effective 6/7/2018 any alleged perpetrator with restraining orders for visitation will not be allowed to visit the facility. All the facility exit doors are locked and can only be accessed using an approved card. Visitors will utilize the facility main entrance to enter the premises, effective 6/7/18. All the facility exit doors are locked using a magnetized lock that releases in case of fire. In case of any other emergency, each locked facility exit door is equipped with an emergency release override switch located beside each exit door to allow the door to demagnetize and open from the inside. The magnetic lock system is also equipped with a master override switch located at each nurse's station. This is in compliance with North Carolina life safety code. Signs have been posted on all exit doors to direct visitors to the main entrance, effective 6/7/18. Facility Executive Director, Director of Nursing (DON), Assistant Director of Nursing and/or Director of Social Services will complete 100% re-education on the location of protective orders in each resident's medical charts and the importance of implementing approaches to ensure the resident's protection, per facility abuse prohibition process. This education will be provided for all licensed nurses, to include full time, part time and as needed licensed nursing staff. This education will be completed by 6/7/2018. Any employee not educated by 6/7/2018 will not be allowed to work until educated. This education will also be added on the new hire orientation process for all new licensed nurses effective 6/7/2018, and will also be provided annually. MONITORING PR[NAME]ESS Effective 6/7/2018 the facility will conduct a directed performance improvement plan with the direct oversees by the Contracted and management company, to assist the facility on making culture changes and reduce employee turnover. This will be accomplished through weekly visit by the 3 times a week visits by the member of the management and consulting company for 4 weeks, then once weekly for three or until the pattern of compliance is maintained. Effective 6/7/2018, the facility will conduct a quality assurance and performance improvement meeting monthly with an agent from the contracted management and consulting company to ensure that the facility systematically identify and address areas that needs performance improvement to assure the facility maintain and retain substantial compliance. This will take place for the next twelve months or until the facility shows the pattern of compliance. Effective 6/7/2018, Executive Director and or Director of Social Services will review all alleged violation to ensure a thorough investigation is completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. Any issues identified during this monitoring process will be addressed promptly. Findings from this monitoring process will be documented on abuse prohibition tool and filed in daily meeting binder after proper follow ups are done. This monitoring process will take place daily to include Saturdays and Sundays for 2 weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 6/7/2018, the facility will conduct a quality assurance and performance improvement meeting monthly with an agent from the contracted management and consulting company that oversees the company to ensure that the facility systematically identify and address areas related to resident's abuse and neglect and ensuring the abuse policies and procedures is implemented. This will take place for the next twelve months or until the facility shows the pattern of compliance. Effective 6/7/2018, Director of Nursing, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor compliance with resident protection, per facility abuse prohibition process, thorough investigation, injuries of unknown sources and resident neglect by conducting clinical meeting daily. This meeting will allow the team to review all allegation of abuse, incidents or accidents that occurred from the prior clinical meeting. Any DSS protective orders and any documented information that indicate suspicion of abuse will be reviewed to ensure measures are in place to protect the resident. Any issues identified during this monitoring process will be addressed promptly. Findings from this meeting will be documented on a daily clinical report form and filed in the clinical meeting binder after proper follow up is done. This monitoring process will take place daily for 4weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 6/7/2018, Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. RESPONSIBLE PARTY Effective 6/7/2018, the center Executive Director and the Director of Nursing will be ultimately responsible to ensure implementation of this plan of correction for this alleged noncompliance to ensure the facility remains in substantial compliance. The credible allegation for immediate jeopardy removal was validated on 6/8/18, which removed the IJ on 06/07/18, as evidenced by staff interviews, in-service record reviews, and observations. The in service included information r/t Resident #84's new alias, new room number, and what action was to be taken if his wife was observed on the facility property. Other observations included one on one (1:1) staff with Resident #84, monitored entry and exits from the facility's main entrance, and a photograph of Resident #84's wife posted at every nursing station and ante room. A care plan was initiated 6/6/18 and focused on Safety: At risk for injury and social isolation r/t spousal abuse. The stated goals included maintained safety from his wife. Interventions included, but were not limited to, relocation to another room, identify by a different name, 1:1 supervision, staff education on name change, room change, safety interventions, monitoring for changes in mood or behavior, and an approved visitor list.

Based on observation, resident interview, staff interviews and record review the facility failed to follow their policy in the areas of prevention, protection, investigaion and reporting for staff to resident physical abuse for 1 of 1 sampled residents (Resident #1). The immediate jeopardy (IJ) began on 10/26/2017 when Nurse Aide (NA) #1 grabbed Resident #1 by the wrists and sat her down hard on the shower seat in the resident's bathroom, resulting in a bruise to her right wrist, and not reporting to Administration. The IJ was removed on 11/16/2017 when the facility's acceptable credible allegation was verified. The facility remains out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to allow the facility to monitor and implement its plan of correction for abuse. Findings included: Review of the facility's Abuse Prevention Policy, revised on 6/2017, stated: It is the responsibility of employees to promptly report to center management any incident or suspected incident of neglect or resident abuse . Staff are state mandated reporters . and must comply with state regulations regarding reporting any reasonable suspicion of a crime against a resident or other individual receiving care by the center. The Policy listed under Investigation: #5. Investigations will be thorough and objective. The Policy listed under Protection: . Any person or persons accused or suspected of involvement in resident abuse . is immediately suspended for the course of the investigation pending the outcome of the investigation. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #1, dated 9/22/2017 revealed the resident had intact cognition. An interview was conducted on 11/13/2017 at 11:05 AM with Resident #1. She stated a couple of weeks ago, she was not sure of the date, she had a bowel movement (BM) and soiled herself at about 6:00 AM. The resident got in her wheel chair and took herself to the bathroom, and turned on the bathroom call light for someone to come and help clean her up. Nursing Assistant (NA) #1 came in and was real mad and kept saying that the other NA should have cleaned her up. The Resident stated she stood up and NA #1 grabbed her by the arm and said, I want you to sit here, moved her over and sat her down very hard on the shower seat, then she scrubbed her hard. Resident #1 said she was crying and scared and she knew the NA was too mad. Resident #1 said she finally said to the NA, you don't have to treat me like a dog. When the shower was over the resident asked for the NA's name, and the NA wouldn't tell her. Resident #1 stated she gave me a bruise right here, and pointed to her inside right wrist, and indicated the bruise was about 2 by 3 with her fingers. Resident #1 told NA #3 what had happened in the shower, and NA #3 said she (the resident) should report it to the Social Worker (SW). The resident stated she wheeled herself to the nurse's station for 3 days after and asked to see the SW, but the SW never came, so she asked NA #4 about it after NA #4 saw her bruise. The resident stated she went to the nurse's station on Halloween, and was frustrated because the SW had not contacted her. A lady at the desk asked what she needed to tell the SW, and Resident #1 stated she just stuck out her arm with the bruise, and the lady said she was the Director of Nursing (DON), and she could help. The DON immediately then transported the Resident to the SW office and said we need to get started on interviews. The DON came back a couple of days after Halloween, and told Resident #1 the decision was up to the DON and she decided not to fire the NA, but had moved her to a different hall and given her another chance. The Resident stated she believed in 2nd chances, but afterward, she was worried that NA #1 would let her temper explode on someone else. Record review revealed the facility filed a 24-Hour Initial Report to the State Agency on 10/31/2017 for resident abuse and neglect. The allegation was: Resident stated that Aide pushed her in the bathroom. The accused individual information listed the details for NA #1. The report was signed by the Director of Nursing. Record reviews revealed the facility filed a 5-Working Day Report to the State Agency on 11/3/2017 for resident abuse and neglect. The allegation was: Resident stated that aide pushed her in the bathroom and was rough and left a bruise on her wrist. Education teaching given and aide was removed from Hall. (The NA at fault) Was not NA #1 was a different aide. Was not a hand print bruise upon investigation. The accused individual information listed details for NA #1. The report was signed by the Director of Nursing. On 11/13/2017 at 4:35 PM, an interview was conducted with NA #1, who requested only to be interviewed with the DON present. NA #1 stated the only thing she recalled was between 6:00 and 7:00 AM, on 10/26/2017, NA #2 had told her that Resident #1 needed her assistance, and so she went in and assisted her. NA #1 had been giving a bath to another resident, and so it was a little while before she was able to go down and help Resident #1. NA #1 stated she went to Resident #1's room before she had given report to day shift, and the Resident was already in the bathroom. She pushed the Resident up to the shower bar, and the Resident grabbed hold of it and sat down in the shower. The NA then gave her a shower and dressed her. She stated the Resident was crying and NA #1 calmed her down, told her not to cry it would be okay, about her being left in the bathroom. When asked about her written statement of 11/1/2017, that she forgot to go back in and clean her up, NA #1 just shrugged her shoulders and said it wasn't that long for the resident to wait and that was all she could remember. When asked about her written statement of 11/1/2017 that she had given report to day shift before she went in to clean up Resident #1, NA #1 said it wasn't that long, and she couldn't remember. Further questions were answered with the same response. On 11/13/2017 at 5:38 PM, a phone interview was conducted with NA #2. NA #2 stated she was working on the 500 hall, and went to the 600 hall to answer a bathroom call light, on the morning of 10/26/2017. Resident #1 was already in the bathroom, sitting in her wheelchair facing towards the call light. The NA smelled BM, and knew it would take some time to clean her up, and the Resident said she needed help to be cleaned up. NA #2 stated she told the Resident she needed to go get a gown and stuff, and then NA #2 went directly to the room NA #1 was in. NA #2 told NA #1 that Resident #1 needed her. NA #1 stated she was not going back in that room. NA #2 went to get linens and proceeded back to the 500 hall. NA #2 stated that Resident #1 put her call light back on at shift change, and NA #2 would've gone back to her room, but saw 2 NA's standing at her door, and they answered the call light. NA # 2 stated she waited after her shift for the DON to arrive, and the DON told NA #2 there was an allegation that she had pushed Resident #1 in the bathroom, and then cut the light off. NA #2 requested the DON move her to another hall to get away from NA #1 and Nurse #1, and the DON moved her to another part of the facility. NA #2 stated she did not know if she had neglected the resident and didn't know if this incident was a dignity issue or something else. On 11/14/2017 at 8:34 AM, an interview was conducted with NA #3. NA #3 stated she had talked to Resident #1, later that morning on 10/26/2017, and was told that NA #1 was mad and mean and rough with her and had grabbed her hard, and she was scared of her. The Resident asked the name of NA #1, but NA #3 told her she didn't know. NA #3 did not report the abuse to the DON that day, and told the Resident it would be better if she reported it herself to the SW. The Resident did not show NA #3 the bruise at that time, and thought the Resident showed her the bruise on 10/31/2017 after the resident had spoken to the DON. NA #3 stated she had been through abuse training, but could not say why she had not reported the abuse herself, and had advised Resident #1 to report it herself. NA #3 stated she talked to Nurse #2 on the morning of 10/26/2017, but did not tell him that Resident #1 had been mistreated during the shower. NA #3 stated she talked to the DON on 10/26/2017 and stated to her that Resident #1 had a problem with NA #1. NA #3 did not tell the DON that Resident #1 had been mistreated and harmed in the shower by NA #1. On 11/13/2017 at 1:47 PM, an interview was conducted with NA #4. NA #4 stated Resident #1 was alert and oriented, and could tell you about her day, and always remembered who NA #4 was. NA #4 indicated Resident #1 needed help with bathing, and dressing. Resident #1 could take herself to the toilet, but when she had occasional incontinent accident, she needed help with being cleaned up. NA #4 stated Resident #1 showed the bruise on her right inner wrist to her, and told her she had been pushed when in the shower and manhandled, and was so scared and upset, and didn't want to be at the facility. The Resident asked for a patient Bill of Rights to see what she could do about it. The NA stated this happened before Halloween, but was not sure of the date. The NA stated she left the Resident's room to see about getting her a Bill of Rights, and decided she had better tell someone of the abuse. The NA saw the HR manager at the nurse's desk, and told her there was abuse in the facility. The HR Manager stated the Administrator and DON needed to be notified. The HR Manager told the DON and then wrote a report. A review of a document dated 10/30/2017, written by the Human Resource Manager (HR) was conducted. The HR Manager reported she was at the 500/600 Hall Nurse's Station when she was notified by NA #4 that abuse was going on in the facility. NA #4 told her Resident #1 was scared to stay at the facility, and the NA saw bruises on Resident #1's arm. HR told NA #4 she was going to speak to the Director of Nursing (DON) about it. The HR Manager told the DON and the DON wrote down something and stated she was going to address it. An interview was conducted on 11/13/2017 at 4:04 PM, with the HR Manager. The HR Manager stated she was at the 500/600 Hall Nursing station on 10/26/2017, when NA #4 had called her over and told her that Resident #1 was scared to stay at the facility because NA #1 had been really mean to her and gave her a bruise. NA #4 reported to her that she saw the bruise on the Resident's arm, like someone would've grabbed her. The HR Manager told NA #4, we have to report this, and so the HR Manager talked to the DON on the 10/30/2017 before she went home. The DON told the HR Manager she would take care of it. The time was late, and so the HR Manager went home and wrote up the report, and took it to the Administrator when she came in on 10/31/2017. On 11/13/2017 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not have a policy on abuse, they followed State guidelines, which meant that abuse had to be reported within 2 hours. The DON stated, and repeated many times, that she first heard of the abuse allegation on 10/31/2017. Resident #1 came to the nurse's desk and said she was looking for the SW. Resident #1 told the DON that a NA had grabbed and pushed her in the shower, and had showed a bruise on her arm. The DON stated she then wheeled Resident #1 to the SW, showed the SW the bruise, and told the SW she was going to start on the interviews. The DON stated she filed a 24-Hour Report that day, and then talked to NA #1 and NA #2, and determined there was no abuse because the bruise was just a round bruise on the Resident's wrist, and it wasn't a hand print bruise. The DON indicated that if a NA had grabbed Resident #1's wrist, it would have left a hand print bruise. The DON stated the bruise must have come from Resident's #1's medication, as she was on [MEDICATION NAME] (a blood thinner), and aspirin. The DON stated after she talked to NA #1, she realized that was the wrong NA, because the Resident was already in the bathroom when NA #1 went in to shower her. The DON stated that NA #2 had pushed Resident #1 into the bathroom, but she had no proof that Resident #1 was abused, so she decided to give NA #2 a second chance and moved NA #2 to a different hall, and that had been her decision. The DON had not asked Resident #1 if she had been fearful or scared, or any of the details of the incident, and her only documentation of what happened to the resident was the sentence she wrote on the 24-Hour and 5-Day Reports. The DON stated the Administrator had told her of the abuse allegation on 10/31/2017, but she had told him she already knew. When asked if she had been notified of the abuse allegation on 10/30/2017 by the Human Resources Manager, the DON stated again that she found out about the allegation when the resident talked to her on 10/31/2017. On 11/14/2017 at 11:00 AM, an interview was conducted with the SW. The SW stated the DON had brought Resident #1 to her on 10/31/2017, and showed the SW the Resident's bruise. The SW stated the bruise was a little less than quarter size on her inner right wrist. The DON stated she would handle it. The SW talked to the DON on 11/3/2017, and the DON reported that NA #2 had put the Resident in the bathroom, and another NA (NA#1), said Resident #1 could take herself to the bathroom. The DON stated she couldn't say what happened, or who did what, so she just removed the NA #2 from the hall. The SW understood the DON to mean that the bruise happened on the way to the bathroom, and since no one had taken the Resident to the bathroom, abuse didn't happen. The SW reported that Resident #1 was alert and oriented. The SW was not familiar with the steps taken to investigate abuse, and only knew that the DON had to report it to the State. On 11/14/2017 at 5:57 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 11/16/2017. DATE: 11/15/2017 PR(NAME)ESSES THAT LEAD TO THE ALLEGED DEFFICIENCY CITED This alleged noncompliance resulted from the Center's former Director of Nursing #1, Nurse Aide #3 and Nurse Aide #4 failure to follow the Abuse Prohibition Policies and procedures revised June 2017. Director of Nursing #1 failed to follow the facility policies procedure as she failed report an allegation from resident #1 to the Executive Director timely. Former Director of Nursing #1 also failed to protect the resident who alleged abuse as she did not suspend Nurse Aide #1 during investigation period and also failed to notify the resident and/or resident #1 responsible party of the findings of the investigation and actions taken post investigation for Resident #1 allegation of abuse voiced on 10/26/2017. Director of Nursing #1 is no longer employed at the Center effective 11/15/2017. New Director of Nursing employed to oversee clinical services effective 11/15/2017. The Director of operation from the Management and consulting company that manages the center, re-educated the Center Executive Director and the Director of Nursing #1 on 11/14/2017 on the center's Abuse Prohibition and Investigation policies and procedures, and emphasized the importance of protecting resident(s), to include suspending the alleged perpetrator during the investigation period, investigating thoroughly all alleged abuse, and/or neglect as well as injuries noted or reported to determine etiology, and reporting such in a timely manner per state regulatory requirements. This education was also provided to the new Director of Nursing on 11/15/2017 by the Director of Operation. The Center Executive Director, and the Director of Social Services re-educated Nurse Aide #3, and Nurse Aide #4 on 11/15/2017 on the center's Abuse Prohibition and Investigation policies and procedures, and emphasized the importance of protecting resident(s), and reporting any allegation of abuse or Neglect to their Direct supervisor and the Executive Director in a timely manner not to exceed 2 hours after forming suspicion, witness the abuse and/or after a resident, another staff and/or family member alleged abuse. On 11/14/2017 at approximately 9:00PM Director of Rehabilitation at the center followed by the facility Director of Social services interviewed resident #1. Resident #1 voiced that on 10/26/2017 approximately between 6:00 AM and 7:00 AM, she had an episode of loose stool, she wheeled herself to the bathroom and turn the bathroom call bell on. Nursing Aide #2 responded to the call bell and told the resident she will notify her assigned Nurse Aide (Nurse Aide #1), and if the assigned aide is not back to care for her, she asked resident #1 to turn the light back on (no time lapse specified). On the morning of 10/26/2017, during initial round, noted resident #1 to be soiled. Nurse Aide #3 communicated to Nurse Aide #1 about resident#1 being soiled and asked for Nurse Aide #1 to clean the resident#1 before leaving on 10/26/2017. Nurse Aide #1 provided care to Resident#1 and gave her a shower on 10/26/2017. Resident #1 added that Nurse Aide#1 pushed her and grabbed her on the arm, which caused a bruise. Resident #1 added that she reported this allegation to Nurse Aide #3 on 10/26/17, Nurse Aide #4 on 10/30/2017, and Director of Nursing #1 on 10/30/2017. Interview with Nurse Aide #4 by the Center Executive Director conducted on 11/13/2017 revealed she reported the Allegation made by Resident #1 to the Center Human Resources Director on 10/30/2017. Interview with Nurse Aide #3, and Nurse Aide # 4 did not report this allegation to their direct supervisor and the center's Executive Director per facility Abuse Prohibition policies and procedures revised June 2017. Director of Human Resources reported the Allegation to Director of Nursing #1 on 10/30/2017 and to the executive Director via written statement on 10/30/2017 that was read by the Center Executive Director on 10/31/2017 On 10/31/2017 and 11/3/2017, the 24 hour report and a 5 day report were sent to the Department of Health and Human Services respectively, related to resident #1's allegation of abuse made on 10/26/2017. These reports were completed and submitted by the former Director of Nursing #1. Five days report completed on 11/3/2017 indicated an investigation that was not detailed enough. On 11/13/2017 another 5 day report was completed after detail investigation conducted by the Center Executive Director, Director of Social Services and/or Director of Nursing #1. The investigation conducted 11/13/2017 by the Center Executive Director, Director of Social services, Director of Rehabilitation Center and MDS nurse by interviewing 100% of all current alert and oriented residents in the facility to determine if any other resident voiced and allegation of abuse or neglect that involve the alleged perpetrator (Nurse Aide #1). No other residents alleged abuse and/or neglect that involve the alleged perpetrator. On 11/15/2017, Director of Human Resources conducted interviews with current employee who were on duty on 10/26/2017 between the 6AM and 7AM to determine if any staff on duty witnessed any abuse and/or neglect towards Resident #1 specifically from Alleged Perpetrator (Nurse Aide #1). No other staff witness any abuse and/or neglect per interview. On 11/13/2017 another 5 day report was completed after detail investigation completed by the Center Executive Director, Director of Social Services and/or Director of Nursing #1 services. Resident's #1 allegation of abuse voiced on 10/26/2017 was unsubstantiated. Nurse Aide #1 did not care for Resident #1 at the time of investigation. Facility Director of Social Services notified resident #1 of the findings of the investigation and actions taken for the Alleged Perpetrator to include customer service re-education. THE PR(NAME)EDURES FOR IMPLEMENTING THE ACCEPTABLE CREDIBLE ALLEGATION FOR THE ALLEGED IMMEDIATE JEOPARDY. 100% audit was completed by the Center executive Director for all allegation of abuse and/or neglect submitted in the last 12 months to determine is the alleged perpetrator was suspended during investigation and the 24 hours as well as 5 days reports are completed and submitted to the state agency as required by regulation and Elder Justice Act in a timely manner. The audit revealed all completed reportable in the last 12 months noted with detail investigation and the Alleged Perpetrator(s) were suspended. This audit was completed on 11/15/2017. 100% audit of all current residents' clinical documentation within the last 30 days was completed by the Director of Nursing #1, Assistant Director of Nursing and/or Nurse Supervisor to determine if there is any documentation in any resident's medical records that indicate allegation of abuse, neglect, and/or misappropriation of resident's properties, if any, determine whether a 24 hours and 5 days investigation reports were completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. The audit revealed no other documented allegation of abuse, and/or neglect documented in resident's medical records. This audit was completed on 11/15/17. Findings of this audit is documented on clinical records audit tool located at the facility compliance binder. On 11/15/2017, 100% interviews was completed by the Director of Social Services, Director of Rehabilitation Services, Dietary Manager, Business office manager and/or Medical Records clerk for all current alert and oriented residents in the facility to identify any other resident with allegation of Abuse, Neglect and or Misappropriation of properties. Four other residents, Resident#2, Resident #3, Resident #4 and Resident #5 voiced allegation of abuse, neglect and/or misappropriation of resident's properties. Alleged perpetrators suspended pending investigation by the facility Executive director, 24 hour report submitted on 11/14/2017, thorough investigation initiated, resident attending Physician and Responsible Party notified of the allegation. Resident #2, #3, #4 and #5 will be informed of the findings and actions taken when the investigation is completed by the Center Executive Director and/or Director of Social Services. Effective 11/15/2017, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Effective 11/15/2017, Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Effective 11/15/2017, the Center Director of Social Services, Director of Recreational Services and/or designated staff member will conduct interviews for each current employee at least once a year. The interview will be intended to determine the employee understanding of the Center Abuse policies and Procedures and ensure that each employee receives the Abuse education at least once every six months. This interview process will be incorporated to the annual employee evaluating. Any staff member not interviewed by the anniversary date will not be allowed to work until educated. Any voiced allegation of abuse, neglect and/or misappropriation of resident's properties will be reported to the Center Executive Director promptly. Alleged perpetrators will be suspended pending investigation by the facility, and reported according to the regulatory requirements. Effective 11/15/2017, Abuse reporting process will be discussed to current alert and oriented residents every months during resident council meeting and at least quarterly during each resident care plan meeting. This process will be managed by the Center Director of Social Services effective 11/15/2017. 100% of current alert and oriented residents in the facility re-educated on 11/15/2017 by the center Director of Social Services, Director of Rehabilitation Services, Dietary Manager, Business office manager and/or Medical Records clerk to ensure that each know about resident council meeting and who to report to in the event an abuse, neglect, and/or misappropriation of resident's properties is noted or witnessed. Residents' re-educated to report any allegation, actual or suspicion of abuse to the nurse, any administrative staff on duty and/or the facility Executive Director effective 11/15/2017. The reporting can be made verbally or in writing. Effective 11/15/2017, the facility initiated a process of open door policy, will hold a staff meeting once a month to encourage staff to express concerns and request training in challenging situations. Effective 11/15/2017, the center administrative staff will observe employees while on duty for any signs of burnout (example decrease in job performance, increase number of unexplained absences, less socializing etc.). Effective 11/15/2017, the nursing administrative team, which includes DON, Nurse supervisors, and/or SDC, initiated a process for reviewing clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. Effective 11/15/2017, 24 hours and 5 days investigation reports is completed and reviewed by the Executive Director before submitted to the state agency and other officials as required by regulation and/or Elder Justice Act per regulatory requirement. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly and appropriate actions will be implemented by the DON, ADON, SDC and/or Nurse Supervisor. This process will be incorporated in a daily clinical rounds. Any negative findings will be documented on the daily clinical checklist form and maintained in the daily clinical meeting binder. Effective 11/15/2017, week end Registered Nurse supervisor and/or designated licensed nurse will review clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. This systemic process will take place every Saturday and Sunday. Any negative findings will be documented on the week end supervisor report form and maintained in the daily clinical meeting binder. Facility Executive Director, Director of Nursing (DON), and/or Director of Social Services will complete 100% re-education on the facility's abuse/neglect policy including notification, protection, and investigation protocols. This education will be provided for all employee, to include full time, part time and as needed staff. This education will be completed by 11/15/2017. Any employee not educated by 11/15/2017 will not be allowed to work until educated. This education will also be added on new hires orientation process for all new employees effective 11/15/2017, and will also be provided semi-annually. THE MONITORING PR(NAME)EDURE TO ENSURE THAT THE CREDIBLE ALLEGATION IS EFFECTIVE AND REMOVE THE ALLEGED IMMEDIATE JEOPARDY Effective 11/15/2017, Executive Director and or Director of Social Services will review all alleged violation to ensure a thorough investigation is completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. Any issues identified during this monitoring process will be addressed promptly. Findings from this monitoring process will be documented on abuse prohibition tool and filed in daily meeting binder after proper follow ups are done. This monitoring process will take place daily to include Saturdays and Sundays for 2weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 11/15/2017, Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. TITLE OF THE PERSON RESPONSIBLE FOR IMPLEMENTING THE CREDIBLE ALLEGATION Effective 11/15/17, the center Executive Director and the Director of Health services will be ultimately responsible to ensure implementation of credible allegation to remove this alleged immediate jeopardy. Compliance Date: 11/15/2017 The Credible Allegation was verified on 11/16/2017 by the following: 1. The survey team reviewed the audit of current resident's medical records titled clinical records audit tool, which reviewed documentation that would indicate any allegation of abuse, neglect, misappropriation of resident's properties and /or injuries of unknown sources. 2. The survey team reviewed the audit of all incidents within the last 30 days which was completed to identify any unknown source of injuries. 3. The survey team reviewed the in-service provided by staff and signed by staff. The survey team conducted staff interviews with 16 on-duty staff. The staff interviewed confirmed the recent in-service regarding abuse identification, reporting, and recognizing signs and symptoms of staff burnout. 4. The survey team interviewed 41 current alert and oriented residents. The residents confirmed education they had received on whom to report abuse to.

Based on observation, resident interview, staff interviews and record review the facility failed to protect residents from staff to resident physical abuse resulting in a bruise to the resident's arm for 1 of 1 sampled residents (Resident #1). The immediate jeopardy (IJ) began on 10/26/2017 when Nurse Aide (NA) #1 grabbed Resident #1 by the wrists and sat her down hard on the shower seat in the resident's bathroom, resulting in a bruise to her right wrist. The IJ was removed on 11/16/2017 when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to allow the facility to monitor and implement its plan of correction for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #1, dated 9/22/2017 revealed the resident had intact cognition. She required extensive assistance with toileting, dressing, personal hygiene and bathing. She was not steady, but able to transfer herself with limited assistance between bed and wheelchair. Her weight was 115 pounds. An interview was conducted on 11/13/2017 at 11:05 AM with Resident #1. Resident #1 stated her body was sick but her mind was not. She stated a couple of weeks ago, she was not sure of the date, she had a bowel movement (BM) and soiled herself at about 6:00 AM. The resident got in her wheelchair and took herself to the bathroom, and turned on the bathroom call light for someone to come and help clean her up. She indicated a NA, who had curly hair and was stout, and was not her night NA, came in about 6:15 AM and turned off the call light and told her if someone didn't come to help her after a while, to put her call light back on. The resident could see what time it was from the big numbered clock on her night stand that faced the bathroom. Resident #1 stated she waited for a long time, and was very still because she didn't want to get any mess on the floor. She stated she was cold and the bathroom smelled bad, and she was embarrassed. Resident #1 stated that NA #3, the day shift NA, came in the bathroom and said how long have you been sitting here waiting, and the resident replied, for an hour. NA #3 told her she was going to get NA #1. NA #1 came in and was real mad and kept saying that the other NA should have cleaned her up. The Resident stated she stood up and NA #1 grabbed her by the arm and said, I want you to sit here, moved her over and sat her down very hard on the shower seat, then she scrubbed her hard. Resident #1 said she was crying and scared and she knew the NA was too mad. Resident #1 said she finally said to the NA, you don't have to treat me like a dog. When the shower was over the Resident asked for the NA's name, and the NA wouldn't tell her, and never apolized to her. Resident #1 stated she gave me a bruise right here, and pointed to her inside right wrist, and indicated the bruise was about 2 by 3 with her fingers. The bruise was not visible on this date, and the resident confirmed that the bruise had gone away by now. NA #3 came to her room after NA #1 had left and the Resident asked NA #3 what the name of NA #1 was, but NA #3 said she didn't know. Record review revealed the facility filed a 24-Hour Initial Report to the State Agency on 10/31/2017 for resident abuse and neglect. The alleged description was: Resident stated that Aide pushed her in the bathroom. This report was signed by the Director of Nursing. Record reviews revealed the facility filed a 5-Working Day Report to the State Agency on 11/3/2017 for resident abuse and neglect. The alleged description was: Resident stated that aide pushed her in the bathroom and was rough and left a bruise on her wrist. Education teaching given and aide was removed from Hall. (The NA at fault) Was not NA #1, was a different aide. Was not a hand print bruise upon investigation. This report was signed by the Director of Nursing. Review of statement by NA #1 included with the 5-Working Day Report revealed she was in the middle of her last round when NA #2 told her Resident #1 needed her. NA #1 said she was getting another resident ready for an appointment and told NA #2 she could not go back down to Resident #1's room because her resident needed breakfast. NA #1 left the hall to get breakfast for that resident, and then finished doing her resident rounds and charting. When she finished with her resident on the hall she actually forgot about going back down there because she had found a few things on the hall that needed to be corrected before change of shift. NA #1 gave report to the oncoming NA #3, and told her NA #2 had answered Resident #1's call light and NA #1 had not gone back in Resident #1's room. When NA #1 was doing her charting NA #3 came up to her and fussed that Resident #1 was in a mess and had feces all over her in the bathroom with the door closed. NA #1 got towels and wash cloths and went back down the hall, and cleaned up the mess that could have been prevented if NA #2 would have just put Resident #1 on the toilet. NA #1 had to first calm down Resident #1 because she was crying terrible. After calming the Resident, she asked what happened and the Resident said she had put on the call light and NA #2 had turned off the light and told her she was going to get her NA. NA #2 had told the resident if your NA doesn't come then turn on your light again. NA #1 gave the resident a shower and dressed her and left around 7:30 AM on that morning. The report was signed on 11/1/2017 by NA #1. On 11/13/2017 at 4:35 PM, an interview was conducted with NA #1, who requested only to be interviewed with the DON present. NA #1 stated the only thing she recalled was between 6:00 and 7:00 AM, NA #2 had told her that Resident #1 needed her assistance, and so she went in and assisted her. NA #1 had been giving a bath to another resident, and so it was a little while before she was able to go down and help Resident #1. NA #1 stated she went to Resident #1's room before she had given report to day shift, and the Resident was already in the bathroom. She pushed the Resident up to the shower bar, and the Resident grabbed hold of it and sat down. The NA then gave her a shower and dressed her. She stated the Resident was crying and NA #1 calmed her down, told her not to cry it would be okay, about her being left in the bathroom. When asked about her written statement of 11/1/2017, that she forgot to go back in and clean her up, NA #1 just shrugged her shoulders and said it wasn't that long for the resident to wait and that was all she could remember. When asked about her written statement of 11/1/2017 that she had given report to day shift before she went in to clean up Resident #1, NA #1 said it wasn't that long, and she couldn't remember. Further questions were answered in that manner. A review of the statement by NA #2 included with the 5-Day Working Report revealed that NA #2 answered the light for Resident #1 who was already in the bathroom. The NA turned off the light and told the Resident she needed to get some things to get her cleaned up. NA #2 walked directly to NA #1 and told her Resident #1 needed her. NA #1 looked down the hall and said, oh well, I'm not going back down there, I already been down there and I'm not going back. NA #2 said she was doing something else at the moment. NA #2 went back to her hall and NA #1 went into another resident room. NA #2 documented she was informed of a complaint against her by Nurse #1, who had received all her information from NA #1 and not the resident. On 11/13/2017 at 5:38 PM, a phone interview was conducted with NA #2. NA #2 stated she was working on the 500 hall, and went to the 600 hall to answer a bathroom call light. Resident #1 was already in the bathroom, sitting in her wheelchair facing towards the call light. The NA smelled BM, and knew it would take some time to clean her up, and the Resident said she needed help to be cleaned up. NA #2 stated she told the Resident she needed to go get a gown and stuff, and then NA #2 went directly to the room NA #1 was in. NA #2 told NA #1 that Resident #1 needed her. NA #1 stated she was not going back in that room. NA #2 went to get linens and proceeded back to the 500 hall. NA #2 stated that Resident #1 put her call light back on at shift change, and NA #2 would've gone back to her room, but saw 2 NA's standing at her door, and they answered the call light. Later, NA #2 was told by NA #3 that NA #1 and NA #3 had gotten in an altercation about it and NA #1 had volunteered to go back in and give Resident #1 a shower. NA #2 stated that bad feelings about the altercation lingered for a few days and on 10/31/2017, Nurse #1 told NA #2 a complaint had been made against her for a dignity issue. NA # 2 stated she waited after her shift for the DON to arrive, because she felt like she was being framed because she had not even touched the resident, and had not pushed the resident in the bathroom because she was already in there. The DON told NA #2 there was an allegation that she had pushed Resident #1 in the bathroom, and then cut the light off. NA #2 requested the DON move her to another hall to get away from NA #1 and Nurse #1, and the DON moved her to another part of the facility. NA #2 stated she did not know if she had neglected the resident and didn't know if this incident was a dignity issue or something else. On 11/14/2017 at 8:34 AM, an interview was conducted with NA #3. NA #3 stated Resident #1 was alert, oriented, and could propel herself to the bathroom in her wheelchair. She has been incontinent at times and when she had soiled herself, she could not clean herself up from that. NA #3 stated on the morning of 10/26/2017, she and NA #1 were conducting walking rounds on the residents, which meant they were going door to door of each resident's room for report. At Resident #1's door, NA #1 stated the Resident was in the bathroom and she had been busy so NA #2 had answered the light and told NA #1 that Resident #1 had needed her. After NA #1 had walked away, NA #3 was standing with NA #5 when Resident #1's call light went on. NA #3 went into Resident #1's bathroom, and Resident #1 told her the NA's had left her like that, and NA #3 looked at her and saw BM on her gown and under pad, and the bathroom smelled like BM, and she was crying and upset. NA #3 told the resident she would get it taken care of. NA #3 went up the hall and told NA #1 she couldn't leave until she cleaned up Resident #1. NA #1 raised her voice and there was some loud altercation between the two, and then NA #1 said she would go down and give the Resident a shower. NA #3 did not think what could happen to a resident by sending a mad NA to the room by herself to clean up the Resident. NA #3 stated she got linens and went to take care of someone else. NA #3 stated after NA #1 left, she had talked to Resident #1, and was told that NA #1 was mad and mean and rough with her and had grabbed her hard, and she was scared of her. The Resident asked the name of NA #1, but NA #3 told her she didn't know. The Resident did not show NA #3 the bruise at that time, and thought the Resident showed her the bruise on 10/31/2017 after she had talked to the DON. On 11/13/2017 at 1:47 PM, an interview was conducted with NA #4. NA #4 stated Resident #1 was alert and oriented, and could tell you about her day, and always remembered who NA #4 was. NA #4 indicated Resident #1 needed help with bathing and dressing. Resident #1 could take herself to the toilet, but when she had an occasional incontinence accident, she needed help with being cleaned up. NA #4 stated Resident #1 showed her bruise on her right inner wrist to her, and told her she had been pushed when in the shower and manhandled, and was so scared and upset, and didn't want to be at the facility. A review of a document dated 10/30/2017, written by the Human Resource Manager (HR) was conducted. The HR Manager reported she was at the 500/600 Hall Nurse's Station when she was notified by NA #4 that Resident #1 was scared to stay at the facility, and the NA saw bruises on Resident #1's arm. An interview was conducted on 11/13/2017 at 4:04 PM, with the HR Manager. The HR Manager stated she was at the 500/600 Hall Nursing station when NA #4 called her over and told her that Resident #1 was scared to stay at the facility because NA #1 had been really mean to her and gave her a bruise. NA #4 saw the bruise on her arm, like someone would've grabbed her. ON 11/13/2017 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated, and repeated many times, that she first heard of the abuse allegation on 10/31/2017, when Resident #1 came to the nurse's desk and said she was looking for the SW. The DON told Resident #1 that she could help, and Resident #1 showed her arm with the bruise on it. Resident #1 told her the NA had grabbed and pushed her in the shower, and was crying when she talked to her, but the DON didn't ask why. The DON stated she determined there was no abuse because the bruise was just a round bruise on the Resident's wrist, and it wasn't a hand print bruise. The DON indicated that if a NA had grabbed Resident #1's wrist, it would have left a hand print bruise, because especially on Caucasians, you could always see the handprint if they were grabbed. The DON stated the bruise must have come from Resident's #1's medication, as she was on [MEDICATION NAME] (a blood thinner), and aspirin. On 11/14/2017 at 11:00 AM, an interview was conducted with the SW. The SW stated the DON had brought Resident #1 to her on 10/31/2017, and showed the SW the Resident's bruise. The SW stated the bruise was a little less than quarter size on her inner right wrist. The DON stated she would handle it. The SW talked to the DON on 11/3/2017, and the DON reported a NA had put the Resident in the bathroom, and another NA said Resident #1 could take herself to the bathroom. The DON stated she couldn't say what happened, or who did what, so she just removed the NA from the hall. The SW understood the DON to mean that the bruise happened on the way to the bathroom, and since no one had taken the Resident to the bathroom, abuse didn't happen. The SW reported that Resident #1 was alert and oriented. On 11/14/2017 at 5:57 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 11/16/2017. DATE: 11/15/2017 PR(NAME)ESSES THAT LEAD TO THE ALLEGED DEFFICIENCY CITED This alleged noncompliance resulted from the Center's former Director of Nursing #1 misinterpretation of regulatory requirements related to protection of residents during allegation of abuse and or neglect investigation, misunderstanding of how to conduct the detail investigation of allegation of abuse or neglect. The former DON stated the way she understood is that she can only document what resident stated on both 24 hour and a 5-day report, she added that when she saw the bruise, she assumed that it resulted from uses of blood thinners. Because of the medication resident is taking she did not consider the bruise to be potentially caused by an alleged perpetrator (Nurse Aide #1). Resident #1 however alleged that Nurse Aide #1 grabbed her while in the bathroom and caused a bruise on her arm 10/26/2017. The DON stated, she felt she protected the resident as she removed the alleged perpetrator from the hall where resident #1 resided during the investigation period. This is contrary to center's abuse Prohibition process which requires for the alleged perpetrator to be suspended pending investigation. Director of Nursing #1 is no longer employed at the Center effective 11/15/2017. New Director of Nursing employed to oversee clinical services effective 11/15/2017. The Director of operation from the Management and consulting company that manages the center, re-educated the Center Executive Director and the Director of Nursing #1 on 11/14/2017 on the center's Abuse Prohibition and Investigation policies and procedures, and emphasized the importance of protecting resident(s), to include suspending the alleged perpetrator during the investigation period, investigating thoroughly all alleged abuse, and/or neglect as well as injuries noted or reported to determine etiology, and reporting such in a timely manner per state regulatory requirements. This education was also provided to the new Director of Nursing on 11/15/2017 by the Director of Operation. On 11/14/2017 at approximately 9:00PM Director of Rehabilitation at the center followed by the facility Director of Social services interviewed resident #1. Resident #1 voiced that on 10/26/2017 approximately between 6:00 AM and 7:00 AM, she had an episode of loose stool, she wheeled herself to the bathroom and turn the bathroom call bell on. Nursing Aide #2 responded to the call bell and told the resident she will notify her assigned Nurse Aide (Nurse Aide #1), and if the assigned aide is not back to care for her, she asked resident #1 to turn the light back on (no time lapse specified). On the morning of 10/26/2017, during initial round, noted resident #1 to be soiled. Nurse Aide #3 communicated to Nurse Aide #1 about resident#1 being soiled and asked for Nurse Aide #1 to clean the resident#1 before leaving on 10/26/2017. Nurse Aide #1 provided care to Resident#1 and gave her a shower on 10/26/2017. Resident #1 added that Nurse Aide#1 pushed her and grabbed her on the arm, which caused a bruise. Resident #1 added that she reported this allegation to Nurse Aide #3 on 10/26/17, Nurse Aide #4 on 10/30/2017, and Director of Nursing #1 on 10/30/2017. Interview with Nurse Aide #4 by the Center Executive Director conducted on 11/13/2017 revealed she reported the Allegation made by Resident #1 to the Center Human Resources Director on 10/30/2017. Interview with Nurse Aide #3, and Nurse Aide # 4 did not report this allegation to their direct supervisor and the center's Executive Director per facility Abuse Prohibition policies and procedures revised June 2017. Director of Human Resources reported the Allegation to Director of Nursing #1 on 10/30/2017 and to the executive Director via written statement on 10/30/2017 that was read by the Center Executive Director on 10/31/2017. On 10/31/2017 and 11/3/2017, the 24 hour report and a 5 day report were sent to the Department of Health and Human Services respectively, related to resident #1's allegation of abuse made on 10/26/2017. These reports were completed and submitted by the former Director of Nursing #1. Five days report completed on 11/3/2017 indicated an investigation that was not detailed enough. On 11/15/2017 another 5 day report was completed after detail investigation conducted by the Center Executive Director, Director of Social Services and/or Director of Nursing #1. The investigation conducted 11/13/2017 by the Center Executive Director, Director of Social services, Director of Rehabilitation Center and MDS nurse by interviewing 100% of all current alert and oriented resident's in the facility to determine if any other resident voiced and allegation of abuse or neglect that involve the alleged perpetrator (Nurse Aide #1). No other residents alleged abuse and/or neglect that involve the alleged perpetrator. Likewise, the Director of Human Resources conducted interviews with current employee who were on duty on 10/26/2017 between the 6AM and 7AM to determine if any staff on duty witnessed any abuse and/or neglect towards Resident #1 specifically from Alleged Perpetrator (Nurse Aide #1). No other staff witness any abuse and/or neglect. Resident's #1 allegation of abuse voiced on 10/26/2017 was unsubstantiated based on findings of investigation conducted. Nurse Aide #1 did not care for Resident #1 at the time of investigation. It is the Center practice to suspend the Alleged Perpetrator at the time of investigation of any alleged Abuse and/or Neglect. THE PR(NAME)EDURES FOR IMPLEMENTING THE ACCEPTABLE CREDIBLE ALLEGATION FOR THE ALLEGED IMMEDIATE JEOPARDY. 100% audit of all residents' clinical documentation within the last 30 days was completed by the Director of Nursing, Assistant Director of Nursing and/or Nurse Supervisor to determine if there is any documentation in any resident's medical records that indicate allegation of abuse, neglect, and/or misappropriation of resident's properties, if any, determine whether a 24 hours and 5 days investigation reports were completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. The audit revealed no other documented allegation of abuse, and/or neglect documented in resident's medical records. This audit was completed on 11/15/17. Findings of this audit is documented on clinical records audit tool located at the facility compliance binder. On 11/15/2017, 100% interviews was completed by the Director of Social Services, Director of Rehabilitation Services, Dietary Manager, Business office manager and/or Medical Records clerk for all current alert and oriented residents in the facility to identify any other resident with allegation of Abuse, Neglect and or Misappropriation of properties. Four other residents, Resident#2, Resident #3, Resident #4 and Resident #5 voiced allegation of abuse, neglect and/or misappropriation of resident's properties. Alleged perpetrators suspended pending investigation by the facility Executive director, 24 hour report submitted on 11/14/2017, thorough investigation initiated, resident attending Physician and Responsible Party notified of the allegation. Resident #2, #3, #4 and #5 will be informed of the findings and actions taken when the investigation is completed by the Center Executive Director and/or Director of Social Services. Effective 11/15/2017, interviews for alert and oriented residents will be completed by the Director of Social Services, Director of Recreational Services and/or designated staff member at least once every quarter to identify any allegation of Abuse, Neglect and or Misappropriation of properties. This interview process will be incorporated to social services quarterly assessment schedule and documented on psychosocial assessment tool. Any voiced allegation of abuse, neglect and/or misappropriation of resident's properties will be reported to the Center Executive Director promptly. Alleged perpetrators will be suspended pending investigation by the facility, and reported according to the regulatory requirements. Effective 11/15/2017, the center nursing administrative team, which includes DON, Nurse supervisors, and/or SDC, initiated a process for reviewing clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. policy. Effective 11/15/2017, 24-hour and 5-days investigation reports are completed and reviewed by the Executive Director before submitted to the state agency and other officials as required by regulation and/or Elder Justice Act. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly and appropriate actions will be implemented by the Executive Director, DON, ADON, and/or Nurse Supervisor. This process will be incorporated in a daily sand up meeting. Any negative findings will be documented on the daily stand up meeting form and maintained in the daily stand up meeting binder. Effective 11/15/2017, week end Registered Nurse supervisor and/or designated licensed nurse will review clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. This systemic process will take place every Saturday and Sunday. Any negative findings will be documented on the week end supervisor report form and maintained in the daily clinical meeting binder. Effective 11/15/2017, week end Registered Nurse supervisor and/or designated licensed nurse will review clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. This systemic process will take place every Saturday and Sunday. Any negative findings will be documented on the week end supervisor report form and maintained in the daily clinical meeting binder. Effective 11/15/2017, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Effective 11/15/2017, Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Facility Executive Director, Director of Nursing (DON), and/or Director of Social Services will complete 100% re-education on the facility's abuse/neglect policy including notification, protection, and investigation protocols. This education will be provided for all employee, to include full time, part time and as needed staff. This education will be completed by 11/15/2017. Any employee not educated by 11/15/2017 will not be allowed to work until educated. This education will also be added on new hires orientation process for all new employees effective 11/15/2017, and will also be provided semi-annually. THE MONITORING PR(NAME)EDURE TO ENSURE THAT THE CREDIBLE ALLEGATION IS EFFECTIVE AND REMOVE THE ALLEGED IMMEDIATE JEOPARDY Effective 11/15/2017, Director of Nursing, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor compliance with abuse policies and procedures, resident's protection, thorough investigation, injuries of unknown sources and resident's neglect by conducting clinical meeting daily (M-F). This meeting will allow all allegation of abuse the team to review the incidents or accidents occurred from the prior clinical meeting to ensure any injury is thoroughly investigated and reported per abuse policy. The nursing administrative team in will also review completion of skin assessments from prior day and ensure any documented injury of unknown source was followed through per policy. Any issues identified during this monitoring process will be addressed promptly. Findings from this meeting will be documented on a daily clinical report form and filed in clinical meeting binder after proper follow ups are done. This monitoring process will take place daily (M-F) for 2weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective 11/15/2017, Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly x 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. TITLE OF THE PERSON RESPONSIBLE FOR IMPLEMENTING THE CREDIBLE ALLEGATION Effective 11/15/17, the center Executive Director and the Director of Health services will be ultimately responsible to ensure implementation of credible allegation to remove this alleged immediate jeopardy. Compliance Date: 11/15/2017 The Credible Allegation was verified on 11/16/2017 by the following: 1. The survey team reviewed the audit of current resident's medical records titled clinical records audit tool, which reviewed documentation that would indicate any allegation of abuse, neglect, misappropriation of resident's properties and /or injuries of unknown sources. 2. The survey team reviewed the audit of all incidents within the last 30 days which was completed to identify any unknown source of injuries. 3. The survey team reviewed the in-service provided by staff and signed by staff. The survey team conducted staff interviews with 16 on-duty staff. The staff interviewed confirmed the recent in-service regarding abuse identification, reporting, and recognizing signs and symptoms of staff burnout. 4. The survey team interviewed 41 current alert and oriented residents. The residents confirmed education they had received on whom to report abuse to.

Based on observation, resident interview, staff interviews and record review the facility failed to report staff to resident physical abuse within 24 hours to the State Agency, failed to thoroughly investigate the abuse allegation for 1 of 1 sampled residents (Resident #1). The immediate jeopardy (IJ) began on 10/26/2017 when NA #3 did not report to the Nurse, the Director of Nursing, or the Administrator, when Resident #1 told her Nurse Aide (NA) #1 grabbed her by the wrists and sat her down hard on the shower seat in the resident's bathroom, resulting in a bruise to her right wrist. The IJ was removed on 11/16/2017 when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to allow the facility to monitor and implement its plan of correction for abuse. Findings included: #1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #1, dated 9/22/2017 revealed the resident had intact cognition. She required extensive assistance with toileting, dressing, personal hygiene and bathing. She was not steady, but able to transfer herself with limited assistance between bed and wheelchair. Her weight was 115 pounds. An interview was conducted on 11/13/2017 at 11:05 AM with Resident #1. Resident #1 stated her body was sick but her mind was not. She stated a couple of weeks ago, she was not sure of the date, she had a bowel movement (BM) and soiled herself at about 6:00 AM. The resident got in her wheel chair and took herself to the bathroom, and turned on the bathroom call light for someone to come and help clean her up. She indicated a NA, who was not her night NA, came in about 6:15 AM and turned off the call light and told her if someone didn't come to help her after a while, to put her call light back on. The resident could see what time it was from the big numbered clock on her night stand that faced the bathroom. Resident #1 stated she waited for a long time, and was very still because she didn't want to get any mess on the floor. She stated she was cold and the bathroom smelled bad, and she was embarrassed. Resident #1 stated that NA #3, the day shift NA, came in the bathroom and asked how long she had been waiting, and the Resident replied, for an hour. NA #3 told her she was going to get NA #1. NA #1 came in and was real mad and kept saying that the other NA should have cleaned her up. The Resident stated she stood up and NA #1 grabbed her by the arm and said, I want you to sit here, moved her over and sat her down very hard on the shower seat, then she scrubbed her hard. Resident #1 said she was crying and scared. Resident #1 said she finally said to the NA, you don't have to treat me like a dog. When the shower was over the Resident asked for the NA's name, and the NA wouldn't tell her. Resident #1 stated she gave me a bruise right here, and pointed to her inside right wrist, and indicated the bruise was about 2 by 3 with her fingers. The bruise was not visible on this date, and the resident confirmed that the bruise had gone away by now. NA #3 came to her room after NA #1 had left and the Resident asked NA #3 what the name of NA #1 was, but NA #3 said she didn't know. Resident #1 told NA #3 what had happened in the shower, and NA #3 said she should report it to the Social Worker (SW). The resident stated she wheeled herself to the nurse's station for 3 days after and asked to see the SW, but the SW never came, so the next day she asked NA #4 about it after NA #4 saw her bruise. The resident stated she went to the nurse's station on Halloween, and was frustrated because the SW had not contacted her. A lady at the desk said what did she need to tell the SW, and Resident #1 stated she just stuck out her arm with the bruise, and the lady said she was the Director of Nursing (DON), and she could help. The DON transported the Resident that day to the SW office and said we need to get started on interviews. The DON came back a couple of days later and told Resident #1 the decision was up to the DON and she decided not to fire the NA, but moved her to a different hall and gave her another chance. The Resident stated she believed in 2nd chances, but afterward, she was worried that NA #1 would let her temper explode on someone else. Record review revealed the facility filed a 24-Hour Initial Report to the Department of Health and Human Services on 10/31/2017 for resident abuse and neglect. The alleged description was: Resident stated that Aide pushed her in the bathroom. The 24-Hour Report listed the Accused Individual Information as NA #1. The Report was signed by the Director of Nursing. Record reviews revealed the facility filed a 5-Working Day Report to the Department of Health and Human Services on 11/1/2017 for resident abuse and neglect. The alleged description was: Resident stated that aide pushed her in the bathroom and was rough and left a bruise on her wrist. Education teaching given and aide was removed from Hall. (The accused NA) Was not NA #1, was a different aide. Was not a hand print bruise upon investigation. The 5-Working Day Report listed the Accused Individual Information as NA #1. The Report was signed by the Director of Nursing. Review of statement by NA #1 included with the 5-Working Day Report revealed she was in the middle of her last round when NA #2 told her Resident #1 needed her. NA #1 said she was getting another resident ready for an appointment and told NA #2 she could not go back down to Resident #1's room because her resident needed breakfast. NA #1 left the hall to get breakfast for that resident, and then finished doing her rounds and charting. When she finished with her residents on the hall she actually forgot about going back down there because she had found a few things on the hall that needed to be corrected before change of shift. NA #1 gave report to oncoming NA #3, and told her NA #2 had answered Resident #1's call light and NA #1 had not gone back in Resident #1's room. When NA #1 was doing her charting NA #3 came up to her and fussed that Resident #1 was in a mess and had feces all over her in the bathroom with the door closed. NA #1 got towels and wash cloths and went back down the hall, and cleaned up the mess that could have been prevented if NA #2 would have just put Resident #1 on the toilet. NA #1 had to first calm down Resident #1 because she was crying terrible. After calming the Resident, she asked what happened and the Resident said she had put on the call light and NA #2 had turned off the light and told her she was going to get her NA. NA #2 had told the resident if your NA doesn't come then turn on your light again. NA #1 gave the resident a shower and dressed her and left around 7:30 AM on that morning. The report was signed on 11/1/2017 by NA #1. On 11/13/2017 at 4:35 PM, an interview was conducted with NA #1, who requested only to be interviewed with the DON present. NA #1 stated the only thing she recalled was between 6:00 and 7:00 AM, NA #2 had told her that Resident #1 needed her assistance, and so she went in and assisted her. NA #1 had been giving a bath to another resident, and so it was a little while before she was able to go down and help Resident #1. NA #1 stated she went to Resident #1's room before she had given report to day shift, and the Resident was already in the bathroom. She pushed the Resident up to the shower bar, and the Resident grabbed hold of it and sat down. The NA then gave her a shower and dressed her. She stated the Resident was crying and NA #1 calmed her down, told her not to cry it would be okay, about her being left in the bathroom. When asked about her written statement of 11/1/2017, that she forgot to go back in and clean the resident up, and that she had given report to day shift before she went in to clean her up, NA #1 just shrugged her shoulders and said it wasn't that long for the resident to wait and that was all she could remember. Further questions were answered with the same response. A review of the statement by NA #2 included with the 5-Day Working Report revealed that NA #2 answered the light for Resident #1 who was already in the bathroom. The NA turned off the light and told the Resident she needed to get some things to get her cleaned up. NA #2 walked directly to NA #1 and told her Resident #1 needed her. NA #1 looked down the hall and said, oh well, I'm not going back down there, I already been down there and I'm not going back. NA #2 said she was doing something else at the moment. NA #2 went back to her hall and NA #1 went into another resident room. NA #2 documented she was informed of a complaint against her by Nurse #1, who had received all her information from NA #1 and not the resident. On 11/13/2017 at 5:38 PM, a phone interview was conducted with NA #2. NA #2 stated she was working on the 500 hall, and went to the 600 hall to answer a bathroom call light. Resident #1 was already in the bathroom, sitting in her wheelchair facing towards the call light. The NA smelled BM, and knew it would take some time to clean her up, and the Resident said she needed help to be cleaned up. NA #2 stated she told the Resident she needed to go get a gown and stuff, and then NA #2 went directly to the room NA #1 was in. NA #2 told NA #1 that Resident #1 needed her. NA #1 stated she was not going back in that room. NA #2 went to get linens and proceeded back to the 500 hall. NA #2 stated when she went back to work on 10/31/2017, Nurse #1 told NA #2 a complaint had been made against her for a dignity issue. The DON told NA #2 there was an allegation that she had pushed Resident #1 in the bathroom, and then cut the light off. NA #2 requested the DON move her to another hall to get away from NA #1 and Nurse #1, and the DON moved her to another part of the facility. NA #2 stated she did not know if she had neglected the resident and didn't know if this incident was a dignity issue or something else. On 11/14/2017 at 8:34 AM, an interview was conducted with NA #3. NA #3 stated Resident #1 was alert, oriented, and could propel herself to the bathroom in her wheelchair. She has been incontinent at times and when she had soiled herself, she could not clean herself up from that. NA #3 stated on the morning of 10/26/2017, she received report from NA #1 that Resident #1 was in the bathroom and NA #1 had been busy so NA #2 had answered the light and told NA #1 that Resident #1 had needed her. Shortly after, NA #3 was standing with NA #5 when Resident #1's call light went on. NA #3 went into Resident #1's bathroom, and Resident #1 told her the NA's had left her like that, and NA #3 looked at her and saw BM on her gown and under pad, and the bathroom smelled like BM, and she was crying and upset. NA #3 told the Resident she would take care of it, and NA #3 went up the hall and told NA #1 she couldn't leave until she cleaned up Resident #1. NA #1 raised her voice and there was some loud altercation between the two, and then NA #1 said she would go down and give the Resident a shower. NA #3 stated she had talked to Resident #1 a little later that morning, and was told that NA #1 was mad and mean and rough with her and had grabbed her hard, and she was scared of her. The Resident asked the name of NA #1, but NA #3 told her she didn't know. NA #3 did not report the abuse to anyone, and told the Resident it would be better if she reported it herself to the SW. The Resident did not show NA #3 the bruise at that time, and thought the Resident showed her the bruise on 10/31/2017 after the resident had spoken to the DON. NA #3 stated she had been through abuse training, but could not say why she had not reported the abuse. On 11/13/2017 at 3:33 PM, an interview was conducted with Resident #1's family member. The family stated the Resident had told them of the NA being mean to her in the shower, that happened on 10/26/2017. The family member tried to call the DON's phone for 3 days in a row, but the voice mail had not been set up and she was unable to leave a message. The family member then called the facility's office in another town and talked to a corporate person about a meeting. The family member stated that by the time she met with the corporate person on 11/2/2017, the facility had called her about the abuse allegation. On 11/13/2017 at 1:47 PM, an interview was conducted with NA #4. NA #4 stated Resident #1 was alert and oriented, and could tell you about her day, and always remembered who NA #4 was. NA #4 indicated Resident #1 needed help with bathing, and dressing. Resident #1 could take herself to the toilet, but when she had occasional incontinent accident, she needed help with being cleaned up. NA #4 stated Resident #1 showed the bruise on her right inner wrist to her, and told her she had been pushed when in the shower and manhandled, and was so scared and upset, and didn't want to be at the facility. The Resident asked for a patient Bill of Rights to see what she could do about it. The NA stated this happened before Halloween, but was not sure of the date. The NA stated she left the Resident's room to see about getting her a Bill of Rights, and decided she had better tell someone of the abuse. The NA saw the HR manager at the nurse's desk, and told her there was abuse in the facility. The HR Manager stated the Administrator and DON needed to be notified. The HR Manager told the DON and then wrote a report. A review of a document dated 10/30/2017, written by the Human Resource Manager (HR) was conducted. The HR Manager reported she was at the 500/600 Hall Nurse's Station when she was notified by NA #4 that abuse was going on in the facility. NA #4 told her Resident #1 was scared to stay at the facility, and the NA saw bruises on Resident #1's arm. HR told NA #4 she was going to speak to the Director of Nursing (DON) about it. The HR Manager told the DON and the DON wrote down something and stated she was going to address it. An interview was conducted on 11/13/2017 at 4:04 PM, with the HR Manager. The HR Manager stated she was at the 500/600 Hall Nursing station when NA #4 had called her over and told her that Resident #1 was scared to stay at the facility because NA #1 had been really mean to her and gave her a bruise. NA #4 reported to her that she saw the bruise on the Resident's arm, like someone would've grabbed her. The HR Manager told NA #4 we have to report this, and so the HR Manager talked to the DON on the 10/30/2017 before she went home. The DON told the HR Manager she would take care of it. The time was late, and so the HR Manager went home and wrote up the report, and took it to the Administrator when she came in on 10/31/2017. On 11/13/2017 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated, and repeated many times, that she first heard of the abuse allegation on 10/31/2017, when Resident #1 came to the nurse's desk and said she was looking for the SW. The DON told Resident #1 that she could help, and Resident #1 showed her arm with the bruise on it. Resident #1 told her the NA had grabbed and pushed her in the shower. The DON stated she immediately wheeled Resident #1 to the SW, showed the SW the bruise, and told the SW she was going to start on the interviews. The DON stated she filed a 24-Hour Report, and then talked to NA #1 and NA #2, and determined there was no abuse because the bruise was just a round bruise on the Resident's wrist, and it wasn't a hand print bruise. The DON indicated that if a NA had grabbed Resident #1's wrist, it would have left a hand print bruise, because especially on Caucasians, you could always see the handprint if they were grabbed. The DON stated the bruise must have come from Resident's #1's medication, as she was on [MEDICATION NAME] (a blood thinner), and aspirin. The DON stated after she talked to NA #1, she realized that was not the NA who had pushed the resident to the bathroom, because the Resident was already in the bathroom when NA #1 went in to shower her. The DON stated that NA #2 had pushed Resident #1 into the bathroom, but she had no proof that Resident #1 was abused, so she decided to give NA #2 a second chance and moved NA #2 to a different hall, and that had been her decision. The DON stated she had called Resident #1's family, but they had told her they already had a meeting with the corporate people. A corporate person had told her everything was fine with the family, so she thought everything was settled. The DON had not asked Resident #1 if she had been fearful or scared, or any of the details of the incident, and her only documentation of what happened to the resident was the sentence she wrote on the 24-Hour and 5-Day Reports. The DON stated the Administrator had told her of the abuse allegation on 10/31/2017, but she had told him she already knew. When the DON was asked if she knew about the abuse allegation from the Human Resource Manager on 10/30/2017, the DON stated again that the first she heard of the allegation was when the Resident told her on 10/31/2017. An interview was conducted on 11/13/2017 at 4:18 PM, with Nurse #1. The Nurse stated she did not know anything about the abuse on the morning of 10/26/2017, and could not remember when she and NA #1 and NA #2 were all on the 500/600 hall, so the staffing schedules were reviewed. The Nurse stated she was informed the next night, which would've been the night of 10/26/2017, by NA #1, that NA #2 had pushed Resident #1 to the bathroom and left her there, while she went to tell NA #1. The Nurse stated she worked the evening of 10/31/2017 and talked to NA #2 on the morning of 11/1/2017 and asked her why she had taken Resident #1 to the bathroom and not completed the task. NA #2 told her she had to finish taking care of her own resident. Nurse #1 told NA #2 that a report had been filed against her for a dignity issue, according to a report she had heard from NA #1, and she did not think it was abuse, but was dignity. She had told NA #2, you just don't push a resident to the bathroom and just leave them. Nurse #1 stated she was informed by the DON on 11/2/2017 that NA #2 had been assigned to another hall, and had already been informed. On 11/13/2017 at 5:29 PM, an interview was conducted with the Administrator. The Administrator stated he had been informed of the abuse allegation when he received a written report from the HR Manager on 10/31/2017. He informed the DON about the report. He stated in his opinion the 24-Hour Report and the 5-Day Report reflected a thorough investigation and interview with the resident. He stated it was concerning that NA #4 had reported the Resident was fearful, but would make no other comments. On 11/14/2017 at 11:00 AM, an interview was conducted with the SW. The SW stated the DON had brought Resident #1 to her on 10/31/2017, and showed the SW the Resident's bruise. The SW stated the bruise was a little less than quarter size on her inner right wrist. The DON stated she would handle it. The SW was not familiar with the steps taken to investigate abuse, and only knew that the DON had to report it to the State. On 11/14/2017 at 5:57 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 11/16/2017. DATE: 11/15/2017 PR(NAME)ESSES THAT LEAD TO THE ALLEGED DEFFICIENCY CITED This alleged noncompliance resulted from the Center's Director of Nursing #1 misinterpretation of regulatory requirements related to how to conduct the detail investigation of any allegation of abuse or neglect. The former DON stated the way she understood is that she can only document what resident states on both 24 hour and a 5-day report Director of Nursing #1 is no longer employed at the Center effective 10/15/2017. New Director of Nursing employed to oversee clinical services effective 10/15/2017. The Director of operation from the Management and consulting company that manages the center, re-educated the Center Executive Director and the Director of Nursing #1 on 11/14/2017 on the center's Abuse Prohibition and Investigation policies and procedures, and emphasized the importance of protecting resident(s), to include suspending the alleged perpetrator during the investigation period, investigating thoroughly all alleged abuse, and/or neglect as well as injuries noted or reported to determine etiology, and reporting such in a timely manner per state regulatory requirements. This education was also provided to the new Director of Nursing on 11/15/2017 by the Director of Operation. On 11/14/2017 at approximately 9:00PM Director of Rehabilitation at the center followed by the facility Director of Social services interviewed resident #1. Resident #1 voiced that on 10/26/2017 approximately between 6:00 AM and 7:00 AM, she had an episode of loose stool, she wheeled herself to the bathroom and turn the bathroom call bell on. Nursing Aide #2 responded to the call bell and told the resident she will notify her assigned Nurse Aide (Nurse Aide #1), and if the assigned aide is not back to care for her, she asked resident #1 to turn the light back on (no time lapse specified). On the morning of 10/26/2017, during initial round, noted resident #1 to be soiled. Nurse Aide #3 communicated to Nurse Aide #1 about resident#1 being soiled and asked for Nurse Aide #1 to clean the resident#1 before leaving on 10/26/2017. Nurse Aide #1 provided care to Resident#1 and gave her a shower on 10/26/2017. Resident #1 added that Nurse Aide#1 pushed her and grabbed her on the arm, which caused a bruise. Resident #1 added that she reported this allegation to Nurse Aide #3 on 10/26/17, Nurse Aide #4 on 10/30/2017, and Director of Nursing #1 on 10/30/2017. Interview with Nurse Aide #4 by the Center Executive Director conducted on 11/13/2017 revealed she reported the Allegation made by Resident #1 to the Center Human Resources Director on 10/30/2017. Interview with Nurse Aide #3, and Nurse Aide # 4 did not report this allegation to their direct supervisor and the center's Executive Director per facility Abuse Prohibition policies and procedures revised June 2017. Director of Human Resources reported the Allegation to Director of Nursing #1 on 10/30/2017 and to the executive Director via written statement on 10/30/2017 that was read by the Center Executive Director on 10/31/2017 Nurse Aide #3, Nurse Aide # 4 did not report this allegation to their direct supervisor and the center's Executive Director per facility Abuse Prohibition policies and procedures revised June 2017. Director of Human Resources reported the Allegation to Director of Nursing #1 on 10/30/2017 and to the executive Director via written statement on 10/30/2017 that was read by the Center Executive Director on 10/31/2017 On 10/31/2017 and 11/3/2017, the 24 hour report and a 5 day report were sent to the Department of Health and Human Services respectively, related to resident #1's allegation of abuse made on 10/26/2017. These reports were completed and submitted by the former Director of Nursing #1. Five days report completed on 11/3/2017 indicated an investigation that was not detailed enough. On 11/13/2017 another 5 day report was completed after detail investigation conducted by the Center Executive Director, Director of Social Services and/or Director of Nursing #1. The investigation conducted 11/13/2017 by the Center Executive Director, Director of Social services, Director of Rehabilitation Center and MDS nurse by interviewing 100% of all current alert and oriented residents in the facility to determine if any other resident voiced and allegation of abuse or neglect that involve the alleged perpetrator (Nurse Aide #1). No other residents alleged abuse and/or neglect that involve the alleged perpetrator. Likewise, the Director of Human Resources conducted interviews with current employees who were on duty on 10/26/2017 between the 6AM and 7AM to determine if any staff on duty witnessed any abuse and/or neglect towards Resident #1 specifically from Alleged Perpetrator (Nurse Aide #1). No other staff witness any abuse and/or neglect. Resident's #1 allegation of abuse voiced on 10/26/2017 was unsubstantiated based on findings of investigation conducted. Nurse Aide #1 did not care for Resident #1 at the time of investigation. It is the Center practice to suspend the Alleged Perpetrator at the time of investigation of any alleged Abuse and/or Neglect. THE PR(NAME)EDURES FOR IMPLEMENTING THE ACCEPTABLE CREDIBLE ALLEGATION FOR THE ALLEGED IMMEDIATE JEOPARDY. 100% audit was completed by the Center Executive Director for all allegation of abuse and/or neglect reported to North Carolina Department of Health and Human Services in the last 12 months to determine if the alleged perpetrator(s) was/were suspended during the investigation period. This audit also identified whether the 24 hours and a 5 days reports are completed and submitted to the state agency as required by regulation and Elder Justice Act in a timely manner. The audit revealed all completed reportable in the last 12 months noted with detail investigation and the Alleged Perpetrator(s) were suspended. This audit was completed on 11/15/2017. 100% audit of all current residents' clinical documentation within the last 30 days was completed by the Director of Nursing, Assistant Director of Nursing and/or Nurse Supervisor to determine if there is any documentation in any resident's medical records that indicate allegation of abuse, neglect, and/or misappropriation of resident's properties, if any, determine whether a 24 hours and 5 days investigation reports were completed and reported to the state agency and other officials as required by regulation and/or Elder Justice Act. The audit revealed no other documented allegation of abuse, and/or neglect documented in resident's medical records. This audit was completed on 11/15/17. Findings of this audit is documented on clinical records audit tool located at the facility compliance binder. On 11/15/2017, 100% interviews was completed by the Director of Social Services, Director of Rehabilitation Services, Dietary Manager, Business office manager and/or Medical Records clerk for all current alert and oriented residents in the facility to identify any other resident with allegation of Abuse, Neglect and or Misappropriation of properties. Four other residents, Resident#2, Resident #3, Resident #4 and Resident #5 voiced allegation of abuse, neglect and/or misappropriation of resident's properties. Alleged perpetrators suspended pending investigation by the facility Executive director, 24 hour report submitted on 11/14/2017, thorough investigation initiated, resident attending Physician and Responsible Party notified of the allegation. Resident #2, #3, #4 and #5 will be informed of the findings and actions taken when the investigation is completed by the Center Executive Director and/or Director of Social Services. Effective 11/15/2017, interviews for alert and oriented residents will be completed by the Director of Social Services, Director of Recreational Services and/or designated staff member at least once every quarter to identify any allegation of Abuse, Neglect and or Misappropriation of properties. This interview process will be incorporated to social services quarterly assessment schedule and documented on psychosocial assessment tool. Any voiced allegation of abuse, neglect and/or misappropriation of resident's properties will be reported to the Center Executive Director promptly. Alleged perpetrators will be suspended pending investigation by the facility, and reported according to the regulatory requirements. Effective 11/15/2017, the center nursing administrative team, which includes DON, Nurse supervisors, and/or SDC, initiated a process for reviewing clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. policy. Effective 11/15/2017, 24-hour and 5-days investigation reports are completed and reviewed by the Executive Director before submitted to the state agency and other officials as required by regulation and/or Elder Justice Act. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly and appropriate actions will be implemented by the Executive Director, DON, ADON, and/or Nurse Supervisor. This process will be incorporated in a daily sand up meeting. Any negative findings will be documented on the daily stand up meeting form and maintained in the daily stand up meeting binder. Effective 11/15/2017, week end Registered Nurse supervisor and/or designated licensed nurse will review clinical documentation for the last 24 hours, completed skin assessments, incident reports for the last 24 hours, and Physician orders [REDACTED]. This systemic process will take place every Saturday and Sunday. Any negative findings will be documented on the week end supervisor report form and maintained in the daily clinical meeting binder. Effective 11/15/2017, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Effective 11/15/2017, Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Effective 11/15/2017, Abuse reporting process will be discussed to current alert and oriented residents every months during resident council meeting and at least quarterly during each resident care plan meeting. This process will be managed by the Center Director of Social Services effective 11/15/2017. Facility Executive Director, Director of Nursing (DON), and/or Director of Social Services will complete 100% re-education on the facility's abuse/neglect policy including notification, protection, and investigation protocols. This education will be provided for all employee, to include full time, part time and as needed staff. This education will be completed by 11/15/2017. Any employee not educated by 11/15/2017 will not be allowed to work until educated. This education will also be added on new hires orientation process for all new employees effective 11/15/2017, and will also be provided semi-annually. 100% audit of all current residents' clinical documentation within the last 30 days was completed by the Director of Nursing, Assistant Director of Nursing and/or Nurse Supervisor to determine if there is any documentation in any resident's medical records that indicate allegation of abuse, neglect, and/or misappropriation of resident's properties, if any, determine whether a 24 hours and 5 days investigation re (TRUNCATED)

Based on observation, record review and staff and resident interviews, the facility failed to maintain a resident's dignity by leaving the resident soiled and unattended which resulted in the resident feeling embarrassed and crying for 1 of 3 residents observed for dignity, (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #1, dated 9/22/2017, revealed the resident had intact cognition. She required extensive assistance with toileting, dressing, personal hygiene and bathing. She was not steady, but able to transfer herself with limited assistance between bed and wheelchair. Her weight was 115 pounds. An interview was conducted on 11/13/2017 at 11:05 AM with Resident #1. Resident #1 stated a couple of weeks ago, she was not sure of the date, she had a bowel movement (BM) and soiled herself at about 6:00 AM. The resident got into her wheel chair herself, and took herself to the bathroom, and turned on the bathroom call light for someone to come and help clean her up. She indicated a NA, who was not her night NA, came in about 6:15 AM and turned off the call light and told her if someone didn't come to help her after a while, to put her call light back on. The resident could see what time it was from the big numbered clock on her night stand that faced the bathroom. Resident #1 stated she waited for a long time, and was very still because she didn't want to get any mess on the floor. She stated she was cold and the bathroom smelled bad, and she was embarrassed. Resident #1 stated that NA #3, the day shift NA, came in the bathroom and asked how long she had been sitting here waiting, and the resident replied for an hour. NA #3 told her she was going to get NA #1. NA #1 came in and kept saying that the other NA should have cleaned her up. Resident #1 stated she was crying and scared. Review of statement dated 11/1/2017, by Nursing Assistant (NA #1) included with a 5-Working Day Report revealed she was in the middle of her last round when NA #2 told her Resident #1 needed her. NA #1 said she was getting another resident ready for an appointment and told NA #2 she could not go back down to Resident #1's room because her resident needed breakfast. NA #1 left the hall to get breakfast for that resident, and then finished doing her rounds and charting. When she finished with her resident on the hall she actually forgot about going back down there because she had found a few things on the hall that needed to be corrected before change of shift. NA #1 wrote that she gave report to oncoming NA #3, and told her NA #2 had answered Resident #1's call light and NA #1 had not gone back in Resident #1's room. The report was signed on 11/1/2017 by NA #1. On 11/13/2017 at 4:35 PM, an interview was conducted with NA #1. NA #1 stated the only thing she recalled was between 6:00 and 7:00 AM, was that NA #2 had told her that Resident #1 needed her assistance, and so she went in and assisted her. NA #1 had been giving a bath to another resident, and so it was a little while before she was able to go down and help Resident #1. NA #1 stated she had gone to Resident #1's room before she had given report to day shift, and the Resident was already in the bathroom. NA #1 then gave her a shower and dressed her. She stated Resident #1 was crying and she calmed her down, and told her not to cry, it would be okay. When asked about her written statement of 11/1/2017, that she forgot to go back in and clean her up, NA #1 just shrugged her shoulders and said it wasn't that long for the resident to wait and that was all she could remember. A review of the statement, undated, by NA #2 included with a 5-Day Working Report revealed that NA #2 answered the light for Resident #1 who was already in the bathroom. The NA turned off the light and told the Resident she needed to get some things to get her cleaned up. NA #2 walked directly to NA #1 and told her Resident #1 needed her. NA #1 looked down the hall and said, Oh well I'm not going back down there, I already been down there and I'm not going back. NA #2 said she was doing something else at the moment. On 11/13/2017 at 5:38 PM, a phone interview was conducted with NA #2. NA #2 stated she went to answer a bathroom call light. Resident #1 was already in the bathroom, sitting in her wheelchair facing towards the call light. The NA smelled BM, and knew it would take some time to clean her up, and the resident said she needed help to be cleaned up. NA #2 stated she told the resident she needed to go get a gown, and then NA #2 went directly to the room where NA #1 was providing care to another resident. NA #2 told NA #1 that Resident #1 needed her. On 11/14/2017 at 8:34 AM, an interview was conducted with NA #3. NA #3 stated Resident #1 was alert, oriented, and could propel herself to the bathroom in her wheelchair. She had been incontinent at times and when she had soiled herself, she could not clean herself up. NA #3 stated on the morning of 10/26/2017, she answered Resident #1's call light at 7:00 when she came on duty for the day shift (7:00 AM to 3:00 PM). She stated the resident was in the bathroom crying and upset, and reported the NA's had left her. NA #3 looked at her and saw BM on her gown and under pad, and the bathroom smelled like BM. An interview was conducted on 11/13/2017 at 4:18 PM, with Nurse #1. She stated she was informed on the night of 10/26/2017, by NA #1, that NA #2 had pushed Resident #1 to the bathroom and left her there, and then went to tell NA #1. Nurse #1 stated she worked the evening of 10/31/2017 and talked to NA #2 on the morning of 11/1/2017 and asked her why she had taken Resident #1 to the bathroom and not completed the task. NA #2 told her she had to finish taking care of her own resident. Nurse #1 stated she was informed by the DON on 11/2/2017 that NA #2 had been assigned to another hall. On 11/13/2017 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she talked to NA #2, and that NA #2 stated Resident #1 was in the bathroom when she turned off the light and went to get NA #1. The DON stated she expected NA #2 to take care of the resident when she answered the call light. The DON stated she decided to give NA #2 a second chance, and moved her to a different hall.

Based on observation, record review and staff interviews the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor these interventions that the committee put into place in October of 2014. The deficiency was in the area of failure to prevent accidents. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. Immediate Jeopardy began on 10/11/15 when Resident #116 left the facility unsupervised and was found by a visitor in the front parking lot of the facility. The resident's wanderguard bracelet failed to activate the alarm system on the door. Immediate Jeopardy began on 11/12/15 when Resident #22 left the facility unsupervised and was found outside at night by staff. The dining room exit door failed to alarm due to a dead battery. Immediate Jeopardy was identified on 11/19/15 at 9:45 AM and was removed 11/20/15 at 10:07 AM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: This tag is cross referenced to F 323: Based on record review and staff interviews, the facility failed to prevent 2 of 4 cognitively impaired residents (Resident #22 and Resident #116) who exhibited wandering behaviors from exiting the facility while unsupervised. During an interview on 11/18/15 at 11:59 AM, the Facility Medical Director stated he was aware of the wanderers but it had not been discussed during Quality Assurance (QA) meetings. He revealed QA should have looked at wandering and we could have fixed it before it became a detriment to the residents. It has to be a safe environment and the safety of the patients. During an interview on 11/20/15 at 9:06 AM, the Administrator indicated that residents with wandering behavior did not come up as a concern in QAA. The Administrator further stated that residents with wandering behavior will be reviewed in QAA. The Administrator was notified of the Immediate Jeopardy on 11/19/15 at 8:45 AM. The facility provided the following Credible Allegation on 11/20/15 at 10:18 AM. Problem Identified: Facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) for residents with wandering/exit seeking behaviors. Interventions: Corporate Management Clinical Support Nurse has completed re-training with facility Administrator, Director of Nursing and Assistant Director of Nursing regarding F520 Quality Assurance, regarding unsafe wandering or elopement including identification of resident wandering behavior, creating a safe environment, completion of resident assessments at the time of admission and the time of any event of unsafe wandering or elopement, notification of any events with potential of adverse resident outcomes to Clinical Support Nurse and completion of Quality Assurance and Performance Improvement Plan to prevent re-occurrence of any adverse outcomes regarding resident care and safety. The DON or administrative nurse will review the 24 hour report, physician's telephone orders and resident incident report daily to ensure that all potential adverse events regarding resident care and safety are addressed and appropriate interventions are in place started 11/19/15. Compliance will be monitored daily by Director of Nursing/administrative nurse and/or facility Administrator with review of daily 24 hour reports, physician telephone orders, and resident incident reports to ensure that all potential adverse events regarding resident care and safety are addressed and interventions are in place. Director of Nursing and/or administrative nurse will conduct a weekly standards of care meeting with review of any resident with unsafe wandering and/or exit seeking behavior. This meeting will include input from facility psychological group and attending physician for current interventions and any necessary changes to the resident care to ensure residents are receiving timely interventions. Potential Residents: All Current residents were reassessed on 11/20/15 by the ADON to identify any residents who are at high risk for wandering behavior. Residents identified as having exit seeking behaviors have a new and/or updated Care plan completed 11/20/15 by MDS nurse. CNA Care Guides have been updated and reviewed with staff to ensure they are aware of residents with a high risk of wandering on 11/20/15 by the ADON. Two notebooks were created that contain the pictures of all residents identified as high risk for wandering on 11/19/15. The notebooks will be located at the receptionist desk and nurse's station to ensure staff is able to identify any resident with a high risk for wandering. All residents currently with a wanderguard have been assessed for wander guard placement. All wander guards are placed on residents as recommended by the manufacturer as of 11/19/15. As of 11/19/15 newly admitted residents will be assessed for the risk of wandering /exit seeking behaviors within 24 hours of admission. As of 11/19/15 any resident experiencing an exit seeking event will be immediately re-assessed and intervention put in place. The DON/Administrator will be notified for follow-up. Training will be completed with all current staff on unsafe wandering or Elopement including, identification of resident wandering behavior, creating a safe environment, and providing a safe environment for residents by the ADON on 11/19/15. Any staff not available for this training will not be allowed to work until training is complete. Maintenance will check wanderguard boxes daily for functioning and document finding on the Door Alarm Check monitoring tool. Any wanderguard box not functioning properly will be corrected immediately by maintenance. All wander guard boxes were audited 11/19/15 by maintenance and are working properly. Maintenance will check the voltage of batteries and audible alarm on all door alarms 4 x weekly for battery life by using a meter and follow manufacturer's recommendation of changing battery when reading is 7.0 voltage or less. Maintenance will document his finding on the Door Alarm Check monitoring tool. All doors alarms were audited 11/19/15 by maintenance and documented with all battery voltage over 7.0 Monitoring: Beginning 11/19/15 the Administrator will monitor the Maintenance Door Alarm Check sheets daily x 4 weeks; then, weekly times 3 months to ensure compliance. The Facility DON and/or designee will monitor the wanderguard placement of identified residents weekly x 4weeks and compare to MARs documentation on wander guards. If any discrepancies are found, the nurse will be identified, reeducated and counseled by the DON or ADON. Director of Nursing will submit a summary of the standards of care meeting at the monthly QAPI meeting x 3 months, then every other month for review, discussion and/or needed changes to ensure compliance until resolved. The facility Administrator will complete a summary of all monitoring efforts and will present it at the facility QAPI meeting monthly with facility Medical Director and facility QAPI committee. The credible allegation was verified on 11/20/15 at 11:30 AM as evidenced by staff interviews on the use of wander guard monitoring tools, when Wander guards boxes are to be checked for functioning; how often voltage of batteries and audible alarms checked on doors and how often wander guard sensor doors would be checked for accuracy of alarming and proper placement. In addition updated Care Plans, care guides and assessments were verified as well as elopement notebooks. Observations of proper placement of wander guards and wanderguard system working effectively. The credible allegation was verified on 11/20/15 at 11:30 AM as evidenced by: interview of all staff related to their being able to identify residents at risk for elopement and verifying staff understood how to identify, report and monitor residents at risk for wandering. Interview staff on when wanderguard boxes are to be checked for functioning; how often voltage of batteries and audible alarms checked on doors and how often wanderguard sensor doors would be checked for accuracy of alarming and proper placement. In addition updated care plans, care guides and assessments were verified as well as elopement notebooks. Observations of proper placement of wanderguards and wanderguard system working effectively.

Based on record review and staff interviews, the facility's administration failed to have available and enforce adherence to manufacturer's instructions for the application of wanderguards and when to change the battery on the door alarm system which resulted in an immediate jeopardy for 2 of 4 cognitively impaired residents (Resident #22 and Resident #116) who exhibited wandering behaviors from exiting the facility while unsupervised. Immediate Jeopardy began on 10/11/15 when Resident #116 left the facility unsupervised and was found by a visitor in the front parking lot of the facility. The resident's wander guard bracelet failed to activate the alarm system on the door. Immediate Jeopardy began on 11/12/15 when Resident #22 left the facility unsupervised and was found outside at night by staff. The dining room exit door failed to alarm due to a dead battery. Immediate Jeopardy was identified on 11/19/15 at 9:45 AM and was removed 11/20/15 at 10:07 AM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: This tag is cross referenced to F 323: Based on record review and staff interviews, the facility failed to prevent 2 of 4 cognitively impaired residents (Resident #22 and Resident #116) who exhibited wandering behaviors from exiting the facility while unsupervised. The Administrator was notified of the Immediate Jeopardy on 11/19/15 at 8:45 AM. The facility provided the following Credible Allegation on 11/20/15 at 10:18 AM. Problem Identified: Facility Administrator, Director of Nursing and Assistant Director of Nursing failed to create a safe environment for residents by not ensuring staff was properly trained on unsafe wandering /exit seeking behavior, not having Policies and Procedures in place for checking door alarms per manufacturer's recommendations and not ensuring the wanderguards were on the resident rather than their wheelchair. New interventions: Choice Management Clinical Support Nurse has completed re-training with facility Administrator, Director of Nursing and Assistant Director of Nursing regarding unsafe wandering or elopement including identification of resident wandering behavior, creating a safe environment, completion of resident assessments at the time of admission and the time of any event of unsafe wandering or elopement, notification of any events with potential of adverse resident outcomes to Clinical Support Nurse and completion of Quality Assurance and Performance Improvement Plan to prevent re-occurrence of any adverse outcomes regarding resident care and safety. Resident #22: Maintenance will check wanderguard boxes daily for functioning and document findings on the Door Alarm Check monitoring tool. Any wander guard box not functioning properly will be corrected immediately by maintenance. All wanderguard boxes were audited 11/19/15 by maintenance and are working properly. Maintenance will check the voltage of batteries and audible alarm on all door alarms 4 x weekly for battery life by using a meter and following manufacturer's recommendation of changing battery when reading is 7.0 voltage or less. Maintenance will document his finding on the Door Alarm Check monitoring tool. All doors alarms were audited 11/19/15 by maintenance and documented with all battery voltage over 7.0. Resident #116: The wander guard implemented on 10/11/15 has worked with no other exit seeking events. Resident assessed for placement of wander guard on 11/19/15 and noted wanderguard had been moved to wheelchair. Wanderguard removed from wheelchair and reapplied to resident #116's ankle. Nursing staff was in serviced by the ADON on 11/19/15 regarding placement of wanderguards. Wanderguard placement has been added the MAR and nurses will check placement every shift starting 3-11 shift 11/19/15. Potential Residents: All Current residents were reassessed on 11/20/15 by the ADON to identify any residents who are at high risk for wandering behavior. Residents identified as having exit seeking behaviors have a new and/or updated Care plan completed 11/20/15 by MDS nurse. CNA Care Guides have been updated and reviewed with staff to ensure they are aware of residents with a high risk of wandering on 11/20/15 by the ADON. Two notebooks were created that contain the pictures of all residents identified as high risk for wandering on 11/19/15. The notebooks will be located at the receptionist desk and nurse's station to ensure staff is able to identify any resident with a high risk for wandering. All residents currently with a wander guard have been assessed for wanderguard placement. All wanderguards are placed on residents as recommended by the manufacturer as of 11/19/15. As of 11/19/15 newly admitted residents will be assessed for the risk of wandering /exit seeking behaviors within 24 hours of admission. As of 11/19/15 any resident experiencing an exit seeking event will be immediately re-assessed and intervention put in place. The DON/Administrator will be notified for follow-up. Training will be completed with all current staff on unsafe wandering or Elopement including, identification of resident wandering behavior, creating a safe environment, providing a safe environment for residents and proper placement of wander guards on the resident and not their wheelchair by the ADON on 11/19/15. Any staff not available for this training will not be allowed to work until training is complete. Maintenance will check wanderguard boxes daily for functioning and document finding on the Door Alarm Check monitoring tool. Any wanderguard box not functioning properly will be corrected immediately by maintenance. Maintenance received in-service training on this procedure on 11/18/15. All wanderguard boxes were audited 11/19/15 by maintenance and are working properly. Maintenance will check the voltage of batteries and audible alarm on all door alarms 4 x weekly for battery life by using a meter and follow manufacturer's recommendation of changing battery when reading is 7.0 voltage or less. Maintenance will document his finding on the Door Alarm Check monitoring tool. All doors alarms were audited 11/19/15 by maintenance and documented with all battery voltage over 7.0. Monitoring: The facility will conduct an interdisciplinary weekly standards of care meeting regarding wandering behavior that will review any resident with unsafe wandering and/or elopement seeking behavior beginning 11/23/15. Members of the interdisciplinary team include but is not limited to the Director of Nursing, Rehabilitation, Social Work and Dietary. This meeting will include input from the facility psychological group and attending MD on current interventions and any necessary changes to the resident care to ensure residents are receiving appropriate and timely interventions. Director of Nursing and/or administrative nurse will conduct a weekly standards of care meeting with review of any resident with unsafe wandering and/or exit seeking behavior. This meeting will include member of the interdisciplinary team with input from facility psychological group and attending physician for current interventions and any necessary changes to the resident care to ensure residents are receiving timely interventions. The credible allegation was verified on 11/20/15 at 11:30 AM as evidenced by: interview of all staff related to their being able to identify residents at risk for elopement and verifying staff understood how to identify, report and monitor residents at risk for wandering. Interview staff on when wanderguard boxes are to be checked for functioning; how often voltage of batteries and audible alarms checked on doors and how often wanderguard sensor doors would be checked for accuracy of alarming and proper placement. In addition updated care plans, care guides and assessments were verified as well as elopement notebooks. Observations of proper placement of wanderguards and wanderguard system working effectively.

Based on record review and staff interviews, the facility failed to prevent 2 of 4 cognitively impaired residents (Resident #22 and Resident #116) who exhibited wandering behaviors from exiting from the facility while unsupervised. The findings included: Immediate Jeopardy began on 10/11/15 when Resident #116 left the facility unsupervised and was found by a visitor in the front parking lot of the facility. The resident's wanderguard bracelet failed to activate the alarm system on the door. Immediate Jeopardy began on 11/12/15 when Resident #22 left the facility unsupervised and was found outside at night by staff. The dining room exit door failed to alarm due to a dead battery. Immediate Jeopardy was identified on 11/19/15 at 9:45 AM and was removed 11/20/15 at 10:07 AM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings included: 1. Resident #22 was originally admitted to the facility on [DATE]. Resident #22's [DIAGNOSES REDACTED]. Nursing note dated on 04/04/15 at 4:15 PM read in part: At 9:45 AM a member of the housekeeping staff brought Resident #22 to the C hall stating that a resident had seen Resident #22 going out a breezeway door that connects the LTC (long term care) to the assisted facility living. The alarm to the door did not sound. The housekeeping staff found Resident #22 sitting outside the door and returned her to the C hall. The resident stated she was looking for her baby. No c/o pain or discomfort. Q (every) 15 minute checks were initiated. Resident received Xanax 0.25 PO (by mouth) for anxiety, her wanderguard was checked for placement and proper functioning. DON (Director of Nursing), Administrator, and member of the Maintenance was notified of the incident at 10:30 AM. Responsible Party was notified at 10:30 AM. Currently resident is sitting at the nursing station asking to see family member. Will continue to monitor. No acute distress. Note written by Staff Nurse #5. Nursing note dated on 09/15/15 at 7:05 PM read in part: Resident brought back in from outside by nurse (nurse name) where she had been sitting under bridgeway (breezeway) beside ambulance after setting off door alarm. Nurse (nurse name) had been responding to alarm when it sounded to see what had set it off when she found her sitting there. Resident was given evening meds at that time and put on q (every) 15 minute checks x 24 hours. She then sat quietly in her w/c (wheelchair). 7:30 PM - Reported to DON (Director of Nursing). 7:35 PM - Notified responsible party. 7:38 PM - Notified Dr. (name of doctor). 10:15 PM - Put to bed and was cooperative at this time. Bed alarm attached and functioning. Resident with eyes closed and respirations even and unlabored. Q (every) 15 minute checks continuing. Note written by Staff Nurse #6. Review of elopement assessment dated on 10/13/15 revealed elopement/wandering risk review indicated elopement risk included interventions of frequent monitoring, personalization of room, staff aware of resident's wander risk and wanderguard was placed. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #22 was severely cognitively impaired and exhibited wandering behavior occurring 1 to 3 days. The assessment also indicated the resident needed extensive assistance of one person physical assist for transfer, dressing and hygiene and limited assistance of one person physical assist for locomotion. The resident was coded as balance not steady, only able to stabilize with human assistance. The resident was assessed to require a wheelchair for mobility. Review of form entitled Report of Resident Exit Seeking/Wandering: Missing From Facility dated 11/12/15, 10:40 PM read in part B hall nurse was pushing resident down hall to her room and made writer aware that resident was behind the dining room outside of the facility on her knees knocking on the window. Resident had went out of door in dining area, door did not alarm. Alarm was broken. Resident had gotten out of wheelchair and had mud on her clothes from knees down. Resident was not hurt. Nurse made CNA (certified nursing assistant) aware of the situation and CNA cleaned resident up and put her into bed. Action taken: Resident on q (every) 15 minute checks. A new plan of care/intervention has been completed to prevent further events. Nursing note dated on 11/12/15 at 11:42 PM read in part: Resident was found outside of dining room this pm, resident was banging on door to come in. Resident was assisted into wheelchair and brought back into building, C Hall nurse and CNA's notified. DON (Director of Nursing) was called and notified also. Resident does have wanderguard on and also personal alarm which are in working order. No apparent injuries noted at first sight. Note written by Staff Nurse #7. Review of the weather history for November 12, 2015 indicated that the actual temperature was 78 degrees Fahrenheit and the low was 46 degrees Fahrenheit. The weather history indicated that it rained on November 10, 2015. Review of Resident #22 updated care plan dated on 11/18/15 addressed the problem of the Resident has exit seeking behavior. Resident was found outside of dining room on 11/12/15 with no injuries. Goal: Resident will not leave building unattended thru next review. Approaches: Personal secure alarm as ordered. Check functioning of secure alarm per policy. Check placement per protocol. Redirect resident PRN (as needed). Observe frequently. Attempt diversional activities PRN (as needed). Routine risk assessment. Meds as ordered. Contact MD (medical doctor) and family of attempts to leave facility. Q (every) 15 minute checks indefinitely. Neuro checks initiated. RP (responsible party) notified. MD (medical doctor) notified. Administrator/DON (Director of Nursing) notified. Maintenance in to fix door. Observation was made of the resident on 11/18/15 at 7:40 AM in her room sitting up in wheelchair waiting for breakfast with the wanderguard attached to the back of the wheelchair. During an interview on 11/18/15 at 7:45 AM, NA (nursing assistant) #6 indicated that she has seen the resident go to the front area and look out the window. The NA #6 further stated that she was told by the Nurse on the hall that the resident is on Q (every) 15 minute checks due to trying to exit the facility. During an interview on 11/18/15 at 8:30 AM, the MDS Coordinator indicated that the resident does wander throughout the facility and a wander guard was placed for safety. Observation was made on 11/18/15 at 10:00 AM of resident sitting in wheelchair behind the nurse's station drinking a soda and the wander guard was attached to the back of wheelchair. During an interview on 11/18/15 at 10:10 AM, Nurse #8 indicated that she has not seen the resident try to exit the building. Nurse #8 further stated that the resident was put on Q 15 minute checks for exiting out of the dining room door. During an interview on 11/18/15 at 10:15 AM, NA #7 indicated that she has not seen the resident try to exit the building. NA #7 further stated that the resident does wheel herself in wheelchair throughout the building. During an interview on 11/18/15 at 10:18 AM, the Social Worker stated that the resident does wheel herself in wheelchair throughout the facility and only tries to exit the facility if she has a Urinary Tract Infection. During an interview on 11/18/15 at 10:20 AM, the Assistant Director of Nursing (ADON) stated that the resident may go to the door to look out but is easily redirected. The ADON further stated that she has not seen the resident try to exit the building. Observation was made on 11/18/15 at 2:30 PM of the resident sitting up in wheelchair in the foyer area visiting with a family member. Observation was made of the wanderguard attached to the resident's wheelchair on the back. During an interview on 11/18/15 at 3:50 PM, NA #8 stated that she saw the resident sitting up in her wheelchair rolling around on the hall at 10:15 PM and 10:40 PM when she was made her last rounds. During an interview on 11/18/15 at 5:00 PM, the Maintenance Director indicated that the dining room door alarm system uses a 9 volt heavy duty battery. The Maintenance Director further stated he checks the battery life by sound every Thursday and does not keep a log when the battery is changed. The Maintenance Director indicated that he has a meter and has not used it in the past to check the life of the battery. The Maintenance Director stated he would contact the alarm system company for manufacturer's instruction. The Maintenance Director further stated that the dining room door alarm is not tied in with the wanderguard system, the dining exit door will alarm when it is opened. The Maintenance Director further stated that he changed the battery on the alarm system for the dining room exit door on 11/13/15 around 12:30 AM when he was notified at home that Resident #22 was found outside. Observation was made of the dining room exit door on 11/18/15 at 5:00 PM of the 9 volt battery and door was alarming properly when opened. During a telephone interview on 11/18/15 at 11:45 PM, Nurse #9 indicated that she saw the resident at 10:00 PM on 11/12/15 sitting in her wheelchair in her room doorway. Nurse #9 further stated that the resident was on Q 15 minute checks due to her wandering throughout the facility. Nurse #9 stated that the nurse on B hall Nurse #7 heard a banging noise and found the resident outside of the dining room door on her knees banging on the glass door with a rock. Nurse #9 stated that the Nurse #7 was pushing Resident #22 in her wheelchair back into the facility. The Nurse stated that the resident was assessed and there was no apparent injuries. The Nursing Assistant (NA) got the resident out of her muddy clothing and cleaned up and put Resident #22 to bed. Nurse #9 said she did not hear the door alarm. The Administrator and the Maintenance Director were notified. During an interview on 11/19/15 at 8:00 AM, Nurse #7 stated that she heard a banging noise and walked around in the facility to find out where the banging noise was coming from and saw the resident on her knees outside the dining room door banging on the door with a rock. Nurse #7 stated she yelled for help and she went out another door about 10 feet away from the resident. Nurse #7 stated that the resident wheelchair was about 6 feet away from her stuck in the mud. Nurse #7 said she checked the resident while she was outside and she was able to stand. The resident was put in her wheelchair and rolled back into the facility. Nurse #7 said the weather outside was damp and the air was brisk. Nurse #7 stated said she immediately called the DON. During an interview on 11/19/15 at 7:55 AM, housekeeping staff #2 revealed that she saw Resident #22 attempt to go out of the door near the kitchen area on last week and she redirected Resident #22. Observation was made on 11/19/15 at 10:30 AM of the area where the Resident #22 was found and there was 12 foot cement sidewalk that goes out from the dining room exit door. Observation was of the construction site which was about 40 feet from the dining room exit door. Review of the manufacturer's instructions dated on December 23, 2014 read in part Parts breakdown depiction: 9 volt battery. Low battery alert: Simultaneous siren chirps and red LED flashes occur at 45 seconds intervals when the battery reaches approximately 7 volts. The Maintenance Director had the manufacturer's instruction sent to facility on 11/19/15. Review of the manufacturer's manual, titled Code Alert, Senior Living Solutions, Wander Management Transmitters, User Guide,release date 5/21/15, page 7, read in part, Warning: When the code watch (wanderguard) is placed on a resident's ankle, be sure to adjust the antennae at each door to a 4 to 5 ft. range to the ankle. Failure to do so may allow a resident to elope because they will be closer to the door when the door detects the transmitter. Also pg. 9 of the manual, read in part, Note: To monitor a resident in a wheelchair, attach the transmitter to the seat or the back of the chair as the metal on the chair can interfere with the transmitter's signal. #4 Adjust the band so that the transmitter is in a comfortable position on the resident's wrist or ankle. During a telephone interview on 11/19/15 at 10:33 AM a Technician from the manufacturer of the wander guard code watch, stated the code watch (wanderguard bracelet) should not be placed on the metal portion of a wheelchair because it could interfere with the transmitter's signal. During an interview 11/20/15 at 9:06 AM, the Administrator indicated that it is her expectation that Maintenance Director use the alarm system manufacturer's instructions and change the battery when it is registering 7 volts by using the meter from this point on. 2. Resident #116 was originally admitted to the facility on [DATE]. Resident # 116's [DIAGNOSES REDACTED]. According to the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], Resident #116's Brief Interview for Mental Status (BIMS) noted she was cognitively impaired with severely impaired decision making skills. In the area of behavior, Resident #116 was coded, with no wandering behaviors, and in the area of Activities of Daily Living, Resident #116 required limited assistance with transfers and used a wheelchair. A Nursing Note dated 7/18/15 at 7:04 PM, read in part, Informed per staff seeing resident out of building. Writer noticed resident sitting in wheelchair outside of building in parking lot. Wheeled back into facility. Wanderguard bracelet placed on right wrist. The note was written by Staff Nurse #1. Review of a document titled Elopement Assessment - Report of Resident Exit Seeking/Wandering: Attempting to leave facility revealed: 7/18/15 12:45 PM-Informed per staff of seeing resident out of building. Writer noticed resident sitting in wheelchair outside of building in parking lot. Wheeled back into facility. The document indicated that the resident did not have on a monitoring device. The action taken by the facility included the placement of wanderguard bracelet on the resident. A Nursing Note dated 7/19/15 at 6:27 PM, read in part, Resident alert, some confusion. Out of bed in wheelchair, propelling within facility. Noticed resident had removed wanderguard bracelet. Placed back onto right ankle. The note was written by Staff Nurse #1. During an interview on 11/18/15 at 5:40 PM Nurse Supervisor# 1, stated she did not recall the elopement incident of 7/18/15. She revealed she did not work that often. Nurse Supervisor #1 was noted on Resident #116's elopement incident report of 7/18/15 as Staff Nurse #1's immediate supervisor. During an interview on 11/18/15 at 5:38 PM, Nursing Assistant #1, stated she did not recall Resident # 116 eloping from facility on 7/18/15. She said she could not recall anything about an elopement incident. On 11/18/15 at 5:48 PM an effort was made to contact Staff Nurse #1 who retrieved Resident #116 from the parking lot and wrote the elopement incident report on 7/18/15. Staff Nurse #1 was no longer employed with the facility and her telephone was disconnected. The resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. According to the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], Resident #116's Brief Interview for Mental Status (BIMS) was 00, which meant Resident # 116 was cognitively impaired with severely impaired decision making skills. In the area of behavior, Resident #116 was coded, with no wandering behaviors, and in the area of Activities of Daily Living, Resident #116 required extensive assistance with transfers and used a wheelchair. A Nursing Note dated 10/11/15 at 8:15 PM, read in part, Another resident's family member was pushing resident down hallway to nurse and stated resident was sitting outside. Registered Nurse supervisor and Assistant Director of Nursing made aware and stated to start every 15 minute checks. Resident #116's responsible person/family member was called and left message to return call. Night nurse made aware. Will monitor. Resident in room at this time. The note was written by Staff Nurse #2. Review of a document titled Elopement Assessment Report of Resident Exit Seeking/Wandering: Attempting to leave facility revealed: 10/11/15 5:00 PM Another resident family member brought resident back in stated she was outside in parking lot. The document indicated the facility's security alarm did not sound, and the resident's monitoring device was observed on the resident at the time the resident was found outside of the building. However, the device was not working. The action taken by the facility included to check the resident's whereabouts every 15 minutes. A Nursing Note dated 10/12/15 at 8:07 AM, read in part, Resident without attempt to leave facility. On every 15 minute checks. The note was written by Staff Nurse #4. Review of Resident #116's Care Plan dated 10/14/15, read in part, Personal secure alarm as ordered, Wanderguard. Check functioning of secure alarm per policy. Check placement per facility protocol. Observe resident's whereabouts frequently. During an interview on 11/18/15 at 3:10 PM Staff Nurse #2 stated she was doing a medication pass on 10/11/15 when another resident's family member brought Resident #116 back into the facility. She stated the family member pushed Resident #116 in her wheelchair down to the medication cart and informed her that Resident #116 was found sitting in her wheelchair in the parking lot. Staff Nurse #2 said at first she did not see a wanderguard bracelet on Resident #116, but she recalled the wanderguard bracelet was on the resident's wheelchair. She stated she did not know how long Resident #116 had been missing. Staff Nurse # 2 said she did not remember which staff member was assigned to work with the resident the day she exited the facility while unsupervised. Staff Nurse #2 said she did know whether or not Resident #116 had exit seeking behavior and she had not observed Resident #116 exhibiting any exit seeking behavior. Staff Nurse #2 explained she did not work on the resident's hall a lot and that she worked every weekend. She stated when she came in to do the incident report staff told her Resident #116 wandered a lot. She relayed that she did not know whether or not the door alarm sounded when Resident #116 exited the facility. During an interview on 11/18/15 at 5:55 PM, Nursing Assistant #4 revealed he was assigned to work with Resident #116 and the resident had never wandered outside of the building. He stated Resident #116 wandered, but she usually sat in her wheelchair near the nursing station. Nursing Assistant #4 said he could not recall whether or not he worked on 10/11/15, the day Resident #116 exited from the facility. During an interview on 11/18/15 at 4:18 PM, the family member that allegedly saw Resident #116 in the parking lot and took her to the staff nurse in the facility, revealed he brought residents back into the facility from outside all the time. The family member stated that some residents sat outside near benches in front of facility, but he did not recall taking any resident to a nurse. During an interview on 11/18/15 at 3:40 PM, the Assistant Director of Nursing said she had not known Resident #116 to have exit seeking behavior and she wondered why Resident #116 was wearing a wanderguard bracelet, because she had never seen her do anything. Although the Assistant Director of Nursing's name was on Resident #116's incident report as a Nurse Supervisor, she did not recall talking to Staff Nurse #2 about the resident exiting the facility on 10/11/15. During an interview on 11/19/15 at 9:00 AM, the Director of Nursing (DON) stated she asked staff to call her about everything. She revealed the Assistant Director of Nursing was on-call in October and she was also on medical leave, the weekend Resident #116 exited the facility while unsupervised. She stated she found out about the incident of 10/11/15 on Monday after the incident. The DON revealed no one notified her when Resident #116 exited from the facility in October. The DON revealed staff should have known Resident #116 was a wanderer because she eloped from the facility in July 2015. The DON said she realized Resident #116 was a wanderer based on the resident's last assessment. She revealed once staff found out Resident #116 had eloped from the facility in July 2015, a wanderguard bracelet was placed on her. The DON said after Resident #116's elopement in July 2015, she expected staff to know whether or not a resident was at risk for elopement, to notify the responsible person and the medical doctor and to initiate fifteen minute checks. She stated she also expected supervisors to start an investigation for her. During an interview on 11/19/15 at 9:29 AM, the Maintenance Director revealed the facility's front door and side door entrance were equipped with a wanderguard system. He stated he usually checked doors once per week. He said he would open the door, set off the door alarm and close the door. He said he would hold a wanderguard bracelet, walk up to the door and set off the alarm. The Maintenance Director stated a wanderguard bracelet had never malfunctioned while he tested the bracelet. He explained the resident with a wanderguard would have to get close to the door in order for the door alarm to sound. The Maintenance Director revealed sometimes he would use a resident with a wanderguard bracelet to test the door alarm and a wanderguard bracelet was placed on a wheelchair because residents would attempt to remove the wander guard when placed on their wrist. The Maintenance Director emphasized that the facility did not have a system in which the door would lock when the resident's wanderguard set off the door alarm. He said there was a code for staff to turn off the alarm once it sounded. The Maintenance Director further revealed individual wanderguard bracelets were tested weekly by a Restorative Aide. During an interview on 11/20/15 at 11:40 AM, a facility Restorative Aide presented documentation indicating that she tested each Resident's wanderguard bracelet weekly. She stated that she always held the testing device away from the wanderguard bracelet, pressed the button down on the tester until it beeped one time and then she tested the wanderguard bracelet itself. She revealed that she would put the testing device next to the wanderguard bracelet until it beeped. The Restorative Aide revealed the green light would come on to indicate the device was working. She revealed if the testing device did not work, she would retest the wanderguard device it at the front door. Review of the manufacturer's manual, titled Code Alert, Senior Living Solutions, Wander Management Transmitters, User Guide,release date 5/21/15, page 7, read in part, Warning: When the code watch (wanderguard) is placed on a resident's ankle, be sure to adjust the antennae at each door to a 4 to 5 ft. range to the ankle. Failure to do so may allow a resident to elope because they will be closer to the door when the door detects the transmitter.Also pg. 9 of the manual, read in part, Note: To monitor a resident in a wheelchair, attach the transmitter to the seat or the back of the chair as the metal on the chair can interfere with the transmitter's signal. #4 Adjust the band so that the transmitter is in a comfortable position on the resident's wrist or ankle. During a telephone interview on 11/19/15 at 10:33 AM a Technician from the manufacturer of the wanderguard code watch, stated the code watch (wanderguard bracelet) should not be placed on the metal portion of a wheelchair because it could interfere with the transmitter's signal. During an observation on 11/19/15 at 9:45 AM, Resident #116 was sitting in her wheelchair in the activity room. The wanderguard bracelet was attached to the lower right corner, metal portion of wheelchair near the right wheel. During an interview on 11/19/15 at 3:27 PM, the Maintenance Director revealed he used a wanderguard bracelet to test doors. The Maintenance Director opened the front double doors about an inch while he had a wanderguard bracelet in his hand. He stated he usually had a resident with him to test the door and the alarm sounded at a shorter distance. After the alarm sounded he keyed in the code to stop the alarm. The Maintenance Director said he would have to open the door in order for the alarm to go off. He revealed if a resident was sitting in front of the door, the alarm would not sound, however if someone opened the door while the resident was sitting in front of door, the alarm would sound. On 11/19/15 at 11:55 AM Resident #116 was observed propelling her wheelchair up the hallway with her feet. On 11/19/15 at 12:25 PM Resident #116 was observed sitting in her wheelchair near the nurse's station with other residents. The resident's wanderguard was attached to the back of wheelchair on a metal brace near the right wheel. On 11/19/15 at 2:12 PM Resident #116 was observed at the hallway entrance near the Social Work office, sitting in wheelchair next to other residents. The resident's wanderguard bracelet was on the back of the wheelchair on the metal brace near the right wheel. On 11/19/15 at 3:19 PM, Resident #116 was observed propelling her wheelchair to the lobby area. Another resident was following her in her wheelchair. Both residents propelled their wheelchairs through the lobby area past the administrative offices and back to the nurse's station. Resident #116's wanderguard remained on the right side of her wheelchair, on a metal brace lower portion of wheelchair near the right wheel. During an interview on 11/19/15 at 11:52 AM, Staff Nurse #3 stated she was assigned to Resident #116's hall on first shift (7:00AM-3:00PM). She said Resident #116 could propel herself in her wheelchair and could go up and down the hall. She stated Resident #116 never left the building by herself. She said most of the time Resident #116 sat in the common areas. Staff Nurse #3 revealed Resident #116 was not one to be monitored for her whereabouts. She relayed Resident #116 used to have a wanderguard bracelet, however, she did not have one anymore because she had not attempted to exit the facility. Staff Nurse #3 revealed she had not observed Resident #116 exhibiting any exit seeking behaviors, was not aware Resident #116 had exited the facility and was not aware the resident had a wanderguard. During an interview on 11/19/15 at 12:09 PM, Nursing Assistant #5, revealed Resident #116 wandered up and down halls in the facility and she never wandered outside of the facility. She stated Resident #116 sat in her wheelchair at the nurse's station and was usually around that area near lunch time. In reference to supervision, Nursing Assistant #5 stated they had a certain number of residents on every fifteen minute checks and Resident #116 was never on the list to check frequently. She stated she had never seen Resident #116 try to open doors. Nursing Assistant #5 said when it was time for Resident # 116 to be checked for toileting, she revealed, nine times out of ten, Resident #116 would be at the nurse's station. Nursing Assistant #5 stated when she started work every morning, the charge nurse would tell them which residents needed to be checked more frequently and Resident #116's name never came up. Nursing Assistant #5 stated she was not aware Resident #116 exited the facility while unsupervised in July 2015 and October 2015. She further revealed she did not know there was a notebook with a list of residents that were wanderers and had exit seeking behaviors. She said no one had discussed the wandering notebook with the nursing assistants. Review of the elopement notebook on 11/19/15 at 12:29 PM revealed Resident #116's exit seeking profile was in the notebook. During an interview on 11/19/15 at 1:06 PM the Director of Nursing (DON) stated from what she was told, Resident #116 was found on 10/11/15 at end of the brick walkway, in the facility parking lot on 10/11/15. On 11/19/15 at 1:58 PM, the Maintenance Director and Assistant Maintenance man measured the distance from the facility doorway to the parking lot. The distance from the front door to the van drop off area in the parking lot, was fifty feet. The distance straight to the second parking lot was another fifty feet. During an interview on 11/19/15 at 2:14 PM, the facility Social Worker stated she did not recall any of Resident #116's elopements. She said the first time she heard about the elopements was yesterday in a staff meeting. She revealed when a resident eloped from the facility, the assigned nurse would call the family to let them know of an elopement. The Social Worker stated all residents go up and down hallways. She said she knew Resident #116 had a chair alarm but she did not know the resident had a wanderguard until yesterday. She revealed Resident #116 would always hang out near the nurse's station. The Social Worker further said usually elopements would be put on 24 hour nursing reports and would be discussed during morning staff meetings. During an interview on 11/19/15 at 2:25 PM, the Minimum Data Set (MDS) Coordinator stated she knew about Resident #116's first elopement in July 2015, and that was when the wanderguard was initiated for Resident #116. The MDS Coordinator revealed she was not aware of the second elopement in October 2015. She said during morning meetings they would discuss protocols regarding falls or elopements and the nurse was supposed to immediately update the resident's care plan. During an interview on 11/20/15 at 9:01 AM, the Administrator revealed her expectation was for Resident #116 not to have any more exit seeking behaviors and the wanderguard would be placed on her ankle. She further stated her expectation was staff would report elopements to the Director of Nursing, the Assistant Director of Nursing, then to her. The Administrator's expectation was for staff to document elopement on the 24 hour report and notify the family and medical director. The Administrator said they usually communicated with Nursing Assistants about elopements. During an interview on 11/18/15 at 11:59 AM, the Facility Medical Director stated he was aware of the wanderers but it had not been discussed during Quality Assurance (QA) meetings. He revealed QA should have looked at wandering and we could have fixed it before it became a detriment to the residents. It has to be a safe environment and the safety of the patients. The Administrator was notified of the Immediate Jeopardy on 11/19/15 at 8:45 AM. The facility provided the following Credible Allegation on 11/20/15 at 10:18 AM. Problem/Incident: 1) Resident # 116 was observed by a family member at 8:15 pm on 10/11/15 sitting in her wheelchair at the edge of the driveway to the front entrance patio and was brought back inside the facility. Resident #116 was assessed and found to be without injury. Staff was alerted to resident #116's exiting the facility, the attending MD and RP were notified. The intervention implemented for resident #116 was placement of a wanderguard to her right ankle and 15 minute checks by staff as to location x 72 hours as precautionary measure after placement of the wanderguard. Resident #116 has had no other exit seeking events since 10/11/15. 2) Resident #22 was discovered on her knees on the sidewalk outside the dining room door at 10:40 pm on 11/12/15. She was assisted back into the facility by nursing staff and asse

Based on record review, observation and staff interviews, the facility failed to update the care plan for 1 of 4 sampled residents reviewed for supervision to prevent accidents (Resident # 32). Findings included: Resident # 32 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] specified Resident # 32's cognitive skills was severely impaired, required limited assistance of 1 person for bed mobility and transfer. The MDS also indicated the resident was independent with no set up help with locomotion on unit. The resident's care plan to prevent fall was dated 2/3/2014. The care plan goal was for the resident will have no injuries from falls through next review. Current interventions listed on the care plan included the following: a) Give resident verbal reminders not to transfer without assistance. b) Observe that resident has and wears properly fitting soled shoes c) Fall assessment routinely d) Call light within reach when in room/bed e) Chair Alarm as indicated f) Provide environment with adequate lighting, free of glare Review of Resident # 32's current care plan revealed it was not updated for the falls that occurred on 5/9/2014 and 6/9/2014. Further review of the care plan revealed the fall prevention care plan was not updated during the last quarterly review dated 9/22/2014. On 5/9/2014 at 10:36 PM, a nursing entry specified "called to resident's room, resident was on the floor, resident stated "I sat myself down on floor" Resident has small scrape on right elbow. Reminded resident the importance of using call bell and asking for assistance." On 6/9/2014 at 4:13 PM, a nursing entry noted "After medication given, heard front door alarm going off. Resident noted sitting in front of door. This writer assisted resident back to room." No intervention indicated after the fall. On 10/9/2014 at 2:00 PM, Resident # 32 was observed in the front entrance doorway trying to push the door. The door alarm went off and staff was observed assisting the resident back into the facility. Interview on 10/9/ 014 at 3: 00 PM, the Minimum Data Set (MDS) nurse when questioned regarding the resident's care plan stated that it was her responsibility to update the residents' care plans at the facility. The MDS nurse further reported that she receives information in the morning stand up meetings about the residents and updates the care plans. She also reported that Resident # 32's fall care plan was not updated by another MDS nurse who was no longer employed by the facility. Interview on 10/9/2014 at 4:00 PM, the Director of Nursing (DON) stated it was her expectation for the care plan to be updated to reflect the resident current status and condition. She added Resident # 32's care plan should have been updated to reflect each fall and interventions.

Based on observation, medical record review, and staff interviews the facility failed to implement interventions to prevent repeated falls and injuries for 1 of 4 sampled residents reviewed for supervision to prevent accidents (Resident #32). Findings included: Resident # 32 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] specified Resident # 32's cognitive skills was severely impaired, required limited assistance of 1 person for bed mobility and transfer. The MDS also indicated the resident was independent with no set up help with locomotion on unit. The resident's care plan to prevent fall was dated 2/3/2014. The care plan had the goal that the resident "will not experience injuries from falls through next review." Current interventions listed on the care plan included the following: a) Give resident verbal reminders not to transfer without assistance. b) Observe that resident has and wears properly fitting soled shoes c) Fall assessment routinely d) Call light within reach when in room/bed e) Chair Alarm as indicated f) Provide environment with adequate lighting, free of glare Review of the resident's assessment of fall risk for months of March 2014, April 2014 and July 2014 revealed the resident scored 22 points each month, which was high risk for falls (Score of 20 or more denotes high risk for falling) The incident report dated 4/23/2014 was reviewed and revealed the resident was found sitting on the floor in her room. The document specified intervention as "obtain UA (Urinalysis)." On 4/24/2014 at 1:30PM, a nursing entry specified Resident # 32 fell on [DATE]. The resident had a bruise, left arm pain and a skin tear. On 4/26/2014 at 8:00 PM, a nursing entry noted "writer heard door alarm sounding and wheel chair alarm. Writer went down Hall to see what was happening. Another Nurse was already on there way down hall. She got to the door observe resident on ground and writer saw resident lying on ground." The nurse note further documented the resident had injury to right forearm and hand. The resident was send to emergency room . The incident report dated 4/26/2014 was reviewed and revealed the resident was observed lying on pavement with injury to right forearm and hand. The document specified intervention as "Frequent observation upon return." Review of the medical imaging report dated 4/26/2014 indicated the resident had "a fall with right forearm injury." The report further noted "There is a soft tissue contusion and laceration of the mid-dorsal medial region. The document indicated the impression as " Soft tissue contusion and laceration without acute bony abnormality. On 5/9/2014 at 10:36PM, a nursing entry specified "called to resident's room, resident was on the floor, resident stated "I sat myself down on floor" Resident has small scrape on right elbow. Resident reminded the importance of using call bell and asking for assistance." On 6/9/2014 at 4:13 PM, a nursing entry documented "After medication given, heard front door alarm going off. Resident noted sitting in front of door. This writer assisted resident back to room." No intervention indicated after the fall. On 8/2/2014 at 7:01 PM, a nursing entry noted "Resident had a fall today getting up unassisted from bed to chair. Resident stated "she got herself up" Resident has a skin tear to right elbow, treatment in place per standing order." The incident report dated 8/2/2014 was reviewed and revealed "Resident fell while getting up unassisted." The document specified intervention as "increase observation." Review of the orthopedic report dated 8/6/2014 documented the resident "seen for right wrist pain. The resident is right hand dominant. The pain started after she fell on the floor after trying to proof that she could walk on 8/2/2014. She was seen by the attending Doctor and x- ray was done. X-ray was taken at the facility that showed distal radius fracture no displaced. Severity of pain: worse 10/10 and best 0/10. Radiation of pain present into the fingers. Quality of pain is dull and aching. Pain is constant unless she is asleep. No nocturnal or rest pain. Pain is aggravated with use of the hand and arm. Pain is better with rest and medication. Associated swelling present. Associated symptoms: she has a skin tear on the right forearm due to the fall." On 10/4/2014 at 3:17 PM, a nursing entry noted "Told by License Clinical Nurse (LPN) that resident said she fell and hit her head. Pt (patient) said she was trying to reach her w/c (wheel chair) in the middle of the floor but missed the w/c." The incident report dated 10/4/2014 was reviewed and revealed "patient fell and hit her head. The document specified interventions as "Physical therapy referral for possible follow up for strengthening." On 10/8/2014 at 10:50 AM, Resident # 32 was observed lying in her bed. The call bell was lying on the bed next to the resident within reach. On 10/9/2014 at 2:30 PM, Nursing Assistant (NA) #1 was interviewed. She stated she was unaware of the resident's recent falls since she was not regularly assigned to the resident. The NA # 1 further stated she was unaware of fall precautions and fall interventions for Resident # 32. Review of the care guide with NA # 1 revealed there was no source of documentation for frequent visual checks for Resident # 32. Further review of the Nurse's Aide care guide revealed no noted instruction or interventions to prevent Resident # 32 from a fall. On 10/9/2014 at 3:00 PM, The Assistant Director of Nursing (ADON) was interviewed. She explained the facility utilized a stand up meeting that met daily each morning to discuss any residents concerns that included falls. The ADON stated when Resident # 32 fell ; it was the responsibility of the nurse to implement an immediate intervention. The ADON also added she was responsible in reviewing the incident reports and making sure the interventions were appropriate for the residents at the facility. Resident # 32's incident report was reviewed with ADON that specified the resident was to be observed frequently and ensure the resident ' s call bell was in reach. The ADON confirmed that the interventions already in place for resident # 32 were used repeatedly even though they were not effective in preventing the resident from falling. ADON also confirmed that there was no documentation or instructions given to staff as to when and how to observe the resident while she was not in her room. ADON also reported that no intervention had been put in place since the last fall on 10/4/2014. She added that they were waiting for Physical Therapist to evaluate the resident. She added that the physical therapist had not evaluated the resident as of 10/9/2014. On 10/9/2014 at 4:00PM, the Director of Nursing (DON) confirmed that she was new at the facility but her expectation was for the facility to implement appropriate interventions for Resident # 32 who scored as a high risk for falls and was severely cognitively impaired. DON further stated that the current fall interventions for Resident # 32 were not effective in preventing the resident from falling and she was going to make changes.

Based on observations, staff interviews and record review, the facility failed to notify the physician of a newly identified pressure ulcer upon discovery until the pressure ulcer progressed to tunneling of the wound for 1 of 2 residents (Resident #4) reviewed for pressure ulcers. The findings included: Review of the facility's policy titled "Standing Order for Wound Protocol" dated 3/26/14 revealed in part "Treatment order must include site, stage, cleansing agent, treatment, secondary dressing if used, frequency of change, and discontinue date if known, complete a pressure/non-pressure documentation form, notify physician/family, document all wounds and changes on the 24 hour report, telephone order must be written before initiating any wound orders." Resident #4 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact. The assessment further revealed the resident was independent with bed mobility and transfers. The same assessment further indicated the resident has rejected care less than daily. The MDS assessment indicated Resident #4 was at risk for developing pressure ulcer and had a healed Stage 2 pressure ulcer on prior assessment, Review of the care plan for Resident #4 updated 2/19/14 revealed the resident was at risk for potential for skin breakdown, bruising and skin tears and pressure ulcer, excoriation related to decreased in mobility, incontinence. The goal stated for the problem was the resident will maintain or develop clean and intact skin. The care plan indicated the following interventions: provide measures to decrease pressure/irritation to skin, Geo mattress, heel protectors, and w/c cushion as indicated, keep skin clean and dry and provide for baths per schedule and as needed, change incontinent pad as soon as possible after voiding or bowel movement and provide incontinent care after episodes, apply barrier cream or protective lotion after incontinence, assist resident to turn and reposition routinely, position with pads and cushions, pillows to prevent pressure, observe skin during personal cares and notify nurse/MD of any skin issues. During the wound care observation on 4/14/14 that began at 2:20 pm, the Wound Care Nurse stated to Resident #4 that she could see the new area that was reported from the weekend while pointing to an open area proximal to the second opened area to the left inner buttocks. The wound bed was pink with no drainage or odor. The Wound Care Nurse cleansed the area with wound cleanser and applied saline soaked gauze followed by dry gauze and tape. During the wound observation, the resident stated he was aware of a new area of skin breakdown to the scrotum identified over the weekend but not of a new area to the buttocks. Interview with the Wound Care Nurse at this time revealed the new area was identified over the past weekend by Nurse #1. She further indicated Nurse #1 had initiated the same treatment of [REDACTED]. The Wound Care Nurse did not have the treatment record available during the dressing change or interview. Review of the weekly interdisciplinary team progress notes dated 4/9/14 documented "Wound note-Stage 3 to inner buttock on scar tissue line reopened. Cleanse daily with wound cleanser and apply wet to dry dressing daily. Monitor for signs and symptoms of infection." Review of the April 2014 Treatment Record revealed an order to cleanse open area to left inner buttocks near the scrotum with wound cleanser and apply wet to dry dressing daily dated 4/4/14. Further review of the same treatment record revealed an order to clean area to scrotum with normal saline; apply triple antibiotic ointment and non adherent dressing dated 4/11/14. During an interview on 4/15/14 at 2:15 pm, the Wound Care Nurse stated the area to the buttocks previously identified on 4/14/14 had tunneled into one large area overnight. The resident refused to allow surveyor to do a second observation of wound care. The Wound Care Nurse stated she did not measure the new pressure area identified, notify the physician or initiate a treatment on 4/14/14 when she identified the area because she thought the area had been addressed by Nurse #1 over the weekend. She stated she just continued the same treatment of [REDACTED]. The Wound Care Nurse was unable to provide documentation of wound assessment or physician notification at this time. She further stated she normally complete documentation on wounds at the time of discovery or assessment. On 4/15/14 at 3:10 pm in an interview, Nurse #1 stated she worked the weekend of 4/11/14- 4/13/14 as the treatment nurse. She further indicated she did not see a new open area to the buttocks. Nurse #1 stated the area that she identified and initiated treatment for [REDACTED].#4. The nurse further stated she would not have written scrotum for an area that was on the buttock. On 4/15/14 at 5:30 pm, the facility (Wound Care Nurse) was unable to provide updated documentation on the changes in the status of the wound. During an interview on 4/15/14 at 5:40 pm, the Director of Nursing indicated it was her expectation for the Wound Care Nurse to follow the protocol and assess any new areas identified, notify the physician and the family.

Based on record review, observations, physician and staff interviews, the facility failed to stop providing care and return at a later time, for a resident who was resistant to care which resulted in mouth injury for 1 of 2 sampled residents reviewed for accidents (Resident #2). Findings included Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognitive status was severely impaired, she was total dependent on staff for bed mobility, and she needed extensive assistance using one person with dressing and personal hygiene. The MDS did not indicate any behavioral problems. Review of the care plan dated 2/25/2014 revealed the resident was not care planned for resistance to care. Review of the facility's staff meeting report dated 1/13/2014 revealed the staff were in-serviced as to how to care for residents who were resistive to care. The report documented "if a resident refuse care and/ or resist care, stop let nurse know or get someone else to try if you notice a change in condition you must report to nurse immediately." During a phone interview with Nurse's Aide # 4 on 4/15/2014 at 1:40 PM, She reported she was getting ready to dress the resident at around 8:00 AM on 4/8/2014. The resident was lying in bed with eyes open. The resident resisted being dressed up by swinging her hands. She wanted to finish with dressing the resident so she pushed the resident harder towards the side rails so she could dress the resident. She added the resident must have hit her mouth on the side rails when she (Nurse's Aide # 4) was trying to dress her. She stated both side rails were up during the time she was dressing the resident and the bed was next to the wall. Nurse's Aide # 4 further added she did not stop dressing the resident when she was resisting being dressed. She further added that she had been trained to stop providing care when the resident is resistive to care and notify the nurse then come back later. Nurse's Aide # 4 also reported that she did not have the reason as to why she did not tell a nurse and stop dressing the resident when the resident was resisting being dressed. She further stated the blood on the wall must have come from the resident's mouth and once she left the room the resident must have spit the blood on the wall. The bed was next to the wall. Nurse ' s Aide # 4 further reported she was aware before 4/8/2014 that the resident was resistive to being dressed in the morning but she could not explain why she did not stop dressing the resident on 4/8/2014.The Nurse's Aide # 4 reported that she was not aware that the resident had been injured when she left the resident ' s room. Review of a written statement by Nurse's Aide # 1 as part of the facility investigation dated 4/8/2014 documented "was passing out tray, resident up on edge of bed can't remember if rail was up or down. Pants were partially up. Nurse's Aide # 2 passing by summoned to assist her (Resident # 2) to chair. Nurse's Aide # 2 came in and was in the process of transferring Resident # 2 to chair. Nurse's Aide # 2 noticed blood. It was bright red blood on the wall. Nurse's Aide # 2 went to get Nurse # 1." Review of a written statement by Nurse # 1 as part of the facility's investigation dated 4/10/2014 documented " Resident was laying on her right side closer to the side rail. Nurse # 1 noted blood on wall, right side rails (rail was up) and sheet. Bed was pulled back and blood was noted on floor. When Nurse # 1 entered Resident # 2's room, the resident was laying on right side. " During the interview with Nurse's Aide # 2 on 4/16/2014 at 11:00 AM, she reported that on 4/8/2014 at 8:30 AM, she was passing out trays. Resident # 2 was sitting on the side of bed. She and Nurse ' s Aide # 1 were passing trays. She and Nurse's Aide # 1 noticed blood on Resident # 2's wall and on the bed sheets. She left the room and asked Nurse # 1 to check the resident to see where the blood was coming from. She (Nurse's Aide #2) asked Nurse's Aide # 4 to come to the resident ' s room and showed her the blood on the wall. During the phone interview with Nurse's Aide # 5 on 4/16/2014 at 11:30 AM, She stated that she fed the resident on 4/8/2014 at 8:30 AM. She noticed stain on the wall which looked burgundy in color. She remembered it appeared like someone had tried to wipe it from the wall. The Nurse's Aide # 5 further reported it was her first time working with the resident. The resident was quite and did not eat much at all. She did not report the stain to anyone but just went on to feed another resident. During the interview with Nurse # 1 on 4/16/2014 at 10: 00 AM, She reported Nurse's Aide # 1 approached her at around 8: 30 AM on 4/8/2014 to report that Resident # 2 had blood on her wall. She checked on the resident. There was no bleeding noted on the resident ' s mouth. Nurse # 1 stated she saw the blood on the wall which was bright red in color splattered on the wall. Nurse # 1 added blood was noted on the resident's sheet on right side of bed and small clot in it. She asked her assigned nurse to check the resident as well. During the interview with Nurse # 2 on 4/16/2014 at 10:40 AM, she reported Nurse # 1 called her around 9:00 AM on 4/8/2014 to Resident # 2's room. She observed blood on the wall. She then asked the resident to open her mouth and she did not notice blood or anything in the resident ' s mouth Grievance report dated 4/8/2014 documented "family member (2nd contact) voiced concern in reference to a bruise to her mom ' s left corner lower lip. She stated "someone has hit her or something " also states "there is blood on the floor to right side of the bed sheet and wall." Nurse's note written by Assistant Director of Nursing (ADON,) dated 4/8/2014 at 5:00 PM documented " Resident noted with discoloration to left side of bottom lip. Swelling noted upon inspection of mouth, inside of lip noted with discoloration and swelling. area is warm to touch. Resident does not open mouth completely on command. 2nd contact (family member) present in room. Voicing concerns Re: area, states wasn ' t present on day before. Resident does mimace when area palpated. Informed 2nd contact would follow up and notify 1st contact (family member) of findings. " Review of the dentist report dated 4/9/2014 documented "Resident was seen for a dental examination on 4/9/2014 due to chief complaint of lower left swelling and bruising outside the lip and cheek area in the lower left region. A large bruise measuring 4.4 cm (Centimeter) X 2.5cm was present extended below the lower left lip region on the exterior face. Inside the mouth a small laceration was noted (6 cm X 6 cm). In my professional opinion the lesion may have been the result of blunt force trauma causing the tissue to contact the edges of her teeth resulting in laceration, swelling and bruising. An odontogenic (tooth) infection would not present in this manner or travel in this pathway. Close monitoring, antibiotics therapy and a 7 day follow up evaluation is recommended. " During the interview with Resident # 2's Doctor on 4/16/2014 at 2:00 PM, he stated he saw the resident on 4/9/2014. The resident had a left lower lip bruise. He added that he could not explain how the resident got the bruise Observation of the resident on 4/16/2014 at 9:30 AM revealed the resident sitting in her wheel chair in front of the nurse's station. The resident was calm and pleasant. A slight sign of bruising was noted on the left lip. Resident # 2's care plan last updated 4/16/2014 indicated the resident was " resistive with Activity of Daily Living ( ADL) care and the resident becomes combative towards staff during ADL care trying to hit the staff, spits at the staff. " The goal was " have all needs anticipated and met without incident/injury through next review. " The Approach for this problem was " approach with a calm and quiet demeanor, monitor and document behaviors, do not argue with resident and when resident becomes combative/ resistive , leave resident safely in wheelchair or bed , and reproach when she as calmed down. " During the interview with Assistant Director of Nurse (ADON) on 4/16/2014 at 3:00 PM, She stated the family approached her on 4/8/2014 at around 5: 00 PM stating there was blood on resident's mouth, wall and the bed rail. She (ADON) went to investigate and she saw the blood on the resident ' s wall, side rails and shirt. She (ADON) also observed a bruise on the resident mouth and began an investigation. She concluded that Nurse's Aide # 4 was dressing the resident and she (Resident #2) was resistive to care and Nurse's aide # 4 continued to dress the resident anyway. The side rails were up. ADON further reported Nurse's Aide # 4 did not report the incident to any staff at the facility. ADON added the resident was resistive to care and got bruised due to improper repositioning technique by Nurse's Aide # 4. . Nurse's Aide # 4 was suspended and 24 hour report was completed and faxed timely to the state agency. The ADON also reported her expectation of the staff was when a resident is resistive to care, the staff was to leave the room and notify the nurse then come later to the resident ' s room. She added that no staff reported to her that there was blood on the resident's wall on 4/8/2014. The blood had been on the wall starting at around 8:00 AM until at 5PM when the family member reported that they saw the blood on the resident's mouth, wall and side rails. During the interview with Director of Nursing (DON) on 4/16/2014 at 4:00 PM, She reported her expectation of the staff when a resident was resistive to care was to stop providing care and report the incident to the nurse. DON added the staff may go back to the resident ' s room later to try to give care. She (DON) also added all the staff at the facility was trained that if they do not stop providing care when the resident is restive to care, they may injure the resident which would be abuse.

Based on observations, staff interviews and record review, the facility failed to assess a pressure ulcer upon discovery and failed to initiate a treatment for [REDACTED].#4) reviewed for pressure ulcers. The findings included: Review of the facility ' s policy titled Standing Order for Wound Protocol " dated 3/26/14 revealed in part " Treatment order must include site, stage, cleansing agent, treatment, secondary dressing if used, frequency of change, and discontinue date if known, complete a pressure/non-pressure documentation form, notify physician/family, document all wounds and changes on the 24 hour report, telephone order must be written before initiating any wound orders. " Resident #4 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact. The assessment further revealed the resident was independent with bed mobility and transfers. The same assessment further indicated the resident has rejected care less than daily. The MDS assessment indicated Resident #4 was at risk for developing pressure ulcer and had a healed Stage 2 pressure ulcer on prior assessment, Review of the care plan for Resident #4 updated 2/19/14 revealed the resident was at risk for potential for skin breakdown, bruising and skin tears and pressure ulcer, excoriation related to decreased in mobility, incontinence. The goal stated for the problem was the resident will maintain or develop clean and intact skin. The care plan indicated the following interventions: provide measures to decrease pressure/irritation to skin, Geo mattress, heel protectors, and w/c cushion as indicated, keep skin clean and dry and provide for baths per schedule and as needed, change incontinent pad as soon as possible after voiding or bowel movement and provide incontinent care after episodes, apply barrier cream or protective lotion after incontinence, assist resident to turn and reposition routinely, position with pads and cushions, pillows to prevent pressure, observe skin during personal cares and notify nurse/MD of any skin issues. Review of the weekly interdisciplinary team progress notes dated 4/9/14 documented " Wound note-Stage 3 to inner buttock on scar tissue line reopened. Cleanse daily with wound cleanser and apply wet to dry dressing daily. Monitor for signs and symptoms of infection. " Review of the April 2014 Treatment Record revealed an order to cleanse open area to left inner buttocks near the scrotum with wound cleanser and apply wet to dry dressing daily dated 4/4/14. Further review of the same treatment record revealed an order to clean area to scrotum with normal saline; apply triple antibiotic ointment and non adherent dressing dated 4/11/14. During the wound care observation on 4/14/14 that began at 2:20 pm, the Wound Care Nurse stated to Resident #4 that she could see the new area that was reported from the weekend while pointing to an open area proximal to the second opened area to the left inner buttocks. The wound bed was pink with no drainage or odor. The Wound Care Nurse cleansed the area with wound cleanser and applied saline soaked gauze followed by dry gauze and tape. During the wound observation, the resident stated he was aware of a new area of skin breakdown to the scrotum identified over the weekend but not of a new area to the buttocks. Interview with the Wound Care Nurse at this time revealed the new area was identified over the past weekend by Nurse #1. She further indicated Nurse #1 had initiated the same treatment of [REDACTED]. The Wound Care Nurse did not have the treatment record available during the dressing change or interview. During an interview on 4/15/14 at 2:15 pm, the Wound Care Nurse stated the area to the buttocks previously identified on 4/14/14 had tunneled into one large area overnight. The resident refused to allow surveyor to do a second observation of wound care. The Wound Care Nurse stated she did not measure the new pressure area identified, notify the physician or initiate a treatment on 4/14/14 when she identified the area because she thought the area had been addressed by Nurse #1 over the weekend. She stated she just continued the same treatment of [REDACTED]. The Wound Care Nurse was unable to provide documentation of wound assessment or physician notification at this time. On 4/15/14 at 3:10 pm in an interview, Nurse #1 stated she worked the weekend of 4/11/14- 4/13/14 as the treatment nurse. She further indicated she did not see a new open area to the buttocks. Nurse #1 stated the area that she identified and initiated treatment for [REDACTED].#4. The nurse further stated she would not have written scrotum for an area that was on the buttock. During an interview on 4/15/14 at 5:40 pm, the Director of Nursing indicated it was her expectation for the Wound Care Nurse to follow the protocol and assess any new areas identified, notify the physician and the family. Se further indicated the nurse was expected to document her assessment in the medical record. The DON further acknowledged she had been informed of the change of the wound identified as tunneling by the Wound Care Nurse. In an interview on 4/16/14 at 5:35 pm, after reviewing the documentation by the wound care nurse for Resident #4 dated 4/15/14, the administrator stated she expected the wound care nurse to document her assessment of the wound, measure the wound and initiate a treatment for [REDACTED]. The administrator further indicated the documentation needed to accurately describe the wound.

Based on record review, staff, family and physician interviews, the facility failed to notify the physician of the development of an unstageable pressure ulcer for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The findings included: Resident #1 was readmitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired. The assessment further indicated the resident required extensive assistance with bed mobility with one person assist. The MDS assessment further indicated the resident was at risk for developing pressure ulcers. The assessment indicated there were no unhealed pressure ulcers at the time of the assessment. The Care Area Assessment (CAA) indicated the problem area was pressure ulcer. The extrinsic risk factor was the resident required staff to move sufficiently to relieve pressure over any one site. The [MEDICATION NAME] risk factors included immobility, altered mental status such as cognitive loss, and incontinence. The CAA further indicated the resident's skin integrity should be monitored and the Medical Doctor (MD) kept aware. The care plan for Resident #1 dated 10/8/13 revealed the resident was at risk for skin breakdown related to incontinence and immobility. The goal stated for the problem was the resident skin would remain intact daily through next review with interventions which included: observe skin daily and report all changes to the nurse promptly, weekly skin assessments by a nurse, monitor labs and report all abnormal findings to MD promptly. A review of the monthly January 2014 physician orders [REDACTED]."Weekly Skin Check Resident Record Sheet " for January 2014 revealed an entry dated 1/15, 1/21 and 1/29/2014 with an indication of no new areas noted. Review of the February 2014 treatment record revealed the weekly skin check was initialed for 2/19/14. The February 2014 "Weekly Skin Check Resident Record Sheet" revealed an entry on 2/5, 2/12, and 2/19/14 with indications for no new areas noted. Review of the facility's "Treatment Recommendations" undated did not reveal a protocol for unstageable ulcers. There was a treatment recommendation protocol noted to apply skin prep to blister daily for 7 days. Review of a telephone physician order [REDACTED]." Medical record review of the facility's "Treatment/Wound Care Progress Notes" dated 2/21/14 revealed "unstageable left heel, 100% necrotic tissue, necrotic edges are loosely separating, drainage noted. Will use silvermed and cover. Added Zinc stresstab to help promote wound healing; also uses profo boot to uplift pressure" noted by Treatment Nurse #1. An interview with Treatment Nurse #1 on 3/4/14 revealed the resident was placed on weekly pressure ulcer log during the week of February 24, 2014. The treatment nurse was unable to provide the specific date. The most recent documentation dated for the week of February 24, 2014 by Treatment Nurse #2 revealed the measurement of the left ankle wound was 2cm x 2 cm, no drainage, wound bed 75% red and 25% black with normal wound edges. The documentation further revealed the unstageable ulcer was acquired in house. Review of the facility's "Report of resident grievance/compliments" undated and untimed revealed a written statement by a family member that indicated "I noticed an awful smell and drainage on a pillow under her left foot. There was a heel protector in place and a sock adhered to her foot with dried drainage. Beneath is an unstageable soon to be III-IV wound that smelled horrible. There was no pressure areas on Resident #1 when she was admitted here and the person who signs her papers should have been notified of this." Review of the "Physical Therapy Plan of Care" dated 2/25/14 revealed "Patient presents with unstageable ulcer on left heel measuring 1.8 X 2.0 X 0.8cm with 100% eschar and foul odor." In an interview on 3/4/14 at 12:38 pm, Treatment Nurse #1 stated she was informed by NA #2 on February 21, 2014 of Resident #1 having a sock stuck to her left foot that was bleeding. She stated her assessment revealed the area was necrotic with eschar separating from the wound bed with drainage and foul odor. The nurse indicated she initiated a treatment of [REDACTED]. She further indicated she did not speak with the attending physician. The nurse stated she faxed a copy of the order for treatment to the attending physician's office. Treatment Nurse #1 was unable to provide a copy of the faxed documentation of notification to the physician or confirmation page. During an interview on 3/4/14 at 1:14 pm, the Physical Therapist (PT) stated she started the wound debridement of the left heel on 2/25/14. She further stated after evaluating the resident's wound, she wrote the order for the evaluation and treatment and informed the nurse which was standard protocol. In a phone interview on 3/5/14 at 11:10 am, the attending physician stated he expected the nurses to notify the physicians anytime a resident developed skin breakdown. He further stated the nurses should notify the physician even if they initiate the wound care protocol. After discussing Resident #1's wound with the physician, he stated he was not aware of the wound. The attending physician further stated he would be coming to the facility to refer to the medical record and discuss but he did not come or call back by the time of exit. During an interview on 3/5/14 at 6:25 pm, the Director of Nursing (DON) stated she expected the treatment nurse to monitor all wounds weekly and document the findings. She further stated she expected the treatment nurse to notify the physician of any changes in the wounds as indicated. The DON stated she expect the nurse that initially identify a wound to assess the area, notify the responsible party and the physician, and document in the medical record. She stated the nurses normally notify the physician via fax on a change of condition form. The DON was unable to provide a copy of the notification to the physician for resident #1.

Based on record review, observation and staff interviews, the facility failed to accurately assess and implement effective interventions for an unstageable pressure ulcer for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. Resident #1 was readmitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired. The assessment further indicated the resident required extensive assistance with bed mobility with one person assist. The MDS assessment further indicated the resident was at risk for developing pressure ulcers. The assessment indicated there were no unhealed pressure ulcers at the time of the assessment. The Care Area Assessment (CAA) dated 10/7/13 indicated the problem area was pressure ulcer. The extrinsic risk factor was the resident required staff to move sufficiently to relieve pressure over any one site. The [MEDICATION NAME] risk factors included immobility, altered mental status such as cognitive loss, and incontinence. The CAA further indicated the resident ' s skin integrity should be monitored and the Medical Doctor (MD) kept aware. The care plan for Resident #1 dated 10/8/13 revealed the resident was at risk for skin breakdown related to incontinence and immobility. The goal stated for the problem was the resident skin would remain intact daily through next review with interventions which included: observe skin daily and report all changes to the nurse promptly, weekly skin assessments by a nurse, monitor labs and report all abnormal findings to MD promptly. A review of the medical record revealed a telephone physician order [REDACTED]. Review of the monthly January 2014 physician orders [REDACTED]."Weekly Skin Check Resident Record Sheet" for January 2014 revealed an entry dated 1/15, 1/21 and 1/29/2014 with an indication of no new areas noted. Review of the February 2014 treatment record revealed the weekly skin check was initialed for 2/19/14. The February 2014 "Weekly Skin Check Resident Record Sheet" revealed an entry on 2/5, 2/12, and 2/19/14 with indications for no new areas noted. Review of the facility 's "Treatment Recommendations" undated did not reveal a protocol for unstageable ulcers. There was a treatment recommendation protocol noted to apply skin prep to blister daily for 7 days. Review of a telephone physician order [REDACTED]." Medical record review of the facility's "Treatment/Wound Care Progress Notes" dated 2/21/14 revealed "unstageable left heel, 100% necrotic tissue, necrotic edges are loosely separating, drainage noted. Will use silvermed and cover. Added Zinc stresstab to help promote wound healing; also uses proof boot to uplift pressure" noted by Treatment Nurse #1. An interview with Treatment Nurse #1 on 3/4/14 at 12:38 pm revealed the resident was placed on weekly pressure ulcer log during the week of February 24, 2014. The treatment nurse was unable to provide the specific date. The most recent documentation dated for the week of February 24, 2014 by Treatment Nurse #2 revealed the measurement of the left ankle wound was 2 centimeters (cm) x 2 (cm) with no drainage, wound bed 75% red and 25% black with normal wound edges. The documentation further revealed the unstageable ulcer was acquired in house. Review of the "Physical Therapy Plan of Care" dated 2/25/14 revealed "Patient presents with unstageable ulcer on left heel measuring 1.8 (cm) X 2.0 (cm) X 0.8 (cm) with 100% eschar and foul odor." Review of a telephone physician's orders [REDACTED].#2. A second telephone physician order [REDACTED].#2. Review of the "Physical Therapy Daily Treatment Note" dated 2/27/14 revealed "Consulted with treatment nurse in reference to packing wound due to undermining present and wound contraction noted already. Recommend packing to prevent closing wound with cavity." An observation of wound care for Resident #1 by PT on 3/5/14 at 1:30 pm revealed a half dollar sized open area to the center of the left heel. There was a minimal amount of yellow slough noted. Debridement was performed by the physical therapist. The area was cleansed with wound cleanser, packed with [MEDICATION NAME] gauze and covered with a non adherent dressing and tape. In an interview on 3/4/14 at 12:38 pm, Treatment Nurse #1 stated she was informed by NA #2 on February 21, 2014 of Resident #1 having a sock stuck to her left foot that was bleeding. She stated her assessment revealed the area was necrotic with eschar separating from the wound bed with drainage and foul odor. The treatment nurse further indicated she initiated a treatment of [REDACTED]. She further indicated she was aware of resident's left heel being black for some undetermined amount of time. Treatment Nurse #1 stated dark black meant necrotic. She stated initially the area started as a bubbly blister. There was no documentation as to the status of the wound in the medical record. She further stated the area was unstageable because she could not see what was underneath. Treatment Nurse #1 stated she did not include unstageable ulcers on the weekly report for monitoring if skin prep was being applied. She further indicated it was the responsibility of the hall nurses to document on any area that was receiving skin prep. After reviewing the medical record, she stated did not see any documentation concerning the wound on the left heel except the entry made by her on 2/21/14. During an interview on 3/4/14 at 1:14 pm, the Physical Therapist (PT) stated she started the wound debridement of the left heel on 2/25/14. PT stated she was asked to look at the wound by Treatment Nurse #1. On 3/4/14 at 2:32 pm during an interview, Nurse #1 stated the hall nurses are responsible for documenting on skin tears. She further indicated the treatment nurse was responsible for documenting on the pressure areas. In an interview on 3/4/14 at 2:47 pm, NA#1 stated the resident's sock was stuck to her foot on Tuesday, February 19th when she was getting her ready for a shower. She further stated Resident #1's left heel had a foul odor to it at that time. She stated she reported the findings to a nurse but could not recall what nurse she told. NA#1 further added when she come to work in the mornings, the resident would not have a soft boot on because she refused it. An interview on 3/4/14 at 3:18 pm with NA #2 revealed she noticed the sock was stuck to the resident's left foot on 2/21/14. On 3/4/14 at 3:59 pm in an interview, Nurse #2 stated she just noted the orders for PT for Resident #1. She further stated the hall nurses are responsible for applying the creams, powders, and skin assessments on the treatment book. Nurse #2 stated the treatment nurse was responsible for monitoring and documenting on the wounds. During an interview on 3/4/14 at 4:32 pm, Nurse #3 stated she completed the skin assessments on January 22nd and 29th, 2014. She further indicated she recalled the resident ' s left heel was inflamed and red. The nurse stated she did not notify the physician because she thought the treatment nurse "was handling all of that. "She further stated "we now have to reposition the resident every two hours since the family requested it." She further stated the turning and repositioning had been implemented since the family complained about the sore on the resident's left heel. In an interview on 3/5/14 at 6:35 am, Nurse #4 stated the resident refused to be turned and that she just liked to be left alone. The nurse stated they now have to make sure the resident is turned since the area on her foot got bad. She further stated she has started documenting in the medical record now if the resident refused to be turned or was combative. An interview on 3/5/14 at 6:40 am with Nurse #5 revealed she completed the skin assessments for resident #1 on February 19, 2014. She further stated she recalled the resident's left heel was necrotic. The nurse further described necrotic as soft, black in color with skin intact. She stated she went to check to see if a treatment was in place and it was. Nurse #5 stated if a treatment was already in progress, then the nurses did not document about it. She stated the nurses only document if the area was a new finding and they start the treatment. On 3/5/14 at 6:47 am in an interview, NA #3 stated the resident did not like to be turned. She further stated she thought it was the resident's right to not be turned. The NA further indicated everyone knew the resident would refuse to turn. She stated if the resident refused to be turn now, they have to notify the nurse so she can document in the chart. NA #3 further indicated the resident had a soft boot on her left foot last night when she came in and it was the first time she had seen the boot on the resident. During an interview on 3/5/14 at 8:43 am, Treatment Nurse # 2 stated when she applied the skin prep to the resident's left heel on January 8, 2014, the heel was necrotic. She further stated necrotic meant dead tissue. The treatment nurse stated she did not notify the physician because there was a treatment for [REDACTED]. She further stated the treatment nurse would not document on an area that was necrotic until the area was open or if there was some kind of problem with it. Treatment Nurse #2 stated she did the measurements on the resident's wound during the week of February 24, 2014 but could not recall what date. In an interview on 3/5/14 at 9:22 am, Nurse #6 stated when she applied the skin prep to Resident #1's left heel on January 1, 2014 she noticed a quarter sized area with a discolored, soft center. She further stated she seen the area again on February 6, 2014 and it was still discolored. Nurse #6 stated she did not document her findings because she thought the treatment nurse did all of the wound documentation and there was a treatment already in place. She further stated a treatment should be changed after a certain amount of time if there is no improvement in the wound and the doctor should be notified. On 3/5/14 at 10:08 am during a phone interview, Nurse #7 stated she recalled the area to Resident's #1 left heel on February 8, 2014 was dark, black eschar tissue. She stated it was the size of two quarters put together. The nurse further stated the area was an unstageable pressure ulcer that was not open. She stated she did not document on the area because it was already being treated. Nurse #7 stated there was no need to notify the doctor because they were putting skin prep on the area. In a phone interview on 3/5/14 at 11:10 am, the attending physician stated he expected the nurses to notify the physicians anytime a resident developed skin breakdown. He further stated the nurses should notify the physician even if they initiate the wound care protocol. After discussing Resident #1's wound with the physician, he stated he was not aware of the wound. The attending physician further stated he would be coming to the facility to refer to the medical record and discuss but he did not come or call back by the time of exit. On 3/5/14 at 3:10 pm during an interview, Nurse #8 stated she completed the skin assessments on 2/5/14 and 2/12/14. She further stated she recalled a darkened area to the left heel on those dates. She stated she did not document on the area because there was a treatment already in progress and the treatment nurse usually did the documentation on the wounds. Nurse #8 further indicated she did not call the physician because the area was being treated. A phone interview on 3/5/14 at 4:05 pm with Nurse #9 revealed she was notified by NA #2 of a sock being stuck to Resident #1's left heel. She stated she recalled doing a skin assessment on February 19, 2014 but she did not document it. She further stated the assessment revealed a hard darkened area to the left heel. She stated she did not notify the physician because the area was being treated with skin prep. During an interview on 3/5/14 at 6:25 pm, the Director of Nursing (DON) stated she expected the treatment nurse to monitor the wounds weekly and document. She further stated she expected the treatment nurse to notify the physician of any changes in the wounds as indicated. The DON stated she expect the nurse that initially identify a wound to assess the area, notify the responsible party and the physician, and document in the medical record. She stated the nurses normally notify the physician via fax on a change of condition form. The DON was unable to provide a copy of the notification to the physician for Resident #1.

Based on observations, staff, fire marshal and emergency medical services (EMS) supervisor interviews, facility policies and record reviews, the facility failed to prevent one of four residents from having respiratory distress by allowing the facility temperature to increase as a result of malfunction of the air condition unit. Findings include: Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. During an interview with the fire chief on 7-24-13 at 1:30pm, he indicated that on 7-14-13 at 11:55 am, the fire department responded to a fire alarm at the facility. Upon their arrival, no fire or smoke was identified but a bad smoke detector head in Zone 28 was determined to be the cause of the alarm. Once this was identified, it was reported by the Fire Chief at approximately 12:30pm to the Maintenance Director, who was on-call for the weekend of 7-13-13 through 7-14-13. A review of the named resident ' s 5 day re-entry MDS dated [DATE] indicated the resident had a BIMS (brief interview for mental status) score of 12, indicating he was able to answer questions and voice concerns about his health issues. He required assistance for transfers and activities of daily living (ADLs) a review of friendly forecast.com for the date of 7-14-13 for Lillington, NC, revealed the daily temperature was a low of 72 degrees and a high of 86 degrees. The humidity for that date ranged from 59% to 99%. On 7-23-13 at 8:00 am an interview was conducted with the Maintenance Director who was on-call for the facility the weekend of 7-13-13 through 7-14-13. He indicated that he did not notify the Administrator that he would not be available in a timely manner to fix the identified smoke detector in Zone 28 of the facility on 7-14-13. He reported that the facility had a central heating and air conditioning system. The air could not be controlled in individual resident rooms. He also indicated that on 7-14-13, the reason the facility became increasingly hot was because the air handlers had shut off when the fire alarm had gone off. This is a safety mechanism to prevent the spread of fire. He reported he had spoken with the Fire Chief who has since shown him how to bypass the trouble area so that the entire fire system is not off-line until maintenance can repair any problems. The Maintenance Director stated he spoke with the Fire Marshall and the Charge Nurse on 7-14-13 and told them he would arrive at the facility within a couple of hours. In the meantime, the fire alarm system was taken off-line and a " Fire Watch " was initiated. A " Fire Watch " consists of a designated staff member making a tour around the facility every 15 minutes to determine the facility does not have any fire activity. He reported the facility thermostat readings were 76 degrees after the fire alarm was reset and the air handlers came back on around 8:00pm. He did indicate that he did not record these readings. During an interview with the Deputy Fire Marshall on 7-24-13 at 10:15 am, he revealed he had not been notified the facility ' s fire alarm system was off-line for an 8 hour period of time. He reported that when he spoke to the Maintenance Director on 7-14-13 at approximately 1:15pm he had been under the impression that he would be arriving around 2:00 pm. An interview was conducted with the Administrator on 7-23-13 at 9:50 am. She reported the staff did not contact her until 6:20 pm on the evening of 7-14-13 to inform her there was no air conditioning in the facility and that it was hot. She stated she left her home for the facility at that time, arriving at approximately 7:30pm. She indicated she had spoken with the Maintenance Director when she was on her way to the facility. The Administrator reported that several families had brought fans from home to use on residents. She also indicated there were large floor drying fans located in the maintenance section of the Assisted Living Side of the facility that could have been utilized to cool off the halls. She stated she felt the nurses attempted to take care of the situation independently while awaiting the Maintenance Director to arrive and were not aware of the availability of those fans; therefore, the fans were not utilized. The Administrator stated that her expectations of the Maintenance staff person on call would be for that person to contact her for a plan of action if he/she was unavailable or he/she should have a back up person available. During an interview on 7-24-13 at 11:00 am the RN in charge (Nurse #1) on 7-14-13, stated that the facility did not start becoming hot until around 1:00 pm when the heat and humidity outside got worse. She reported she had spoken with the Maintenance Director at the time the fire alarm had gone off and had been told to take the fire alarm system off-line and to begin 15 minute " Fire walks. " Fire walks involve making walking rounds of the facility every 15 minutes to make sure there is no fire or smoke present in the facility. She stated she was under the impression that he was on his way. The RN stated that when the Maintenance Director had not shown up by 3:00 pm, she attempted to call him again and was told it would be another couple of hours before he could be at the facility. At that time, 3:00 pm, the RN contacted the Director of Nursing, who had a personal emergency and was unable to assist. The RN reported that she instructed the staff to give the residents extra ice and water and perform frequent checks on the residents as the facility temperature continued to rise. Nurse #1 reported she contacted the Maintenance Director again around 5:00 pm and he asked her to check the thermostat on " A " hall to see what the temperature was reading. The temperature was 80 degrees. She stated it wasn ' t the heat that was the main problem; it was the mixture of the heat and the high humidity. During an interview on 7-23-13 at 3:30 pm with Nurse #2 (An evening nurse working 7:00pm until 7:00am) on 7-14-13 reported the facility was extremely hot when she reported to work on 7-14-13. She stated that several residents and families were complaining about the heat and some family members went out and bought fans for the resident ' s rooms. Nurse #2 stated, during her shift, four residents were identified as having respiratory issues, but was unknown if related to the heat in the facility. These residents were sent out to the local emergency room s for evaluation. She reported that one resident (Resident #3) was admitted to the hospital related to his respiratory issues which thought to be exacerbated by the heat in the facility. Nurse #2 reported that she had not made any attempts to contact any of the administrative staff because other nursing staff members were doing that while she was assisting with the sick residents. She reported the facility did start to cool off around 10:00 pm that evening. An interview was conducted on 7-24-13 at 4:20 pm with a second shift NA (NA #1) who worked on 7-14-13. She stated that the facility was hot when she came to work and that families and residents were complaining of the heat. She reported that many of the residents requested that the windows be opened but the humidity was so high, it made the temperature more uncomfortable. She stated that she had been assigned Resident #3 who had been sent out to the hospital. Upon entering the resident ' s room, the resident was sweating profusely, blood pressure was elevated at 140/98, oxygen saturation (O2 Sats) were in the low 80 ' s and the resident was complaining of difficulty breathing. During an interview on 7-24-13 at 4:25 pm with NA#2 who worked on 7-14-13, the NA quoted " I don ' t usually sweat, but I was visibly sweating. " The staff was passing extra ice water to the residents to help keep them cooler. The NA stated that the rooms were so hot that it almost felt cool in the hallway when she came out of a room. She reported the facility began to cool off around 9:30 pm. During an interview with an alert and oriented Resident #4 on 7-24-13 at 4:14 pm, he stated that he got really hot but did not notice the facility getting hot until in the afternoon. This resident reported he stayed in his room with the door closed and his room stayed cool until later. Once he started feeling the heat, he reported he opened his room door, got into his wheelchair and rolled around in the facility. He reported the staff passed ice water to keep every one hydrated. He stated the facility began to cool off around 11:00 pm. During an interview with the emergency medical services supervisor (EMS) on 7-24-13 at 11:45 am, he revealed he had been contacted by the paramedics who had been transporting the residents from the facility to the local emergency room s on 7/14/13. He reported that his paramedics were concerned because there had been four residents transported from the facility throughout the day with respiratory related illnesses they thought may be related to the increased temperature in the facility. He reported he arrived at the facility around 8:30 pm and found the facility to be " Hot and humid " upon his entry. He reported that the maintenance man and his assistant as well as the Administrator were present in the facility. The EMS Supervisor stated he was present in the facility for 45 minutes and the facility had started to cool off prior to his leaving. Observation of the smoke detector head in Zone 28 that set off the fire alarm was observed to be in the Assisted Living portion of the building. The smoke detector was not replaced but cleaned and is in working order. Record review of preventative maintenance records identified that all smoke detectors including the smoke detector in Zone 28 that set off the fire alarm were inspected along with the manual pull stations, and control panel on 5-3-13 and deemed to be in working order a fire, safety and security company. This inspection is conducted on an annual basis. A review of the facility ' s disaster plan did not have a policy and procedure in place for temperatures that fall below 71 degrees or rise above 81 degrees. A review of an undated job description for the Maintenance Director stated " Able to respond to needs of facility 24 hours a day, 7 days a week. " And " Responds to emergency maintenance needs promptly. " The Maintenance Director did not have a copy of a signed job description in his employee file until 7-25-13. A record review was conducted of the nurse ' s notes from nurse #2 who identified Resident #3 was having respiratory difficulty. She reported in her notes that the resident was sweating profusely and that the resident reported he was too hot. She noted there were visible signs of respiratory distress which included: nasal flaring, chest retractions, shortness of breath, labored breathing and use of accessory muscles. The resident ' s vital signs were: Blood Pressure 140/98, and Heart Rate 87. His oxygen saturation (O2 Sat) rate was 84% on 3 liters of oxygen with a nasal cannula. The nurse requested a NA to stay with the resident while she went to get a non-rebreather mask. While she was gone from the room, the resident ' s O2 Sats dropped to 70%. The non- rebreather mask was placed on the resident and the O2 Sats returned to 92%. The resident continued to complain of being hot. Nurse #2 contacted the physician and was given orders to transport the resident to the hospital for evaluation. A record review was conducted of the EMS report dated 7-14-13. The scene information described the resident as: " Pt has been in the heat x 10 hr and became short of breath. Possibly 110 degrees in the resident ' s room. Air conditioning went out all over the home. Pt was placed on a non-rebreather and still couldn ' t keep O2 sats above 92%. After getting the Pt out of the heat, O2 sats came up to 97%. " Record review of the hospital discharge summary dated 7-17-13 revealed the following: " The resident was admitted to the hospital from the nursing home because he was having shortness of breath. It was very hot and I think it was all precipitated by the fact that it was very hot and he has possibly [MEDICATION NAME], shortness of breath. He got to the hospital, we gave him Solu-[MEDICATION NAME] and gave him IV antibiotics. "

Based on observations, staff, fire marshal and emergency medical services (EMS) supervisor interviews, facility policies and record reviews, the facility failed to prevent one of four residents from having respiratory distress by allowing the facility temperature to increase as the result of a system malfunction causing the air condition unit to shut off. Findings include: Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the named resident ' s 5 day assessment MDS dated [DATE] indicated the resident had a BIMS (brief interview for mental status) score of 12, indicating he was able to answer questions and voice concerns about his health issues. He required assistance for transfers and activities of daily living (ADLs). A record review was conducted of the nurse ' s notes dated 7-14-13 from nurse #2 who identified Resident #3 was having respiratory difficulty. She reported in her notes that the resident was sweating profusely and that the resident reported he was too hot. She noted there were visible signs of respiratory distress which included: nasal flaring, chest retractions, shortness of breath, labored breathing and use of accessory muscles. The resident ' s vital signs were: Blood Pressure 140/98, and Heart Rate 87. His oxygen saturation (O2 Sat) rate was 84% on 3 liters of oxygen with a nasal cannula. The nurse requested a NA to stay with the resident while she went to get a non-rebreather mask. While she was gone from the room, the resident ' s O2 Sats dropped to 70%. The non- rebreather mask was placed on the resident and the O2 Sats returned to 92%. The resident continued to complain of being hot. Nurse #2 contacted the physician and was given orders to transport the resident to the hospital for evaluation. A record review was conducted of the EMS report dated 7-14-13. The scene information described the resident as: " Pt has been in the heat x 10 hr and became short of breath. Possibly 110 degrees in the resident ' s room. Air conditioning went out all over the home. Pt was placed on a non-rebreather and still couldn ' t keep O2 sats above 92%. After getting the Pt out of the heat, O2 sats came up to 97%. " A record review of the hospital discharge summary dated 7-17-13 revealed the following: " The resident was admitted to the hospital from the nursing home because he was having shortness of breath. It was very hot and I think it was all precipitated by the fact that it was very hot and he has possibly [MEDICATION NAME], shortness of breath. He got to the hospital, we gave him Solu-[MEDICATION NAME] and gave him IV antibiotics. " The resident had a three day hospital stay and was discharged back to the facility on [DATE]. An interview was conducted with the Administrator on 7-23-13 at 9:50 am. She reported the staff did not contact her until 6:20 pm on the evening of 7-14-13 to inform her there was no air conditioning in the facility and that it was hot. She stated she left her home for the facility at that time, arriving at approximately 7:30pm. She indicated she had spoken with the Maintenance Director when she was on her way to the facility. The Administrator reported that several families had brought fans from home to use on residents. She also indicated there were large floor drying fans located in the maintenance section of the Assisted Living Side of the facility that could have been utilized to cool off the halls. She stated she felt the nurses attempted to take care of the situation independently while awaiting the Maintenance Director to arrive and were not aware of the availability of those fans; therefore, the fans were never utilized. The Administrator stated that her expectations of the Maintenance staff person on call would be for that person to contact her for a plan of action if he/she was unavailable or he/she should have a back up person available.

Based on observations, record review and staff interviews, the facility failed to ensure medications were administered as ordered by the physician for 1of 1 sampled residents (Resident #1) resulting in readmission to hospital in less than 24 hours from discharge. Findings include: Review of the facility ' s pharmacy policy on new admission orders A licensed nurse assures medications are incorporated into the resident ' s specific allocation prior to the next med pass. " Resident #1 was admitted to facility on 6/11/2013. Medical [DIAGNOSES REDACTED]. Medication orders included [MEDICATION NAME] Extended Release 60 milligrams by mouth twice a day, Omega Fish oil one capsule by mouth twice a day, Ramipril 5 milligrams by mouth daily at bedtime, [MEDICATION NAME] 50 milligrams by mouth twice a day, [MEDICATION NAME] 80 milligrams by mouth at bedtime, [MEDICATION NAME] via inhalation twice a day, [MEDICATION NAME] 75 milligrams by mouth at bedtime, [MEDICATION NAME] 4 milligrams by mouth at bedtime, [MEDICATION NAME] 20 milligrams by mouth twice a day, [MEDICATION NAME] 600 milligrams by mouth twice a day, [MEDICATION NAME] 25 milligrams by mouth three times a day, and [MEDICATION NAME] 10 milligrams by mouth twice a day. No MDS assessment was completed for the resident. Review of the admission assessment dated [DATE] indicated the resident arrived to the facility at 5:45pm. Blood pressure recorded on admission assessment was 157/92. A Nurse ' s note dated 6/11/2013 indicated " meds ordered. " Review of Resident #1 June 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nurse ' s note dated 6/12/2013 at 2:55am indicated the resident was complaining of chest pain, and shortness of breath. Vital signs documented were blood pressure 150/91, pulse 92, respirations 22 and oxygen saturation of 86%, with [MEDICATION NAME] given and a call was placed to the medical doctor. The Nurse ' s notes also indicated a new order to send to emergency room for evaluation. Review of the discharge summary from the hospital with admission date of [DATE] and discharge date of [DATE] indicated " Patient was recently discharged from hospital to facility but apparently patient ' s medication was not ready on the discharge at the facility and patient ended up at local hospital with [MEDICAL CONDITIONS]. " On 7/3/2013 at 10:10am, the unit manager indicated " MEDICATION ORDERS FOR [REDACTED]. Then the orders are faxed to pharmacy so meds will be obtained the same day. " The Unit Manager further indicated " if a medication is needed right away and is not available in the E-kit (Emergency kit), we can call pharmacy and have them call it in to backup pharmacy. " On 7/3/2013 at 10:45am, the Director of Nursing (DON), indicated nurse #1 was no longer employed by facility and was unable to be reached by phone for interview. The DON provided information of admission orders [REDACTED]. The DON confirmed medications were not delivered by the pharmacy and were not obtained from backup pharmacy. The DON indicated " My expectation is that when we accept a resident, there will be no delay in treatment or meds given. " On 7/3/2013 at 12:34pm, during interview the attending physician indicated " My expectation is one of two things when residents are admitted to the facility in the afternoon. I expect them to give the medications. If they cannot give the medications, backup pharmacy should be called or they should not take the resident until the next day. " The attending physician further indicated " Some of these patients are so sensitive, that they need their medication. They will end up in heart failure or something. It is not fair for the guy to end up in the hospital with [MEDICAL CONDITIONS]. "

Based on observation, staff and resident interviews and record review, the facility failed to provide supervision to prevent a cognitively impaired resident, at risk for elopement, from leaving the facility unattended for 1 of 1 resident (#8) and failed to maintain van safety equipment in good working condition to prevent a resident from falling for 1 of 2 residents (#2). Immediate Jeopardy began on 10/30/10 for Resident #2. Immediate Jeopardy began on 2/12/11 for Resident #8. The facility provided an acceptable credible allegation of compliance on 2/26/11 at 12:42 a.m. The Immediate Jeopardy was removed on 2/26/11 at 12:45 a.m. The facility remained out of compliance at a scope and severity level "D" (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of employee training regarding the facility's policy and procedures for elopement, checking wanderguards/alarms, observing and reporting residents with signs and symptoms of elopement, keeping resident's safe that have eloped, and to ensure the completion of evaluating the effectiveness of interventions implemented for safety and wheelchair securement in the facility ' s Quality Assurance Process. Findings: 1. Resident #8 was admitted on [DATE] at 1:50 p.m. with [DIAGNOSES REDACTED]. A review of the resident's North Carolina Medicaid FL2 Level of Care Screening Tool, dated 1/31/11, indicated the resident required extensive assistance with ambulation, transfer, dressing, bathing and toileting. A review of an Interdisciplinary Assessment, dated 2/1/11 indicated the resident was alert, but had poor decision making. He had behaviors of wandering, physically abusive and resistant to care. Resident refused an assessment of his activities of daily living status at that time. The assessment further indicated the resident was at risk for elopement and falls. A review of an Interim/Admission Care Plan, dated 2/1/11, indicated potential for elopement related to an attempt to leave the facility and dementia. The interventions included every 15 minute checks by staff until the resident adjusted to the environment, wanderguard in place, redirect resident when needed and reassure resident when needed. The goal was that the resident would not elope. A review of the nurse's notes indicated the following: On 2/1/11 at 11 p.m., the resident was resistant to care. He ambulated without assistance, but his gait was unsteady. "Resident continues to try to leave facility." Checks were being done every 15 minutes. One-to-one care was provided during that shift. The physician was notified and an order was obtained for Ativan 1 milligram (mg) every 6 hours and as needed for increased agitation. On 2/3/11 at 12:15 p.m., (late entry for 2/2/11, 7 a.m. to 7 p.m. shift), resident had increased agitation at 4:05 p.m.. The resident was combative with staff. The physician assessed the resident and an order was received for Haldol, one time dose. The physician's orders [REDACTED]. On 2/5/11 at 6:30 p.m., the resident was "extremely agitated, pacing" "trying to exit facility." Haldol was given by mouth for agitation, but the resident spit it out. The physician was notified and an order was received. A physician's orders [REDACTED]. At 6:55 p.m., the resident threw the table into the closet door and cracked it. He was attempting to pick up and throw the furniture around in the room and was hitting at the staff. At 7 p.m., 911 was called and the resident was transported out of the facility by emergency medical services (EMS). On 2/6/11 at 8:30 p.m., the resident returned to the facility. New medication orders were written. An undated physician's orders [REDACTED]. A review of a Minimum Data Set (MDS), dated [DATE], indicated the resident had moderately impaired cognition. He had behaviors of wandering. He required limited assistance with bed mobility and toilet use. He required extensive assistance with transfers, dressing and hygiene. He required supervision with walking and locomotion. His balance was not steady, but was able to stabilize without human assistance. On 2/8/11 at 2 a.m., the nurse's note indicated the resident had been up earlier, walking the hallway and attempting to leave the facility. The nursing staff redirected the resident back to his room. On 2/9/11 at 7 a.m., (late entry for 2/8/11, 7 a.m. to 7 p.m. shift), the resident became "extremely agitated" at 12:15 p.m. The resident was physically and verbally abusive to the staff. Resident #8 was "wandering halls looking for a way to elope from the facility." The physician was notified and an order was received for Haldol 2.5 mg IM now, one time dose. The Haldol IM injection "had little effects." The physician was notified again at 2 p.m. and a new order was received for Haldol 1 mg by mouth every 6 hours as needed. A review of a psychiatric services initial evaluation, dated 2/10/11, indicated the resident had "adjustment disorder with a mixed disturbance of emotions and conduct." The assessment indicated the resident's decision making ability was severely impaired. The evaluation further indicated "at risk for elopement because he is not used to being confined. He is going through alcohol withdrawal and shows signs of some dementia." On 2/12/11 at 9:45 a.m., a nurse's note indicated the resident was walking around the nurse's desk. At 9:55 a.m., the resident fell to the floor at the nurse's desk. He was nonverbal and his eyes were closed. The physician was notified and the resident was sent to the emergency department. At 5 p.m., the resident returned to the facility. On 2/12/11 at 10 p.m., a nurse's note (by Nurse #1) indicated at 8 p.m., the resident took his medications without difficulty. He was alert and oriented x 2. At 8:25 p.m., "during rounds resident noted unaccounted for during search." The nurse noted the resident's window was open. At 8:28 p.m., "staff reported an individual was observed off the facility." Nurse #1 "scouted neighborhood" and found resident 1 block away from the facility. The resident stated "I want to go home." The physician was notified and an order was received for an involuntary commitment. On 2/12/11 at 10:05 p.m., the resident was noted to be receiving one-to-one monitoring at that time. On 2/13/11 at 12:30 a.m., the resident was sent out to the hospital, accompanied by the sheriff. The resident was issued a discharge notice due to it being in the best interest of his safety and welfare as well as the facility could no longer meet his needs. On 2/12/11 (sic, 2/13/11) at 4:30 a.m., the hospital nurse called and notified the facility that the resident would not be admitted . After being evaluated, they could not find a reason for an admission. On 2/13/11 at 5:15 a.m., the resident was sent back to the facility. On 2/13/11 at 9 a.m., the nurse's note indicated the resident was on one-to-one monitoring by a nursing assistant. During an observation and interview on 2/25/11 at 4:50 p.m., Resident #8 was observed lying in bed. Nursing Assistant (NA) #1 was in the room with the resident. The resident thought he was in another town. His speech was mumbled. He was asked if he had ever tried to leave the facility and he said "no." He denied ever crawling out through the window. He had a wanderguard on his left wrist. NA #1 stated she asked the resident after he eloped how he got out of the facility. He told her threw the window. She asked him why he did it, he said, "Well, they said I was crazy, I was just going to show them how crazy I really was." She indicated the resident doesn't talk much now. During an interview on 2/25/11 at 6:21 p.m. and 9:35 p.m., NA #6 stated she worked on a different hall and had never worked with Resident #8, but knew the resident. On 2/12/11, she had walked outside to get something out of her car. She indicated her car was parked on the paved parking lot, in the parking spots facing the road. She indicated she looked down the road to the left and saw Resident #8 walking next to the road towards the university (away from Lillington) down Highway 421. Highway 421 was a four lane highway leading in and out of Lillington. NA #6 had written a statement after the incident, and this was reviewed with the NA #6. After NA #6 saw Resident #8 walking down the road, she stated she got in her car and drove down the road to see if it was in fact the resident. She indicated she drove by the resident and made a u-turn at Club Drive and returned to the facility. She indicated the resident was at the side street, Club Drive. This occurred at 8:30 p.m. When she arrived back at the facility, Nurse #1 was outside. Nurse #1 got into NA #6's car and they drove back down to the resident. The resident was fighting the nurse and aide and waving at cars that passed by. NA #6 stated she used her cell phone to call the nurse supervisor, Nurse #2. She stated Nurse #2 and Nurse #1 walked the resident back to the facility because he wouldn't get into her car. She indicated the resident didn't say what he was doing, or where he was going. NA #6 stated when they were walking the resident back, they noticed the screen was out of the resident's window. She indicated on 2/12/11, before he eloped, he had went out one of the fire alarmed doors (emergency exit). She stated he was wearing a wanderguard that night. NA #6 stated they had an inservice that night, on 2/12/11 after the incident about what to do if someone was missing, such as notify the supervisor, do a building search and make sure all residents are accounted for. She was questioned what she had been taught about residents who had eloped from the facility. She stated if the resident was in danger, then she could call the police. She stated she didn't think he was at danger when he was walking along the highway, until he started fighting the staff, then they were all in danger. He was pushing the staff out into the road. She stated she had not been inserviced on how she should handle the situation if the resident was already out of the facility and she had driven by the resident or saw them walking next to the road. She stated she did have her cell phone with her at that time. She didn't think she could handle the resident by herself and thought it would be safer for both of them if she got help. During an interview on 2/25/11 at 6:04 p.m., Nurse #1 stated on 2/12/11 she had given the resident his medications and then proceeded to the resident next door. She stated "from time to time" she was checking on him. She stated about 10 minutes later, she looked back in on the resident and he was not there. She looked in other resident's room and could not find him. She went back into the resident's room and looked in the bathroom and closet and he was not there. She saw that the window was open, and indicated when she saw the window earlier, it wasn't open. NA #6 was on break and informed her she saw somebody that looked like Resident #8 walking down the street. Nurse #1 stated she went with NA #6 get the resident. She asked him where he was going, he said home. He was at the street light on Club Drive. The resident walked back with them to the facility. She couldn't remember the time that this occurred. She stated NA #6 went with her initially to get the resident, but he refused to go. They had to call the nurse supervisor, Nurse # 2. Nurse #1 stated the resident was so aggressive, kept holding her hand tight. She indicated the resident was "tired," but did not sustain any injuries. He said he passed through the window. After they brought him back to the facility, he was placed on one-to-one monitoring. She stated she had not received any education recently on elopement. During an interview on 2/25/11 at 5:13 p.m., NA #2 stated she was assigned Resident #8 on 2/12/11, on the 2nd shift. She stated he was "wild acting," he would say he was going to go to bed, but he would go somewhere else. She stated 2/12/11 was the first time she had ever worked with him. She had been informed in report that they should keep a close watch on the resident, because he was at risk for elopement. She stated the resident had gotten out the door before, but someone was there to get him. NA #2 was just about to go in the break room, when another NA told her Resident #8 was missing, and to come back from break. She went back to the hall. She stated Nurse #1 had looked back in Resident #8's room and noticed he wasn't on the bed anymore. She checked the bathroom and the next room, then she went back to the resident's room. The nurse felt a breeze and realized the window was open. He had pushed the screen out. She stated when the resident came back he was laughing. They checked him, and he did not have any injuries. The resident stated "he was just trying to give them a job to do." He didn't tell them how he had gotten out. She stated they did inservice her about elopement when she was first employed, about 7 or 8 months ago. During an interview on 2/25/11 at 7:45 p.m., Nurse #2 indicated he was the Registered Nurse in the building on the 2nd shift on 2/12/11. He stated Nurse #1 informed him she was going outside because her resident went out. He closed up his medication cart and went outside. He stated by the time he got outside, Nurse #1 was "out of sight." He stated a nurse aid called and said the resident was at the intersection and was fighting them. Nurse #2 ran down to the intersection. He stated the resident had gotten "pretty far." The resident was wearing regular clothes and it was dark outside. The resident would not get into the vehicle. Resident #8 kept trying to get away, was trying to trip the nurse and was grabbing on to Nurse #2's pants. Nurse #1 and Nurse #2 walked him back to the facility and NA #6 drove her car back to the facility. He stated the resident's window in his room was open and the screen has out. Nurse #2 stated the resident was in "danger" walking along the highway and the aid should have stayed with him instead of driving back to the facility. He stated no passing cars had stopped. Nurse #2 indicated Resident #8's decision making was "not the best." He stated it had been reported that he had tried to get out of the facility before. A review of online maps indicated the intersection where Resident #8 was located was 0.1 to 0.2 miles away from the facility at the intersection of Highway 421 and Club Drive. During an interview on 2/25/11 at 5:25 p.m., NA #4 stated Resident #8 would try to get up and walk and get out of the doors. She had been assigned to him one time. She stated she had observe him going towards the side door for A hall. During an interview on 2/25/11 at 5:42 p.m., NA #3 stated one day the emergency exit door alarm went off, and the resident had gotten out of the facility. He went out the door in the restorative dining room. During an interview on 2/25/11 at 5:51 p.m., NA #5 stated she stayed overnight with him (11 p.m. - 7 a.m.) when he was first admitted on [DATE] because he was running around the facility looking for an exit. She was given a checklist to check on the resident every 15 minutes. The next morning, she gave the checklist to the NAs on the hall and told them that the nurse would talk with them. Resident #8 was very agitated on 2/1/11, running all around the facility. "He was very fast and looking for an exit." "He could see that it was an exit and he would say he wanted to go home." The resident's family and his friend visited that evening. After they left, he became a different person, he was rolling his eyes and shaking. She indicated one Saturday, when she was assigned one-to-one, he became different after supper. The nurse gave the resident a medication and instructed her to put him to bed. She stated once she put him to bed, he woke up and started hitting the window with his hand. He took a table and threw it and broke the closet door. "He started throwing his chair, he was so strong." The nurse told him they would call 911, then he changed his behavior and had "good manners." During an observation on 2/25/11 at 8 p.m., the resident's window was measured by Maintenance #1. The measurements were as follows: from the floor to the bottom of window 33 3/4" (inches), width 46 1/4", height 59 1/2", and would open to 21 inches. The window was a side to side opening, it opened on the right and slide to the left. The window had been bolted and it now opened to 5". During a record review and interview on 2/25/11 at 2:15 p.m., the Director of Nursing (DON) indicated she got a call around 9 p.m. on 2/12/11 and was told Resident #8 kicked the screen out and went out the window. She stated the staff had just checked on him and the nurse was close to him with the medication cart. She looked in and he wasn't there. The window was open. The staff went outside the facility. There was a staff member (NA # 6) out with the smokers, and she said "he went that way." They drove their car to him, tried to get him in the car, but he saw the staff's badges and wouldn't get in. The DON stated that "going out a window never dawned on me." She stated they put bolts on all the windows on the A hall, to where they could not be opened enough for one to crawl out. The DON indicated the first day of admission, they identified the resident at risk, put a wanderguard on the resident and developed a care plan. She stated they evaluated all residents at risk for elopement and began inservicing the next day. She had talked with the staff on 2/12/11 after the incident, but didn't start an inservice signature sheet that night. The DON had provided an inservice education record for wanderguards, alarms, elopements, reporting potential injuries and documenting on treatment records. The sheet had 6 LPN signatures, 23 NA signatures, 1 restorative aid signature and 1 medication aide signature. Nurse #1 and NA #2 were not on the signature sheet. The DON indicated she could not find any more signatures sheets. The DON and Administrator indicated that was not all of their staff. During an interview on 2/25/11 at 7:15 p.m., Maintenance #1 stated he had been given a list of residents and instructed to bolt their windows. He stated he had bolted Resident #8's window the day that he eloped. He stated he didn't have enough screws to bolt everyone's window on the list and he had just finished bolting a few windows on the C and D halls on 2/25/11. He stated the Administrator had asked him on 2/25/11 if he had finished bolting the windows and he informed her that he had not. She instructed him to finish bolting the windows on 2/25/11. During an interview on 2/25/11 at 8:05 p.m., the Director of Nursing stated she had started inservicing regarding elopement, wanderguards and alarms. The DON and Administrator were questioned if they had inserviced the staff on how to respond if a resident was observed out on the highway, and they had not. The DON stated she was not informed NA #6 had driven her car down the road to see if it was the resident and then drove her car back to the facility to get help. However, NA #6's statement indicated she had driven her car and came back to the facility. The Administrator indicated NA #6 should have stayed with the resident. The Administrator stated they looked at people with wanderguards and who were able to pull themselves up, to determine the necessity of placing bolts on their windows. She stated some of the residents at risk for elopement were mobile with the wheelchair only. She indicated they had not initially decided to bolt everyone's window who were at risk for elopement. She stated she was not sure when the maintenance staff had finished bolting the windows. She stated "it could have been yesterday, it could have been today." A review of the facility's Quality Assurance Action Plan indicated the facility had written a corrective action plan for the following: wanderguard audits for placement/functioning, wanderguard door system checks, elopement risk assessments on every resident, care plan updates, one-to-one monitoring of Resident #8, pre-admit audits for wandering behaviors, 24 hour nursing report review, wanderguard placement for any resident at risk for elopement, list of resident's with wanderguards on each medication cart, and facility staff inservices regarding reporting and documenting of elopement and elopement potential/attempts, as well as wanderguard placement, function and documentation. The plan also indicated Resident #8 would be placed at a facility with a locked unit. The plan did not address bolting of the resident's windows. During validation of the facility's action plan on 2/25/11, care plans of the resident's at risk for elopement were reviewed. Resident #10 (a resident at risk for elopement, as identified by the facility) did not have a care plan in place for elopement risk. Inservices had not been completed for the facility staff. The staff had not been inserviced on keeping a resident safe if they had eloped from the facility. During interviews with the staff on 2/25/11, NA #1 stated if a resident had eloped from the facility and was walking down the highway, she would leave the resident if he was combative and go to the facility to get help. Maintenance #1 provided a list of residents, whose windows he had bolted on 2/25/11. He indicated he had not bolted 5 resident's windows until 2/25/11. The facility's administrator was notified of the Immediate Jeopardy on 2/25/11 at 4:00 p.m. The facility provided an acceptable credible allegation of compliance on 2/26/11 at 12:42 a.m. The facility's credible allegation of compliance included in part: 1. Resident #8 remains inside the facility receiving one to one care. Resident will be allowed outside the facility with supervision. Resident #8 has wanderguard in place and working properly. Resident's wanderguard is checked for function and placement daily. Resident #8 ' s chart has been reviewed; new risk assessment completed, and care plan updated. Care Plan update includes recognizing resident #8 putting on clothes while voicing desire to leave and moving toward facility exit. Interventions include talking to resident in a soothing tone to dissuade exit-seeking behavior and administering as needed medication for agitation. Care plan updates have been added to CNA care card for direct care staff instruction. Resident remains at risk for elopement as evidenced by current documentation in the medical record. Resident #8 will be placed at a facility with a locked unit. Facility has sent out FL-2s for placement and currently awaiting response. 2. Current admissions have the potential to be affected by deficient practice. Therefore current residents residing in the facility have had chart audits to determine any current risk for elopement. Residents identified at risk by the assessment received an updated care plan identifying possible behaviors and appropriate interventions. Care plans include individual exit seeking behaviors with appropriate interventions to prevent elopement. Interventions on care plans will be added to care cards for direct care staff. In addition, residents at risk for elopement have windows adjusted to prevent exit. 3. Systems for problem that are in place to prevent elopements are: ? The admissions director, administrator and/or director of nursing will review pre-admission data including hospital records, PAASAR's, etc to determine any prior history of elopements or attempts prior to admission. ? Discharge summaries will be reviewed by a member of the Administrative nursing team on day of admission to review for same information. ? Nurses shall document reports from other staff, residents, families, etc regarding behaviors or threats of elopement. This is to be documented in the medical record, reported to physician and responsible party and documented on the 24 hour nursing report. ? All staff will be educated prior to the start of the shift and for newly hired staff by the DON/Nurse Consultant/Unit Coordinator/Supervisor regarding the following: a) Elopement policy and procedure. b) Maintaining resident safety during an incident c) Identification of signs and symptoms of a potential elopement. d) Procedure for notifying and documenting an elopement. ? Reports of any actual or attempted elopements shall be reported to the Administrator and/or Director of Nursing immediately so that an action plan for further incidents can be initiated. ? The 24 hour nursing report will be reviewed at the next day ' s clinical meeting so that appropriate interventions for treatment and services can be initiated. ? Wanderguard will be placed on resident attempting elopement upon discovery of attempt. ? A list of current residents with wanderguards will be placed on each nurses' cart. ? Wanderguards will be checked daily for placement and function. Checks will be turned into Administrator to ensure they are completed. ? Wanderguard door system will be checked daily for function. Checks will be turned into Administrator to ensure they are completed. ? Facility staff have received inservices regarding reporting and documenting of elopement and elopement potential/attempts, as well as wanderguard placement,function,and documentation. ? Administrator/designee will review clinical meeting minutes (weekly) for elopement activity. In addition a random audit of 5 resident charts will be conducted for 30 days by DON/Supervisors to monitor for potential elopement activity. This audit will result in every resident being reviewed. ? Residents identified as elopement risks will have their medical record monitored by the DON/Unit Coordinator/Supervisors three times a week for 30 days to identify any increase in behaviors that may result in an elopement. ? Any staff failure to report or document as per this procedure will be either re-inserviced or disciplined as needed. 4. Identified trends and patterns will be reviewed with the QA Committee for 3 months and quarterly thereafter. This plan will be adjusted as necessary. Validation of the credible allegation of compliance began on 2/25/11 at 4:30 p.m. The validation included reviewing the lesson plans and education records for the in-services that were completed; interviews with staff related to inservices conducted regarding reporting and documenting of elopement potential/attempts, as well as wanderguard placement, function and documentation and keeping residents safe; review of wanderguard audits; audit and system check of the wanderguard door system; observation of the medication carts for wanderguard logs and review of resident's care plan with risk for elopement. 2. Resident # 2 was admitted to the facility on [DATE] with an accumulative [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment of 1/18/11 revealed Resident # 2 had moderate cognitive impairment. Resident # 2 was able to communicate effectively and understand others. Resident # 2 required assistance of one to stabilize her balance for surface-to-surface transfers. A review of the Nurses Notes for 10/30/10 6:00 PM revealed Resident # 2 ' s wheelchair tilted over in the facility van during transport from dialysis to the facility. Resident # 2 was evaluated in the Emergency Department due to complaints of a headache and a bump on the back of her head. A review of the emergency room report dated 10/30/10 revealed the resident complained of head ache and a computed tomography (CT) scan of the head without contrast was negative. The resident was diagnosed with [REDACTED]. During an interview on 2/25/11 at 9:55 am, Resident # 2 was observed seated in a wheelchair in her room, able to sit upright without leaning. Resident # 2 stated, regarding 10/30/10: "On the way back to the facility, the van turned and the wheelchair fell over. There was a belt but no seatbelt. The front straps were fastened. We came up to the driveway here. The back straps were fastened but not the front, else how could it turn over.The nurse came out and looked at me and (the driver) got me up and got me out of the van and started toward the lobby. Somebody looked at my head because I had a headache and a knot. Somebody looked at it and called the rescue squad and took me to the doctor. The van I go to dialysis in now, it's the same van. Yesterday I went on the same van to dialysis. " During an interview on 2/24/11 at 3:10 pm, Van Driver # 1 stated, "I was picking (Resident # 2) up from dialysis about five miles from the facility. She was in a standard wheelchair with no leg rests and had a gel cushion in the seat. She was loaded onto the van in the wheelchair by me. She was in the back of the van on the left side where the wheelchairs go. I put her in that place facing forward and at a slight angle to the right so I could get to the straps on the left side. There was a shoulder harness but not a seat belt. I fastened the two wheelchair straps in the front and the two in the back. When I turned into the loop (a U-turn from the eastbound 2-lane highway to the westbound 2-lane highway) to the left, the wheelchair tilted to the right and (Resident # 2) yelled. I could see the right side of the wheelchair almost touching the floor and (Resident # 2) was leaning over the right side of the wheelchair. I pulled immediately into the driveway (of the facility) blocking the driveway and saw the weekend supervisor outside. I yelled to her that (Resident # 2) had fallen over and she came out and assessed her. We found all the wheelchair straps were still attached to the floor but the straps on the left side slid through the retractors and didn't hold fast." (Resident # 2) said she didn't hurt anywhere. We assisted her and the chair to an upright position. " On 2/24/11 at 3:15 PM, a demonstration of how Resident # 2 was secured in the van by Van Driver # 1 on 10/30/10 was observed. The demonstration was performed by Van Driver # 1 (the previous van driver on 10/30/10), Van Driver # 2 (current van driver), and the DON acting as Resident # 2 sitting in a standard wheelchair. Observation of the wheelchair securement system revealed floor tracks (long pieces of metal) were fastened to the floor of the van with holes every few inches that allowed for different widths of wheelchairs to be secured. The wheelchair straps connected to retractor devices in the track on one end and connected to the wheelchair frame with S hooks on the other end. The retractors allowed manual tightening of the straps by turning a knob to remove slack in the straps. During the demonstration, Van Driver # 1 pushed the DON onto the van lift at the right rear of the van and raised the lift. Van Driver # 1 pushed the DON into the van and positioned the wheelchair in the left rear corner of the van. The wheelchair was facing forward and slightly to the right at a 45 degree angle. Van Driver # 1 stated that was so she could get on the left side between the wheelchair and the wall of the van and access the straps on the floor on the left side. Van Driver # 1 demonstrated fastening the S hook of the left front strap to the front inside frame of the wheelchair and attached the other end to the retractor a few inches outside of the front wheel. Van Driver # 1 attached the S hook of the left rear strap to the rear frame of the wheelchair behind the wheel. Van Driver # 1 attached the right front and rear straps to the wheelchair the same way. Van Driver # 2 stated it was the left front and rear straps that did not remain tight and allowed the wheelchair to tilt when the van turned left. Van Driver # 2 stated the harness strap, which was attached to the left top rear of the van, was connected into a retractor on the floor in the right corner of the van on 10/30/10. Van Driver # 1 demonstrated fastening the harness strap over the left shoulder of the DON and showed where it would have been attached to the retractor on the right rear floo

Based on observations, record review, resident interview and staff interviews, the facility failed to provide adequate pain management and administer pain medication according to physician's orders [REDACTED]. Findings include: 1. Resident # 1 was admitted to the facility on [DATE]. The resident ' s accumulative [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident # 1 had memory deficits and required cueing with decision making in new situations only. The MDS indicated Resident # 1 had no difficulty communicating or understanding others. A review of Resident # 1 ' s medication regime revealed [MEDICATION NAME] 5/500 (a narcotic [MEDICATION NAME]) was ordered to be given as follows: one tablet by mouth at 12:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM while awake. During medication pass observation on 12/6/10 at 10:30 a.m., Nurse #3 was observed preparing Resident #1's morning medications. Nurse #3 poured multiple medications, including [MEDICATION NAME] 5/500 mg (milligrams) 1 tablet. She entered the resident's room at 10:40 a.m. Nurse #3 asked Resident #1 how she was doing that morning. She replied, "Not so good, I haven't had my medication. I haven't had my pain medication either." She stated it happened often that her medications were given late. The resident stated her pain level was an 8, on a pain scale of 0 to 10. She indicated she had a leg with no cartilage and it was "very painful." Resident #1 stated she could not remember what time she had her last dose of pain medication, but indicated it was the night shift nurse (Nurse #4) that had administered it to her last. She stated Nurse #4 had told her that she would be receiving the pain pill around change of shift. Resident #1 stated no one had been in to give her the pain medication. During an interview and record review on 12/6/10 at 10:45 a.m., Nurse #3 stated she did not receive in the change of shift report that Resident #1 was asking for her pain medication. She stated the resident had asked her that morning sometime between her medication pass, but did not recall what time. A medication pass observation began with Nurse #3 at 9:42 a.m., the request was not observed during that time period. Nurse #3 stated the resident's [MEDICATION NAME] was ordered to be administered at 8:00 a.m. She indicated she was late passing her medications because another resident (Resident #2) had chest pain that morning. A review of the narcotic administration log for Resident #1's [MEDICATION NAME], indicated she last received it at 12:45 a.m. Nurse #3 indicated she had not administered [MEDICATION NAME] to the resident until 10:40 a.m. She indicated she was supposed to administer medications 1 hour before or 1 hour after the ordered medication time. Another review of the Controlled Drug Receipt/Record /Disposition form for Resident #1's [MEDICATION NAME] revealed Nurse # 3 documented the medication was given at 9:10 AM on 12/6/10. The next dose was documented at 1:00 PM (less than 4 hours later), and again at 4:00 PM (less than 4 hours later) by Nurse # 3. During a second interview on 12/6/10 5:15 PM, Resident # 1 stated she did not have any cartilage in her knees and they were very painful. Resident # 1 stated on a scale of 1-10, the pain was usually 5-10. Resident # 1 stated, "This morning my pain was around an 8. It was 8:00 AM when I asked (Nurse # 3) about my 8 AM pain medicine, but I didn't get it until around 10:30 AM. It happens just about all the time. I should have had it at 8:00 AM, but it's a very strange thing if I get my pain medicine at 8 AM. They are usually late." During an interview on 12/6/10 at 5:20 PM, the DON stated stated she was not informed by Nurse # 3 that a resident was having chest pains or that Resident # 1 received her 8:00 AM medication at 10:40 AM. The DON stated Nurse # 3 indicated to her that she had given Resident # 1's medication at 9:10 AM. The DON stated she expected emergency situations to be addressed promptly. The DON stated the nurses also had 1 hour before and 1 hour after the scheduled time to give medications and her expectation was the medications would be given within that timeframe.

Based on observation, staff interviews and record review, the facility failed to provide mental health services for a resident with [MEDICAL CONDITION] and three attempts to commit suicide while residing at the facility for 1 of 1 resident (#79). The resident attempted to commit suicide twice by electrical shock and the third attempt was by cutting his arm. Immediate Jeopardy began on 6/1/10. The facility's administrator was notified of the Immediate Jeopardy on 10/20/10 at 4:45 p.m. The facility provided an acceptable credible allegation of compliance on 10/22/10 at 3:40 p.m. The Immediate Jeopardy was removed on 10/22/10 at 6 p.m. The facility remained out of compliance at a scope and severity level "D" (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of employee training regarding reporting, assessing and monitoring residents with physical, emotional and mental changes or comments/gestures of self-harm; identifying residents with the potential for suicide gestures; and initiating the facility's policy for suicide precautions. Findings: Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Medicare 5 day Minimum Data Set (MDS), dated [DATE], indicated the resident required some supervision with daily decision making in new situations only with short term memory loss. The MDS indicated the resident did not have any indicators of [MEDICAL CONDITION] or depression and no behavioral symptoms. He required limited assistance with transfers, walk in room/corridor, locomotion on/off unit, dressing and toilet use. He required extensive assistance with bathing. He was continent of bowel and bladder. A Resident Assessment Protocol, dated 5/5/10, indicated the resident triggered for cognitive loss due to having short term memory problems due to dementia. It was noted the resident would not have improvements, only declines due to his disease process. A review of the resident's admission physician's orders [REDACTED]. as [MEDICATION NAME], a short acting benzodiazapine) 0.25mg 1 tab by mouth twice daily, [MEDICATION NAME] (heart medication), aspirin (blood thinner), [MEDICATION NAME] (laxative), [MEDICATION NAME] (heart medication), [MEDICATION NAME] sulfate (iron supplement), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (Alzheimer's medication) 10 mg by mouth every morning and [MEDICATION NAME] (also known as [MEDICATION NAME], for cholesterol). A review of the social work progress notes by SW #1, dated 5/7/10, indicated the resident had transferred to the facility to be near his family. She indicated the resident was adjusting well to the change. He was alert and oriented with confusion at times. She indicated he was independent with making his decisions. She further indicated there were no mood indicators or behaviors to note at that time. The Medicare 14 day assessment, dated 5/13/10, indicated the resident was independent with his activities of daily living with some setup help only. A pharmacy recommendation, dated 5/18/10, indicated the resident was on [MEDICATION NAME] and [MEDICATION NAME]. The pharmacist indicated that [MEDICATION NAME] had the potential to decrease the metabolism of [MEDICATION NAME] and increase the serum concentration of HMG-CoA reductase inhibitors, such as [MEDICATION NAME]. The physician indicated to decrease [MEDICATION NAME] and to discontinue [MEDICATION NAME]. A physician's orders [REDACTED]. The [MEDICATION NAME] was not tapered, it was stopped abruptly. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of a nurse's note, dated 6/1/10 at 1850 (6:50 p.m.), indicated the resident complained of feeling "stressed out." The nurse indicated she gave the resident prescribed [MEDICATION NAME] and later checked on him and he indicated his chest and stomach hurt. The nurse then administered two [MEDICATION NAME], 5 minutes apart as prescribed. He then stated his chest was not hurting anymore, but he felt bad and wanted to go to the hospital. The nurse called the resident's physician and he prescribed [MEDICATION NAME] 5/500mg, three times daily for pain. A nurse's note, dated 6/1/10 at 7 p.m. - 7 a.m., indicated the resident was complaining of pain. The resident was given medication with relief. The nurse indicated the resident was getting up out of bed from the chair to the bed without assistance. She spoke to him about the concerns about falling on the floor. She went to give the resident his medications and she "noticed a brokened (broken) clothes hanger jammed in the outlet. The nurse indicated "equipment removed from room." The resident stated "2 men came in this room, dragged me out blindfolded and did it, I didn't do it." There was no indication the physician was notified. A review of an Incident/Accident Report, dated 6/1/10 (by Nurse #5) indicated the nurse walked into Resident #79's room and she noted a "broken wire clothes hanger sticking out of the electrical outlet." The nurse revised the report (at an unknown date and time) and indicated she meant an unplugged surge protector. The surge protector was removed from the room. Nurse #5 indicated in a statement she had removed the wire hanger from the outlet with a dry cloth. The incident report indicated the physician was not notified. Nurse #5 was unavailable for interview. During an interview on 10/20/10 at 7:03 p.m., Nursing Assistant (NA) #5 stated she was working on the 3 p.m. - 11 p.m. shift on 6/1/10. She had gone down to check on the resident and found him on the floor. The resident had "undone a hanger and twisted it in a way to put it into the outlet." Whenever she got to the room, the hanger was not in the outlet. There was a surge protector in the room, but it was not plugged in. She indicated they had seen the lights flicker and the electricity for the wall with the electrical outlet was not working. She stated "something happened, he blew the fuse because the power was not working on that wall." They removed the surge protector because there was no purpose for it in the room. The resident did not say that he had done it. She indicated the resident used to be in a different room and he was in the bed closer to the window. The resident's bed ran parallel with the window and closet. She stated there was an over bed table by the window, and it left enough room for the resident to get over to the outlet by the headboard. She stated the bed would not lock and the resident could have moved it also. NA #5 stated the resident used to eat good, but he starting eating less after he returned from the hospital stay. She further stated the resident used to be more active, but did not usually go to the dining room. NA #5 stated the resident liked staying in his room. Resident #79 "would close himself up if you would let him" "would want the lights off" and "liked to stay in bed." A review of a laboratory report, dated 6/3/10, indicated the resident's international normalized ratio (INR, a blood test to determine the blood clotting time with [MEDICATION NAME] use) was 7.7, indicating his blood was too thin. The resident's [MEDICATION NAME] was discontinued and a repeat lab was ordered. A nurse's note (written by Nurse #2), dated 6/4/10 at 7:30 a.m., indicated the nurse was called to the room, the resident was laying supine with an oxygen mask on his forehead, "bleeding freely" from 2 open wounds on his right forearm. The resident was responsive, but not alert. The nurse further indicated "Pt (patient) was bleeding freely." The physician was notified, 911 was called and the resident was transported to the hospital. A review of an Incident/Accident Report" completed by Nurse #2, dated 6/4/10, indicated on 6/4/10 at 7:30 a.m., the resident had gotten a disposable razor and removed the blade. The resident was bleeding from 2 lacerations to the right forearm. He was alert, responsive and confused. The resident was transported to the hospital. A witness statement from Nurse #2 indicated she was called to the resident's room by a nursing assistant. The resident was found holding his arm over a trash can, bleeding freely from wounds to (not legible). The razor blade from the disposable razor was found in the resident's bed, covered with blood. Nurse #2 indicated blood covered the resident's fingers on his left hand. However, no wounds were found on his left fingers. A witness statement by Nurse #3 indicated a nursing assistant reported the resident cut himself. He was holding his arm over the trash can, bleeding upon entering the room. The razor was found under the resident in his bed. She also noted blood covered the resident's fingers on his left hand. During an interview on 10/19/10 at 4:35 p.m., Nurse #2 stated when she got to the resident's room (on 6/4/10), he was lying in bed with his arm over the trash can and he was "bleeding freely." She stated they found a disposable razor in his bed that the resident had taken apart. The blade had dried blood on it. Nurse #2 asked him what happened and he did not say anything. The resident did tell her that he cut himself. Nurse #2 asked him why he cut himself and the resident stated "no one would listen to me." A review of the hospital discharge summary, dated 6/14/10, indicated the resident had been admitted for [MEDICAL CONDITION], severe depression, agitation with dementia and two lacerations on the right arm (one measured 5 centimeters (cm) and the second measured 4 cm). The lacerations were sutured in the hospital and he received two units of blood. The resident was started on [MEDICATION NAME] 10 mg daily (antidepressant), [MEDICATION NAME] 1mg twice daily (for agitation associated with dementia), [MEDICATION NAME] 10 mg daily (for dementia) and [MEDICATION NAME] had been increased from 10 mg daily to 10 mg twice daily. The hospital discharge summary further indicated, "Apparently there was some problem with a CNA or so in the nursing home and his care has gotten somewhat compromised. He was being cared for by a CNA in the nursing home. Apparently he became depressed with the whole situation and he tried to cut his hand with a razor." The hospital History and Physical, dated 6/5/10, indicated the resident had "last (sic) of sleep," feelings of worthlessness, sadness and hopelessness and "tried to kill himself by slitting his right wrist with a razor." The resident was admitted to the hospital with [REDACTED]." The resident was discharged back to the facility on [DATE]. During an interview on 10/20/10 at 1:28 p.m., NA #1 stated the resident used to say he was tired of living and nobody loved him. She stated she reported his comments to Nurse #7. NA #1 had worked the night shift on 6/3/10. On 6/4/10, NA #1 stated she checked on the resident and she noticed the resident was bleeding. She then went to get the nurse. She stated he was bleeding a lot. She stated he had just cut a little slit to make his arm bleed. Nurse #7 was no longer employed by the facility. Attempts were made to contact her by phone, but she did not return the calls. During an interview on 10/20/10 at 4:26 p.m., Nurse #6 stated she had been called to the resident's room on 6/4/10 because he was bleeding. She stated he had also taken some wires, maybe the call light wires, and he was going to stick it in the electrical outlet. She indicated the resident had cut the wires before he cut himself. The resident stated he cut the wires because he was going to commit suicide. During an interview on 10/21/10 at 10:03 a.m., Nursing Assistant #2 stated she helped clean the resident up on 6/4/10 after he had cut himself. She remembered the resident saying that day that he wanted to go home. The resident's call light wires were cut and the wall electrical outlet was "messed up." The resident had "pulled the part out like you would plug something up to." She thought they had to fix the power that day. She also thought the resident used his razor to get the socket loose. She indicated when the resident first came to the facility, he just didn't like it but he didn't say why. "He was angry, wouldn't let you do anything for him, he was depressed." She stated the nurses knew he was depressed. He wouldn't really eat, but his family member could get him to eat. The resident had mentioned a concern about NA #6 mistreating him. The resident didn't understand her accent and he said she was "mean." She stated the resident had told everybody about NA #6. The resident stated NA #6 would try to get him to eat and try to get him to sit up, but he didn't want to. During an interview on 10/20/10 at 4:14 p.m., the Director of Nursing (DON) stated she was informed the resident had removed the electrical outlet plate and electrical outlet from the wall and there were shavings found on the floor on 6/4/10. The DON stated it appeared the resident had taken the razor and shaved some of the wires. She verified there were three suicide attempts. On 6/1/10, the resident put the hanger into the electrical outlet, on 6/4/10 he cut the call light wires and electrical outlet wires, and on 6/4/10 the resident cut his arm trying to kill himself. A review of the medical record indicated there was no documentation about the resident cutting the call light wires and electrical outlet wires. There was no incident report for this suicide attempt. There was no evidence the facility reported it to the physician. On a social work progress note, dated 6/4/10, SW #1 documented it was reported to her at 8:30 a.m. that the resident had tried to commit suicide. The nurse informed her the resident had taken a razor apart and cut his right forearm. He was transferred to the hospital. SW #1 further stated it was reported to her that morning he stuck a metal clothes hanger in an electrical plug. The resident stated he didn't do it, he said two men had done it. She indicated she would continue to follow up with the resident while he was in the hospital and provide support for the family. During an interview on 10/19/10 at 3:15 p.m. and 4:10 p.m., Social Worker (SW) #1 stated on 6/1/10, the resident had been complaining of pain. She stated she informed Nurse #3. SW #1 the resident kept saying he wanted to go to the hospital. The nurse gave the resident a breathing treatment and after the treatment, the resident was saying he was hurting "a little bit." She stated the nurse checked the resident's vital signs and she said everything was fine. The resident said his "body" was hurting. SW #1 stated on 6/1/10, the resident informed her he was hearing voices. Resident #79 stated the "devil voices" in his head were telling him to kill himself. SW #1 stated the resident indicated God controlled him, but the devil voices tell him to kill himself. She stated she informed Nurse #3 of the resident's [MEDICAL CONDITION]. SW#1 stated Nurse #3 indicated she would notify the physician and keep an eye on the resident. SW #1 reviewed her social work progress notes and indicated she had not documented the resident's complaints of hearing voices that were telling him to kill himself, or that she had informed the nurse. SW #1 stated on 6/2/10, she was informed the resident had taken a hanger and put it in a wall socket. On 6/2/10, SW #1 went to talk with the resident about the incident. The resident told her he had put the hanger in the socket in an attempt to kill himself. Resident #79 again told SW #1 that he was hearing voices that were telling him to kill himself. SW #1 stated between Thursday night (6/3/10) and Friday (6/4/10) morning, the resident had gotten a razor and removed the blade and he cut himself. She indicated she did not talk with the resident that morning, because he had already been sent to the hospital when she got to work. SW #1 stated Resident #79 had informed her a staff member at the facility did not like him and she had been rude and talked ugly to him. The resident described this staff member as a black lady with an accent. SW #1 stated she could never figure out who the resident was describing. She indicated she had completed a grievance report for the alleged mistreatment and reported it to the DON. She further indicated the report of mistreatment would have also been reported to the Administrator. The DON and Administrator were responsible for conducting abuse investigations. She reviewed the grievance log and the grievance reports and could not find a report for the allegation. She stated she would usually make an entry in her social work notes of any allegations. She reviewed her social work notes and indicated she had documented the resident's concerns with the staff member, but she was unable to find her notes. She was questioned about the order for a psychiatric consult on 5/20/10. She was not aware of the resident having a physician's orders [REDACTED]. She did not receive notification and SW #1 indicated the resident had never been seen by psychiatric services while he was residing at the facility. During an interview on 10/19/10 at 4:05 p.m., the Administrator stated he did not have any report about an allegation of mistreatment for [REDACTED]. During an interview on 10/20/10 at 10:02 a.m., SW #1 stated she specifically remembered writing a social work progress note on 6/1/10 about the resident hearing voices and that she had reported it to Nurse #3. She stated she could not find that note. She indicated she had also written a note on 6/2/10 when the resident told her he was hearing voices and had tried to kill himself by putting the hanger in the electrical outlet. She indicated it was not her practice to make copies of her social work progress notes, only her personal notes. She indicated she had written the social work progress note on 6/4/10 and wrote about the 2 incidents because the staff had reminded her about the suicide attempt on 6/1/10. During an interview on 10/20/10 at 12:33 p.m., Nurse #3 stated the resident used to say he wanted to go to the hospital. It had been reported to her the resident would do things to try to get out of the facility, such as complain of chest pain. She stated one morning she had come in to work and was counting medications. She was called down to Resident #79's room. She indicated the resident had gotten a razor and cut himself on the arm. She stated, "He had blood everywhere." She further stated the resident had "done something with the socket and it had messed up the electricity in the room and maintenance had to fix it" (on 6/4/10). She stated the resident had informed her he was stressed out (on 6/1/10). He never stated to her that he wanted to kill or hurt himself. She was questioned whether SW #1 had reported to her the resident was hearing voices and wanted to kill himself, she stated "Not that I recall." She had not reported the resident's [MEDICAL CONDITION] to the physician because she was not informed by SW #1 the resident was having suicidal thoughts. She was questioned if the resident had ever indicated to her a nursing assistant was mistreating him. She indicated she had "heard it through the grapevine" that either he had been mistreated or the resident was alleging mistreatment by NA #6. Nurse #3 stated she had some issues with NA #6 not completing a task assigned to her, but she had never seen NA #6 mistreat anyone. During an interview and observation on 10/20/10 at 1:45 p.m., Maintenance Staff #1 stated the resident had busted the electrical outlet cover and electrical outlet by his bed, on the right wall. He stated the screw was not in place and the live wires were exposed. The resident had pulled the plug out of the wall. Maintenance Staff #1 stated the live wires had touched the metal plate and it had tripped the breaker. He indicated the power was not working in the resident's room when he arrived at the facility. He stated the resident had already been taken out of the room. During an interview and observation on 10/20/10 at 10:08 a.m., SW #1 stated the resident used to be in room [ROOM NUMBER]. She thought his bed used to be parallel with the right side of the room. There were 2 outlets visible, one on the right wall and one of the left wall. She indicated she was not for sure which outlet the resident had tampered with (on 6/1/10), but thought it was the outlet on the right wall next to the current resident's headboard. The current resident's bed was parallel with the window and closet, the same as Resident #79's bed position would have been. The headboard was up against the right wall. The quarterly MDS, dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired with short term memory loss. The MDS indicated the resident did not have any indicators of [MEDICAL CONDITION] or depression and no behavioral symptoms. He was requiring total assistance with bed mobility, transfers and toilet use. He required extensive assistance with walking in his room/corridor, dressing, personal hygiene and bathing. He was incontinent of bowel and bladder. The MDS indicated the resident had experienced a weight loss. On 8/10/(10), SW #1 documented the resident was alert and oriented with confusion at times. She indicated there were no mood or behavior indicators to note at that time. There was no further documentation about the resident's suicide attempts or interventions. A review of Resident #79's medical record indicated the care plans were last updated on 10/18/10. There were care plans for cognitive loss/dementia, activities of daily living, fall risk, nutrition, risk for dehydration, [MEDICAL CONDITION] drug use, oxygen use, anticoagulant therapy, impaired ability to eat, skin integrity and weight loss. There was no care plan to address the resident's suicide ideations and attempted suicides. During an interview on 10/20/10 at 10:47 a.m., MDS Coordinator #1 reviewed the resident's care plans and indicated she did not update the care plan when he was readmitted to the facility after having tried to commit suicide. She indicated there should have been a care plan update. During an interview on 10/21/10 at 10:14 a.m., NA #3 stated she used to work with the resident more when he was in her assigned area. She stated Resident #79 "never really used to get out of him room." She stated the resident did not get out of his room now, except to go to restorative dining for lunch and dinner. She indicated some days he ate well. Sometimes he would eat all of his breakfast, and then again some days he would barely nibble on it. She indicated before his hospitalization , he might eat about 1/2 (one-half) of his meals. During an interview on 10/20/10 at 3:19 p.m., Nurse #4 stated before the resident was hospitalized , he used to want to call his family a lot. She stated he doesn't get up much and doesn't socialize as much now. She indicated the resident was really quiet, kept to himself a lot and slept more frequently now. He might go sit in activities or by the nursing station and sometimes he would stay in his room. She indicated he would sit in his room a lot now. Nurse #4 stated the resident "used to transfer with you just standing there," but was extensive to total assistance now. She indicated the resident used to keep a razor in his room because he used to be able to shave himself. She stated whenever the resident returned from the hospital, his status has declined. During an interview on 10/20/10 at 10:32 a.m., NA #4 stated the resident doesn't stay out of his room very long now. She indicated he would go to restorative for lunch, but then he would go right back in his room. She stated she did invite him to activities. During an interview and observation on 10/19/10 at 10:55 a.m., Resident #79 was observed sitting in his room in his wheelchair. The television was on, but he was not facing it. He had concerns about the staff not answering his call bell timely. He stated the activities did not meet his interests, however he did say he liked to play bingo. He was asked if he attended bingo on 10/18/10 and he stated no one invited him. He indicated he had been losing weight, but he didn't know why and had not been trying to lose weight. During an interview on 10/21/10 at 1:21 p.m., Activity Assistant #1 stated every once in a while Resident #79 would go to the group activities. She indicated he was a passive participant, he would sit and watch only. She indicated she provided in room activities for him twice weekly. A review of Resident #79's activity logs indicated the activity department had provided in room visits twice weekly from May 2010 through October 2010. A review of the activity logs indicated the following group activity participation: May 2010 5/3/10, 5/17/10 and 5/20/10. June 2010 None July 2010 None August 2010 8/3/10, 8/6/10, 8/8/10, 8/11/10, 8/18/10, 8/23/10, 8/24/10, 8/29/10, 8/30/10. September 2010 9/12/10, 9/16/10, 9/17/10, 9/29/10 October 2010 9/4/10, 9/5/10, 9/6/10, 9/7/10, 9/17/10 A review of the resident's weight history indicated the following: 4/30/10 - 166.4 lbs (pounds) (admission weight) 6/1/10 - 147.8 lbs 6/15/10 - 145.8 lbs (readmission from hospital) 6/28/10 - 158.9 lbs 9/21/10 - 132.8 lbs 10/19/10 - 141.7 lbs A review of the dietary progress notes, dated 6/18/10, indicated the resident had significant weight loss related to erratic poor appetite and PO (by mouth) intake "which is prob (probably) associated w/ (with) dx (diagnosis) severe depression which is being addressed medically." The Registered Dietician also noted the resident was on a substantial amount of diuretics which may have attributed to the weight loss also. During an interview on 10/20/10 at 3:38 p.m. and 10/21/10 at 11:08 a.m., Physician #1 stated Resident #79 was "terribly depressed." He stated he knew the resident was depressed, but he did not know he was hearing voices. Physician #1 indicated the nurses had never reported to him the resident was having [MEDICAL CONDITION]. He stated he would have expected the nurses to notify him as soon as possible and put interventions in place. He would have made a decision to send him out or keep the resident at the facility based on how acute his condition was at that time. He stated if the resident had been safe to remain in the facility, he would have told the staff to know his where about at all times and be monitoring him. Physician #1 stated he saw the resident in the hospital and the resident told him in passing there was a nursing assistant mistreating him at the nursing home. He stated the resident indicated he did not have anyone to talk to and he was depressed. During an interview on 10/20/10 at 12:00 p.m. and 4:14 p.m., the DON was questioned about her involvement with the resident's suicide attempts. She indicated she had read the nurse's notes about the resident putting the wire in the electrical outlet. She stated she asked the nurse how he put it in the electrical outlet and he didn't get injured. She indicated the nurse clarified he had put the hanger in an unplugged surge protector. The DON asked the nurse if he was trying to kill himself. The resident stated 2 men had done it. She indicated the nurse put an addendum on the report that he had put the hanger into a surge protector. On 6/4/10, Resident #79 took apart a razor and cut his wrist. She stated no one had said anything to her about the resident having thoughts of wanting to kill himself or that he was hearing voices. She stated the resident's guardian indicated the resident had wanted to come to the facility to be around his family. However, when he got to the facility, he decided he wanted to go back to Fayetteville because his church family was not visiting as often. The hospital tried to send him to Fayetteville, but there were no facilities that would accept him. The DON indicated Nurse #3 and SW #1 had not informed her of the resident's [MEDICAL CONDITION]. She stated "I would expect them to contact me and we would need to put them (the resident) on precautions, get some kind of immediate action in place." She stated she would have expected SW #1 report the resident's [MEDICAL CONDITION] to her. She was questioned about the resident's allegation of mistreatment. She indicated she had not received and she had not investigated any allegation of mistreatment of [REDACTED]. She was questioned about Physician #1's statement on the hospital discharge summary regarding mistreatment of [REDACTED]. reading this." She stated all she knew was that a nursing assistant was terminated at another facility because they were hateful to him. She was questioned if any interventions were put into place after the resident began having [MEDICAL CONDITION] and suicide attempts. She looked through her desk and indicated she did not have a file on him. She indicated they had placed residents on suicide precautions before. The resident had not been placed on suicide monitoring. She was questioned why the physician was not notified and why the resident was not placed on suicide monitoring. She indicated it was a failure at all levels. The facility's administrator was notified of the Immediate Jeopardy on 10/20/10 at 4:45 p.m. The facility provided an acceptable credible allegation of compliance on 10/22/10 at 3:40 p.m. The facility's credible allegation of compliance included in part: 1. Resident #79 has been re-assessed by his physician and found to be in stable condition under the current treatment regimen. This resident's care is currently being followed by the facility Medical Director and currently seen on a monthly basis for his psychiatric as well as physical needs. Medical Director will refer for psychiatric services if needed. Licensed nursing and C.N.A. staff assigned to his care will monitor this resident daily per his care plan. This care plan will be updated as any changes in condition would occur. These changes will also be documented and reported any changes in his condition including his history of depression and suicide ideation and gestures. If his current condition changes and he demonstrates verbal or physical actions and statements that suggest thoughts of suicide or self-harm the Charge Nurse will initiate one to one staff coverage to protect the resident until the Attending Physician or Facility Medical Director can be contacted for further direction. - 10/21/10 and ongoing. 2. Current admissions who have had suicide ideation, actual attempts at suicide and/or known history of suicide ideation have the potential to be affected by alleged deficient practice. Therefore current residents residing in the facility on 10-20-10 have had chart reviews completed to determine if any other residents are at risk for alleged deficient practice. No other residents have been identified. - 10/20/10 and ongoing. On 10-22-10 current residents will be evaluated by a Social Workers who have been trained by the facility's Regional MDS/Case Mix

Based on staff interviews and record review, the facility failed to develop a care plan for a resident with [MEDICAL CONDITION] and three attempts to commit suicide while residing at the facility for 1 of 1 resident (#79) and failed to implement a care plan for 1 of 3 residents (#28) with specific splint orders. Resident #79 attempted to commit suicide twice by electrical shock and the third attempt was by cutting his arm. Immediate Jeopardy began on 6/14/10, when the resident was readmitted to the nursing home. The facility's administrator was notified of the Immediate Jeopardy on 10/20/10 at 4:45 p.m. The facility provided an acceptable credible allegation of compliance on 10/22/10 at 3:40 p.m. The immediate jeopardy was removed on 10/22/10 at 6:00 p.m. The facility remained out of compliance at a scope and severity level "D" (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of employee training regarding reporting, assessing and monitoring residents with physical, emotional and mental changes or comments/gestures of self-harm; identifying residents with the potential for suicide gestures; and initiating the facility's policy for suicide precautions. Findings: 1. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Medicare 5 day Minimum Data Set (MDS), dated [DATE], indicated the resident required some supervision with daily decision making in new situations only with short term memory loss. The MDS indicated the resident did not have any indicators of [MEDICAL CONDITION] or depression and no behavioral symptoms. He required limited assistance with transfers, walk in room/corridor, locomotion on/off unit, dressing and toilet use. He required extensive assistance with bathing. He was continent of bowel and bladder. A Resident Assessment Protocol, dated 5/5/10, indicated the resident triggered for cognitive loss due to having short term memory problems due to dementia. It was noted the resident would not have improvements, only declines due to his disease process. A review of a nurse's note, dated 6/1/10 at 1850 (6:50 p.m.), indicated the resident complained of feeling "stressed out." A nurse's note, dated 6/1/10 at 7 p.m. - 7 a.m., indicated the nurse went to give the resident his medications and she "noticed a brokened (sic) clothes hanger jammed in the outlet. The nurse wrote, "equipment removed from room." The resident stated "2 men came in this room, dragged me out blindfolded and did it, I didn't do it." A review of an Incident/Accident Report, dated 6/1/10 (by Nurse #5) indicated the nurse walked into Resident #79's room and she noted a "broken wire clothes hanger sticking out of the electrical outlet." The nurse revised the report (at an unknown date and time) and indicated she meant an unplugged surge protector. During an interview on 10/20/10 at 7:03 p.m., Nursing Assistant (NA) #5 stated she was working on the 3 p.m. - 11 p.m. shift on 6/1/10. She had gone down to check on the resident and found him on the floor. The resident had "undone a hanger and twisted it in a way to put it into the outlet." Whenever she got to the room, the hanger was not in the outlet. There was a surge protector in the room, but it was not plugged in. She indicated they had seen the lights flicker and the electricity for the wall with the electrical outlet was not working. She stated "something happened, he blew the fuse because the power was not working on that wall." NA #5 stated the resident liked staying in his room. Resident #79 "would close himself up if you would let him" "would want the lights off" and "liked to stay in bed." A nurse's note (written by Nurse #2), dated 6/4/10 at 7:30 a.m., indicated the nurse was called to the room, the resident was laying supine with an oxygen mask on his forehead, "bleeding freely" from 2 open wounds on his right forearm. The resident was responsive, but not alert. The nurse further indicated "Pt (patient) was bleeding freely." The physician was notified, 911 was called and the resident was transported to the hospital. A review of an Incident/Accident Report" completed by Nurse #2, dated 6/4/10, indicated on 6/4/10 at 7:30 a.m., the resident had gotten a disposable razor and removed the blade. The resident was bleeding from 2 lacerations to the right forearm. He was alert, responsive and confused. The resident was transported to the hospital. During an interview on 10/19/10 at 4:35 p.m., Nurse #2 stated when she got to the resident's room (on 6/4/10), he was lying in bed with his arm over the trash can and he was "bleeding freely." She stated they found a disposable razor in his bed that the resident had taken apart. The blade had dried blood on it. Nurse #2 asked him what happened and he did not say anything. The resident did tell her that he cut himself. Nurse #2 asked him why he cut himself and the resident stated "no one would listen to me." During an interview on 10/20/10 at 1:28 p.m., NA #1 stated the resident used to say he was tired of living and nobody loved him. During an interview on 10/20/10 at 4:26 p.m., Nurse #6 stated she had been called to the resident's room on 6/4/10 because he was bleeding. She stated he had also taken some wires, maybe the call light wires, and he was going to stick it in the electrical outlet. She indicated the resident had cut the wires before he cut himself. The resident stated he cut the wires because he was going to commit suicide. During an interview on 10/21/10 at 10:03 a.m., Nursing Assistant #2 stated she helped clean the resident up on 6/4/10 after he had cut himself. She remembered the resident saying that day that he wanted to go home. The resident's call light wires were cut and the wall electrical outlet was "messed up." The resident had "pulled the part out like you would plug something up to." She thought they had to fix the power that day. She also thought the resident used his razor to get the socket loose. She indicated when the resident first came to the facility, he just didn't like it but he didn't say why. "He was angry, wouldn't let you do anything for him, he was depressed." She stated the nurses knew he was depressed. He wouldn't really eat, but his family member could get him to eat. During an interview on 10/20/10 at 4:14 p.m., the Director of Nursing (DON) stated she was informed the resident had removed the electrical outlet plate and electrical outlet from the wall and there were shavings found on the floor on 6/4/10. The DON stated it appeared the resident had taken the razor and shaved some of the wires. She verified there were three suicide attempts. On 6/1/10, the resident put the hanger into the electrical outlet, on 6/4/10 he cut the call light wires and electrical outlet wires, and on 6/4/10 the resident cut his arm trying to kill himself. During an interview on 10/20/10 at 3:38 p.m. and 10/21/10 at 11:08 a.m., Physician #1 stated Resident #79 was "terribly depressed." Physician #1 stated he saw the resident in the hospital and the resident told him in passing there was a nursing assistant mistreating him at the nursing home. He stated the resident indicated he did not have anyone to talk to and he was depressed. Resident #79 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the hospital discharge summary, dated 6/14/10, indicated the resident had been admitted for [MEDICAL CONDITION], severe depression, agitation with dementia and two lacerations on the right arm (one measured 5 centimeters (cm) and the second measured 4 cm). The lacerations were sutured in the hospital and he received two units of blood. The resident was started on [MEDICATION NAME] 10 mg daily (antidepressant), [MEDICATION NAME] 1mg twice daily (for agitation associated with dementia), [MEDICATION NAME] 10 mg daily (for dementia) and [MEDICATION NAME] had been increased from 10 mg daily to 10 mg twice daily. The hospital discharge summary further indicated, "Apparently there was some problem with a CNA or so in the nursing home and his care has gotten somewhat compromised. He was being cared for by a CNA in the nursing home. Apparently he became depressed with the whole situation and he tried to cut his hand with a razor." The hospital History and Physical, dated 6/5/10, indicated the resident had "last (sic) of sleep," feelings of worthlessness, sadness and hopelessness and "tried to kill himself by slitting his right wrist with a razor." The resident was admitted to the hospital with [REDACTED]." The resident was discharged back to the facility on [DATE]. A review of Resident #79's medical record indicated the care plans were last updated on 10/18/10. There were care plans for cognitive loss/dementia, activities of daily living, fall risk, nutrition, risk for dehydration, [MEDICAL CONDITION] drug use, oxygen use, anticoagulant therapy, impaired ability to eat, skin integrity and weight loss. There was no care plan to address the resident's suicide ideations and attempted suicides. During an interview on 10/20/10 at 10:47 a.m., MDS Coordinator #1 reviewed the resident's care plans and indicated she did not update the care plan when he was readmitted to the facility after having tried to commit suicide. She indicated there should have been a care plan update. 2. Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with cumulative [DIAGNOSES REDACTED]. The resident was coded on the most recent MDS (minimum data set) dated 08/30/10 as having short and long term memory problems and as being impaired in the decision making process. In addition, the resident was coded as having partial loss limitiations on both of her arms, hands, legs, and feet. There was nothing found in the RAPs (resident assessment protocols) or in the resident's care plan about the contractures. A review of the physician orders [REDACTED]. The order was initially dated 06/09/09. There was an additional order that read "don/doff knee orthosis daily 5 to 8 hours to both knees." Observation of the resident on 10/20/10 at 11:15 AM and again on 10/22/10 at 2:35 PM revealed that the hand and the knee splints were in place. Interview with the MDS Coordinator on 10/21/10 at 11:36 AM it was revealed "if it is on TAR (treatment administaration record) or on the MAR (medication administration record), I don't think it needs to be on the care plan. A review of the MAR and the TAR for Resident #28 revealed that the order for the hand splint was on the MAR as a fyi (for your information) and that there was nothing about the knee splints. The MDS Coordinator then stated "I guess it should be on the care plan." The facility's administrator was notified of the Immediate Jeopardy on 10/20/10 at 4:45 p.m. The facility provided an acceptable credible allegation of compliance on 10/22/10 at 3:40 p.m. The facility's credible allegation of compliance included in part: 1. Resident #79 has been re-assessed by his physician and found to be in stable condition under the current treatment regimen. This resident's care is currently being followed by the facility Medical Director and currently seen at least on a monthly basis. - 10/21/10 2. Current admissions who have had suicide ideation, actual attempts at suicide and/or known history of suicide ideation have the potential to be affected by alleged deficient practice. Therefore current residents residing in the facility on 10-20-10 have had chart reviews completed by the Assistant Director of Nurses, two MDS Nurses, and two Charge Nurses to determine if any other residents are at risk for alleged deficient practice. No other residents have been identified. - 10/20/10 On 10-22-10 current interviewable residents have been interviewed by Licensed Social Workers and/or Registered Nurses who have been trained by the facility's Regional Assessment Coordinator in the utilization of the PHQ9 depression assessment tool and who were not involved in the care of Resident #79 during the alleged deficient practice. - 10/22/10 Facility incident logs have been reviewed since January 1, 2010 to identify any other resident who can be identified at risk for alleged deficient practice and none were found. - 10/21/10 Beginning on 10-21-10, the Administrator implemented a plan for new admission and re-admission charts and resident incident reports to be reviewed at the daily clinical meeting by the Interdisciplinary team composed of the Director of Nursing, Assistant Director of Nursing, Nurse Managers, MDS nurse, Social Worker, Activities Director and/or Dietary Manager. Residents identified at risk for alleged deficient practice will be assessed by a physician, and a treatment plan will be put in place. - 10/21/10 3. Systems/Training in place to ensure alleged compliance are: ? The Admissions Director, Administrator and/or Director of Nursing will review pre-admission data including hospital records, PAASAR's, etc to determine any prior history of suicide ideation or attempts prior to admission. If this information raises any questions about the abilities of the facility's clinical programs and services to properly care for this referral, the MD Director and the Administrator along with the Interdisciplinary team comprised of Director of Nursing, Assistant Director of Nursing, Nurse Managers, MDS nurse and/or Social Worker will make a decision about the admission of this referral. If the decision is made to admit this referral, the above stated IDT team will initiate a written care plan based upon his preadmission information and communicate this plan to those caregivers assigned to his care. ? New admission and re-admission charts will be reviewed by the clinical team at the daily clinical meetings to ensure that any new information including hospital discharge summaries have been reviewed. Any additional information gathered will be integrated into the resident's existing care plan. Any discrepancies in the physician orders [REDACTED]. ? Any medical history and/or written records will be reviewed by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) or MDS (Assessment) nurse prior to filing in residents chart. Additional information will be integrated into the residents plan of care. ? Nurses shall document all reports from other staff, residents, families, etc regarding behaviors or threats of self injury or ideation of harm are to be documented in the medical record, reported to physician and responsible party and documented on the 24 hour nursing report. ? The 24 hour nursing report and all new incident reports will be reviewed at the next days clinical meeting (Monday thru Friday) so that the Director of Nurses can initiate and implement appropriate interventions for treatment and services. Week-end and Holidays reports will be reviewed at the next working days clinical meeting. Should an emergent situation arise on week-ends or Holidays the DON, ADON and/or Medical Director shall be notified to ensure that the residents immediate needs are cared for. ? Physician orders [REDACTED]. Any refusal of the resident or responsible party (RP) to sign a consent for authorization for services will be reported at the daily clinical meetings and documented in the resident's medical record and reported to the residents physician. ? Weekly behavior meetings will be conducted by the standards of care committee comprised of the DON, Social Worker, Activities Director and/or the MDS nurse. Changes in condition and/or response to treatment plans will be reviewed. The summary of these findings will be documented in the residents current medical record and physician and responsible party notifications will be made. ? The following Inservice Education (points A and B below) began on 10-21-10 at 1:00pm and conducted by the DON, ADON and/or Staff Development Coordinator who are all registered nurses. Employees not inserviced by 10-21-10 will be inserviced before reporting for their next day of work. A. Licensed nurses and certified nursing assistants topics are "Reporting changes in condition to include identifying residents with the potential for suicide gestures;assessing and monitoring residents for with physical and emotional and mental changes to ensure that each resident receives the necessary services to ensure their optimum well-being; Initiating the existing facility policy for suicide precautions. These precautions include removing physical items such as scissors which the resident could use to cause harm, observing the resident closely for any such self-destructive behavior which if noted will be reported by the Charge Nurse to the DON and the resident's physician. These observations and communications shall be documented in the nurse's notes. Mental Health referrals will be made as soon as possible if designated by the physician. Other precautions might include interventions such as remaining with the resident and calling for assistance, one-to-one staff coverage, every 15 minute checks, transport to a hospital emergency room , etc. This in service will also be included in new employee orientation. B. Other facility staff having non-direct contact with the residents from the following departments as Housekeeping, Dietary, Activities, Maintenance, Business Office, and Social Services staff will also receive inservices by the DON, ADON and/or SDC. These topics will include "Reporting any comments and/or gestures of self-harm made by residents or about residents immediately to a licensed nurse so that appropriate care and interventions be put in place. If the resident is in immediate danger stay with the resident and call for assistance." - 10/21/10 and ongoing This inservice will also be included in new employee orientation. ? Any staff failure to report or document as per this procedure will be either re-inserviced or disciplined as needed. - Ongoing 4. Monitoring will be done by reviewing all new admission and re-admission charts daily at the clinical meetings (Monday Thru Friday) and those admissions arriving on a week-end or Holiday will be reviewed by the charge nurse on day of admission and then again by the clinical team on the next work day's clinical meeting. This monitoring is a permanent and on-going system. Five (5) other charts will be audited by the DON, ADON or SDC daily for 30 days, weekly for 60 days and monthly for 3 months. All trends and patterns will be reported to the QA Committee who will adjust this plan as necessary. - Ongoing Validation of the credible allegation of compliance begun on 10/22/10 at 3:55 p.m. The validation included reviewing the lesson plans for the in-services that were completed, interviews with staff related to the physician notification, assessing and monitoring residents with ideation or gestures of self harm. In addition, the physician's notes and the care plan for Resident #79 were reviewed.

Based on observation, staff interviews and record review, the facility failed to notify the physician of a resident's [MEDICAL CONDITION] and three attempts to commit suicide for 1 of 1 resident (#79). The facility failed to notify the physician of the first attempt. On the date of second and third attempts, the physician was notified and the resident was sent out to the emergency department. Immediate Jeopardy began on 6/1/10. The facility's administrator was notified of the Immediate Jeopardy on 10/20/10 at 4:45 p.m. The facility provided an acceptable credible allegation of compliance on 10/22/10 at 3:40 p.m. The Immediate Jeopardy was removed on 10/22/10 at 6 p.m. The facility remained out of compliance at a scope and severity level "D" (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of employee training regarding reporting, assessing and monitoring residents with physical, emotional and mental changes or comments/gestures of self-harm; identifying residents with the potential for suicide gestures; and initiating the facility's policy for suicide precautions. Findings: Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission day Minimum Data Set (MDS), dated [DATE], indicated the resident required some supervision with daily decision making in new situations only with short term memory loss. The MDS indicated the resident did not have any indicators of [MEDICAL CONDITION] or depression and no behavioral symptoms. A Resident Assessment Protocol, dated 5/5/10, indicated the resident triggered for cognitive loss due to having short term memory problems due to dementia. It was noted the resident would not have improvements, only declines due to his disease process. A review of a nurse's note, dated 6/1/10 at 6:50 p.m. indicated the resident complained of feeling "stressed out." The nurse documented that she gave the resident [MEDICATION NAME] and later checked on him. The resident stated his chest and stomach hurt. The nurse then administered two [MEDICATION NAME], 5 minutes apart as prescribed. He stated his chest was not hurting anymore, but he felt bad and wanted to go to the hospital. The nurse called the resident's physician and he prescribed [MEDICATION NAME] 5/500mg, three times daily for pain. A nurse's note (by Nurse #5), dated 6/1/10 at "7 p - 7 a" indicated the resident was complaining of "pain." The resident was given medication with relief. The nurse indicated the resident was getting up out of bed from the chair to the bed without assistance. She spoke to him about the concerns about falling on the floor. She went to give the resident his medications and she "noticed a brokened (sic) clothes hanger jammed in the outlet. The nurse documented "equipment removed from room." The resident stated "2 men came in this room, dragged me out blindfolded and did it, I didn't do it." There was no indication the physician was notified. A review of an Incident/Accident Report, dated 6/1/10 (by Nurse #5) indicated the nurse walked into Resident #79's room and she noted a "broken wire clothes hanger sticking out of the electrical outlet." The nurse revised the report (at an unknown date and time) and documented she meant an unplugged surge protector. The surge protector was removed from the room. Nurse #5 documented in a statement she had removed the wire hanger from the outlet with a dry cloth. The incident report indicated the physician was not notified. Nurse #5 was unavailable for interview. During an interview on 10/20/10 at 7:03 p.m., Nursing Assistant (NA) #5 stated she was working on the 3 p.m. - 11 p.m. shift on 6/1/10. She had gone down to check on the resident and found him on the floor. The resident had "undone a hanger and twisted it in a way to put it into the outlet." Whenever she got to the room, the hanger was not in the outlet. There was a surge protector in the room, but it was not plugged in. She indicated they had seen the lights flicker and the electricity for the wall with the electrical outlet was not working. She stated "something happened, he blew the fuse because the power was not working on that wall." A nurse's note (written by Nurse #2), dated 6/4/10 at 7:30 a.m., indicated the nurse was called to the room, the resident was lying supine with an oxygen mask on his forehead, "bleeding freely" from 2 open wounds on his right forearm. The resident was responsive, but not alert. The physician was notified, 911 was called and the resident was transported to the hospital. A review of an Incident/Accident Report" completed by Nurse #2, dated 6/4/10, indicated on 6/4/10 at 7:30 a.m., the resident had gotten a disposable razor and removed the blade. The resident was bleeding from 2 lacerations to the right forearm. He was alert, responsive and confused. The resident was transported to the hospital. A witness statement from Nurse #2 indicated she was called to the resident's room by a nursing assistant. The resident was found holding his arm over a trash can, bleeding freely from wounds to (not legible). The razor blade from the disposable razor was found in the resident's bed, covered with blood. Nurse #2 indicated blood covered the resident's fingers on his left hand. However, no wounds were found on his left fingers. A witness statement by Nurse #3 indicated a nursing assistant reported the resident cut himself. He was holding his arm over the trash can, bleeding upon entering the room. The razor was found under the resident in his bed. She also noted blood covered the resident's fingers on his left hand. During an interview on 10/19/10 at 4:35 p.m., Nurse #2 stated when she got to the resident's room (on 6/4/10), he was lying in bed with his arm over the trash can and he was "bleeding freely." She stated they found a disposable razor in his bed that the resident had taken apart. The blade had dried blood on it. The resident did tell her that he cut himself. Nurse #2 asked him why he cut himself and the resident stated "no one would listen to me." A review of the hospital discharge summary, dated 6/14/10, indicated the resident had been admitted for [MEDICAL CONDITION], severe depression, agitation with dementia and two lacerations on the right arm (one measured 5 centimeters (cm) and the second measured 4 cm). The lacerations were sutured in the hospital and he received two units of blood. The resident was started on [MEDICATION NAME] 10 mg daily (antidepressant), [MEDICATION NAME] 1mg twice daily (for agitation associated with dementia), [MEDICATION NAME] 10 mg daily (for dementia) and [MEDICATION NAME] had been increased from 10 mg daily to 10 mg twice daily. The hospital discharge summary further indicated, "Apparently there was some problem with a CNA (Certified Nursing Assistant) or so in the nursing home and his care has gotten somewhat compromised. He was being cared for by a CNA in the nursing home. Apparently he became depressed with the whole situation and he tried to cut his hand with a razor." The hospital History and Physical, dated 6/5/10, indicated the resident had "last (sic) of sleep," feelings of worthlessness, sadness and hopelessness and "tried to kill himself by slitting his right wrist with a razor." The resident was admitted to the hospital with [REDACTED]." The resident was discharged back to the facility on [DATE]. During an interview on 10/20/10 at 1:28 p.m., NA #1 stated the resident used to say he was tired of living and nobody loved him. She stated she reported his comments to Nurse #7. NA #1 had worked the night shift on 6/3/10. On 6/4/10, NA #1 stated she checked on the resident and she noticed the resident was bleeding. She then went to get the nurse. She stated he was bleeding a lot. She stated he had just cut a little slit to make his arm bleed. Nurse #7 was no longer employed by the facility. Attempts were made to contact her by phone, but she did not return the calls. During an interview on 10/20/10 at 4:26 p.m., Nurse #6 stated she had been called to the resident's room on 6/4/10 because he was bleeding from cutting his arm. She stated he had also taken some wires, maybe the call light wires, and he was going to stick it in the electrical outlet. She indicated the resident had cut the wires before he cut himself. The resident stated he cut the wires because he was going to commit suicide. During an interview on 10/20/10 at 4:14 p.m., the Director of Nursing (DON) stated she was informed the resident had removed the electrical outlet plate and electrical outlet from the wall and there were shavings found on the floor on 6/4/10. The DON stated it appeared the resident had taken the razor and shaved some of the wires. She verified there were three suicide attempts. On 6/1/10, the resident put the hanger into the electrical outlet, on 6/4/10 he cut the call light wires and electrical outlet wires, and on 6/4/10 the resident cut his arm trying to kill himself. A review of the medical record indicated there was no documentation about the resident cutting the call light wires and electrical outlet wires. There was no evidence the facility reported it to the physician. During an interview on 10/19/10 at 3:15 p.m. and 4:10 p.m., Social Worker (SW) #1 stated on 6/1/10, the resident had been complaining of pain. She stated she informed Nurse #3. SW #1 stated the resident kept saying he wanted to go to the hospital. SW #1 indicated on 6/1/10, the resident informed her he was hearing voices. Resident #79 stated the "devil voices" in his head was telling him to kill himself. She stated she informed Nurse #3 of the resident's [MEDICAL CONDITION]. SW #1 stated Nurse #3 indicated she would notify the physician and monitor the resident. SW #1 stated on 6/2/10, she was informed the resident had taken a hanger and put it in a wall socket. On 6/2/10, SW #1 went to talk with the resident about the incident. The resident told her he had put the hanger in the socket in an attempt to kill himself. Resident #79 again told SW #1 that he was hearing voices that were telling him to kill himself. Review of the Social Work Progress notes revealed no documentation was available related to the incident of 6/1/10 or reporting the resident's statements to the RN. During an interview on 10/20/10 at 12:33 p.m., Nurse #3 stated the resident used to say he wanted to go to the hospital. It had been reported to her the resident would do things to try to get out of the facility, such as complain of chest pain. She stated the resident had informed her he was stressed out (on 6/1/10). He never stated to her that he wanted to kill or hurt himself. She stated she did not recall SW #1 reporting to her the resident was hearing voices and wanted to kill himself. She had not reported the resident's [MEDICAL CONDITION] to the physician because she was not informed by SW #1 the resident was having suicidal thoughts. During an interview on 10/20/10 at 3:38 p.m. and 10/21/10 at 11:08 a.m., Physician #1 stated Resident #79 was "terribly depressed." He stated he knew the resident was depressed, but he did not know he was hearing voices. Physician #1 indicated the nurses had never reported to him the resident was having [MEDICAL CONDITION]. He stated he would have expected the nurses to notify him as soon as possible and put interventions in place. He would have made a decision to send him out or keep the resident at the facility based on how acute his condition was at that time. He stated if the resident had been safe to remain in the facility, he would have told the staff to know his whereabouts at all times and be monitoring him. During an interview on 10/20/10 at 12:00 p.m. and 4:14 p.m., the DON indicated Nurse #3 and SW #1 had not informed her of the resident's [MEDICAL CONDITION]. She stated "I would expect them to contact me and we would need to put them (the resident) on precautions, get some kind of immediate action in place." She was questioned why the physician was not notified and why the resident was not placed on suicide monitoring. She indicated it was a failure at all levels. The facility's administrator was notified of the Immediate Jeopardy on 10/20/10 at 4:45 p.m. The facility provided an acceptable credible allegation of compliance on 10/22/10 at 3:40 p.m. The facility's credible allegation of compliance included in part: 1. Resident #79 has been re-assessed by his physician and found to be in stable condition under the current treatment regimen. This resident's care is currently being followed by the facility Medical Director and currently seen at least on a monthly basis. - 10/21/10 2. Current admissions who have had suicide ideation, actual attempts at suicide and/or known history of suicide ideation have the potential to be affected by alleged deficient practice. Therefore current residents residing in the facility on 10-20-10 have had chart reviews completed by the Assistant Director of Nurses, two MDS Nurses, and two Charge Nurses to determine if any other residents are at risk for alleged deficient practice. No other residents have been identified. - 10/20/10 On 10-22-10 current interviewable residents have been interviewed by Licensed Social Workers and/or Registered Nurses who have been trained by the facility's Regional Assessment Coordinator in the utilization of the PHQ9 depression assessment tool and who were not involved in the care of Resident #79 during the alleged deficient practice. - 10/22/10 Facility incident logs have been reviewed since January 1, 2010 to identify any other resident who can be identified at risk for alleged deficient practice and none were found. - 10/21/10 Beginning on 10-21-10, the Administrator implemented a plan for new admission and re-admission charts and resident incident reports to be reviewed at the daily clinical meeting by the Interdisciplinary team composed of the Director of Nursing, Assistant Director of Nursing, Nurse Managers, MDS nurse, Social Worker, Activities Director and/or Dietary Manager. Residents identified at risk for alleged deficient practice will be assessed by a physician, and a treatment plan will be put in place. - 10/21/10 3. Systems/Training in place to ensure alleged compliance are: ? The Admissions Director, Administrator and/or Director of Nursing will review pre-admission data including hospital records, PAASAR's, etc to determine any prior history of suicide ideation or attempts prior to admission. If this information raises any questions about the abilities of the facility's clinical programs and services to properly care for this referral, the MD Director and the Administrator along with the Interdisciplinary team comprised of Director of Nursing, Assistant Director of Nursing, Nurse Managers, MDS nurse and/or Social Worker will make a decision about the admission of this referral. If the decision is made to admit this referral, the above stated IDT team will initiate a written care plan based upon his preadmission information and communicate this plan to those caregivers assigned to his care. ? New admission and re-admission charts will be reviewed by the clinical team at the daily clinical meetings to ensure that any new information including hospital discharge summaries have been reviewed. Any additional information gathered will be integrated into the resident's existing care plan. Any discrepancies in the physician orders [REDACTED]. ? Any medical history and/or written records will be reviewed by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) or MDS (Assessment) nurse prior to filing in residents chart. Additional information will be integrated into the residents plan of care. ? Nurses shall document all reports from other staff, residents, families, etc regarding behaviors or threats of self injury or ideation of harm are to be documented in the medical record, reported to physician and responsible party and documented on the 24 hour nursing report. ? The 24 hour nursing report and all new incident reports will be reviewed at the next days clinical meeting (Monday thru Friday) so that the Director of Nurses can initiate and implement appropriate interventions for treatment and services. Week-end and Holidays reports will be reviewed at the next working days clinical meeting. Should an emergent situation arise on week-ends or Holidays the DON, ADON and/or Medical Director shall be notified to ensure that the residents immediate needs are cared for. ? Physician orders [REDACTED]. Any refusal of the resident or responsible party (RP) to sign a consent for authorization for services will be reported at the daily clinical meetings and documented in the resident's medical record and reported to the residents physician. ? Weekly behavior meetings will be conducted by the standards of care committee comprised of the DON, Social Worker, Activities Director and/or the MDS nurse. Changes in condition and/or response to treatment plans will be reviewed. The summary of these findings will be documented in the residents current medical record and physician and responsible party notifications will be made. ? The following Inservice Education (points A and B below) began on 10-21-10 at 1:00pm and conducted by the DON, ADON and/or Staff Development Coordinator who are all registered nurses. Employees not inserviced by 10-21-10 will be inserviced before reporting for their next day of work. A. Licensed nurses and certified nursing assistants topics are "Reporting changes in condition to include identifying residents with the potential for suicide gestures;assessing and monitoring residents for with physical and emotional and mental changes to ensure that each resident receives the necessary services to ensure their optimum well-being; Initiating the existing facility policy for suicide precautions. These precautions include removing physical items such as scissors which the resident could use to cause harm, observing the resident closely for any such self-destructive behavior which if noted will be reported by the Charge Nurse to the DON and the resident's physician. These observations and communications shall be documented in the nurse's notes. Mental Health referrals will be made as soon as possible if designated by the physician. Other precautions might include interventions such as remaining with the resident and calling for assistance, one-to-one staff coverage, every 15 minute checks, transport to a hospital emergency room , etc. This in service will also be included in new employee orientation. B. Other facility staff having non-direct contact with the residents from the following departments as Housekeeping, Dietary, Activities, Maintenance, Business Office, and Social Services staff will also receive inservices by the DON, ADON and/or SDC. These topics will include "Reporting any comments and/or gestures of self-harm made by residents or about residents immediately to a licensed nurse so that appropriate care and interventions be put in place. If the resident is in immediate danger stay with the resident and call for assistance." - 10/21/10 and ongoing This inservice will also be included in new employee orientation. ? Any staff failure to report or document as per this procedure will be either re-inserviced or disciplined as needed. - Ongoing 4. Monitoring will be done by reviewing all new admission and re-admission charts daily at the clinical meetings (Monday Thru Friday) and those admissions arriving on a week-end or Holiday will be reviewed by the charge nurse on day of admission and then again by the clinical team on the next work day's clinical meeting. This monitoring is a permanent and on-going system. Five (5) other charts will be audited by the DON, ADON or SDC daily for 30 days, weekly for 60 days and monthly for 3 months. All trends and patterns will be reported to the QA Committee who will adjust this plan as necessary. - Ongoing Validation of the credible allegation of compliance begun on 10/22/10 at 3:55 p.m. The validation included reviewing the lesson plans for the in-services that were completed, interviews with staff related to the physician notification, assessing and monitoring residents with ideation or gestures of self harm. In addition, the physician's notes and the care plan for Resident #79 were reviewed.