Every finding on record at Longleaf Neuro-Medical Treatment Center

Based on record review, resident interview and staff interviews, the facility failed to ensure safe wheelchair transport for one resident reviewed for accident prevention. Staff transported the resident in a wheelchair without leg rests attached, resulting in the resident's left leg dragging on the floor and becoming caught underneath the wheelchair, causing minor injury to the resident's knee. This practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2). The findings included:Resident #2 was admitted on [DATE] with diagnoses including functional quadriplegia, cerebral palsy, right arm pain and localized edema.Review of the care plan dated 7/25/2025 revealed Resident #2 required extensive assistance with activities of daily living related to cerebral palsy. The care plan indicated the resident participated in activities of daily living (ADL's) by alerting staff to needs and performing limited hygiene tasks with setup and supervision. The annual Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. The assessment indicated the resident utilized a wheelchair for mobility and was dependent on staff for upper body dressing, lower body dressing, footwear application, personal hygiene, rolling left and right, and chair-to-bed transfers. Sit-to-stand, lying-to-sitting, sitting-to-lying, and toilet transfers were not attempted due to medical condition or safety concerns. The resident was also coded as incontinent of bowel and bladder. On 6/17/26 at 12:30 pm an interview with Resident #2 revealed that on 6/4 she was going out to an appointment and she needed to be in a manual wheelchair. She stated that she normally used the motorized wheelchair that she was currently sitting in, but when she went out to appointments, she used a manual wheelchair. Staff got her into the manual wheelchair, but one of the leg rests was broken. It did not have the pad part that she rests her leg on. She stated that she sat in the manual wheelchair while they looked for different leg rests. Eventually, a man, she thinks he was maintenance, brought them the different leg rests. The man said that she had to get out of the chair in order for him to put them on. The Health Care Tech (HCT) asked if she was ready to go back to her room and she stated yes. The HCT started pushing her to her room without the leg rests and her left leg was dragging. Her leg got caught under the chair and she felt pain in her knee. Resident #2 stated that she yelled out my knee and the HCT stopped immediately and asked if she was ok. Resident #2 says she stated that she was fine and the HCT then pulled her backwards into her room. She stated that no HCT tried to hold her legs up while pushing her to her room. Resident #2 stated that she does not have any permanent injury or pain from the incident. She could not remember the name of the HCT pushing her.On 6/17/2026 at 3:38 pm HCT #1 stated that she got Resident #1 up and into her wheelchair morning of 6/4/2026. She could not remember the exact time but states that it was early as she got off at 7:00 am. She stated that her and HCT #2 got Resident #2 up to the manual wheelchair using the mechanical sit to stand lift. This was the regular time that they usually get resident up but they put her in the manual wheelchair because they knew she was going to an appointment. The manual wheelchair was already in the room and but there were no leg rests. She stated that she did not know when resident last used the manual wheelchair or when it was left in the room. She and HCT #2 proceeded to put resident in the manual wheelchair and Resident #2 immediately became upset when she saw there were no leg rests. She stated that Resident #2 started yelling and complaining and said go find my leg rests. HCT #2 went to find leg rests while she (HCT #1) started cleaning the room and getting things ready. She (HCT #1) asked resident if she wanted to go into the hallway until they found the leg rests and Resident #2 said no. HCT #2 returned with some leg rests back but they were missing a leg piece and resident started yelling again. HCT #2 told Resident #2 they could not find the correct leg rests and would tell the nurse. HCT #1 stated that they left Resident #2 in room, in manual wheelchair with the incorrect leg rests. HCT #1 stated that one of the leg rests was missing the cushion. HCT #1 stated that she went to chart and HCT #2 went to tell nurse about leg rests and to get other residents up. In an interview with HCT #2 on 6/17/26 at 3:24 pm it was revealed that she and HCT #1 went into Resident #2 room to get her up for the day. She stated that she was familiar with Resident #2 and knew her to be a 2-person assist. HCT #2 stated that she and HCT #1 got Resident #2 into her manual wheelchair using the mechanical sit to stand lift. The wheelchair had only one leg rest and Resident #2 became upset and said to go and find her other leg rest. She went to look for the leg rests but could not find the correct leg rests. Resident began cursing and was upset so she and HCT #1 left Resident #2 in the room while they did other things. HCT # 2 stated that she was helping other residents when she noticed Resident #2 rolling herself out of the room cursing saying no one helping her. HCT #2 stated that she had never seen Resident #2 come out of her room in the manual wheelchair, by herself. HCT #2 stated resident was moving very slowly and was only able to use right arm to maneuver the wheelchair. Once she had been in the hall a few minutes, the maintenance man walked up with the new leg rests. He stated that he needed Resident #2 to get out of the wheelchair in order for him to work on it. At this point, HCT #3 walked up and asked Resident #2 if she was ready to go back to her room. HCT #2 stated that HCT #3 started pushing Resident #2 back to the room while HCT #2 walked along beside them. HCT #2 stated she heard HCT #3 telling Resident #2 to lift her legs up. HCT #2 stated that she told HCT #3 that usually, when someone's legs don't work, she roll them backwards. HCT #2 stated that it seemed as soon as she said that Resident #2 leg went under the chair a little bit and resident yelled out. HCT #3 immediately stopped and asked resident if she was ok while HCT #2 helped resident get her leg out. HCT #2 stated that she offered to get nurse to look at Resident #2 leg before going to room but resident said no. HCT #2 stated that she believed that Resident #2 can lift her legs if resident wants to. HCT#2 stated that she had never seen Resident #2 stand or walk unassisted or with assistance.In an interview with HCT #3 on 6/17/26 at 12:03 pm, HCT #3 stated she was assigned to another resident on 6/4/2026 for 1 to 1 supervision when she was asked by nurse to help with Resident #2. She stated that Nurse #1 asked her to help HCT #2 transfer Resident #2 from wheelchair to another chair. HCT #3 stated that she has worked with Resident #2 before and was aware that Resident #2 was total care and could not stand or walk. HCT #3 stated that she went to Resident #2, who was sitting in the hallway, and asked if she was ready to go to her room. HCT #3 did notice plant ops (maintenance) waiting with the leg rests and that there were no leg rests on Resident #2 wheelchair. Resident #2 said yes, she was ready to go to room, and she begin to push her down the hallway when Resident #2 said ouch. She immediately stopped and asked her if she was okay and she said yes. HCT #3 continued on to the room and helped transfer resident to chair. She stated that Resident #2 did not complain about pain or say anything else about leg. She did not see any issue with pushing resident in chair without leg rests as she believed resident would be able to pick up feet.In an interview with Maintenance Worker on 6/4/2026 at 1:27 pm he stated that he was asked to put leg rests on the wheelchair for Resident #2. He stated that he believed that it was the Nurse that called in the request. When he arrived at the hall, Resident #2 was sitting outside of her room in a wheelchair. The wheelchair had leg rests on it and he removed them. He stated that he told them he was unable to put the new leg rests on the wheelchair with resident sitting in chair. He stated that he tried not to work on any equipment that a resident was actively using. He stated that it was just precautionary. He stated that the HCT started pushing Resident #2 and resident yelled out my knee, my knee. He estimated that the HCT had taken 4 or 5 steps when the resident yelled out. He stated that the HCT stopped immediately and asked resident if she was ok. He stated that they continued on to the room and once they had transferred the resident out of the chair, one of the HCT's pushed the wheelchair back out to him. He then put on the leg rests. On 6/17/2026 at 2:02 pm the Occupational Therapist stated that staff should not have tried to push resident in wheelchair without leg rests. She stated that Resident #2 was a max 2-person assist with mechanical sit to stand lift for transfers to bed and power scooter and would not have been able to hold her legs up unassisted.An interview with Center Director (Administrator) in the presence of the Assistant Center Director on 6/17/2026 at 4:30 pm revealed that the expectation was for staff to transport residents in wheelchairs with leg rests. She stated that there may be some circumstances where it would be permissible for staff not to use leg rests such as resident request or resident able to self-propel. She stated that she also believed that Resident #2 was able to move her legs despite the diagnosis of quadriplegia. She believed that staff thought Resident #2 able to self-propel. She stated that this incident had already been investigated by the facility and was no deficiency.

Based on record review and staff interview, the facility failed to provide care in a safe manner. During incontinence care a resident fell while standing and sustained a fracture of the left distal femoral shaft (break in the lower portion of the thighbone just above the knee) with malalignment. This practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was admitted to the facility on [DATE] with diagnoses that included major neurocognitive disorder due to vascular disease with behavioral disturbance and disorganized schizophrenia. Resident #1 was not available for interview because she was hospitalized at the time of the investigation.The care plan dated 7/9/2025 and revised 3/26/2026 documented Resident #1 was at risk for falls/injury related to dementia, poor safety awareness, aggression, and medication use. Interventions included implementing fall prevention measures, assisting the resident with personal hygiene, queueing and reorientation as needed, and monitoring behaviors and safety concerns. Staff were also to provide assistance with transfers and activities of daily living (ADL) as needed. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact. The MDS documented that Resident #1 used a wheelchair for mobility and required extensive total assistance with activities of daily living (ADL), including toileting hygiene, bathing, personal hygiene, and transfers. Resident was coded as dependent for sit-to-stand transfers and required substantial/maximal assistance for chair/bed-to-chair transfers. Toilet transfers were not attempted due to medical condition or safety concerns but indicated Resident #1 was always incontinent with bladder and bowel. The MDS coded the resident as having no falls since admission, reentry, or prior assessment. The MDS recorded weight was 125 pounds, height was 5 feet 3 inches and resident was not on any blood thinners.An interview with Health Care Technician (HCT) #1 on 5/6/2026 at 12:50 pm revealed she entered the Resident #1 room with HCT #2 on 5/4/2026 between 2:50 pm and 3:00 pm, after Resident #1 returned from activities because resident repeatedly stated she was wet. HCT #1 stated they were changing Resident #1 in her room, with the walker facing the bed. HCT #1 indicated that this was the way they always changed the resident if she was up and out of bed. HCT #1 stated she stood on one side and HCT #2 stood on the other side, and they assisted the resident to stand from the wheelchair using the walker to hold herself up. HCT #1 stated they removed Resident #1's tabbed wet brief and put a dry tabbed brief on. HCT #1 recalled that resident was wearing a silky like gown and once they had the brief on, all they had to do was drop the gown. HCT #1 stated that once they dropped the gown, resident said, I'm falling, and began going down. HCT #1 stated she did not recall the exact placement of the wheelchair but stated it was not far away. HCT #1 stated they attempted to move the wheelchair underneath the resident, but the resident sat on the edge of the wheelchair. HCT #1 stated she and HCT #2 recognized Resident #1 was not positioned far enough back in the wheelchair and attempted to pull the resident further onto the wheelchair cushion using the gait belt but were unable to move the resident. Resident #1 fell to her knees from the seat of the wheelchair and then fell to the side at an awkward angle. HCT #1 stated the resident landed with one leg, she could not recall which leg but thought it may have been the left, underneath the bed. HCT #1 stated she and HCT #2 used the gait belt to pull Resident #1 from underneath the bed and then obtained a mechanical lift pad. HCT #1 stated she and HCT #2 rolled the resident from side to side to place the mechanical lift pad underneath her and then HCT #1 went to get the nurse while HCT #2 stayed with the patient. HCT #1 did recall that patient immediately began complaining of knee pain after the fall.In an interview with HCT #2 on 5/14/2026 at 2:15 pm she stated that on 5/4/2026 she and HCT #1 entered Resident #1 room after resident returned from activities. She could not remember the exact time but thought it may have been a little after 3:00 pm. They went into the room to change the resident because the resident kept saying that she was wet. HCT #2 stated that they frequently changed resident in her room from the wheelchair. HCT #2 stated that after resident was changed, she attempted to sit before they put the wheelchair fully back under her. HCT #2 stated that resident sat on the edge of the seat of the wheelchair and then began falling forward to her knees. They did attempt to keep the resident on the wheelchair, but they were not able to keep her from falling. Once she fell, she was under the bed a little bit, so they used the gait belt to pull her from under the bed. HCT #2 stated they got the mechanical lift pad from outside of the room and rolled resident two times to put the pad under her. HCT #2 stated they did this because they knew that they would need the mechanical lift to get patient up off the floor. HCT #2 stated she stayed with resident while HCT #1 got the nurse. HCT #2 stated that she did not recall Nurse #1 doing any range of motion checks with the resident or resident refusing. HCT #2 stated that once Nurse #1 said it was ok, they used the mechanical lift to pick resident up off floor and placed her on the bed.A nursing note (Nurse #1) dated 5/5/2026 at 6:20 pm stated that on 5/4/2026 Nurse #1 was called to Resident #1 room by Health Care Technician (HCT). Nurse #1 stated that upon arriving, resident was lying on back with mechanical lift pad already underneath her.In an interview with Nurse #1 on 5/6/2026 at 12:31 pm she stated that on 5/4/2026 sometime after 3:00 pm, Health Care Technician (HCT) #2 came and got her saying that Resident #1 was on the floor. When she arrived in the room, Resident #1 was lying on floor, on a mechanical lift pad. She stated that Resident #1 would not allow nurse to check her range of motion (ROM) but was complaining of knee pain. Nurse #1 stated that there were no visible signs of injury. She stated that since resident was complaining of knee pain, an x-ray was ordered and it showed a fracture. Resident #1 was sent out to the hospital once the x-ray confirmed a fracture.A physician progress note dated 5/5/2026 at 10:15 am documented the resident sustained an assisted fall after attempting to sit down prior to seating being in place. The resident complained of left knee pain following the fall. Records further showed that on 5/5/2026 an x-ray of left knee showed fracture of the distal femoral shaft with malalignment.A review of records revealed that resident was discharged from the facility on 5/5/2026 and admitted to the hospital.The Director of Nursing (DON) stated in an interview on 5/14/2026 at 2:45 pm that nursing staff frequently changed Resident #1 from her wheelchair. The DON stated that it would have been better for staff to get the Resident into the bathroom for incontinence care, but Resident #1 does not always cooperate. The DON agreed that residents should not fall during incontinence care or while staff were providing care.In an interview with Care Director (facility Director) on 5/14/2026 at 2:51 pm she stated that during the facility investigation it was found that Resident #1 needed to be changed. HCT #1 and HCT #2 entered resident's room, put a gait belt on resident, put the walker in front of resident and asked her to stand up. Resident #1 was able to stand with no issue, but when she went to sit back down in the wheelchair, she sat too close to the edge of the wheelchair. The HCT's attempted to slide her back into the wheelchair utilizing the gait belt but were unable to and resident fell out of the chair to her knees. At the time of the fall Resident #1's mobility was plus two assist with transfers with gait belt and rolling walker. An interview with the Medical Director was conducted on 5/14/2026 at 2:25 pm. The Medical Director stated that she was aware that Resident #1 had a fall from her wheelchair on 5/4/2026. The Medical Director indicated she had some concerns about the way the incident was documented in that there were no nurses' notes detailing the incident. The Medical Director stated it was okay for staff to change residents from their wheelchair, but it must be done in a safe manner.

Based on record review, staff interviews, and Medical Director interview, the facility failed to provide care and services in accordance professional standards of practice when staff moved and repositioned the resident after a fall prior to nursing assessment for 1 of 3 resident reviewed for accidents (Resident #1). Findings included:A review of the records showed Resident #1 was admitted to the facility on [DATE] with diagnoses that included major neurocognitive disorder due to vascular disease with behavioral disturbance, and disorganized schizophrenia. Resident #1 was not available for interview because she was hospitalized at the time of the investigation. A review of the care plan dated 7/9/2025 showed problems, goals, and interventions that included providing socialization through staff review, cueing and reorientation as needed, assessing for mood changes, administering medications as ordered, assisting with personal hygiene, monitoring for continence patterns, implementing fall prevention measures related to dementia, poor safety awareness, aggression, and medication which placed the resident at risk for further falls/injury.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact. The MDS documented that Resident #1 used a wheelchair for mobility and required extensive to total assistance with activities of daily living (ADL), including toileting hygiene, bathing, personal hygiene, and transfers. Resident was coded as dependent for sit-to-stand transfers and required substantial/maximal assistance for chair/bed-to-chair transfers. Toilet transfers were not attempted due to medical condition or safety concerns but indicated Resident #1 was always incontinent with bladder and bowel. The MDS coded the resident as having no falls since admission, reentry, or prior assessment.A nursing note documented by Nurse #1 dated 5/5/2026 at 6:20 pm stated that on 5/4/2026 Nurse #1 was called to Resident #1 room by Health Care Technician (HCT) (did not specify which HCT). Nurse #1 documented that upon arriving, resident was lying on back with mechanical lift pad already underneath her.An interview with HCT #1 on 5/6/2026 at 12:50 pm revealed she entered the Resident #1 room with HCT #2 on 5/4/2026 between 2:50 pm and 3:00 pm, after Resident #1 returned from activities because resident repeatedly stated she was wet. HCT #1 stated they were changing Resident #1 in her room, with the walker facing the bed. HCT #1 stated she stood on one side and HCT #2 stood on the other side, and they assisted the resident to stand from the wheelchair using the walker to hold herself up. HCT #1 stated they removed Resident #1 wet incontinent brief and put a dry incontinent brief onto resident. HCT #1 recalled that resident was wearing a silky like gown and once they had the brief on, all they had to do was drop the gown. HCT #1 stated that once they dropped the gown, resident said, I'm falling, and began going down. HCT #1 stated she did not recall the exact placement of the wheelchair but stated it was not far away. HCT #1 stated they attempted to move the wheelchair underneath the resident, but the resident sat on the edge of the wheelchair. HCT #1 stated she and HCT #2 recognized the wheelchair was not positioned far enough back and attempted to pull the resident further onto the wheelchair cushion using the gait belt but were unable to move the resident. Resident #1 fell to her knees from the seat of the wheelchair and then fell to the side at an awkward angle. HCT #1 stated the resident landed with one leg, she could not recall which leg but thought it may have been the left, underneath the bed. HCT #1 stated she and HCT #2 used the gait belt to pull Resident #1 from underneath the bed and then obtained a mechanical lift pad. HCT #1 stated she and HCT #2 rolled the resident from side to side to place the mechanical lift pad underneath her and then HCT #1 went to get the nurse while HCT #2 stayed with the patient. HCT #1 did recall that patient immediately began complaining of knee pain after the fall. In an interview with HCT #2 on 5/14/2026 at 2:15 pm she stated that on 5/4/2026 she and HCT #1 entered Resident #1's room after resident returned from activities. She could not remember the exact time but thought it may have been a little after 3:00 PM. They went into the room to change the resident because the resident kept saying that she was wet. HCT #2 stated that they frequently changed resident in her room from the wheelchair. HCT #2 stated that after resident was changed, she attempted to sit before they put the wheelchair fully back under her. HCT #2 stated that resident sat on the edge of the seat of the wheelchair and then began falling forward to her knees. They did attempt to keep resident on the wheelchair, but resident weighed over 250 pounds, so they were not able to keep her from falling. Once she fell, she was under the bed a little bit, so they used the gait belt to pull her from under the bed. HCT #2 stated they got the mechanical lift pad from outside of the room and rolled resident two times to put the pad under her. HCT #2 stated they did this because they knew that they would need the mechanical lift to get patient up off the floor. HCT #2 stated she stayed with resident while HCT #1 got the nurse. HCT #2 stated that she did not recall Nurse #1 doing any range of motion checks with the resident or resident refusing. HCT #2 stated that once Nurse #1 said it was ok, they used the mechanical lift to pick resident up off floor and placed her on the bed. In an interview with Nurse #1 on 5/6/2026 at 12:31 pm she stated that on 5/4/2026 sometime after 3:00 pm, Health Care Technician (HCT) #2 came and got her saying that Resident #1 was on the floor. When she arrived in the room, Resident #1 was lying on floor, on a mechanical lift pad. She stated that Resident #1 would not allow nurse to check her range of motion (ROM) but was complaining of knee pain. Nurse #1 stated that there were no visible signs of injury. She stated that since resident was complaining of knee pain, an x-ray was ordered and it showed a fracture. Resident #1 was sent out to the hospital once the x-ray confirmed a fracture. A physician progress note dated 5/5/2026 at 10:15 am documented the resident sustained an assisted fall after attempting to sit down prior to seating being in place. The resident complained of left knee pain following the fall.Records further showed that on 5/5/2026 an x-ray of left knee showed fracture of the distal femoral shaft (break in the lower portion of the thighbone just above the knee) with malalignment.A review of records revealed that resident was discharged from the facility on 5/5/2026 and admitted to the hospital.An interview with the Medical Director was conducted on 5/14/2026 at 2:25 pm. The Medical Director stated that if a resident falls, the HCT should get the nurse, and the nurse should do a clinical assessment before attempting to move the resident. However, if there are extenuating circumstances such as HCT does not feel resident is safe, she would expect HCT to move resident to a more secure location. The Medical Director stated that in the case of Resident #1, the HCT's should have gotten the nurse to access for injuries before they moved the resident.On 5/14/2026 at 2:45 pm an interview with the Director of Nursing (DON) revealed her expectation was if a resident falls, unlicensed staff should get licensed staff before attempting to move the resident. The DON stated that HCT #1 and HCT #2 should not have rolled the resident to put the mechanical lift pad under her prior to the nurse evaluating the resident for injuries.In an interview with Care Director on 5/14/2026 at 2:51 pm she stated that per the facility policy, if resident falls, they should not be moved until assessed by a Registered Nurse (RN). If it was an assisted fall, then the assessment could be done by a Licensed Practical Nurse (LPN). The Care Director stated that HCT #1 and HCT #2 should not have moved the resident until the resident was evaluated by a nurse. She stated that the HCT's were anticipating having to get the resident up with the mechanical lift but should have waited for nurse to examine resident for injuries.

Based on observations, record review, and resident, staff and physician interviews, the facility did not provide care in a safe manner when 1.) Resident #3 fell to the floor from a mechanical lift (a device that uses electric or hydraulic power to safely transfer patients who have limited mobility) during a transfer from the bed to a chair sustaining a 4-centimeter posterior (at the back or rear of something) scalp laceration (cut or tear in the skin of the scalp) requiring evaluation in the emergency room and wound closure with 7 staples and 2.) Resident #4 fell out of a shower bed requiring evaluation in the emergency room sustaining an occipital hematoma (a collection of blood in or around the back part of the brain), a 2 x 2 centimeter (cm) reddened area to the left elbow, and an abrasion (superficial skin injury) to the left buttocks. This deficient practice affected 2 of 3 residents reviewed for accidents (Resident #3 and Resident #4).The findings included: 1.Resident #3 was admitted to the facility on [DATE] with diagnoses that included severe vascular dementia with agitation (characterized by restlessness, distress, and potentially aggression, often stemming from the person's inability to communicate needs or understand their environment) and a movement disorder (a neurological condition that affects the ability to control physical movements, causing either too much or too little movement, impacting coordination, gait, posture, and sometimes speech or swallowing). A review of Resident #3's Physician's order dated 11/30/2020 revealed her mechanical lift order was updated from a 1 person assist to a 2 person assist for transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired. Resident #3 was dependent on staff for eating, oral hygiene, toileting hygiene, showering/bathing herself, upper and lower body dressing, personal hygiene, putting on/taking off footwear, rolling left and right, chair/bed to chair transfer, and tub/shower transfer. A review of Resident #3's Physician's orders revealed she was not receiving any anti-coagulant (blood thinning) medication. A nursing progress note dated 11/24/25 indicated Nurse #1 was summoned by Health Care Technician (HCT) #2 to Resident #3's room and found Resident #3 lying on floor on her back with bright red bleeding to back of her head. Calls were placed to 911, the Physician and the House Supervisor. A written witness statement dated 11/24/25 from HCT #1 was reviewed. In the witness statement, HCT #1 indicated on 11/24/25 she was assigned Resident #3. HCT #1 stated she got Resident #3 dressed, put the lift pad (sling: A fabric harness or pad placed under and around the patient's body to support their weight during the transfer. The sling attaches to the lift's spreader bar or hooks) under her and went to get help to transfer her with the mechanical lift. HCT #1 saw HCT #2 and asked her to help. HCT #1 stated they went in and secured Resident #3's sling onto the lift and she was lifted in the air. HCT #1 moved the mechanical lift to place Resident #3 in a chair, and Resident #3 fell out of the lift. Multiple telephone attempts were made to interview Health Care Technician (HCT) #1 who was assigned to Resident #3 on 11/24/25 but were unsuccessful as she was no longer employed at the facility. A written witness statement dated 11/24/25 from HCT #2 was reviewed. HCT #2 indicated prior to leaving her completed shift, she was called by HCT #1 to assist with a transfer for Resident #3. HCT #2 stated upon entering Resident #3's room, Resident #3 was hooked up to the mechanical lift and raised off the bed. HCT #2 stated when HCT #1 moved the mechanical lift out and turned it, the right shoulder strap came undone, and Resident #3 fell. On 12/5/25 at 11:34 AM an attempt was made to interview HCT # 2 by telephone; however, she declined to talk to this surveyor about the incident. A telephone interview was conducted with Nurse #1 on 12/8/25 at 8:43 AM. She stated she was in the hallway at approximately 7:35 AM (on 11/24/25) conducting visual checks of the residents when a HCT (HCT #1) stuck her head out from a doorway and asked an HCT (HCT #2) to help her. The HCTs were in the room for a few seconds and HCT #2 asked her to come into Resident #3's room. She stated Resident#3 was lying with her head facing the door and had blood-soaked hair on the back of her head. Nurse #1 stated Resident #3 was alert and awake with her eyes open. Nurse #1 stated she asked what happened and HCT #1 said (implied) Resident #3 jumped out of the sling, which was not the resident's typical behavior. Nurse #1 stated she alerted the House Supervisor, the Physician, and 911 and stayed with Resident #3. Nurse #1 further stated that using the mechanical lift required a minimum of 2 people; 1 person for lift, 1 person for the resident's head, correct placement of the pad, attaching the pad to the 4 points on the mechanical lift, and making sure everything was secured before moving a resident. The hospital record for Resident #3 included a hospital history and physical note dated 11/24/2025 which indicated Resident #3 sustained a witnessed fall from a mechanical lift to the floor resulting in a 4-centimeter posterior scalp laceration requiring evaluation in the emergency room and wound closure with 7 staples. A computed tomography (CT) scan (a noninvasive imagining procedure that uses x-rays to create detailed images of the body) of Resident #3's head, neck, lumbar spine (the lower back section of the spine) and pelvic girdle (basin-shaped ring of bones (two hip bones, sacrum, coccyx) that connects the spine to the legs) revealed no abnormal findings. An x-ray completed on Resident #3's chest revealed no relevant findings. Resident #3 was discharged back to the facility on [DATE] with instructions to remove her staples in 7 to 10 days. A telephone interview was conducted with Nurse #2 on 12/5/25 at 12:55 PM. He stated that morning (11/24/25) at start of his shift he was in the medication room and a HCT (HCT #2) came and asked him for a flashlight. He stated he went to Resident #3's room and saw her on her back positioned next to the mechanical lift. Nurse #2 stated he asked HCT #1 what happened and HCT #1 stated she did not operate the mechanical lift by herself. A telephone interview was conducted with the House Supervisor #1 on 12/5/25 at 12:38 PM. House Supervisor #1 stated she received a call at the start of her shift that Resident #3 fell. Upon her arrival to Resident #3's room, Resident #3 was on the floor with her head facing door. House Supervisor #1 stated the physician was present and she stayed on the floor with her, attending to Resident #3's bleeding head, and stabilized her head until emergency services (EMS) arrived. House Supervisor #1 stated she asked HCT #1 what happened and HCT #1 told her she was not sure how the resident fell. HCT #2 informed House Supervisor #1 that Resident #3 was already attached to the mechanical lift when she arrived in the room. A telephone interview was completed on 12/5/25 at 1:07 PM with Physician #1. The Physician stated he was called about Resident #3's fall and went to assess her. Physician #1 stated Resident #3 and was on the ground with a laceration on back of her head, he asked staff not to move her until EMS arrived. Physician #1 further stated it was his expectation that staff identify any issues with a resident transfer prior to the move. He stated he expected staff to operate mechanical lifts as they were trained. An interview was completed on 12/8/25 at 12:05 PM with the interim Director of Nursing (DON). The DON revealed it was her understanding that HCT #1 put Resident #3 on the (lift) pad, hooked the pad to the mechanical lift, raised Resident #3 off the bed but did not move her. HCT #1 called for help, HCT #2 came to help her, and they began to move the mechanical lift. The interim DON stated one of the slings went down and Resident #3 fell to the floor. She stated HCT #1 was immediately taken off the unit and both HCTs were taken off patient care until the investigation was completed. The interim DON further stated she had HCT #1 and HCT #2 reenact what happened due to conflicting statements. The interim DON stated after the reenactment, HCT #1 was terminated due to inconsistencies in the 2 HCTs statements. The interim DON stated it was her expectation that staff followed the mechanical lift protocol, 2 staff members were always required for a lift, staff should inspect the mechanical lift prior to using, inspect the sling to ensure it was the correct size and was in good condition, the sling was correctly placed on the resident, and the sling was secured to the correct sections of the loops on the mechanical lift. She further stated once the sling was looped, staff were to ensure the hooks were closed. During an interview on 12/8/28 at 3:36 PM the Administrator stated her expectation was that staff followed the policy when they used a mechanical lift which included 2-person assistance. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses which included progressive neurological condition, cervical spinal stenosis (the narrowing of the spinal canal in the neck, compressing the spinal cord and nerve roots), and communication deficit disorder. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #4 was non-verbal and non-ambulatory with impairment of range of motion on bilateral upper/lower extremities. Resident #4 was totally dependent on staff for all her activities of daily living (ADL) and transfers. Resident #4 was not prescribed anticoagulant (blood thinning) medication. Review of Resident#4's care plan dated 4/9/25 revealed a goal for total care with all activities of daily living (ADL) as resident was unable to participate in her ADL with interventions which included the use of a shower bed, all procedures explained to her with encouraged compliance, and if resident is agitated, she may require additional staff for safety. The care plan also had a goal of at risk for falls with interventions which included notifying guardian of any falls/injuries, increased observation during periods of agitation, and frequent observation as resident is unable to use call bell system. A progress note dated 9/5/25 completed by Health Care Technician (HCT) #4 documented she gave Resident #4 a shower on the shower bed. HCT #4 documented when she started to lower the head of the shower bed Resident #4 began to squirm and her body proceeded to slide down to the end of the shower bed. She started calling out for help as Resident #4 was sliding off the shower bed. Resident #4 landed on her buttocks on the left side. HCT #4 called for the nurse to explain what happened. During a telephone interview on 12/8/25 at 4:00 pm with HCT# 4, she stated she had given showers to Resident #4 in the past without difficulties and gave Resident #4 a shower on the shower bed on 9/5/25. HCT #4 further stated she started Resident #4's shower the head of the shower bed was raised to allow for the water to flow down the shower bed to the drain at the bottom of the shower bed. HCT #4 indicated the water would not drain unless the head of the shower bed was raised. HCT #4 further stated she explained to Resident #4 that she was going to lower the head of the shower bed and when she started to lower the head of the shower bed, Resident #4 started moving and squirming around, began to slide down the shower bed, and fell off the shower bed at the opening at the end of the shower bed. HCT #4 explained she yelled out for help but Resident #4 was on the floor when help arrived at the shower room. HCT #4 indicated she could not stop Resident #4 from sliding off the shower bed, as it happened so fast. HCT #4 further indicated she reported the incident to the floor nurse, and the floor nurse reported the incident to the Unit Manager. HCT #4 stated the Unit Manager made the Physician aware. HCT #4 recalled the Physician came to the unit and assessed Resident #4 and gave orders to send her to the Emergency Department (ED) for evaluation. The interview further revealed HCT #4 did not know if the HOB was supposed to be raised or flat during a shower. HCT #4 stated she received training on the use of the shower beds but did not recall if the HOB was supposed to be raised or flat. During an interview with HCT #5 on 12/8/25 at 1:52 pm, she stated she thought it was the residents' preference for the HOB to be raised. When questioned about the non-verbal residents' preference she stated the HCT would make the choice to have the HOB raised or flat on the shower bed. A progress note dated 9/5/25 completed by Nurse #5 documented she was called to the shower room and found Resident #4 lying on the floor on her back. Resident #4 was parallel to the shower bed. Upon assessment she palpated (examine a part of the body by touch) a knot on the back of her head with no bleeding noted. Nurse #5 called the Unit Manager as well as the Physician. Orders were placed to send Resident #4 to the ED for evaluation. No vital signs were documented in the progress note. In a telephone interview on 12/8/25 at 3:15 pm with Nurse #5, she stated she was called to the shower room to assess Resident #4 after she fell off the shower bed on 9/5/25. Nurse #5 indicated Resident #4 was lying unclothed on the shower room floor. Nurse #5 further stated HCT #4 reported to her that Resident #4 slid off the shower bed through the open area at the bottom of the shower bed onto the floor. Nurse #5 explained she assessed Resident #4 and palpated a knot on the back of Resident #4's head. Nurse #5 further explained she called the Unit Manager and the Physician. Nurse #5 stated Resident #4 was sent to the ED for evaluation. The Unit Manager (UM) was interviewed on 12/8/25 at 2:20 pm. The UM stated she was made aware of Resident #4's fall by Nurse #5. The UM further stated when she walked in the shower room, she found Resident #4 on the floor on her left side. The UM indicated during an assessment of Resident #4 she palpated a raised area on the back of Resident #4's head, a 2 x 2 cm reddened area was visually noted to the left elbow, and a superficial abrasion noted to the left buttock area. The UM explained Resident #4 was not moved; however, she covered Resident #4 with a blanket for privacy and placed a pillow under her head prior to Emergency Medical Technicians (EMTs) arrival at the facility. The UM stated HCT #4 explained she was giving Resident #4 a shower on the shower bed. When she lowered the head of the shower bed Resident #4 started moving and squirming around, slid down the shower bed, and fell off the shower bed through the opening at the end of the shower bed. A progress note dated 9/5/25 completed by Physician #2 documented he received a call from the UM reporting that Resident #4 had fallen from the shower bed. Physician #2 arrived approximately 2 minutes later, and Resident #4 was on the floor wet with a towel under her head. Resident #4 was moving her right side and her head and neck. Resident #4 was non-verbal and it was difficult to tell her level of consciousness. Physician #2 documented the nursing staff attempted to obtain vital signs but were unsuccessful. Physician #2 obtained systolic blood pressure (BP) manually and was 174, oxygen saturation initially was 93 to 94 percent (%), heart rate 120 and respiratory rate between 16 and 18 breaths per minute. (Normal vital sign ranges: BP under 120/80 mmHg (millimeters of mercury), Heart Rate 60 to 100 beats per minute, Respiratory rate 12-20 breaths per minute and oxygen saturation 96% to 99%). An abrasion was noted to her left elbow, a bruise to her left hip, and no open wound or bleeding noted from the scalp. Resident #4 was transported to the ED for further evaluation. In a telephone interview with Physician #2 on 12/8/25 at 2:41 pm, he stated he was notified of Resident #4's fall and when he went into the shower room, everything was slippery and wet. Physician #2 further stated he gave orders for Resident #4 to be sent to the ED for evaluation. When asked was this fall preventable, he replied the shower bed should have side rails all around the shower bed. Review of Resident #4's hospital Discharge summary dated [DATE] revealed Resident #4 was brought to the ED by Emergency Medical Systems (EMS) at approximately 9:42 am. Resident #4's past medical history revealed she was bed-bound with left side extremity contracture (a condition of shortening and hardening of muscles, tendons or other tissues often leading to restricted joint mobility). She was evaluated for occipital hematoma (collection of blood at the back of the head) after a fall from a shower bed at the facility. A Computed Tomography (CT) scan of the Spine (which is a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of spine) was completed with no acute fracture noted. A CT scan of the head was completed which showed no skull fracture. Clinical Impression: closed [NAME] injury. Resident #4 was discharged back to the facility on 9/5/25 with no new orders. On 12/8/25 at 2:45 pm an observation was made of the facility's shower bed used for Resident #4. The shower bed was approximately 3 feet tall and approximately 78 inches in length on a metal frame with locking wheels. At the head of the shower bed on the left side was a lever used for raising and lowering the head of the shower bed. Along the sides of the shower bed there were side rails which were located in the middle of the shower bed leaving approximately 24 inches of space at the head of the shower bed and at the bottom of the shower bed. The shower bed had a hole at the bottom in the middle of the shower bed used to drain the water. During an interview with the Director of Nursing (DON) on 12/8/25 at 3:38 pm, she stated she was out when Resident #4 fell from the shower bed and heard about it from staff when she returned to work but could not recall the date. The DON noted she reviewed Resident #4's Electronic Medical Record (EMR). The DON indicated the shower beds were new and were received in December 2024. A video training course was provided for the staff on how to use the shower bed. The DON explained 2 staff members may be necessary when using the shower bed, and the head of the shower bed should not be raised to ensure the safety of the residents to prevent this from happening again. DON stated the HCT's were in-serviced on patient care and use of the shower bed to keep HOB flat. The interview further revealed Resident #4's care plan was revised for her to be provided with bed baths and no showers.

Based on record review and staff interviews the facility failed to protect residents from the accused staff during an investigation of staff to resident abuse. On 2/15/24 staff observed Nurse Aide (NA) #1 strike Resident #21 with a closed fist twice in the face and push him down on the floor. An abuse investigation was initiated on 2/15/24. On 2/16/24, during the abuse investigation, NA #1 arrived at the facility, clocked in at 6:56 AM and was given a resident care assignment. NA #1 clocked out at 10:56 AM. This deficient practice was for 1 of 3 residents (Resident #21) reviewed for abuse and had the high likelihood of serious injury/harm for other residents. Immediate Jeopardy began on 2/16/24 when Nurse Aide #1 provided direct care to residents following witnessed physical abuse of Resident #21 on 2/15/24. Immediate Jeopardy was removed on 3/15/24 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower level and severity of E (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put in place were effective. Findings included: Review of the facility policy dated 7/26/23 entitled Protecting Patients/Residents from Rights Infringements, revealed it is management staff member's responsibility to determine the need for, and implement a plan of protection to safeguard the involved resident and others as indicated. Part of plan may include investigative leave for involved employees. Review of a facility reported incident report completed by the Risk Manager dated 2/15/24 revealed Resident #21 allegedly hit Nurse Aide (NA) #1 on the left side of her face twice while NA #1 was trying to redirect resident. Resident #21 attempted to hit NA #1 again and NA #1 put her arms up to brace herself and pushed back at Resident #21. Resident #21 fell backwards to the floor. There were no injuries noted. On 2/16/24 the report was revised to indicate the police were notified. The report made no mention of NA #1 being suspended. Review of the police report dated 2/16/24 and revised on 2/21/24 related to the 2/15/24 incident with NA #1 and Resident #21 was reviewed. Under the heading of Crime/Incident the report noted Simple Assault Individual [with] Disability. The case status was noted as Further Investigation. The narrative indicated that an incident described as an alleged assault occurred between NA #1 and Resident #21 on 2/15/24. A 2/21/24 supplement to the initial report noted that witness statements were reviewed and indicated NA #1 did swing at the resident and pushed the resident down as well. The report further indicated that multiple staff indicated NA #1 stated that the next time he (Resident #21) hits her she will lose her job. An interview was conducted with the Advocate on 2/29/24 at 10:45 AM who stated after NA #1 was interviewed on 2/15/24 she was instructed to leave the facility and not return until contacted by the Director of Nursing. Review of an email sent by the Director of Nursing (DON) dated 2/15/24 at 3:54 PM to NA #1's staffing agency read, in part Please make sure she [NA#1] is contacted to not report to work tomorrow .We will reach out to her on Monday regarding her schedule. Review of the written 24-hour report dated 2/16/24 revealed Resident #21 had fallen the previous day but there was no mention of NA #1's involvement. The document did not indicate which of the house supervisors made the notation. Review of NA #1's timecard for 2/16/24 revealed she worked from 6:56 AM until 10:56 AM. A phone interview was conducted with NA #1 on 2/29/24 at 9:27 AM. She reported staff and residents were in the 2nd floor dayroom on 2/15/24 because residents were being moved to the 5th floor. NA #1 explained some construction needed to be completed on the 2nd floor. She reported Resident #21 wanted to go back to his room. NA #1 stated he picked his walker up and tried to lift it over two residents (Resident #38 and Resident #49) to go back to his room. They were sitting in front of him, and the space was too small to fit his walker between the residents. She reported she grabbed the walker and placed it on the floor to prevent one of the other residents from getting hurt. NA #1 stated Resident #21 was standing close to her. She reported he shouted, shut the f*** up and hit her on the left side of her face. NA #1 stated she pushed him on his shoulders with both hands to put distance between the two of them. She stated Resident #21 fell between the table and chair on his back. NA #1 reported Resident #21 stated when I get up, I'm going to hit you again. She stated she went to the Nurse Manager and was sent to the facility employee health department for her injuries. Her injuries included a split lip and a cracked tooth. She stated she returned to work the next day (2/16/24) and Resident #21 apologized to her for hitting her. NA #1 stated he was not on her assignment, so she did not respond to him. She stated she was contacted on 2/16/24 while she was on the unit and interviewed by the Advocate and the Director of Standards about the 2/15/24 incident with Resident #21. She reported after the interview she was instructed to leave the facility and placed on leave. During an interview with the Director of Standards on 3/14/24 at 9:30 AM she reported she interviewed NA #1 on 2/16/24. She stated NA #1 was working with residents prior to the interview. Review of the staffing schedule dated 2/16/24 revealed NA #1 was assigned three residents (Resident #55, Resident # 86, and Resident #5). Resident #5 was not able to be interviewed. During an interview on 3/14/22 at 10:11 AM Resident #55 stated he did not recall who worked with him on 2/16/24. Resident #86 was unavailable for interview. An interview was conducted with Resident #21 on 2/27/24 at 2:44 PM who reported he had not seen NA #1 since the incident on 2/15/24. He stated he did not apologize to the nurse aide for his actions. An interview was conducted with the Assistant Director of Nursing (ADON) on 2/29/24 at 2:41 PM who stated she was asked by the Advocate on 2/16/24 if she (the ADON) knew how to get in touch with NA #1. She stated the DON was out of the facility on 2/16/24 but she was aware that the DON had sent an email to NA #1's agency for her to not return. The ADON stated she contacted staff on the floor and discovered NA #1 was present. She stated she removed NA #1 from the floor and escorted her to the Advocate's office. She stated after NA #1 completed her interview with the Advocate and the Director of Standards her keys and badge were taken. The ADON stated NA #1 was informed by the Advocate to not return until she was notified. An interview was conducted with the Director of Nursing (DON) 3/14/24 at 9:45 AM who stated had NA #1 been an employee of the facility she would have gone ahead and taken NA #1's keys and badge on 2/15/24 so she could not have re-entered the building until notified to return to work. She stated there was a leave with pay process for facility employees but there was not one at that time for agency employees. She stated she was not in the facility on 2/16/24. The DON stated the charge nurses on the floor made the assignments for nurse aides. The DON stated the scheduled charge nurse called out on 2/16/24. She reported Nurse #3 stayed over and made the assignments. Attempts were unsuccessful to contact Nurse #3 who made the assignments and gave NA #1 an assignment on 2/16/24. A phone interview was conducted with House Supervisor #2 on 3/14/24 at 11:23 AM. She stated she recalled on 2/16/24 she was in the Nursing office when someone called down and spoke with House Supervisor #3. She reported the person on the other end of the call stated NA #1 was on the 5th floor and she was not on the schedule. House Supervisor #2 stated she was unsure who was on the other end of the call. House Supervisor #2 indicated she and House Supervisor #3 checked the master schedule and NA #1 was on it as scheduled to work. She reported she learned from other employees about the incident with NA #1 and Resident #21 at approximately 10:15 AM. House Supervisor #2 stated she ensured NA #1 was no longer on the floor at that time. She reported if a house supervisor received a call asking if someone was able to work she would check the master schedule. A phone interview was conducted with House Supervisor #3 on 3/14/24 at 4:20 PM. She stated she did not remember the phone call on 2/16/24 related NA #1. House Supervisor #3 stated it was protocol for the House Supervisor to check the master schedule to ensure who was scheduled to work. Unless it was changed on the master schedule, she would not have had any knowledge of an abuse investigation involving NA #1. An interview was conducted with Nurse # 1 on 3/14/24 at 11:02 AM who stated if she made the assignments for nurse aides on her floor and someone was present who was not scheduled to work, she would contact the house supervisor on duty. She stated she worked on 2/16/24 but did not recall NA #1. She started she was unaware of any issue with NA #1. During an interview with Nurse #2 on 3/14/24 at 11:04 AM she stated when she normally made the schedule for nurse aides if someone was present who was not on the schedule, she contacted the house supervisor on duty. The Administrator was notified of immediate jeopardy on 3/14/24 at 12:20 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and The facility failed to protect all residents from abuse when NA #1 worked on the floor of the facility for approximately 4 hours the day following an incident where NA#1 struck resident # 21 with a closed fist twice in the face and pushed him down to the floor. The timecard for NA #1 revealed she worked from 6:56 AM-10:56AM. Interview with NA #1 and review of assignment sheet indicated she had an assignment for three residents. The DON and ADON met with NA #1 on 2/15/24 immediately after the incident and NA #1 was interviewed and was told to leave pending an investigation. The staffing agency was also notified by DON on 2/15/24 immediately after the incident. NA #1 did not have her badge removed at the time of the incident and she returned the following day to work. On 2/16/24, NA #1 had been removed from the schedule and the House Supervisor was unaware of the incident and put her back on the schedule for 3 residents. The agency did not respond to the phone message or email that was sent out. The ADON noticed that NA #1 was working at approximately 9:30 AM and removed her from the floor and brought her into 1st floor standards office for further interview and removal from the premises. All residents of the facility had the potential to suffer adverse outcomes due to this non-compliance. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete: To prevent any additional occurrence of this incident the management team including Social Work Director, Medical Director, Director of Information Management, Director of Pharmacy, Safety Officer, Business Manager, Director of Plant Operations, Supervisor of Environmental Services, Supervisor of Nutritional Services, Chief of Police, Director of Standards, Director of Psychology, Director of Risk Management, Director of Advocacy, House Supervisors, Event Review Specialist, Center Director, Human Resources Director, Director of Professional Services and nursing leadership team Unit Nurse Managers, ADON, Director of Nursing, Nurse Consultant, who are responsible for reporting allegations of abuse, neglect and misappropriation as well as placing employees on investigative leave were educated by the Administrator, Assistant Care Center Director on 3/14/24 on the update to the policy Protecting Patients and Residents from Rights infringement which includes the protective interventions of the facility as detailed below: C. Protective Intervention (Updates to the policy are reflected in item # 3 listed below) 1. Upon observing, discovering, or hearing about suspected rights infringements (including abuse, neglect, exploitation, and misappropriation of resident property), all staff will immediately intervene, within the scope of their ability, to protect the health and safety of the resident(s) involved. 2. It is Department Managers'/ designated Center Management staff's responsibility to determine the need for, and implement, a plan of protection to safeguard the resident(s) involved in the incident, and other residents as indicated. a. Protective measures include but are not limited to Investigative Status placements (state employees are placed on this status when they are on investigative leave with pay) and immediate suspension for all other contracted personnel. b. Department Managers, who are responsible for the supervision of the alleged perpetrator, will be notified by the Standards Department or designee by email and verification of receipt of the email of the allegation of abuse and the protection plan of the resident at the time of the incident. If no email response is received, the Standards Director or designee will contact the Department Manager responsible for the alleged perpetrator by phone. It is the responsibility of the department manager to inform all other managers in the department immediately via phone, email or direct contact to ensure the protection of all residents. 3. The manager that oversees the alleged perpetrator will retrieve the employee's ID Badge and keys so they no longer have access to the facility. The manager that oversees the alleged perpetrator will also be responsible for agency personnel and will contact the appropriate agency representative at the time of the incident by phone and/ or email. The employee/ or agency personnel may not return to the facility until they are notified by the department manager/designee that the investigation has been completed and that they are cleared to return to the facility. Department Managers/ designated Center Management will notify a member of Advocacy (Advocacy personnel are hired by the Division of State Operated Healthcare facilities to be a third party representative or advocate for the residents in this facility) immediately of the plan of protection that has been implemented. Advocacy will make the Department Manager/designated Center Management staff aware if they have continued concerns regarding the safety of the resident(s) involved and/or other residents as indicated. Immediate Jeopardy Removal date: 3/15/2024 Onsite validation of the immediate jeopardy removal plan was completed on 3/14/24. Interviews confirmed members of the facility management team were educated on the updated policy which detailed the employee's manager is responsible for retrieving the badge and keys of any employee who was accused of mistreatment of a resident by the Assistant Administrator of the facility. The manager is responsible for notifying the appropriate agency representative of any incident via phone and/or email. Education included all nursing supervisors; floor shift supervisors and house supervisors will be notified if nursing staff members are placed on leave. The Director of Standards will be responsible for notifying security that the employee's badge is not to be reissued unless further notification is received. The immediate jeopardy removal date of 3/15/24 was validated.

Based on record review, observation, and interviews with police, psychologist, physician, resident, and staff, the facility failed to protect Resident #21 from physical abuse perpetrated by Nurse Aide (NA) #1. On [DATE] Resident #21 was attempting to leave a common area of the facility by lifting his walker up over his head to get past two residents who were seated. NA #1 prevented his exit by placing her hands on the walker to position it back on the floor. Resident #21 hit NA #1 and told her to shut up followed by the use of profanity. NA #1 then struck Resident #21 with a closed fist twice in the face and pushed him down to the floor. The resident sustained a small scratch on his face. He indicated the incident made him mad. A reasonable person would have been traumatized by being physically abused by their caregiver in their home environment. This deficient practice affected 1 of 3 residents reviewed for abuse. Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included dementia and intermittent explosive disorder. Resident #21's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed to be cognitively intact. He was assessed as not having any behaviors during the 7-day lookback period. Resident #21 utilized a walker. Resident #21's care plan last reviewed [DATE] revealed he was care planned for behaviors. His behaviors on his care plan included aggression, pacing, cursing, anger at staff/others, violence, decreased impulse control and impatience. The care plan revealed his behavior was not easily redirected. Interventions included: remain unhurried and calm, stand to the side when talking with, do not invade his personal space, do not overwhelm with excessive noise or stimulation, if resistive attempt conversation and distraction and try to lead into the task, and if he cannot be redirected then provide for his safety. Review of a facility reported incident report completed by the Risk Manager dated [DATE] revealed Resident #21 allegedly hit Nurse Aide (NA) #1 on the left side of her face twice while NA #1 was trying to redirect resident. Resident #21 attempted to hit NA #1 again and NA #1 put her arms up to brace herself and pushed back at Resident #21. Resident #21 fell backwards to the floor. There were no injuries noted. On [DATE] the report was revised to indicate the police were notified. Review of the police report dated [DATE] and revised on [DATE] related to the [DATE] incident with NA #1 and Resident #21 was reviewed. Under the heading of Crime/Incident the report noted Simple Assault Individual [with] Disability. The case status was noted as Further Investigation. The narrative indicated that an incident described as an alleged assault occurred between NA #1 and Resident #21 on [DATE]. A [DATE] supplement to the initial report noted that witness statements were reviewed and indicated NA #1 did swing at the resident and pushed the resident down as well. The report revealed the following: Based on new information, it appears that [NA #1] pushed off of [Resident #21] resulting in his fall. Other witnesses described [NA #1] as hitting [Resident #21]. Witnesses [NA #3, NA #2, NA #4, and NA #5] have been labeled as Direct Witnesses to the incident. [NA #2] described [NA #1] swinging back against [Resident #21]. [NA #3] described a push back. [NA #4] described [NA #1] as hitting back. Most of the witness statements describe [NA #1] as saying that the next time he hits her she will lose her job. A phone interview was conducted with the Chief of Police for the facility on [DATE] who stated he planned to go to the local District Attorney's office to press charges against NA #1. A facility reported investigation completed by the Event Review Specialist dated [DATE] revealed staff who witnessed the incident reported NA #1 pushed the resident and did swing out at him but were not sure if contact was made. The allegation was substantiated for abuse. Charges for assault were pending. An interview was conducted with Resident #21 on [DATE] at 2:44 PM who stated on [DATE] NA #1 shoved him, so he shoved her back. He then stated she hit and pushed him, and he fell on the floor. Resident #21 stated NA #1's fingernail scratched his face. There were no other injuries. Resident #21 stated it made him mad. He further stated he was not afraid of her. NA #1's written statement dated [DATE] revealed on [DATE] at 11:10 AM the residents were waiting to be moved to the 5th floor. All residents were in the dayroom as the furniture had been moved from the unit. The statement indicated Resident #21 got up to go to his room. NA #1 informed him there was no furniture in his room and he had to remain in the day room. He put his walker over the top of other residents and attempted to climb over their wheelchairs. NA #1 reported she told Resident #21 was being unsafe and tried to move the walker off another resident. He shouted, shut the f*** up and punched her in her face. NA #1 stated he was coming to punch her again and she pushed him to the floor. She stated he was getting up to hit her again and she walked to the nurse's station to report it. I NA #1 provided a second statement on [DATE] which stated Resident #21 decided he was going back to his room and proceeded to climb over two other residents risking one of them getting hurt. She reported she told Resident #21 to wait. He then shouted at her and punched her in the face. She reported she pushed him back not with the intent to hurt him or make him fall but for separation. He fell back between the chair and the dining table and immediately proceeded to get up while threatening to hit her again. A phone interview was conducted with NA #1 on [DATE] at 9:27 AM. She reported staff and residents were in the 2nd floor dayroom on [DATE] because residents were being moved to the 5th floor. NA #1 explained some construction needed to be completed on the 2nd floor. She reported Resident #21 wanted to go back to his room. NA #1 stated he picked his walker up and tried to lift it over two residents (Resident #38 and Resident #49) to go back to his room. They were sitting in front of him, and the space was too small to fit his walker between the residents. She reported she grabbed the walker and placed it on the floor to prevent one of the other residents from getting hurt. NA #1 stated Resident #21 was standing close to her. She reported he shouted, shut the f*** up and hit her on the left side of her face. NA #1 stated she pushed him on his shoulders with both hands to put distance between the two of them. She stated Resident #21 fell between the table and chair on his back. NA #1 reported Resident #21 stated when I get up, I'm going to hit you again. She stated she went to the Nurse Manager and was sent to the facility employee health department for her injuries. Her injuries included a split lip and a cracked tooth. She stated she had only worked with the resident since December. NA #1 stated she had been trained in Crisis Prevention Institute (CPI) techniques (CPI techniques are verbal de-escalation strategies that emphasize physical interventions as a last resort to protect residents and staff.); however, she was so shocked Resident #21 hit her that she acted instinctively. She indicated she should not have pushed him. Resident #38 was not able to be interviewed. An interview was conducted with Resident #49, who was alert and oriented to person, place, time and situation on [DATE] at 3:33 PM who stated NA #1 tried to take Resident #21's walker away and he punched her in the face on [DATE]. He stated NA #1 then pushed Resident #21 down. Review of NA #4's written statement revealed on [DATE] all residents were waiting in the dayroom to be moved to the 5th floor. She reported she witnessed Resident #21 swing and hit NA #1. NA #1 hit him back in the face. She further reported she was unsure if Resident #21 tripped or was pushed to the floor. During an interview with NA #4 on [DATE] at 3:20 PM NA #4 stated she was sitting in the dayroom on the 2nd floor on [DATE] while the residents and staff were waiting for the move to the 5th floor. She reported she saw Resident #21 get up and lift his walker above his head to get past two other residents. NA #4 stated she was sitting approximately 15 feet away and could not hear the conversation. She stated NA #1 spoke to Resident #21 and Resident #21 swung at NA #1. NA #4 stated NA #1 punched Resident #21 twice on his face and he ended up on the floor on his back. She reported Resident #21 did not say anything or express nonverbal indications of pain. Review of NA #2' s written statement revealed on [DATE] all the residents had been moved to the dayroom. Resident #21 was between two other residents and tried to move between them with his walker above his head. NA #1 got up from her chair and grabbed Resident #21's walker. Resident #21 swung his fist and she stated she was not sure if he hit NA #1. She reported NA #1 swung back twice and pushed Resident #21 on the floor between the table and another resident. She stated Resident #21 looked embarrassed and didn't respond to anyone's efforts to help. When Resident #21 was getting up NA #1 was yelling next time you hit me I won't have a job. An interview was conducted with NA #2 on [DATE] who stated all the residents were in the dayroom on [DATE]. She stated Resident #21 was stating the move to the 5th floor was taking too long and tried to move past the two residents in front of him. NA #2 stated Resident #21 put his walker above the other residents' heads. She stated NA #1 went up to him and tried to take the walker. NA #2 stated she heard Resident #21 tell NA #1 to shut the f*** up b**** and drew back. She stated Resident #21 punched NA #1. NA #2 stated NA #1 punched Resident #21 with a closed fist twice in the face. NA #2 stated NA #1 then grabbed Resident #21's arms and pushed him to the floor. She further reported NA #1 stated to Resident #21 that if he hit her again she would lose her job. NA #2 reported Resident #21 looked embarrassed and would not talk when staff tried to engage him. NA #3's written statement revealed on [DATE] Resident #21 was trying to get through a crowd of people with his walker and NA #1 said something to him. He replied, could you shut the f*** up and hit her. She pushed him to the floor and stated, next time I will lose my job. During an interview with NA #3 on [DATE] she stated she was working with another resident on a 1:1 basis and saw the [DATE] incident out of the corner of her eye. She reported she saw NA #1 punch Resident #21. NA #3 stated she was approximately 5 feet away from the incident and was unsure where NA #1's punch landed on Resident #21. She reported he landed on his back and did not indicate he was injured. Review of Nurse #1's written statement revealed on [DATE] NA #1 came to the nurse's station and stated she needed to go to the hospital because Resident #21 punched her twice in the face. NA #1 stated Resident #21 wanted to go to his room and she told him that due to the furniture being moved out he could not. Resident #21 then punched her (NA #1) in the face. She reported she (NA #1) put her hands up to block the resident. NA #1 was sent to the facility Employee Health department. After NA #1 left unit NA #2 and NA#3 reported the resident was on the floor on his buttocks after the incident. NA #2 and NA #3 reported NA #1 pushed Resident #21 after being hit. She (Nurse #1) assessed the resident and found no injury. He had no signs, symptoms, or complaints of pain. On [DATE] at 12:04 PM an interview was conducted with Nurse #1. She stated NA #1 came to her on [DATE] and stated Resident #21 had hit her in the face. She stated after NA #1 had left the area to go to Employee Health she was told by NA #2 that NA #1 had punched Resident #21 and pushed him to the floor. Nurse #1 stated Resident #21 spoke to Psychologist #1 after the incident. She stated she assessed Resident #21 for injuries when she was made aware he was struck by NA #1. She stated he did not have any injuries. Psychologist #1's written statement revealed on [DATE] he was on the 2nd floor of the facility to assist with the resident move to the 5th floor. He indicated the residents were sitting in close proximity in south end of hall and staff were close together. Psychologist #1 reported he went to the nurse's station to discuss a way to intervene. He stated NA #1 came to the desk and stated she had been punched twice in the face by Resident #21. She stated he pushed Resident #21 to get him away from her. Psychologist #1 stated he saw Resident #21 walk by the nurse's station and went out to monitor him. He stated he sat with Resident #21 in the dayroom and he stated he was tired of waiting for the move and impatient. Psychologist #1 stated he apologized for the inconvenience and offered to get him a drink. He reported Resident #21 refused the drink but had calmed down. A phone interview was conducted with Psychologist #1 on [DATE] at 3:13 PM. He stated he was at the nurse's station on [DATE] when NA #1 came in and stated she was struck by Resident #21. Psychologist #1 stated he spoke with Resident #21 after the incident. He reported Resident #21 was frustrated by the amount of time the move to the 5th floor was taking. Psychologist #1 further stated Resident #21 reported he was tired of waiting and lunchtime was approaching. He stated he worked with Resident #21 frequently. Psychologist #1 stated Resident #21 was easily provoked and got angry very quickly. He reported Resident #21 did not react well to confrontation. Psychologist #1 stated the move was taking longer than planned and only one elevator was available for use. He reported he took Resident #21 down to his room to wait after the incident which seemed to work well. An interview was conducted with Physician #1 on [DATE] at 2:46 PM who stated Resident #21 had no injuries from the incident that occurred on [DATE]. He stated anyone who was pushed backwards would have potential for harm but Resident #21 did not have any additional risk for harm. An interview was conducted with the Assistant Administrator on [DATE] at 3:15 PM. She reported NA #1 should not have struck or pushed Resident #21. The Assistant Administrator stated staff receive training on de-escalation techniques, such as avoiding confrontation, and NA #1 should have utilized those techniques. She stated the facility did not tolerate resident abuse. The Assistant Administrator stated having all residents and staff in the dayroom awaiting the move to the 5th floor may have led to the incident. She reported the facility was developing an alternative plan for the residents' return to the 2nd floor. The Assistant Administrator was notified of immediate jeopardy on [DATE] at 4:37 PM. On [DATE] the facility provided the following corrective action plan with a completion date of [DATE]: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Summary of deficient practice on [DATE]. Interviews with staff who witnessed an altercation between Resident #21 and NA #1 revealed Resident #21 attempted to leave the dining room and lifted his walker to maneuver between two residents. NA #1 stopped him by grabbing his walker. Resident #21 punched NA #1 and told her to shut the f . up, b . NA #1 then punched Resident #21 twice and pushed him to the floor. She then said, if you hit me again, they will have my job. Immediately following the event on [DATE], Resident #21 was assessed by Registered Nurse (RN) #1. Resident #21 denied/had no signs or symptoms of pain or injury. Resident #21 was placed on nursing assessment every shift for 24 hours and level of supervision was increased to Special Observation Every 30-Minute Checks. The Psychologist was on the unit at the time of the incident and assessed and monitored Resident #21 with no residual negative effects. Resident #21 was relocated to the 5th floor as planned for unit temporary relocation from [NAME] 2, along with the other residents residing on [NAME] 2. A psychiatric consult for Resident #21 was also ordered [DATE] for [DATE] and was completed. It was noted, No changes recommended at this time, though would continue to monitor. Note pharmacokinetic interactions may cause fluctuation in his effective serum concentration of medications. May consider reduction in Zyprexa [antipsychotic] if patient remains stable or if bradykinesia worsens or other parkinsonian symptoms develop. NA #1 (agency staff) was sent home for the remainder of the shift on [DATE]. The staffing agency was notified by Director of Nursing (DON) that an investigation was in progress involving NA #1 and she was not to return to work at this time. Initial 24-hour report initiated within 2 hours for suspected abuse on [DATE]. On [DATE] the Center's Police were notified of the suspicion of a crime. It was determined by the Police there was sufficient evidence of a crime for prosecution. On [DATE], NA #1 reported to the facility at 7:12 AM even though her agency had been instructed to remove her from the schedule. When the administrator was informed NA #1 was immediately removed from the floor at 9:30 AM and interviewed regarding the alleged abuse at 9:43AM in the standards office of the facility. Resident #21 was not on her assignment, and she monitored residents in the day area. Immediately following the interview the staffing agency called NA #1 at Longleaf Neuro Medical Treatment Center (LNMTC) and notified her that she could not work due to the current investigation. NA #1 is not allowed to return to work at the facility. On [DATE] [NAME] County Adult Protective Services was notified of the alleged abuse. To identify other residents that may have been impacted by the suspected abuse, the Psychologist interviewed all (9) residents that reside in the same location as Resident #21 with a (Brief Interview for Mental Status) BIMS score of 8 or more on [DATE]. These residents were asked Are you troubled or bothered by any events you have seen over the past few days? All residents indicated No The facility also asked the residents Has anyone touched you without your permission? to assess to see if they experienced abuse and all responded, No. Nurses and NA's caring for 5 residents residing on Resident #21's unit with a BIMS score of less than 8 were interviewed by RN House Supervisor on [DATE] (evening shift), [DATE] (day shift), and [DATE] (evening shift) and asked, Have there been any behavior changes since time of incident? All responses were No. Residents with a BIMS of less than 8 were not capable of answering the question, Have you been abused or hurt by staff. Skin assessments were completed for all residents with a BIMS of less than 8 and were noted to be free from signs evidence or injury of physical abuse on [DATE]. On [DATE], to continue to identify other residents that might have been impacted, all residents (25) throughout the facility with a BIMS score of 8 or higher were interviewed on [DATE] by the Psychologist. They were asked the following question: Has anyone touched you without your permission? Residents (13) that were not interviewed on [DATE] were also asked :Are you troubled or bothered by any events you have seen over the past few days? All residents indicated No to these questions. Also, on [DATE], RN #2, RN #3, and RN #4 assessed all residents (67) throughout the facility with a BIMS score 8 or below by conducting skin assessments and no residents showed any sign of injury or abuse. 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: To prevent any additional occurrence of this incident staff re-trained as follows on Resident Rights and prevention of abuse: Resident Rights and Abuse Prohibition Training Each resident has the right to be free from all types of abuse, including physical, mental, sexual and verbal abuse. The staff of LLTC are responsible for intervening and responding promptly and appropriately to protect residents in the event of alleged, suspected, or observed abuse. All known or suspected incidents shall be reported, investigated, documented, and addressed . Abuse is the willful infliction of injury, unreasonable confinement; intimidation 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. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Retaliation by staff is abuse regardless of whether harm was intended. Physical Abuse: The infliction of physical discomfort, pain, or injury through the use of physical force by other than accidental means. Examples of physical abuse include but are not limited to: a. Hitting, biting, slapping, punching, kicking, pushing b. Corporal punishment to control or correct behavior including pinching, spanking, slapping of hands, flicking, or hitting with an object Staff to Resident Abuse: a. All allegations/occurrences of all types of staff-to-resident abuse must be reported to Advocate, supervisor, and Center Director immediately. b. Includes, but is not limited to: 1) all allegations/occurrences of physical, sexual, mental, and verbal abuse, including deprivation of goods and services by staff, and involuntary seclusion. 2) staff taking or distributing demeaning or humiliating photographs or recordings of residents through social media or multimedia messaging. 3) reports from residents of abuse perpetrated by staff; allegations will not be dismissed on the basis of a resident's cognitive impairment(s) c. Accidents that may not be considered to be abuse include instances such as a staff member tripping and falling onto a resident or a staff member quickly turning around or backing into a resident they know was there. Staff are required to intervene to protect residents engaged in altercations utilizing diversion, distraction, redirection, verbal cues, or assisting in separating and relocating residents and to report all resident- to- resident altercations to the nurse/supervisor immediately for immediate assessment and actions. Staff are also responsible for intervening to assist with residents who have escalating behavior, and assist with redirecting residents to prevent staff or other resident harm. Allegations/reporting reasonable suspicion of a crimes: a) All staff shall report any reasonable suspicion of a crime against a resident to the nurse/supervisor and Advocate. The Center Director/designee is responsible for reporting to the HCPR, local law enforcement and adult protective services. b) Cases of abuse of serious bodily harm are reported immediately but not later than 2 hours after forming suspicion c) Cases that result in no serious bodily harm and cases of neglect, exploitation, or misappropriation of resident property are reported no later than 24 hours. Immediately after ensuring the safety of the resident(s), staff who observe, discover, or hear about suspected rights infringements (including abuse, neglect, exploitation, and misappropriation of resident property) will report all incidents to the designated supervisory staff on duty and to an internal Advocate. In the event that the designated supervisory staff on duty is suspected or known to have been involved in the present situation, the next level supervisor/manager and the Advocate will be contacted. Protective Intervention 1. Upon observing, discovering, or hearing about suspected rights infringements (including abuse, neglect, exploitation, and misappropriation of resident property), all staff will immediately intervene, within the scope of their ability, to protect the health and safety of the resident(s) involved. 2. In instances where an injury is suspected, Resident Event Response Policy AM ,d+[DATE] will be followed to ensure that /resident(s) receive immediate medical assessment and treatment. 3. It is Department Managers'/ designated Center Management staff's responsibility to determine the need for, and implement, a plan of protection to safeguard the resident(s) involved in the incident, and other residents as indicated. a. Protective measures may include but are not limited to Investigative Status placements. b. Other residents are interviewed (if interviewable as defined by BIMS score on current MDS) or assessed for potential like abuse (including resident to resident), neglect, exploitation or mistreatment including injuries of unknown source, and misappropriation of resident property as a part of the investigation process. If additional potential victims are identified during this assessment and interview process, those cases will be also be reported and investigated. 4. Department Managers/ designated Center Management will notify Advocacy of the plan of protection that has been implemented. Advocacy will make the Department Manager/designated Center Management staff aware if they have continued concerns regarding the safety of the resident(s) involved and/or other residents as indicated. Resident Rights Tips: 1. Avoid contradicting or arguing with residents. 2. Be conscious of how you are speaking with the residents. 3. Ask the residents questions rather than ordering them to do things. 4. Do not take things personally. 5. Be aware of your emotions, tone of voice, and body language. 6. Do not initiate physical contact if the resident's behavior is escalating. 7. If a resident is becoming violent, assess the surrounding areas and move other residents to a safer location and, where possible, remove objects the resident could use to harm themselves or others. 8. Be team players, when incidents arise, work together to ensure the safety of everyone that is involved. Staff Fingernail Requirements In accordance with AM ,d+[DATE], Staff Dress Code Policy for all staff, please be reminded: Fingernails, whether natural or artificial, are to be no longer than one-quarter of an inch beyond the ends of the fingers to prevent danger of scratches and abrasion to residents. Fingernails must always be clean to avoid dangers of cross-contamination. Nail polish and artificial nails, if used must be intact. Grossly chipped/lifting nail polish/artificial nails are a potential infection risk. All staff including agency staff were required to complete in-person mandatory Resident Rights re-training conducted by Staff Development Instructors/department managers/supervisors [DATE] -[DATE]. On [DATE] the Nursing Home Administrator /Interim Assistant Director instructed department managers to provide this training to staff that were not on-duty upon their return to work and that they could not work until education was completed. The Nursing Home Administrator/Interim Assistant Director is responsible for ensuring this training is completed. This Resident Rights training is included in New Employee Orientation for all new hires including agency staff. Staff Development Director/designee is responsible for ensuring all new hires and agency personnel receive this training effective [DATE]. On [DATE] an Ad-HOC QI Committee convened to review an immediate plan of correction for immediate jeopardy to the incident on [DATE]. During the Ad-Hoc meeting a decision was made to utilize a staff observation tool to be completed by the house supervisor or designee as well as, a staff quiz that includes questions that relate to resident rights and physical abuse. The observation checklist includes observations of staff interactions with residents including appropriate behaviors, and actions to facilitate communication response to residents and procedure explanations. Both tools will be completed by the House Supervisor or designee 3 times per unit each week for 5 weeks to include all shifts. Monitoring will continue weekly thereafter for 8 weeks. Results will be brought monthly to the Quality Assurance Committee for continued Quality Improvement and Compliance and ongoing monitoring. Alleged date of Compliance was [DATE]. Onsite validation of the corrective action plan was completed on [DATE]. Interviews confirmed all staff were educated on resident rights and abuse prohibition. Education included reporting of suspected abuse and guidelines for staff fingernails. Observations were made of House Supervisors completing the staff observation tool. Review of audits of staff quizzes and observation tools were conducted. Due to interventions within the corretive action being completed on [DATE] the complaince date was verified as [DATE].

Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the complaint investigation survey of 6/29/23. This was for one deficiency in the area of investigate/prevent/correct alleged violation (F610) that was recited on the current recertification and complaint investigation survey of 3/14/24. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F610: Based on record review and staff interviews the facility failed to protect residents from the accused staff during an investigation of staff to resident abuse. On 2/15/24 staff observed Nurse Aide (NA) #1 strike Resident #21 with a closed fist twice in the face and push him down on the floor. An abuse investigation was initiated on 2/15/24. On 2/16/24, during the abuse investigation, NA #1 arrived at the facility, clocked in at 6:56 AM and was given a resident care assignment. NA #1 clocked out at 10:56 AM. This deficient practice was for 1 of 3 residents (Resident #21) reviewed for abuse and had the high likelihood of serious injury/harm for other residents. During the complaint investigation survey of 6/29/23 the facility was cited for failing to implement measures to safeguard other residents during an investigation into an allegation of abuse.

Based on record review, observation, staff interviews, and resident interviews the facility failed to implement their abuse policy in the area of reporting related to notifying Adult Protective Services (APS) and law enforcement of an allegation of staff physical abuse towards a resident for 1 of 3 residents investigated for abuse (Resident #21). Findings included: Review of the facility policy entitled Protecting Patients/Residents from Rights Infringements, dated 7/26/23 revealed an immediate report will be made to local Adult Protective Services when there is reason to believe a resident has been abuse, or exploited. Review of the facility policy entitled Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility, dated 4/6/23 revealed a suspected crime must be reported to the facility's Police Chief within two hours. Review of a facility reported incident initial report completed by the Risk Manager dated 2/15/24 revealed on 2/15/24 at 12:19 PM Resident #21 allegedly hit Nurse Aide (NA) #1 on the left side of her face twice while NA #1 was trying to redirect resident. Resident #21 attempted to hit NA #1 again and NA #1 put her arms up to brace herself and pushed back at Resident #21. Resident #21 fell backwards to the floor. There were no injuries noted. This report was resubmitted on 2/16/24 to reflect the police had been notified on 2/16/24 at 11:35 AM. An interview was conducted with the Risk Manager on 2/29/24 at 10:31AM. She reported she did not contact the police on 2/15/24 regarding the incident because she did not have all the information. The facility Risk Manager reported she completed the report based on the initial statement given by Nurse Aide #1 that Resident #21 hit her and she placed her arms up to brace herself in a defensive motion. She stated when she was made aware of the reasonable suspicion of a crime she reported the incident to the facility police department and the initial report was revised on 2/16/24. The facility reported incident investigation report dated 2/21/24 related to the 2/15/24 allegation of staff (NA #1) to resident (Resident #21) physical abuse was completed by the Event Review Specialist. The report revealed notification to adult protective services was made 2/19/24. The allegation was substantiated for abuse. During a follow up interview with the Risk Manager she indicated she was unaware APS needed to be notified until she was instructed by her supervisor, the Director of Standards, to make the report to APS on 2/19/24. During an interview with the Event Review Specialist on 2/29/24 at 10:33 AM she reported she normally completed the facility reported incident reports and made the necessary notifications to law enforcement and APS. She reported the facility Risk Manager was helping her by completing the initial report on 2/15/24. The Event Review Specialist stated the facility was made aware of the reasonable suspicion of a crime on 2/15/24 but the Risk Manager was not aware. The Director of Standards was unavailable for interview. An interview was conducted with the Assistant Administrator on 2/28/24 at 3:15 PM. She stated the facility police department and APS should have been notified by the Risk Manager within 2 hours when the allegation was made that NA #1 had struck Resident #21. The Assistant Administrator reported she planned to ensure strategies were put in place to ensure that the required notifications are completed. The facility provided and implemented the following corrective action plan with a completion date of 2/20/24. 1. The police report was filed regarding abuse investigation for Resident #21 on 2/16/24. Reporting to APS for the purpose of Abuse reporting was completed 2/19/24. 2. All other residents were not affected by this incident. The facility developed a checklist and went over the list of investigations for the prior 3 months and ensured reports were made to Adult Protective Services and the Police. 3. Staff members responsible for reporting Initial Allegation of Abuse (Center Director, Assistant Center Director, Director of Standards, Event Review Specialist and Director of Nursing) were educated during the Ad-hoc committee meeting on 2/19/24 to notify the police and APS (Adult Protective Services) of all incidences of initial allegations. The Director of Nursing will ensure that all initial allegations submitted after hours will include a report to APS and the Police. 4. Monitoring tools were created to monitor that all allegations and Investigation Reports will be reviewed by Care Center Director or Designee to ensure that APS and the Police have been notified of the initial allegation of abuse weekly on an on-going basis. An Ad-hoc QAPI meeting was conducted on 2/16/24 and it was determined ongoing monitoring and results will be presented to the QAPI committee for review. The corrective action plan was validated on 3/14/24. Interviews confirmed all staff responsible for reporting initial allegations of abuse were educated to notify the Police and APS of allegations of abuse. The Assistant Administrator stated if the DON was not available after hours another member of management would be available to ensure those reports were made. Review of the monitoring tools revealed that notifications had been made as required. The corrective action was verified as completed on 2/20/24.

Based on record review and staff interviews, the facility failed to have a transfer agreement in place for transferring residents to the local hospital for evaluation and treatment, which had the potential to effect 89 of 89 residents who resided in the facility. The findings included: A review of the Resident Care: Medical Emergency policy dated 3/1/2018 indicated residents were transported to [NAME] Medical Center emergency room (a local hospital) as warranted by the physician. A review of the facility contracts with local entities revealed the facility had not executed a transfer agreement with the local hospital. On 2/29/2024 at 5;30 p.m. in an interview with the Interim Administrator and the Administrative Nurse Consultant, they both stated the facility did not have a written transfer agreement with the local hospital to transfer the residents for treatment as needed. They both stated they did not know the facility was to have a transfer agreement with the local hospital and explained residents had been transported and accepted at the local hospital for evaluation and treatment as needed.

Based on record review and staff interviews, the facility failed to implement measures to safeguard other residents during an investigation into an allegation of abuse that was initially identified as an injury of unknown origin for 1 of 3 residents (Resident #1) reviewed for abuse. Findings included: The Residents Rights Policy with the subject Protecting Patients/Residents from Rights Infringements dated April 6, 2023, read in part that The staff of [facility] are responsible for responding promptly and appropriately to protect residents in the event that rights infringements are alleged or suspected. All known or suspected rights infringements shall be reported, investigated, documented, and addressed in accordance with this policy. It further read in part that It is Department Managers'/designated [facility] staff's responsibility to determine the need for, and implement, a plan of protection to safeguard the resident(s) involved in the incident, and other residents as indicated. Resident #1 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. The initial allegation report with a fax date and time stamp of 5/30/23 at 4:55 PM revealed an injury of unknown source. The allegation details read that Resident #1's left hand/fingers noted with swelling from unknown origin. The details of physical or mental injury/harm read in part that x-ray reports left 2nd and 3rd proximal phalanx fractures (broken fingers) with mild displacement and soft tissue swelling noted. The investigation report with a fax date and time stamp of 6/04/23 11:48 PM revealed a summary of the facility's investigation which read in part that there were no witnesses to an incident resulting in the fracture of Resident #1's fingers. The resident shared conflicting statement during her interview, saying at first that she injured her hand herself. She then said that someone was with her when it happened, beating her on the hips and chest. The investigation report did not indicate if other residents were assessed as part of the investigation. The investigation report was completed by the Event Review Specialist. On 6/28/23 at 2:30 PM an interview with the Event Review Specialist revealed she had completed the investigation into the injury of unknown origin for Resident #1. She indicated she based her investigation on the Advocacy Director's and Administrator's instructions. The Event Review Specialist reported that nursing staff would have been responsible for assessing or interviewing other residents. On 6/28/23 at 5:14 PM an interview with the Standards Director revealed she felt Resident #1's injury was an isolated incident that was caused by the resident herself while pulling on her abdominal binder and gastric tubing and that no other residents were interviewed or assessed. On 6/28/23 at 5:18 PM an interview with the Assistant Director of Nursing revealed it was determined Resident #1's injury was an isolated incident and that no other residents were interviewed or assessed as part of this investigation to ensure other residents had not been abused. She was unable to explain why it had been determined to be an isolated incident. On 6/28/23 at 5:31 PM an interview with the Director of Nursing revealed no other residents were interviewed or assessed during this investigation. She stated the facility staff's perception of the incident was that it was an isolated incident. She was unable to explain why this was determined to be an isolated incident. On 6/28/23 at 5:49 PM an interview with the Interim Administrator revealed that the investigation did not include other resident assessments or resident interviews to ensure other residents were protected from abuse.

Based on observations, resident and staff interview and record review the facility failed to treat residents with dignity and respect when Nursing Assistant (NA) #3 spoke to Resident #2 in a manner that made him feel like a child, like he was being talked down to, and resulted in the resident being tearful. Resident #3 observed the incident and was visibly upset by the verbal exchange between NA #3 and Resident #2. This deficient practice affected 2 of 2 residents reviewed for dignity and respect. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included vascular dementia. Resident #3's current care plan revealed, in part, the resident had cognitive loss/impairment. Resident #2 was admitted [DATE] with diagnoses which included in part dementia with behavioral disturbance. Resident #2's current care plan revealed, in part, the resident had cognitive loss/ impairment. Resident #3's medical record revealed a progress note completed by the facility psychologist on 9/19/22. The psychologist was summoned to evaluate Resident #3 due to an incident that occurred with NA #3 and Resident #2. Resident #3 was observed by staff as visibly upset by the exchange but was redirected and calmed without further intervention required. A 9/19/22 progress note in Resident #2's medical record was completed by the facility psychologist. The facility psychologist was alerted to Resident #2's episode of increased agitation that afternoon and that resident was eventually redirected and calmed by staff after NA #3 was removed from the area. Interview on 10/19/22 at 3:30 PM with NA #3 revealed she was assigned to Residents #2 and #3 on 9/19/22. NA #3 stated she entered Resident #2's room and asked him why he was telling lies about her and saying she did not provide care for him. Resident #2 became upset yelling and cursing at her, asking her to leave his room and followed her into the hallway. NA #3 stated Resident #3 came into the hall during the incident and started yelling. NA #3 stated she went to Nurse #8 and requested a change in assignment for the remainder of the shift. NA #3 stated she had worked with Resident #2 before and joked and played with him. NA #3 stated she had never had an issue with Resident #2 or Resident #3 previously. Interview on 10/19/22 at 3:45 PM with Nurse #8 revealed she was assigned to Residents #2 and #3 on 9/19/22. Nurse #8 reported that NA #3 came to her and stated that something was going on with Resident #2 and she needed to switch residents. NA #3 did not tell Nurse #8 what she meant by something was going on. Nurse #8 observed Residents #2 and #3 in the hallway both agitated and yelling. Resident #2 stated to Nurse #8 that NA #3 had asked him why he was lying, and this upset him. She explained that Resident #2 was a very religious man and when NA #3 said he lied it had upset him, but he later felt badly about how he reacted to NA #3. Nurse #8 stated Resident #2 was tearful when he spoke to the facility psychologist following the incident but later calmed down. Nurse #8 stated she asked the facility psychologist to see Residents #2 and #3 that afternoon and he did. Nurse #8 stated Residents #2 and 3 were calm after NA #3 was removed from the assignment. Observation of Resident #2 on 10/19/22 at 1:15 PM revealed resident was well groomed and sitting in a high-backed wheelchair in an activity. Resident #2 was alert, soft spoken with noted confusion. Interview was attempted with Resident #2 regarding the incident on 9/19/22 with NA #3 however resident did not recall. Observation of Resident #3 on 10/19/22 at 1:10 PM revealed resident was sitting in the activity area and was calm and alert with no behaviors observed. Interview with Resident #3 revealed he had no complaints or concerns and was unable to recall the incident that occurred on 9/19/22. A 9/26/22 facility investigation report completed by management and signed by the Administrator and Director of Nursing revealed that management became aware of an incident on 9/19/22 at 3:30 PM involving NA #3, Resident #2, and Resident #3. Incident was investigated as possible staff to resident abuse. A full investigation of the incident including interviews with staff and residents was conducted by the facility. Investigation revealed NA #3 asked Resident #2 why you telling all those lies. Report stated that Resident #2 yelled at NA #3 to get out of his room. When Resident #2 was interviewed by facility management he stated NA #3 made him mad when she approached him and accused him of saying things he didn't say. Resident #2 further stated NA #3 talked to him like a child, talking down to him and playing with him and he could not stand that. Report indicated that Resident #3 came out of his room during the incident and was visibly upset by what happened. Report stated that Resident #2 was witnessed by other staff as distraught on 9/19/22 following the incident with NA #3. The report concluded on 9/26/22 that the allegation of mental abuse involving NA # 3 and Resident #2 and Resident #3 was found to be substantiated. Interview on 10/19/22 at 12:50 PM with the facility Standards Director regarding the investigation that was completed revealed that both Resident #2 and #3 were yelling and agitated during the incident on 9/19/22. NA # 3 was suspended while the investigation was pending and received a written warning at the completion of the investigation with the allegation of staff to resident abuse substantiated for Resident #2 and Resident #3. Interview on 10/21/22 at 9:30 AM with interim Administrator revealed that he expected that staff treated all residents with dignity and respect.

Based on record review and interviews with staff, the physician and medical director, the facility failed to notify the physician until 9/12/22 of a change in bowel function that included no bowel movement for 6 days resulting in administration of laxatives and enemas for 1 of 3 residents reviewed for change in condition. (Resident # 1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis which included, in part, stroke. Review of Resident #1's active physician orders for September 2022 revealed the following orders: milk of magnesia 30 milliliters every 3 days as needed if no bowel movement and docusate sodium 100 milligrams twice daily. Review of Resident #1's bowel movement record revealed no bowel movements from 9/6/22 through 9/14/22. Review of Resident #1's Medication Administration Record for September 2022 indicated the first date the order for milk of magnesia was administered was on 9/13/22. Interview on 10/20/22 at 9:10 AM with Nurse #4 revealed she was assigned to Resident #1 on 9/10/22 and did not inform the physician of resident not having a bowel movement since 9/6/22. Nurse #4 stated she was a travel nurse and did not have access to the computer to check the bowel movement records. Nurse #4 stated she was not sure of the facility bowel protocol but that she administered medications per the physician orders and was usually informed in report by the previous nurse if a resident required a laxative. Nurse #4 did not recall being notified on 9/10/22 of Resident #1 not having a bowel movement since 9/6/22. Interview on 10/20/22 at 11:15 AM with Nurse #5 revealed she was assigned to Resident #1 on 9/10/22. Nurse #5 stated she thought the bowel protocol indicated a resident received a laxative on the 3rd day when no bowel movement. Nurse #5 stated she was a travel nurse and was not able to access the computer system bowel movement records for the residents. The nurse on the shift before her would usually tell her which residents required a laxative. Nurse #5 did not recall being notified that Resident #1 required a laxative. On 9/12/22 at 7:15 AM a note was entered in the facility's Sick Call Logbook, a hard copy notebook with information documented for the physician, read, Day 6 no bowel movement as of today. Abdomen soft and non-tender, non-distended with positive bowel sounds. Interview on 10/20/22 at 5:25 PM with Nurse #7 revealed she was assigned to Resident #1 on 9/9/22 and 9/12/22 and she did not know why she had not initiated the bowel protocol including notification of the physician. A nursing note dated 9/13/22 completed by Nurse #3 documented Resident #1 received as needed milk of magnesia. Interview with Nurse #3 on 10/19/22 at 4:00 PM revealed she was assigned to Resident #1 on 9/13/22 and administered milk of magnesia per standing order. Nurse #3 did not recall informing the physician. A nursing note dated 9/14/22 at 1:19 PM entered by Nurse #2 noted Resident #1 was 8 days with no bowel movement, bowel sounds were active, abdomen was non tender, and Physician #1 was notified with no new orders received. Nurse #2 noted on 9/14/22 at 1:30 PM rectal exam was completed, and Physician #1 was notified. On 9/14/22 two notes were documented in the Sick Call Logbook regarding Resident #1 which revealed the following: Decreased breath sounds and bowel sounds were noted with no time documented. Lactulose was given at 9:00 PM and it was noted to be ineffective as of 11:00 PM. Interview with Nurse #2 on 10/19/22 at 2:00 PM revealed she had been off for a few days and when she returned on 9/12/22, she checked the bowel movement record that morning and found Resident #1 had not had a bowel movement for 6 days. She verbally reported this to physician #2 and received no new orders. The following day (9/13/22) she completed a rectal exam and reported findings of soft stool to Physician #2. Interview on 10/20/22 at 3:20 PM with Physician #1 revealed she did not recall being notified by phone, verbally or the sick call book on 9/12/22 that Resident #1 had not had a bowel movement since 9/6/22. Physician #1 stated she assessed Resident #1 on 9/13/22 for a routine visit and his abdomen was normal. Physician #1 stated on 9/14/22 Nurse #2 reported that Resident #1 had not had a bowel movement since 9/6/22. Physician #1 stated she expected to be notified by day 5 if a resident had no bowel movement. Interview with Nurse #1 on 10/19/22 at 1:00 PM revealed he was assigned to Resident #1 on 9/6/22, 9/8/22, 9/9/22 and 9/13/22. Nurse #1 stated the bowel protocol indicated the 2nd shift nurse administered per standing order or specific physician order bowel medication when a resident did not have a bowel movement for 3 days. Nurse #1 indicated he recalled Resident #1 was having constipation prior to hospitalization and went 6 or 7 days without a bowel movement before the bowel protocol was initiated or the physician notified. Nurse #1 did not recall why the physician was not notified prior to 6 or7 days of Resident #1 not having a bowel movement. Interview on 10/19/22 at 9:30 AM with Nurse Supervisor #1 revealed that the 3:00 PM to 11:00 PM nurses checked the bowel movement records in the computer for their residents and if no bowel movement in 2 days they initiated interventions. If no specific physician orders, they implemented the standing orders. The nurse documented in the physician Sick Call Book that an as needed laxative was administered due to no bowel movement per facility protocol. Interview on 10/19/22 at 9:50 AM with Unit Manager #1 revealed the nursing assistants recorded bowel movements in the computer system. 3:00 PM -11:00 PM nurses checked the computer system for bowel movements and determined which residents required laxatives. Residents with no bowel movement in 2 days received either the specific laxative ordered by the physician or the standing order for an as needed laxative. Policy indicated if no bowel movement in 2 days initiate the protocol of laxative first and then progress to an enema on day 4 if still no bowel movement, notifying the physician after each step. Interview on 10/20/22 at 10:21 AM with Physician #2 revealed Resident #1 should have received as needed medication per the bowel protocol on day 3. Physician #1 stated he expected to be notified at day 3 of no bowel movement. On the third day that a resident does not have a bowel movement the nurse should record it in the facility Sick Call Logbook. This allows the doctor to order interventions, to track patterns of constipation or if further bowel regimen was necessary. Interview on 10/20/22 at 12:56 PM with facility Medical Director revealed the computer tracking system should have been used to monitor the resident's bowel movements and the physician should have been notified on day 3 of no bowel movement. Interview on 10/20/22 at 2:30 PM with the Director of Nursing (DON) she expected the nurses to follow the bowel protocol including notification of the physician.

Based on record review and interviews with staff and the physicians the facility failed to implement interventions for a change in bowel function that included no bowel movement for 8 days resulting in administration of laxatives and enemas for 1 of 3 residents reviewed for bowel function. (Resident # 1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis which included, in part, stroke. Review of Resident #1's active physician orders for September 2022 revealed the following orders: milk of magnesia 30 milliliters every 3 days as needed if no bowel movement and docusate sodium 100 milligrams twice daily. Resident #1's active care plan revealed a problem of constipation and at risk for adverse symptoms related to inadequate bowel elimination. Interventions included to document all bowel movements, alert physician of issues, monitor for signs of inadequate bowel elimination such as changes in mental status, mood, behavior, abdominal pain, or distention and follow facility protocol. Review of Resident #1's bowel movement record revealed no bowel movements from 9/6/22 through 9/14/22. Interview on 10/19/22 at 9:25 AM with Nursing Assistant (NA) #1 revealed bowel movements including size and consistency were documented in the computer system at the end of the shift. The system generated an alert for the nurses when a resident went 2 days or more without a bowel movement. Interview on 10/19/22 at 9:45 AM with NA #2 revealed that bowel movements were recorded in the computer system at the end of the shift including the size and consistency and if no bowel movement occurred it was reported to the nurse. Review of Resident #1's Medication Administration Record for September 2022 indicated the first date the order for milk of magnesia was administered was on 9/13/22. Interview on 10/20/22 at 9:10 AM with Nurse #4 revealed she was assigned to Resident #1 on 9/10/22 and did not administer the as needed ordered medication milk of magnesia for resident not having a bowel movement since 9/6/22. Nurse #4 stated she was a travel nurse and did not have access to the computer to check the bowel movement records. Nurse #4 stated she was not sure of the facility bowel protocol but that she administered medications per the physician orders and was usually informed in report by the previous nurse if a resident required a laxative. Nurse #4 did not recall being notified on 9/10/22 of Resident #1 not having a bowel movement since 9/6/22. Interview on 10/20/22 at 11:15 AM with Nurse #5 revealed she was assigned to Resident #1 on 9/10/22. Nurse #5 stated she thought the bowel protocol indicated a resident received a laxative on the 3rd day when no bowel movement. Nurse #5 stated she was a travel nurse and was not able to access the computer system bowel movement records for the residents. The nurse on the shift before her would usually tell her which residents required a laxative. Nurse #5 did not recall being notified that Resident #1 required a laxative and did not administer the as needed ordered milk of magnesia. On 9/12/22 at 7:15 AM a note was entered in the facility's Sick Call Logbook, a hard copy notebook with information documented for the physician, read, Day 6 no bowel movement as of today. Abdomen soft and non-tender, non-distended with positive bowel sounds. Interview on 10/20/22 at 5:25 PM with Nurse #7 revealed she was assigned to Resident #1 on 9/9/22 and 9/12/22 and she did not know why she had not initiated the bowel protocol including administration of the as needed milk of magnesia. Interview with Nurse #2 on 10/19/22 at 2:00 PM revealed she had been off for a few days and when she returned on 9/12/22, she checked the bowel movement record that morning and found Resident #1 had not had a bowel movement for 6 days. She verbally reported this to Physician #1 and received no new orders. The following day (9/13/22) she completed a rectal exam and reported findings of soft stool to Physician #1. Interview with Nurse #1 on 10/19/22 at 1:00 PM revealed he was assigned to Resident #1 on 9/6/22, 9/8/22, 9/9/22 and 9/13/22. Nurse #1 stated the bowel protocol indicated the 2nd shift nurse administered per standing order or specific physician order bowel medication when a resident did not have a bowel movement for 3 days. Nurse #1 indicated he recalled Resident #1 was having constipation prior to and went 6 or 7 days without a bowel movement before the bowel protocol was initiated. Nurse #1 did not recall why the bowel protocol was not initiated prior to 6 or7 days of Resident #1 not having a bowel movement. A nursing note dated 9/13/22 completed by Nurse #3 documented Resident #1 received as needed milk of magnesia. Interview with Nurse #3 on 10/19/22 at 4:00 PM revealed she was assigned to Resident #1 on 9/13/22 and administered milk of magnesia per standing order. A nursing note dated 9/14/22 at 1:19 PM entered by Nurse #2 noted Resident #1 was 8 days with no bowel movement, bowel sounds were active, abdomen was non tender, and Physician #1 was notified with no new orders received. Nurse #2 noted on 9/14/22 at 1:30 PM rectal exam was completed, and Physician #1 was notified. A physician's order dated 9/14/22 lactulose 30 milliliters Now via feeding tube was documented on the Medication Administration Record (MAR) given on 9/14/22 at 2:45 PM. If no bowel movement by 9 PM give another dose was ordered and documented on 9/14/22 at 9:00 PM. Interview on 10/20/22 at 3:20 PM with Physician #1 revealed she assessed Resident #1 on 9/13/22 for a routine visit and his abdomen was normal. Physician #1 stated on 9/14/22 Nurse #2 reported that Resident #1 had not had a bowel movement since 9/6/22 and further orders were given. Physician #1 stated she expected the ordered as needed medication to be given every three days for no bowel movement however delay in administration did not cause Resident #1 harm. Review of Resident #1's bowel records revealed the following bowel movements a small loose on 9/14/22 at 10:38 PM, a medium loose bowel on 9/15/22 at 10:42 AM and an extra large on 9/16/22 at 10:37 PM. Review of Resident #1's physician orders and Medication Administration Record (MAR) revealed the following: Order dated 9/15/22 indicated lactulose 45 milliliters now and every 8 hours until bowel movements. The MAR indicated this was administered on 9/15/22 at 4:00 PM and at 12:00 Midnight. Order dated 9/16/22 lactulose 45 milliliters now and then daily until bowel movements are regular and loose. If bowel movements become loose, hold for 24 hours and restart at 30 milliliters once per day. Administer fleets enema now. The MAR indicated these were administered on 9/16/22. Interview on 10/19/22 at 9:30 AM with Nurse Supervisor #1 revealed that the 3:00 PM to 11:00 PM nurses checked the bowel movement records in the computer for their residents and if no bowel movement in 2 days they initiated interventions. If no specific physician orders, they implemented the standing orders. The nurse documented in the physician Sick Call Book that an as needed laxative was administered due to no bowel movement per facility protocol. Interview on 10/19/22 at 9:50 AM with Unit Manager #1 revealed the nursing assistants recorded bowel movements in the computer system. 3:00 PM -11:00 PM nurses checked the computer system for bowel movements and determined which residents required laxatives. Residents with no bowel movement in 2 days received either the specific laxative ordered by the physician or the standing order for an as needed laxative. Policy indicated if no bowel movement in 2 days initiate the protocol of laxative first and then progress to an enema on day 4 if still no bowel movement, notifying the physician after each step. Interview on 10/20/22 at 10:21 AM with Physician #2 revealed Resident #1 should have received as needed medication per the bowel protocol on day 3. Physician #2 stated he expected on the third day that a resident does not have a bowel movement the nurse should administer the as needed medication for constipation and record it in the facility Sick Call Logbook. This allows the doctor to order interventions, to track patterns of constipation or if further bowel regimen was necessary. Interview on 10/20/22 at 2:30 PM with the Director of Nursing (DON) she expected the nurses to follow the bowel protocol including administration of the as needed medication for no bowel movement for three days.

Based on observation, record review, resident, staff and Physician interviews the facility failed to safeguard a resident from entrapment when Resident #21's half side rail was in the up position, he fell out of bed, his right arm became caught between the side rail and the mattress, and he was unable to free himself. Resident #21 sustained 2 abrasions to his knee and was at high likelihood of suffering serious injury or death as a result of the entrapment. The facility also failed to follow the manufacturer's instructions for a mechanical lift when transferring Resident #8 out of bed resulting in the resident falling out of the lift face first to the floor. Resident #8 experienced pain and sustained soft tissue swelling, a scalp hematoma, and a laceration to the forehead. This deficient practice affected 2 of 6 residents reviewed for accidents. Immediate Jeopardy for example #1 began on 8-16-22 when Resident #21's right arm became entrapped in the side rail of his bed when he fell out of bed and example #2 began on 1-20-22 when health care tech (HCT) #1 and HCT #2 failed to place mechanical lift straps according to manufacturer's instructions causing Resident #8 to fall out of the lift face first. Immediate Jeopardy was removed on 9-10-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: 1.Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting dominant right side. An Occupational Therapy assessment was conducted for Resident #21 on 3-3-22. Review of the assessment revealed Resident #21 was assessed for the continued use of his side rails. The Occupational Therapist documented the resident was no longer able to use the side rails for assistance in bed mobility and required two people to assist with bed mobility. The Occupational Therapist recommended discontinuation of Resident #21's side rails. Physician order dated 3-3-22 revealed an order for Resident #21's side rails to be discontinued. The Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was moderately cognitively impaired and required extensive assistance with two people for bed mobility, transfers and dressing. The MDS documented Resident #21 as having impairment on one side for upper and lower extremities and unsteady, only able to steady with staff assistance with transfers. Documentation in the MDS revealed resident had one fall without injury since his previous MDS assessment on 6-14-22. Resident #21 was not documented for side rails. Resident #21's care plan dated 6-15-22 revealed a goal that he will be free from falls or injury. The interventions associated with the goal were in part increase observations during periods of agitation, assist with mobility, resident with a history of not using his call light so provide frequent observation. Resident #21 was not care planned for side rails. Review of the facility's side rail monitoring tool revealed the facility had begun weekly random monitoring for the use of side rails on 5-15-22. The monitoring tool, completed by Restorative Aide #1 also revealed continued issues with residents having side rails used when there was an active physician order to have the side rails discontinued. During an interview with Restorative Aide #1 on 9-7-22 at 2:38pm, the Restorative Aide stated she had been conducting side rail monitoring once weekly on random residents since May 2022. The aide stated the monitoring tool was started when the facility had decided to discontinue resident side rail use throughout the facility until the residents were assessed by therapy and identified with a need for side rails. She explained she would choose 5-6 residents randomly to assess if residents who were not to have side rails, had their side rails in the up position. The Restorative Aide said there continued to be an issue with residents having their side rails placed in the up position when they were not supposed to have them. The aide stated the issue would occur about two times out of a four-week period. She explained if the side rail was in the up position, she would put it down and document on the monitoring sheet that the side rail was in the up position and she had put it down. She stated even though there continued to be issues with the side rails, she was not instructed to increase the monitoring. The aide also explained giving the completed monitoring tool each week to the nurse assigned to the unit. HCT #5 was interviewed by telephone on 9-7-22 at 5:08pm. HCT #5 confirmed he had worked the 11:00pm to 7:00am shift on 8-15-22 and was assigned to Resident #21. He explained he had last provided care to Resident #21 between 6:30am and 7:00am on 8-16-22. The HCT stated Resident #21's side rail was in the down position. Review of the Nurse #1's documentation dated 8-16-22 at 9:30am revealed documentation of Resident #21 being found sitting on the floor beside the bed with his head resting on the side of the mattress and his right arm trapped between the resident's side rail and mattress. The nurse documented the resident denied any pain but had 2 scrapes on his left knee. Review of the mobile x-rays of Resident #21's right arm and left side dated 8-17-22 revealed no remarkable findings. Review of the facility's investigation report dated 8-26-22 completed by the facility's Risk Manager revealed Resident #21 fell on [DATE] from his bed. The report documented Resident #21 had side rails on his bed which the facility determined should not have been present. The investigation reported the facility conducted a re-enactment of Resident #21's fall showing the resident was sitting on the floor with his back against the bed and his right arm was caught between the side rail and the mattress. During an interview with Resident #21 on 9-7-22 at 9:35am, the resident was observed sitting up in his wheelchair. He stated the day he fell out of bed (8-16-22) he was trying to get up in his wheelchair. Resident #21 was not able to verbalize how he caught his arm in the side rail but was able to gesture that his arm became caught between the side rail and mattress. The resident denied he had been hurt. An interview with Health Care Tech (HCT) #3 occurred on 9-7-22 at 9:40am. HCT #3 stated she was assigned to Resident #21 on 8-16-22 for the 7:00am to 3:00pm shift. She explained she had not seen the resident that morning until she heard him calling for help a little after 9:00am. HCT said she entered Resident #21's room and saw him sitting on the floor positioned in the middle area of the bed with his back against the bed. She stated she left the room to find help. The HCT discussed seeing Nurse #1 in the hall and requested she come to Resident #21's room. She stated once the nurse had assessed the resident, she assisted in helping the resident into his wheelchair. HCT #3 said she did not see that Resident #21 had his right arm trapped in the side rail until she returned with the nurse. Nurse #1 was interviewed on 9-7-22 at 11:30am. Nurse #1 confirmed she was assigned to Resident #21 on 8-16-22 during the 7:00am to 3:00pm shift. She explained HCT #3 had walked down the hall and requested she come to the resident's room. The nurse stated when she walked into the room, she saw Resident #21 sitting on the floor positioned in the middle area of the bed with his head against the mattress on the bed and his right arm was caught between the side rail and the bed. She said Resident #21 could not have raised the side rails himself due to his [CONDITION(S)]. She explained she assisted in removing the resident's right arm from the side rail and stated when the arm was no longer caught between the side rail and the bed, the resident began to slide into a lying position. Nurse #1 said she assisted Resident #21 to a flat position on the floor and assessed him for any wounds, pain and fractures. She stated once the assessment was complete and no injuries were found, HCT #3 assisted the resident by a mechanical lift into his wheelchair. Once in the wheelchair the nurse stated she saw 2 small abrasions to Resident #21's left knee but explained the abrasions were not bleeding and the resident had denied any pain. Nurse #1 stated Physician #2 assessed the resident later that afternoon and the resident complained of pain to his left rib area. She discussed the Physician ordered an x-ray of Resident #21's left side as well as his right arm. The nurse said she had reported the incident to the Unit Manager #3 and the house supervisor. Observation of a reenactment of Resident #21's entrapment occurred on 9-8-22 at 9:28am with HCT #3 and Nurse #1. The reenactment included the same bed Resident #21 occupied on 8-16-22 with the same half rails that were permanently affixed to the bed. The side rails could be moved up and down but were unable to be removed from the bed. During the reenactment Nurse #1 stated Resident #21's head of the bed was raised approximately 30 degrees when the entrapment occurred on 8-16-22. Neither Nurse #1 nor HCT #3 could remember if the bed was raised. HCT #3 sat on the floor with her back against the bed and placed her right arm between the side rail and the bed. She explained the resident had slid down more so he was in a slouched position with his head resting against the mattress. On 9-7-22 at 10:53am, the Director of Patient Advocacy was interviewed. She explained when a resident's rights had been violated, she would open her own investigation. She discussed being informed by the DON on 8-24-22 of the fall on 8-16-22 with Resident #21 and was informed by the facility Resident #21's resident's rights may had been violated due to the use of the side rails. The Director of Patient Advocacy stated she would interview staff and residents as part of her investigation but explained she had not interviewed any other residents or Resident #21 during her investigation of the 8-16-22 fall and arm entrapment in the side rails. She stated she could not remember why she had not interviewed other residents but had found Resident #21's rights were violated because he should not have had the side rails in place. The Director of Standards was interviewed on 9-7-22 at 11:15am. The Director of Standards stated she had assisted the facility in the investigation of Resident #21 becoming trapped in his side rail on 8-16-22. She explained through her part of the investigation she was unable to determine how the side rail became raised but was able to determine Resident #21 was not to have side rails. During an interview with Physician #2 on 9-7-22 at 1:20pm, the Physician discussed Resident #21's condition and stated he did have some use of his right leg but that the right leg was weaker than his left, so the resident possibly had moved his right leg off the bed causing him to slide off the bed. She confirmed she saw Resident #21 the afternoon of 8-16-22 after his fall that morning. Physician #2 stated she could not find anything wrong with the resident during her assessment but stated the resident complained of pain on his left side in the rib area, so she ordered an x-ray of Resident #21's left side and as a precaution ordered an x-ray of his right arm. The Physician said the x-rays showed no injury to the resident's right arm or left side. She explained there was a possibility the resident could have broken his arm when he fell out of the bed and became trapped between the side rail and bed. During an interview with Restorative Aide #1 on 9-7-22 at 2:38pm she revealed that after Resident #21's fall on 8-16-22 in which his arm became entrapped between his half side rail and his mattress she continued completing the side rail monitoring tool at the same frequency (once weekly on random residents selecting 5-6 residents for review per week) and was not instructed to increase the monitoring or begin monitoring all residents. The Director of Nursing (DON) was interviewed on 9-9-22 at 8:30am. The DON stated she would have expected HCT #3 to have rounded on Resident #21 when she started her shift at 7:00am and not wait until after 9:00am. She also said she would have expected HCT #3 to have used the call light or called out for help instead leaving the resident alone in his room. The DON explained she was aware there were on going issues with residents' side rails being left in the up position but stated the Assistant Director of Nursing #1 reviewed the monitoring tools and discussed any on going issues with the Unit Managers. The DON stated there were no formal actions taken to resolve the ongoing issues with the side rails being left in the up position. 2. The operating manual for the mechanical lift used by the facility dated 12/2019 revealed to use the crossed loop connection of the loops for the lift, cross the leg loops for one leg support through the leg loop closest to the leg support on the other side of the sling. To transfer a person from a bed or stretcher the individual operating the lift should make sure they understand which size sling and which method of connecting the sling to the hanger bars was to be used. To position the leg supports, staff were to lift one of the resident's legs and pull the leg support under the leg, being sure not to twist or fold the leg support. Lay the leg support loops across the resident's thigh and repeat for the resident's other leg. Staff were to connect the sling loops to the hanger bar hooks to transfer the resident in the desired sitting, half-sitting or lying position and with the leg supports in the required position (crossed loop or crossed leg support). Staff were to double check the sling loop connection to the hanger bar hooks to make sure the sling was securely attached with the loops in the bottom of the hanger bar hooks. The Nursing Policy T-7A, Mechanical Lifts/Vander-Lift dated 5/1/18 revealed when using the crossed loop connection cross the leg loops for one leg support through the leg loop closest to the leg support on the other side of the sling. This method is comfortable for most residents. Prior to lifting the resident, check the leg support underneath each thigh to make sure it is not twisted or bunched up and is smooth. Make necessary adjustments by lifting the resident's legs. Once the sling is securely attached to the hanger bar assembly, use the control to lift the resident just clear of the object. This should be approximately 2 inches above the object you are lifting from. Check one more time and smooth out and remaining wrinkles. After the resident has been lifted clear of the bed, chair, etc., position the resident so that he/she is facing the lift column. Resident #8 was admitted to the facility on [DATE]. Her active diagnoses included dysphagia, [CONDITION(S)], intracranial injury of other and unspecified nature, and hypertension. Resident #8's Minimum Data Set assessment dated [DATE] revealed she was assessed as moderately cognitively impaired. She had no moods or behaviors. She was totally dependent on 2 staff for transfers. Resident #8's care plan dated 12/21/21 revealed she was care planned to be totally dependent on staff for transfers via lift. The interventions included to follow facility protocol for use of the mechanical lift. Review of a nursing note dated 1/20/22 revealed the Wound Care Nurse was called Resident #8's room at approximately 8 AM due to a fall from the lift during transfer. The nurse found the resident lying prone with the lift leg underneath the resident's abdomen and head and face down. Resident #8 had blood coming from her face. The resident was calmed, and Physician #3 was called for as well as 911 as the nurse did not feel comfortable moving the resident due to the increased possibility of serious injury. Multiple staff came to assist and assessed the resident and attended to the resident until emergency medical services arrived. Review of a hospital CT head scan without contrast dated 1/20/22 revealed Resident #8 had soft tissue swelling, scalp hematoma, and laceration overlaying the forehead. There was no acute intracranial pathology. No evidence for intracranial hemorrhage. Review of a hospital CT cervical spine scan without contrast dated 1/20/22 revealed Resident #8 had no evidence for acute fractures or subluxation (a slight misalignment of the vertebrae). Resident #8 was not admitted to the hospital and returned to the facility with three stiches on 1/20/22. Review of a nursing note dated 1/21/22 revealed Resident #8 was assessed by the Wound Care Nurse and new orders were written to apply [MEDICATION(S)] twice a day to the forehead laceration until healed and leave open to air. Remove stitches per physician orders. Review of the Medication Administration Record for January 2022 revealed she was ordered on 1/21/22 [MEDICATION(S)] 5 milligrams by mouth every 8 hours for 48 hours. The resident received all 6 doses of the medication at 1:30 PM, and 10 PM on 1/21/22, at 6 AM, 1:30 PM, and 10 PM on 1/22/22, and at 6 AM on 1/23/22. On 1/24/22 she was ordered [MEDICATION(S)] 5 milligrams by mouth every 8 hours as need for 48 hours and then discontinue. No doses of this order were administered. Review of a written statement dated 1/20/22 revealed HCT #1 wrote the HCTs were getting Resident #8 ready for her shower. The resident was alert and aware of the procedure. HCT #2 put the lift pad underneath Resident #8. HCT #1 put straps on to the lift after HCT #2 told her to hook the straps on. She then began to lift and remove Resident #8 from the bed to roll to shower bed in Resident #8's room taking all precautions. HCT #2 was holding Resident #8's legs to put on the shower bed. Resident #8 began to shift her weight. HCT #1 was not told if anything on the lift pad was twisted. HCT #1 noted as Resident #8 shifted her weight the resident slipped out of the lift pad. HCT #1 told HCT #2 the resident was falling out of the sling. Resident #8 fell from lift pad onto the floor face down. HCT #1 stayed after noting blood from Resident #8's head on floor. HCT #1 asked Resident #8 if she hurt anywhere, and Resident #8 indicated her head. HCT #2 went to get help from the nurse and staff to report the incident. HCT #1 stayed until emergency medical services arrive to move Resident #8 and be checked out. HCT #1 indicated she hooked the 2 top straps and 1 bottom right strap to the lift. During an interview on 9/7/22 at 12:40 PM HCT #1 stated Resident #8 was her resident and HCT #2 came to help move her from the bed. She stated she and HCT #2 placed the lift straps on the resident. She thought she placed the front straps and HCT #2 placed the back straps to the best of her memory. She stated the strap on the right back clip was placed in a way that the right side of the lift pad was looser than the left. She was not aware of this until the resident fell . She was pushing the lift and HCT #2 was in front of the resident guiding the resident. She stated she noted the resident was sliding to the right and fell . She stated it happened so fast all she could remember was Resident #8 ' s head hit the floor. The way the clips were placed on the lift left the right side too loose. She stated she noted this about the straps after she fell . The resident shifted to the right which caused her to slide out of the looser right side. She saw the resident was bleeding from the head and told HCT #2 to get help and put towels around the resident ' s head and did not move the resident until nursing arrived. The resident had a goose bump to her forehead, complaints of pain to her head, and a laceration that was bleeding. She stayed with the resident and nursing until emergency medical services arrived. Both HCTs were then called down to The Director of Patient Advocacy and were interviewed by her. HCT #1 told her what she had witnessed including that the resident was shifting her body and slid out. They did their investigation and concluded it was faulty equipment. They had HCT #1 demonstrate how they had placed the resident in the lift pad with the use of a dummy and everything she did was correct. When asked, HCT #1 thought they might have spoken to her about how the resident had been placed in the lift pad and double checking the straps but could not remember. Review of a written statement dated 1/20/22 revealed HCT #2 wrote she and HCT #1 were preparing Resident #8 for shower in the morning. HCT #2 put the lift pad under the resident while HCT #1 hooked Resident #8 to the lift. HCT #2 held Resident #8's legs while other HCT was pulling the lift from the bed to place Resident #8 on the shower bed. HCT #1 turned the lift slightly to the right side and Resident #8 slipped out of the lift headfirst and hit the floor. They were using a large lift pad and the pad was properly put under her before hooking the pad to the lift. Resident #8 did not state any unusual discomfort while being lifted off the bed. HCT #2 wrote that they noted the lift pad was positioned incorrectly after the fact and it was too late to correct. During an interview on 9/7/22 at 3:12 PM HCT #2 stated she was assisting HCT #1 with showers and Resident #8 was getting her shower. She stated the lift pad they had placed under her and to the lift. Stated the face hit the floor first and she was in the lift about 3 to 4 feet from the floor when she fell , and it was a hard fall as the resident did not have the capacity to break the fall. The resident was facing away from the lift. She started to slide to the right side and fell . HCT #1 stated something was wrong with one of the straps. She stated they reenacted how they placed Resident #8 in the sling with the dummy doll and Occupational Therapist #1 was present to observe. She concluded she had completed the demonstration correctly and had not done anything wrong. HCT #1 had applied the bottom straps wrong because the sling looked wrong after the resident fell from it but she was not sure why. Review of a written statement dated 1/20/22 revealed the Wound Care Nurse wrote she was called to Resident #8's room and found the resident lying prone (face down) with the lift leg underneath her stomach. Blood was noted around her head and swelling and laceration to her forehead were also noted. Resident #8 was yelling and crying. The Wound Care Nurse advised HCT #1 and HCT #2 not to move resident or lift. She then called for help and to get the Physician #3 and call 911 as well. She then tried to calm Resident #8 down and make sure she was not being moved. Other staff arrived to help. She advised them to call 911 as soon as possible as the resident was still bleeding. Upon looking at the lift pictures, she noted the leg strap on the right side was twisted and possibly the leg straps were not hooked on the same loop, but the picture did not show both sides clearly. Resident #8 did have a fear of heights and falling. During an interview on 9/7/22 at 3:44 PM the Wound Care Nurse stated 1/20/22 she was on the unit when Resident #8 sustained her fall from the lift. Someone called out for help and when she walked into the room the resident was lying prone on the floor over the lift legs with her face down on the floor. There was blood from the wound to her forehead on the floor. She stated she would not let anyone move her until Physician #3 was present and told them to go ahead and call 911. She stayed with the resident to comfort the resident as she was very upset. The resident had a prior history of fear of falling from surfaces including the lift and the best way to describe her state at that time was hysterical. She was crying, and saying things like, I told you I was going to fall. She always made statements she was going to fall no matter what surfaces she was on, which was why she was very difficult to console at that time. In addition, the Wound Care Nurse was concerned about spinal damage and was trying to keep Resident #8 still to avoid further possible injures to the resident and this added to the resident ' s anxiety. She calmed once emergency medical services arrived and the resident was turned over to the supine position. The resident was in distress for the 7 to 10 minutes it took for emergency medical services to arrive. She stated one of the leg straps appeared to be twisted or not placed correctly. She stated while she was trying to calm Resident #8, she observed the lift pad, and it just did not look right like the left side of the sling was higher than the right side. She and ADON #2 who is now retired both discussed the appearance of the sling and ADON #2 then took photos of the sling. She stated she then gave a statement of what had occurred from her point of view and that concluded her involvement in the incident. Review of a written statement dated 1/20/22 revealed ADON #2 wrote she was told Resident #8 had fallen from the lift around 8:10 AM. When she arrived in Resident #8's room, the resident was lying face down with arm under her stomach and on top of the lift legs. There was a large amount of blood around her head. Physician #3 arrived and ADON #2, HCT #2, and the Wound Care Nurse, repositioned the resident so they could assess the injury. Resident #8 obtained a laceration to her forehead and abrasion to her nose. When emergency medical services arrived ADON #2 pointed out the lift sling was hung wrong. It was facing the wrong way (away from the trunk of the lift) and one lower strap was twisted. She took a picture when she arrived on the scene but did not discuss it until the resident was on her way to the hospital. ADON #2 no longer worked at the facility and was unavailable for interview. Review of a written statement dated 1/20/22 revealed Occupational Therapist #1 wrote lifts required at least two staff members. The sling is placed and positioned with consideration to resident weight. The sling size is determined by the trim. The sling strap located at the lower extremities should be placed under each thigh and crossed only at the top. Once the resident is up in the lift, the resident should be facing the staff driving (moving) the lift. In review of photos presented, the sling appeared not hooked correctly on the lift and neither HCT applied the lift sling correctly in the demonstration. It was suggested to complete an inspection of the equipment used. During an interview on 9/7/22 at 1:48 PM Occupational Therapist #1 stated following the incident on 1/20/22 with Resident #8 she was asked to be present during the reenactment of the incident as she was with occupational therapy and provided expertise about lifts in the facility. She stated upon observing the reenactment, she observed the staff had incorrectly crossed the bottom lift pad straps through the sling positioning handle instead of through the sling loops per manufactures instructions. She stated the sling positioning handle is only used to hold and stabilize the resident during transfers and should never be used to cross the bottom straps. She stated this resulted in the sling being uneven and allowed Resident #8 to fall from the lift pad when she shifted her weight. Also, the staff had positioned the resident to be facing away from the person operating the lift which was the opposite of the manufactures recommendations as the weight not distributed as evenly as if the resident had been facing the person operating the lift. After observing these concerns, she was then asked to come and do a demonstration for the HCTs. She walked them through the correct procedure for lift pad placement including instructing both not to cross the bottom straps through the sling position strap as well as having the resident face the person operating the lift. Both things she had observed them do incorrectly. Review of a facility management event investigation signed 2/3/22 revealed ADON #2 stated she had taken a picture of the lift upon entering Resident #8's room and noticed that the lift sling was twisted. She denied discussing this with HCT #1 and HCT #2. The Wound Care Nurse shared during the investigation that it appeared the leg strap on the right side was twisted and noted that the leg straps were not hooked on the same loop onto the lift. HCT #1 and HCT #2 completed a reenactment of the using of the lift independently from one another as part of the investigation. Pictures were taken demonstrating how each of the HCTs used the lift including attaching the loops. HCT #1 was the lead HCT operating the lift who attached all the loops except for the bottom left loop which she stated was attached by HCT #2. HCT #1 did not demonstrate that she stopped the lift to double check the loops after it was attached to the lift after starting to lift Resident #8. HCT #2 stated she did not attach any of the loops but did place the lift pad underneath Resident #8. The investigation report continued and read that both HCTs were responsible to ensure the safety of the resident and following the lift procedures. Resident #8 was injured during the incident with a hematoma, laceration to forehead, and abrasion to her nose. She made complaints of pain. Resident #8 was assessed by the Wound Care Nurse, and the Physician #3 prior to being sent out to the hospital immediately for a CT scan without contrast and CT scan of cervical spine without contrast. The scan revealed no acute intracranial pathology. No evidence for intracranial hemorrhage. There was soft tissue swelling, scalp hematoma, and laceration overlying the frontal calvarium (Forehead and scalp). Resident #8 received three stitches for the laceration. An order was written to apply [MEDICATION(S)] twice a day to laceration until healed. Pain medication was prescribed for 48 hours as needed. Resident #8 was placed on 30-minute checks on all shifts and implemented neuro checks. Management agreed with advocacy findings of substantiation for neglect of Resident #8 by HCT #1 and HCT #2. The Director of Patient Advocacy investigated the allegation of neglect. The investigation description of management outcomes and action plan signed 2/3/22 revealed staff human error was the cause and both staff HCT #1 and HCT #2 were re-trained on the lift and policy on 1/22/22. HCT #2 was hired on 7/8/19 and initially trained on the lift policy on 7/16/19 and attended a re-in-service on 2/14/20. HCT #1 was hired on 7/6/21 and completed a lift demonstration and training on the lift policy on 12/17/21. During an interview on 9/7/22 at 9:16 AM the Director of Patient Advocacy services stated her department kept a different case record than the facility as their focus was resident rights. She stated she became aware of the incident on 1/20/22 at 8:39 AM. ADON #2 contacted the Director of Patient Advocacy and told her Resident #8 was inappropriately placed in a lift by staff. The two employees involved were HCT #1 and HCT #2. She stated once she was notified of the incident, she began by notifying the nursing home Administrator. The initial discussions about cases that are going to be open must happen with the Administrator or designee to begin the investigation. She then spoke with Quality Assurance Specialist #1 and coordinated the beginning of the case and arranged to meet and compile information associated with the case and arrange interviews. They met with both HCTs in the classroom to get a sense of what happened and, in addition to their interviews, they had the HCTs reenact the incident from their perspective separately. HCT #1 and HCT #2 did not demonstrate correct application of the lift pad. She stated based on the information provided and the interviews of staff who were on the scene, they found the straps were not appropriately applied to the lift by the HCTs. She stated the way the HCTs described what they did in their reenactment and the photographs received regarding how the lift pad had been applied verified this. Occupational Therapist #1 provided her expertise on how the lift pad should have been applied by the HCTs and also how the way the two HCTs did actually apply the pad caused the resident to slide

Based on observations, record review resident staff, and Physicain interviews the facility failed to provide oversight to ensure effective systems were in place for ongoing monitoring after concerns were identified with side rails and mechanical lift transfers placing other residents at risk for entrapment with side rails and accidents involving mechanical lifts. In addition, Administration failed to act or revise measures implemented for the use of side rails when auditing revealed the system implemented was ineffective. Immediate Jeopardy for example #1 began on 8-16-22 when the facility failed to act and revise the ongoing monitoring of side rails and a resident was found entrapped in his half side rail. Example #2 began on 1-20-22 when the facility failed to have ongoing monitoring of staff after a resident's fall from a mechanical lift. Immediate Jeopardy was removed on 9-10-22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems are put into place are effective. Findings included: This tag is cross referenced to: F689 Based on observation, record review, resident, staff and Physician interviews the facility failed to safeguard a resident from entrapment when Resident #21's half side rail was in the up position, he fell out of bed, his right arm became caught between the side rail and the mattress, and he was unable to free himself. Resident #21 sustained 2 abrasions to his knee and was at high likelihood of suffering serious injury or death as a result of the entrapment. The facility also failed to follow the manufacturer's instructions for a mechanical lift when transferring Resident #8 out of bed resulting in the resident falling out of the lift face first to the floor. Resident #8 experienced pain and sustained soft tissue swelling, a scalp hematoma, and a laceration to the forehead. This deficient practice affected 2 of 6 residents reviewed for accidents. During an interview with the Administrator on 9-8-22 at 10:10am, the Administrator explained the facility had been monitoring the side rails but realized increased monitoring should have been completed since there were ongoing issues. The Administrator also commented staff were educated on the mechanical lifts but realized monitoring should have been completed. The Director of Nursing (DON) was interviewed on 9-9-22 at 8:30am. The DON stated there were no formal actions taken to resolve the ongoing issues with the side rails being left in the up position after concerns had been identified. The Administrator was notified of Immediate Jeopardy on 9-8-22 at 10:10am. The facility provided the following credible allegation of Immediate Jeopardy removal: Administration accepts and understands the deficient practice cited. Executive Leadership Team will immediately be trained on CMS QAPI Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIP) by COB 9/9/22. Leadership staff will be trained by DHHS/DSOHF Chief of Medical Services and Quality and Patient Safety Manger. Effective today, Facility Administration will conduct root cause analysis for all accidents, conducting a thorough investigation, and protecting other residents from similar situations, and ongoing monitoring to prevent accidents. Ongoing monitoring will be conducted by Standards Management, Administration and Nursing Department leadership. 5 observations per shift per unit according to resident's care needs for a month. 3 observations per shift per unit for 2 weeks. 1 observation per shift per unit for 1 week. Ongoing monitoring will continue at observations for 3 months. Effective today, performing purposeful rounding by nurses to ensure all resident care needs are met for safety. Rounds will be made based on need but no more than every 2 hours. A Root Cause Analysis has been initiated by the Director of Standards (Quality Improvement) 9/8/22 on both the resident that was affected by the side rail entrapment and the resident affected by mechanical deficient practice. Quality Improvement Committee had a called meeting on 9/8/22 to review the facilities' protocol for corrective actions regarding all accidents. The committee determined that the current system needed to be revised to include root cause analysis of all accidents to further develop action planning from investigation protocol. In addition, all action plans in the future will include identification of like residents with potential for serious adverse outcomes actions to prevent the occurrence or reoccurrence, and monitoring to ensure process changes were made and sustained, reducing the potential for recurrent events. Administration will identify additional personnel resources to conduct the required investigations and root cause analysis. This will be completed by 9/9/22. Training for identified personnel will be conducted by Director of Standards Management (Quality Improvement) using QAPI Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs) by 9/9/22. Events that meet definition of an accident defined as an unintended or unexpected event leading to the injury or potential/suspected injury of an individual served should immediately be elevated to Administration. Nurses will be educated on definition of an accident and the process of identifying and elevating accidents on 9/9/22 by Unit Nurse Managers and Assistant Directors of Nursing. Administration will assure RCA is initiated. Completed RCAs are reviewed by Facility Administrator effective 9/9/22. Immediate Jeopardy will be removed as of 9/10/22 The facility's credible allegation of immediate jeopardy removal was validated onsite on 9-9-22 through interviews with facility staff including nursing staff, Director of Nurses and the Administrator. The staff verbalized receiving education on 9-8-22 that included the use of side rails, entrapment, danger of entrapment and how to prevent entrapment. Education was also completed on the mechanical lift with a return demonstration prior to any staff reporting for work. Management also attended a training on 9-9-22 at 1:00pm that included using QAPI guidance with performance improvement projects. The facility's date of immediate jeopardy removal of 9-10-22 was validated.

Based on record reviews, staff, facility Pharmacist, and Physicians' interviews, the Pharmacist failed to identify drug irregularities and provide recommendations for the use of as needed (PRN) [CONDITION(S)] (drug that affect the mental state) for 4 of 5 residents reviewed for unnecessary medications (Residents #7, #32, #69 and #5). Findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)]. A Physician's order dated 3/21/22 read in part for [MEDICATION(S)] (antianxiety medication) 2 milligrams (mg) by mouth every 6 hours PRN for agitation and may give intramuscularly (IM) if refuse by mouth. A Physician's order dated 7/22/22 read in part for [MEDICATION(S)] 2 mg by mouth or tube every 6 hours PRN for agitation and may give IM if refuse by mouth or tube. Reviews of the monthly drug regimen reviews for April through August completed by Pharmacist #1 for Resident #7 revealed no recommendations for a stop date for the [MEDICATION(S)]. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications. She stated she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/08/22 at 1:38 PM with Physician #4 revealed he was aware of the need for a stop date for PRN [CONDITION(S)] medications and did not know why Resident #7's [MEDICATION(S)] did not have a stop date. He stated the monthly drug regimen review by the Pharmacist should have identified it and he did not know why they had not. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why the Pharmacist had not identified it during the monthly drug regimen reviews. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. A Physician's order dated 12/28/21 read in part for [MEDICATION(S)] (antianxiety medication) 1 milligrams (mg) by mouth every 8 hours PRN for breakthrough agitation and may give intramuscularly (IM) if refuse by mouth. A Physician's order dated 7/06/22 read in part for [MEDICATION(S)] 2 mg by mouth every 6 hours PRN for agitation and may give IM if refuse by mouth. A Physician's order dated 7/20/22 read in part for [MEDICATION(S)] 2 mg by mouth every 6 hours PRN for agitation. Reviews of the monthly drug regimen reviews for January through August completed by Pharmacist #1 for Resident #32 revealed no recommendations for a stop date for the [MEDICATION(S)]. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications. She stated she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/08/22 at 1:38 PM with Physician #4 revealed he was aware of the need for a stop date for PRN [CONDITION(S)] medications and did not know why Resident #32's [MEDICATION(S)] did not have a stop date. He stated the monthly drug regimen review by the Pharmacist should have identified it and he did not know why they had not. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why the Pharmacist had not identified it during the monthly drug regimen reviews. 3. Resident #69 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)]. A Physician's order dated 4/15/22 read in part for [MEDICATION(S)] (antianxiety medication) 1 milligrams (mg) by mouth every 8 hours PRN for breakthrough agitation and may give intramuscularly (IM) if refuse by mouth. A Physician's order dated 6/06/22 read in part for [MEDICATION(S)] 2 mg by mouth every 6 hours PRN for agitation and may give IM if refuse by mouth. Reviews of the monthly drug regimen reviews for April through August completed by Pharmacist #1 for Resident #69 revealed no recommendations for a stop date for the [MEDICATION(S)]. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications. She stated she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/08/22 at 1:38 PM with Physician #4 revealed he was aware of the need for a stop date for PRN [CONDITION(S)] medications and did not know why Resident #69's [MEDICATION(S)] did not have a stop date. He stated the monthly drug regimen review by the Pharmacist should have identified it and he did not know why they had not. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why the Pharmacist had not identified it during the monthly drug regimen reviews. 4. Resident #5 was admitted to the facility 8/17/20 with diagnoses which included dementia with behavioral disturbances and major depressive disorder with psychotic features. A physician's order dated 4/14/22 for [MEDICATION(S)] (an antianxiety medication) 1 milligram (MG) by mouth every 8 hours as needed for agitation. There was no end or stop date for the order. The annual Minimum Data Set, dated dated dated [DATE] revealed Resident #5 was rarely understood and rarely understands with severely impaired cognitive skills. She received antianxiety and antidepressants 7 days during the look back period. Reviews of the monthly drug regimen reviews for May 2022 through August 2022 revealed no recommendations for a stop date for the as needed [MEDICATION(S)]. The drug regimen reviews were completed by Pharmacist #1. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications. She stated she had not recommended a stop date for the as needed [MEDICATION(S)] due to lack of awareness of the regulation. An interview with Physician #5 on 9/9/22 at 10:49 AM revealed he was not aware Resident #5 had an order for an as needed antianxiety medication without a stop date. Physician #5 stated the pharmacist should have corrected it. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why Pharmacist #1 had not identified it during the monthly drug regimen reviews.

Based on record reviews, staff, facility Pharmacist, and Physician interviews, the facility failed to ensure Physician's orders for as needed (PRN) [CONDITION(S)] (drug that affect the mental state) were time limited in duration for 4 of 5 residents reviewed for unnecessary medications (Residents #7, #32, #69, and #5). Findings included: 1. Resident #7 was admitted to the facility on [DATE] with a diagnosis which included [CONDITION(S)]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7's care plan last revised on 9/07/22 revealed a focus for psychoactive medication to manage symptoms associated with mood disorder and residual [CONDITION(S)]. The interventions included monitoring for adverse side effects and documentation of behaviors to establish medication effectiveness. A Physician's order dated 3/21/22 read in part for [MEDICATION(S)] (antianxiety medication) 2 milligrams (mg) by mouth every 6 hours PRN for agitation and may give intramuscularly (IM) if refuse by mouth. There was no stop date. A Physician's order dated 7/22/22 read in part for [MEDICATION(S)] 2 mg by mouth or tube every 6 hours PRN for agitation and may give IM if refuse by mouth or tube. There was no stop date. Reviews of the monthly drug regimen reviews for April through August completed by the Pharmacist for Resident #7 revealed no recommendations for a stop date for the [MEDICATION(S)]. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications and she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/08/22 at 1:38 PM with Physician #4 revealed he was aware of the need for a stop date for PRN [CONDITION(S)] medications and did not know why Resident #7's [MEDICATION(S)] did not have a stop date. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why there was no stop date. 2. Resident #32 was admitted to the facility on [DATE] with a diagnosis which included non-Alzheimer's dementia. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #32 had severe cognitive impairment. Resident #32's care plan last revised on 7/13/22 revealed a focus for psychoactive medication to manage symptoms associated with dementia and behaviors that disrupt the environment. The interventions included monitoring for adverse side effects and control of behaviors. A Physician's order dated 12/28/21 read in part for [MEDICATION(S)] (antianxiety medication) 1 milligrams (mg) by mouth every 8 hours PRN for breakthrough agitation and may give intramuscularly (IM) if refuse by mouth. A Physician's order dated 7/06/22 read in part for [MEDICATION(S)] 2 mg by mouth every 6 hours PRN for agitation and may give IM if refuse by mouth. A Physician's order dated 7/20/22 read in part for [MEDICATION(S)] 2 mg by mouth every 6 hours PRN for agitation. Reviews of the monthly drug regimen reviews for January through August completed by the Pharmacist for Resident #32 revealed no recommendations for a stop date for the [MEDICATION(S)]. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications and she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/08/22 at 1:38 PM with Physician #4 revealed he was aware of the need for a stop date for PRN [CONDITION(S)] medications and did not know why Resident #32's [MEDICATION(S)] did not have a stop date. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why it did not have a stop date. 3. Resident #69 was admitted to the facility on [DATE] with a diagnosis which included [CONDITION(S)]. The significant change Minimum Data Set, dated dated dated [DATE] revealed Resident #69 had moderately impaired cognition. Resident #69's care plan last revised on 8/12/22 revealed a focus for psychoactive medication to manage symptoms associated with [CONDITION(S)]. The interventions included monitoring for adverse side effects. A Physician's order dated 4/15/22 read in part for [MEDICATION(S)] (antianxiety medication) 1 milligrams (mg) by mouth every 8 hours PRN for breakthrough agitation and may give intramuscularly (IM) if refuse by mouth. A Physician's order dated 6/06/22 read in part for [MEDICATION(S)] 2 mg by mouth every 6 hours PRN for agitation and may give IM if refuse by mouth. Reviews of the monthly drug regimen reviews for January through August completed by the Pharmacist for Resident #69 revealed no recommendations for a stop date for the [MEDICATION(S)]. An interview on 9/08/22 at 11:22 AM with Pharmacist #1 revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications and she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/08/22 at 1:38 PM with Physician #4 revealed he was aware of the need for a stop date for PRN [CONDITION(S)] medications and did not know why Resident #69's [MEDICATION(S)] did not have a stop date. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why there was no stop date. 4. Resident #5 was admitted to the facility 8/17/20 with diagnoses which included dementia with behavioral disturbances and major depressive disorder with psychotic features. A physician ' s order dated 4/14/22 read in part [MEDICATION(S)] (an antianxiety medication) 1 milligram (MG) by mouth every 8 hours as needed for agitation. There was no end or stop date for the order. The annual Minimum Data Set, dated dated dated [DATE] revealed Resident #5 was rarely understood and rarely understands with severely impaired cognitive skills. She received antianxiety and antidepressants 7 days during the look back period. The care plan updated 7/8/22 indicated Resident #5 required psychoactive medication to manage symptoms associated with major neurocognitive disorder, psychotic depression, and anxiety. Resident #5 was at risk for adverse side effects and negative mood/behavior changes. The interventions included administer psychoactive medications as ordered, taper/change/discontinue medications as ordered, and monitor for adverse side effects of medications and report to the physician. A review of the monthly drug regimen review from May 2022 through August 2022 completed by Pharmacist #1 for Resident #5 revealed no recommendations for a stop date for the [MEDICATION(S)]. The August 2022 monthly drug regimen review was signed by Physician #5. An interview with Pharmacist #1 on 9/8/22 at 11:22 AM revealed she was aware of the need for a stop date for PRN [CONDITION(S)] medications but thought it pertained only to antipsychotic medications and she had not recommended a stop date for the [MEDICATION(S)] due to lack of awareness of the regulation. An interview on 9/09/22 at 8:07 AM with the Administrator revealed she was aware of the need for a stop date for as needed [CONDITION(S)] medications and did not know why there was no stop date. An interview with Physician #5 on 9/9/22 at 10:49 AM revealed he was not aware Resident #5 had an order for an as needed antianxiety medication without a stop date. Physician #5 stated the pharmacist should have corrected it.

Based on record review and staff interviews the facility failed to accurately complete the Minimum Data Set (MDS) assessment in the areas of anticoagulant medication (Resident #49) and ventilator or respirator (Resident #67) for 2 of 23 residents whose MDS assessments were reviewed. Findings included: 1. Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the quarterly Minimum Data Set (MDS) assessment for Resident #49 dated 07/12/2022 revealed he received anticoagulant (blood thinning) medication on 7 of 7 look back period days. A review of his July 2022 Medication Administration Record (MAR) did not reveal any evidence Resident #49 received anticoagulant medication. On 09/08/2022 at 8:48 AM an interview with MDS Nurse #2 indicated she completed the medications section of Resident #49's MDS assessment dated [DATE]. She reviewed his MAR and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained he had received an antiplatelet medication, but this was not an anticoagulant. She stated she completed the section inaccurately. On 09/09/2022 at 12:01 PM an interview with the Administrator indicated Resident #49's MDS assessments should be accurate. 2. Resident #67 was admitted to the facility on [DATE] The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was moderately cognitively impaired and was documented as having a mechanical vent. Review of Resident #67's medical record revealed no documentation of the resident having mechanical ventilation. An observation of Resident #67 occurred on 9-6-22 at 10:35am. The observation revealed Resident #67 did not have mechanical ventilation. The MDS supervisor was interviewed on 9-8-22 at 1:30pm. The MDS supervisor reviewed Resident #67's MDS dated [DATE] and stated it was a mistake that the resident was documented as having mechanical ventilation. She said Resident #67 had never had mechanical ventilation and should not have been documented. During an interview with the Director of Nursing (DON) on 9-9-22 at 8:30am, The DON stated Resident #67 should not have been documented as having mechanical ventilation and that it was a human error. She also stated she expected residents MDS documentation to be accurate.

Based on record review and staff interviews the facility failed to develop and implement an individualized person-centered care plan for 1 of 1 resident (Resident #41) reviewed for care plans. Findings included: Resident #41 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 was cognitively intact and was coded for the use of oxygen. Review of Resident #41's care plan dated 7-12-22 revealed no goals or interventions for oxygen. During an interview with the MDS supervisor on 9-8-22 at 1:30pm, The MDS supervisor reviewed Resident #41's care plan and stated he was not care planned for his oxygen. She also reviewed Resident #41's MDS dated [DATE] and said Resident #41 should have been care planned for his oxygen. The MDS supervisor stated it was an oversite when the resident's care plan was developed. The Director of Nursing (DON) was interviewed on 9-9-22 at 8:30am. The DON stated if Resident #41 was ordered and receiving oxygen daily then she would have expected the resident to have been care planned for his oxygen.

Based on observations, record review and facility staff interviews, the facility failed to ensure a physician's order was obtained for the use of a personal alarm for 1 of 5 residents reviewed for falls (Resident #72). The findings included: Resident #72 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was moderately cognitively impaired. He had no behaviors. He required extensive assistance for all activities of daily living except was total dependent for dressing and toileting. He had range of motion impairment on 1 upper extremity and both lower extremities. Resident #72 was coded as having no falls and no alarms. Resident #72's care plan updated 8/9/22 revealed a care plan for falls related to visual impairment, mental illness, abnormal gait, and poor safety awareness. There was not a care plan for a personal alarm. A review of the August 2022 and September 2022 physician's orders revealed no order for a chair alarm. An observation on 9/7/22 at 9:31 AM revealed Resident #72 was sitting in his wheelchair. A chair alarm was present on the left upper back of the wheelchair. There were 3 staff members present and 2 were observed to test the function of the chair alarm. On 9/8/22 at 2:16 PM MDS nurse #3 stated if a resident had a chair alarm there should be a physician's order for the alarm. On 9/8/22 at 2:23 PM MDS nurse #3 observed Resident #72 sitting in his wheelchair and a chair alarm was present on the upper right back of the wheelchair. She stated it would have been an intervention for a fall, but she was not sure why Resident #72 had a chair alarm, and it was not present when she completed his last MDS assessment. On 9/8/22 at 3:36 PM MDS nurse #3 said she could not find a reason for the chair alarm, but the alarm would require a physician's order and there was not a physician's order for the alarm. On 9/9/22 at 1:36 PM Restorative Aide #2 stated she remembered walking Resident #72 because he was scheduled to receive restorative walking 3 times per week. She added she and another restorative aide along with the transportation aide walked Resident #72 on Tuesday (9/6/22), Wednesday (9/7/22) and Thursday (9/8/22). Restorative Aide #2 said she checked the chair alarm to make sure it was working. On 9/9/22 at 1:42 PM Restorative Aide #3 stated she remembered walking Resident #72 and when he was back in his wheelchair, she made sure the chair alarm was working properly. She said she did not know why Resident #72 had a chair alarm. On 9/9/22 at 1:48 PM MDS Nurse #3 stated there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/9/22 at 3:05 PM the Director of Nursing stated Resident #72 should not have had an alarm on his chair. She stated there should be a physician's order for an alarm.

Based on observations, record review, physician and staff interviews the facility failed to prevent 1 of 3 (Resident #1) sampled cognitively impaired residents with exit seeking behaviors from exiting the facility. The resident was found crossing the highway and running down the grassy median between the north and south bound lanes. The Immediate Jeopardy began on 5/18/17 when Resident #1 exited the facility unattended by the facility staff and was observed crossing a divided highway and running down the grassy median between the north and south bound lanes. The Immediate Jeopardy was removed on 8/18/17 when the facility provided evidence of completing policy revision and implementing staff in-service education on the revised elopement policy and procedure based on the approved credible allegation. The facility remained out of compliance with potential for more than minimal harm that is not immediate jeopardy (D) whereby significant corrections were required because the plan of correction was not fully integrated into the facility's quality assurance program. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Area Assessment of the annual Minimum Data Set ((MDS) dated [DATE] revealed the care areas that triggered and were carried to care plan included cognitive loss/dementia, behavioral symptoms and psychotropic drug use. The quarterly MDS dated [DATE] revealed Resident #1 was severely cognitively impaired. He had behaviors not directed towards others and rejection of care for 1-3 days. He required supervision for all activities of daily living (ADLs). He had no functional limitations in range of motion and did not use any mobility devices. He was always continent of bowel and bladder. The care plan which was reviewed on 4/26/17 revealed Resident #1 was a wander/elopement risk. Resident is a wander/paces halls/pilfers through other resident's personal items and tries to open locked unit doors. Risk for injury r/t (related to) elopement. The approaches included; know resident's whereabouts at all times, use diversional techniques as needed. The care plan also addressed psychotropic drug use stating, Resident requires psychotropic drug use to manage symptoms associated with dementia, schizophrenia. The care plan also stated Resident with mental illness (Bipolar Disorder and dementia), cognitive impairment, behavioral outbursts such as being combative, resistive, refusing care/assistance/vital signs/refusing meds and meals at times due to thinking they have poison in them, etc. Resident is at risk for decline in psychosocial needs. The behavioral care plan read Confusion from mental illness -Bipolar and dementia makes it difficult for resident to follow directions or complete task at times; can be resistive or aggressive at times when staff attempts care or assists with tasks; as risk for unmet needs and injury due to behaviors. Resident has h/o (history of) being paranoid and currently will state that his food/medicine have been poisoned, spits, hallucinates he is fighting demons, will barricade himself in a room, won ' t allow staff to enter his room at times, will throw objects occasionally, and will try to open locked unit doorway. A review of the incident report log revealed a resident elopement was recorded on 5/18/17 at 07:00AM. Staff report resident pulled several times at dayroom door and it opened. Resident entered out entry door and entered into elevator. On 8/10/17 at 2:20 PM Health Care Technician (HCT) #2 stated she was assigned as the 5th floor dayroom monitor for the 7:00am to 3:00pm shift. She stated her responsibilities including documenting which residents left the unit. She stated all residents on the 5th floor require an escort to exit the floor. She demonstrated the log where each resident who left the unit was signed out with a staff member and signed back in when they returned to the unit. Another HCT was interviewed on 8/19/17 at 2:55PM. HCT #3 stated Resident #1 was independent for all activities of daily living (ADLs), walked independently and liked to go to the dayroom or look outside the window at the end of the hall. She stated if Resident #1 went near the exit door the staff were to redirect him. She stated there was a staff member assigned as the day room monitor. HCT #3 stated Resident #1 tried to get out of the locked 5th floor door. She stated she was aware of the one time he did get out but she was unsure of exactly when it happened. HCT #3 stated she had arrived at work the day he got out and other staff called out to her to help find the missing resident from 5th floor. HCT #3 stated she was not aware of how or where he got out. She added in the past she had observed Resident #1 to push, bang, hit and kick the exit doors on the 5th floor. On 8/10/17 at 5:00PM the 5th floor unit manager stated the dayroom monitor stays in the dayroom for the whole 8 hour shift because some of the residents do not get along so the HCT assigned to the dayroom tries to keep those residents separated, keep the area uncluttered and to monitor the entry door to prevent elopement. She stated there were several residents on the floor who tried to elope and the list included Resident #1. The unit manager said Resident #1 would pack his belongings into a pillow case so that was when the staff knew he wanted to go home. She stated the resident could become agitated when the staff tried to redirect him or asked him too many questions. She added she was aware Resident #1 had exited the 5th floor dayroom unit entry door and got out of the building. She stated he was wearing a wander management alarm bracelet and went out a side exit on the administration side of the building which did not alarm because it deactivated automatically at 6:00am. The unit manager reported when Resident #1 was returned to the 5th floor he was assessed for injury and then he went into his room, slammed the door closed and did not want to be disturbed. She added she visited him but he would not talk to her. She said an investigation was started and it was found that the HCT in the dayroom had been pulled from another floor. The facility security officer (FSO) #1 was interviewed on 8/11/17 at 7:45AM. He was the FSO on duty on 5/18/17 when the phone in the security office rang and he was told a male resident was coming down the elevator. He stated he and the other 2 facility staff members (HCT #5 & Housekeeper #1) went out of the office into the 1st floor lobby area where he had to swipe his identification badge to enter into the 1st floor hallway. He stated he saw the house supervisor (HS) coming towards him in the hallway but he did not see the resident. He stated the HS asked him if he had seen the resident but he told the HS no. The FSO stated he went to his left down the administration hallway and did not see anyone so then went down the stairwell near the 1st floor entry door with the HS. The stairs led down to the basement. He stated he then went down the fire escape and did not see anyone. He stated he received a phone call the resident was apprehended by 3 other staff members. The FSO stated he picked up the resident and the staff members in the FSO car and returned them to the facility to the main front entrance. He stated he escorted Resident #1 back to his room on the 5th floor then went to view the surveillance video tape with other facility staff. HCT #4 was interviewed on 8/11/17 at 8:45AM. She stated on 5/18/17 she was pulled from her regular 2nd floor 11:00pm to 7:00am position and placed as the dayroom monitor on 5th floor because they needed more help. She stated Resident #1 came to the dayroom, watched TV and that he walked up and down the hall and he kept standing at the entrance door. She said she didn't know the resident's name but that she saw him wiggling the L-shaped thing then the door opened and she saw him go out the door which automatically locked when it closed. She said she then got up and unlocked the entrance door with her badge and told him to come back because security was going to get him. She stated Resident #1 shook his head no as the elevator door closed then she went back onto the unit and yelled for help. She said she didn't see any other HCTs but 2 nurses came. HCT #4 reported the nurses went down the elevator and she stayed on the floor to monitor the medication cart and watch the dayroom. HCT #4 said she didn't know the nurses names. HCT #4 added she had probably worked on 5th floor 5-10 times since the first of the year and had been the dayroom monitor before. She did not know how frequently but usually when she was pulled to work another floor it was not to monitor the dayroom because only 5th floor had a day room monitor on the 11:00pm to 7:00am shift. On 8/11/17 at 9:00AM the House Supervisor (HS) said Resident #1 was independent and ambulatory. She reported he frequently paced the hall way with a bag/sack packed and always ready to go. The HS said on 5/18/17 she was sitting in the supervisor's office when the phone rang and Nurse #1 told her a resident got out the 5th floor unit entry door and was on the elevator. HS said she went outside the office which was located on 1st floor beside the elevators to wait for the resident to exit the elevator. After a few seconds she noted the door did not open so she looked down the hall towards the front reception door and saw the resident there. She said she called his name for him to come back but he started running and went to the right towards administration wing. She said she ran after him but did not see him anymore. She said to her knowledge all the doors down that hall were locked so she went back to the wall phone in the middle of the 1st floor main hall and called the Code M for missing resident. She said numerous staff started arriving along with FSO #1 who helped her check the doors along the administration hall to make sure they were locked and to look for Resident #1 in the few unlocked rooms. HS said she could not remember which phone (wall phone or facility provided cell phone) she used to call FSO but she said she told FSO that the resident was out of the unit (5th floor) and possibly out of the building. The HS said the portable phone could call other phones but it could not be used for the intercom system to announce the Code M. During an interview on 8/11/18 at 9:40AM Health Care Technician (HCT) #1 stated she heard the code announced over the intercom system so she came down the middle stairs from the 2nd floor to the 1st floor where someone told her the resident was seen going towards the administration wing. HCT #1 said she passed by the HS and the ADON when she saw a fire door across from one of the offices. She said they had looked in all the unlocked rooms and bathrooms but he was not found. HCT #1 said she then told a nurse He must have gone out the fire door, so she and the nurse went out the fire door. She and the nurse were running and looking next to the loading docks at the back of the facility and still did not see him so they continued around the back of the building past the fenced in outdoor resident area. She said they saw some people standing outside the school next door so the nurse went in that direction and she went towards the boiler building. HCT #1 then stated she was looking around the outside of the boiler building when she saw something moving. She went through the shrubs and saw Resident #1 going into the edge of the ditch beside the highway so she screamed his name and he took off running across the highway. HCT #1 said she could not cross the ditch where she was because it was 5-7 feet deep so she ran along the ditch in the same direction as the resident was running down the median. There was an opening near the corner of the fenced in lot so that was where she crossed the edge of the ditch and the highway after an unknown person stopped his vehicle and stopped traffic. She said she crossed the road and told the resident not to run anymore. She said at this point the resident stopped running and she took him by the arm and told him they needed to cross the road now while the traffic was stopped. She said he tried to pull away and did not want to go back but she talked to him and convinced him to return to the facility side of the road. Once back on the facility side of the road they walked back along the fenced in lot (outside the fence) and that was when the nurse (Nurse #1) came and assisted her. HCT #1 said Resident #1 told her he didn't want to go back and he continued to try to pull away from her until the nurse arrived then he gave up and kneeled down to his knees. She said HCT #5 saw them and came to assist too. HCT #1 said the HCT #5 took her place beside Resident #1. Then the FSO saw them and he brought the car over to them and everyone got into the car. On 8/11/17 from 10:00am until 10:35AM a walking tour with HCT #1 of the area from the fire exit door to the place where she saw him cross the highway was conducted. The distance measured approximately 1000 feet. Based on the interview with HCT #1 the resident then ran down the median another 1000 feet to the point where HCT #1 crossed the highway to Resident #1. The speed limit on the highway was 45 miles per hour. On 8/11/17at 10:50AM during a phone interview Nurse #1 said she had just completed her medication pass, taken her cart into the medication room then when she went out of the medication room to get some cups HCT #4 told her a man just left out of the unit on the elevator. Nurse #1 said she normally worked on a different floor and she was not familiar with the resident so she obtained a description of the resident. Nurse #1 said she called the HS to report the elopement then she also called the FSO. She stated she did not call a Code M because she did not know the resident's name and she knew the HS office was beside the elevator. While on the phone with the FSO she heard the overhead page for the Code M. She said she called the HS first because she knew the supervisor's office was next to the elevator. Nurse #1 said she then went down the elevator but stopped on each of the floors to see if he was there. Once on 1st floor she was told the resident went down the administrative hall so she checked the doors and did not see him. She stated a fire exit door was observed so she opened it and it did not alarm. She said she went outside the building with others but she did not remember who. She said she saw some people standing outside the school next door so she ran over towards them but as she got closer she could see it was not the resident. She then went towards the highway and saw Resident #1 running down the highway median and a facility staff member (HCT#1) was yelling she needed help. Nurse #1 said she could not cross the ditch so she was running down the highway towards the other staff up past the fenced in lot and saw HCT #1 walk the resident back across the highway while holding onto the resident's arm. She said she used her personal cell phone to call the ADON to get the FSO to bring the car to pick them up. She stated Resident #1 had tried to run again while being escorted away from the highway. She said when she took him by the arm to assist HCT #1 the resident went down on his knees like he was giving up. Nurse #1 reported she assessed Resident #1 for any injuries while waiting on the FSO car to arrive. She said he had no obvious injury. On 8/11/17 at 2:15PM HCT #5 said she was in the FSO office heard the overhead page so she and the other person went through the 1st floor front reception door. That was when the HS told her the resident name and that he was seen going down the administrative hall. She said she went down the hall checking doors but when he was not found she and the nurse from another unit want out the main front door. She said they searched towards the street in front of the building when another staff member arriving to work said They got him. She then went through a parking lot and continue to walk until she saw HCT #1 and a nurse (Nurse #1) struggling with Resident #1 so she went to assist them because he was being resistant. She saw they were holding him by cuffed arms (the HCT had her left arm overlapped at the elbow and holding on by the wrist to the resident ' s right arm) and he was elbowing them and they were walking in a circle. She said she called the resident ' s name as she was approaching and he just dropped to his knees. She did not hear the resident say anything. She said she rode in the FSO car back to the building to the front door. She assisted Resident #1 inside the building then she obtained a wheelchair and pushed him back to the 5th floor. She said there were others with her while transporting him back to 5th floor. On 8/11/17 at 4:07PM Resident #1's physician stated the resident had 2 strikes against him because he had both schizophrenia and a major neurocognitive disorder. The physician reported he was both the medical and psychiatric doctor for the resident. He was aware the resident had eloped and he saw the resident on 5/23/17 and the resident had refused to allow a blood draw to check a lab level required for his clozapine (antipsychotic medication used to treat schizophrenia). The doctor stated the resident told him the world was coming to an end then quoted scripture. The doctor said Resident #1 was always psychotic to a certain level and never had a day when he was not psychotic, just that some days were better than others. The doctor said he did not think anyone would have a higher suspicion that he would act to get out one day verses any other day. He stated Resident #1 had a preoccupation with leaving and he just went out that day unexpected and then his fight or flight response kicked in. He said the resident had been off the unit and on 1st floor going to activities and to attend church. On 8/11/17 at 5:00PM Resident #1 was observed sitting on the side of his bed eating his dinner meal. When he answered questions he only answered he did not remember except he did say what town he was from. He said he did not remember going out of the facility. On 8/17/17 at 8:00PM the surveillance video was observed. There was only video and no sound. There were 5 separate camera recordings. The surveillance video demonstrated Resident #1 was dressed in long pants with a long sleeve shirt and was wearing shoes. The information from the recorded surveillance video follows: The 5th floor dayroom/nursing station camera revealed Resident #1 pulled on the 5th floor magnetic exit door 3 times and on the third pull at 6:23:41AM the door came open. He exited the door went straight to the elevator and continuously pressed the elevator button. The elevator door opened and he went into the elevator. At 6:23:50AM HCT #4 used a badge to open the 5th floor magnetic door and she was able to see the resident get on the elevator. She did not attempt to touch the resident but appears to be talking to him. When the elevator door closed she used her badge to return to the unit. The facility documentation record of the video surveillance stated HCT #4 gets to unit door & yells out. At 6:23:54AM HCT #4 reentered the unit. The 5th floor elevator video demonstrated Resident #1 exiting the magnetic door at 6:23:41am and holds the elevator button. At 6:23:55AM HC#4 was in the exterior 5th floor elevator area with the resident and at 6:24:01am the resident entered the elevator and the door closes. After the door closed HCT #4 used her badge to reenter the locked magnetic entry dayroom door. The elevator door reopened and Resident #1 stepped off the elevator then quickly back onto elevator. At 6:24:23am the elevator door closed again. At 6:24:34AM A nurse is seen leaving the 5th floor magnetic entry dayroom door and goes to elevator. She gets on the elevator to the right of the one the resident was on. The 1st floor elevator camera surveillance video demonstrated: At 6:25:11AM Resident #1 exited the elevator and walks toward the front main entrance. At 6:25:13AM Resident #1 stopped and looked backwards behind himself then starts jogging/running towards the front entrance. At 6:25:24AM the HS comes into view at the elevator and started walking towards Resident #1. She did jog/run for a short time. At 625:47AM the HS stopped and went to the phone located on the wall across the hall from the cafeteria. The resident continued to jog/run towards the front main entrance. While on the phone the HS turned to face the phone and had her back to the resident. At 6:25:58AM Resident #1 turns and walks toward the administrative hall. HS has her back to the resident at this time. At 6:26:06AM the HS hangs up the phone and looks around. The resident is not in sight. At 6:30:25AM HCT #1 is observed walking down the 1st floor hallway. The rear building (nurse entry) camera demonstrated: At 6:25:01AM until 6:25:12am the door opens, movement was seen then Resident #1 is seen running on sidewalk to the right. The facility document this as the fire exit door of the administration hallway. At 6:25:17AM the resident was out of camera view. At 6:26:09AM FSO#1 walks out the fire exit door. At 6:29:53AM HCT #1 and 4 other staff came out the fire exit door and run out of view. On 8/18/17 at 9:30AM the Administrator along with the Director of Nursing and the Standards of Care (QI) nurse were informed of the immediate Jeopardy. An acceptable Credible Allegation was received on 8/9/17 at 7:30PM and follows: This plan of correction constitutes Longleaf Neuro-medical Treatment Center's credible allegation of compliance. F323: Supervision to Prevent Accidents Response for Tag F323 The resident left the unit, and got on the elevator. An HCT exited the unit behind the resident, attempted verbal re-direction, which was unsuccessful. The elevator door closed and the HCT lost sight of the resident. The HCT went back into the unit to alert unit staff of the elopement. A nurse exited the unit without announcing an overhead page for the elopement. Upon exiting the elevator, the resident proceeded down the hallway and eloped from the facility. The House Supervisor observed the resident after he exited the elevator. The House Supervisor stopped in the hallway to use the telephone to announce a Code M, which is the emergency code for an elopement. As she was using the telephone, she turned her back, and lost sight of the resident. The resident then exited the building through a fire exit located on the 1st floor of the facility. The deficient practice was a failure by the House Supervisor to maintain line of sight vision of the resident. The House Supervisor decided to page the emergency code, to obtain additional assistance, rather than maintaining supervision of the resident and attempting redirection. There was an immediate response when the resident, cited in this Immediate Jeopardy citation, eloped from the facility. When the resident was observed eloping from the locked nursing unit due to a door lock malfunction, staff responded, located the resident and returned him safely to the facility within thirteen (13) minutes. Corrective action will be taken by the Director of Nursing with the HCT (HCT#4) and House Supervisor upon their return to work. The nurse (nurse #1) involved is no longer employed at the facility. The corrective action will be taken before they accept their assignment. The following actions have been implemented prior to 8/18/17 to address the elopement. 5-18-17 - A review of the elopement event and development of an action plan was initiated by the Standards Department. 5-18-17- Immediately following the elopement, the Plant Operations staff assessed the lock on the 5th Floor unit door and determined a door malfunction had occurred. The striker plate was not aligned properly with the magnet on the door hardware. The striker and magnet were not making a secure connection which contributed to the door releasing when the resident jerked on the door handle. The Plant Operations staff readjusted the door alignment on the 5th Floor Door Lock. 5-18-17- The Center Director made a decision to replace the lock on the 5th Floor unit entrance door. The lock was replaced. As a systemic action, a decision was made to replace all the resident unit door locks and requisitions were submitted to order locks to replace the locks currently in use. The Plant Operations staff readjusted the striker and magnet on the lock on 5/18/17, so there was a proper connection. The 5th floor magnetic door lock was replaced on 5/19/17. 5-18-17- Discussion occurred regarding the feasibility of adding a lock to the exit from which the resident escaped. However, the exit is a designated fire exit located in an administrative office suite designated as business occupancy. A decision was made by the Center Director to research this issue further with DHHS Life Safety, as business occupancy areas are required to have free egress in the event of an emergency. An email was received from the Business Manager that the door lock project was sent out for E Quote. Per the email, depending on the cost, it could require additional purchasing/bid process. On 7/12/17, the Purchasing Director received E Quote pricing for installation of 14 additional card access doors. Cost to add card readers was $39, 400. On 7-12-17, the Purchasing Director sent an email to the Center Director stating a request for quote (RFQ) had to be sent due to the cost. On 8-15-17- an on-site visit was conducted by a DHHS Property and Construction Architect to assess possible solutions for lock additions to business occupancy areas. On 8-16-17- Center Director received a report from the DHHS Property and Construction Architect summarizing the North Carolina State Building Code Requirements for institutional and business occupancy areas. Recommendations given regarding how to address fire egress issues associated with fire exits in business occupancy areas. On 8-16-17, the Center Director forwarded a copy of the report to the Assistant Director, Neuromedical Treatment Centers and Deputy Secretary Facility Based Behavioral Health and Developmental Disability Services at the Division of State Operated Healthcare Facilities. 5-24-17- An email was sent from the Assistant Center Director to the Business Manager requesting information about extending the alarm programming for the fire exit (from which the resident eloped) from 6pm-6am to a 24 hour alarm. The Business Manager sent an email response to the Assistant Center Director regarding the reprogramming of the door alarms. It had been determined by the Business Manager that the alarm system was an old system, dating back to 1998. The Plant Operations staff did not have the knowledge to reprogram the alarms. 5-24-17- Event Review Committee (subcommittee of QI), reviewed the event and approved an action plan to address the elopement. 5-25-17- A meeting was held with the Business Manager, Plant Operations Director, Plant Operations Assistant Director, Police Chief, and IT Director to discuss reprogramming of alarms on exit doors. On 5-31-17, the Business Manager sent an email response to the Assistant Center Director regarding the reprogramming of the door alarms. It had been determined by the Business Manager that the alarm system was an old system, dating back to 1998. The Plant Operations staff did not have the knowledge to reprogram the alarms. 5-31-17- The Business Manager sent an email response to the Assistant Center Director recommending that access control be added to all doors. Per the Business Manager, the process to obtain approval/funding for the additional card access readers would be a sole source contract as addition of the new card readers would be added to the current card reader system (GALAXY). The Business Manager sent door lock project out for E Quote and pricing was obtained for installation of 14 card access readers for $39,400. 5-31-17- Director of Nursing (DON) conducted a Nurse Supervisor Meeting. DON provided instructions for staff to monitor doors at all times and be sure staff were pulling doors closed when entering and exiting units. (These expectations regarding door security were already in place. DON reminded the Nurse Supervisors to re-educate their staff members about the importance of securing doors.) The Nurse Supervisors submitted meeting minutes with signature rosters to the Director of Nursing. 6-5-17-Entrance magnetic door locks replaced on 4th Floor, 3rd Floor and 6th Floor (Resident Activity Area). 6-5-17- Center Director consulted with Elevator Contractor regarding feasibility of retrofitting elevators with a locking mechanism to control resident access. Due to age of elevators, and potential maintenance issues associated with the keying mechanisms, the elevator contractor did not recommend this as a viable option. 6-6-17- Door Lock replaced on 2nd Floor, and door locks on Alzheimer 1st Floor, Alzheimer 2nd Floor were checked. 6-7-17- A monitoring plan for resident unit door locks was developed and implemented. A monthly check of all unit door locks to verify proper alignment and functioning was added to the Plant Operations Preventative Maintenance Program. 6-8-17- Staff Development staff began a planning process to develop a video on Door Security/Elopement Prevention. Content was developed and videotaping was completed. 6-14-17- 5th Floor Nurse Manager conducted a staff meeting in which she provided instructions related to hall monitoring, staff monitoring of resident rooms, and dayroom staff monitoring. HCTs, LPNs, and RNs attended the meeting. 6-14-17- 7/20/17- Nurse Managers for the Alzheimer Unit, 2nd Floor, 3rd Floor, and 4th Floor conducted staff meetings to review door monitoring requirements. (The door monitoring requirements were not new. The instructions were a reminder to staff about the importance of securing doors.) HCTs, LPNs and RNs attended the meeting 6-22-17- Director of Nursing communicated a policy change in an email to the Nurse Supervisors requiring that pulled staff who are not familiar with the residents on that unit, not be assigned as the Dayroom Monitor. In addition, staff who are assigned as Dayroom Monitors must position themselves close to the entrance door. The policy change was that staff who are pulled and do not know the residents on that unit are not assigned to be the dayroom monitor role. This policy change was discussed in the meetings the Nurse Managers had with their staff. 6-22-17- 1st version of the Door Security/Elopement Prevention video was submitted to Director of Nursing for review. 6-22-17- A walk-through was conducted by the Center Director, Assistant Center Director, Business Manager and Director of Standards Management to review the results of the facility assessment regarding the various locking arrangements in place at facility exits (e.g. maglocks, key locks, free access) 7-5-17- Email received from the Business Manager that the door lock project was sent out for E Quote. Per the email, depending on the cost, it could require additional purchasing/bid process. 7-12-17- Purchasing Director received E Quote pricing for installation of 14 additional card access doors. Cost to add card readers was $39, 400. 7-12-17- Purchasing Director sent an email to the Center Director stating a request for quote (RFQ) had to be sent due to the cost. 7-12-17- Center Director ' s office sent an email to all facility staff regarding a requirement to review a Door Security/Elopement Prevention Video that was posted to the LMS Training System. All facility staff are to review the training by 8/31/17. The video was assigned through the Learning Management System, which generates an email to the employee when it is assigned. All facility staff have email. The Staff Development Department generates reports from the LMS system so we can track that training was completed. The target completion date for the training is August 31, 2017 and 344 out of 433

Based on record review and staff interviews, the facility neglected to initiate emergency medical treatment for 1 of 1 residents, Resident # 1, who was found without a pulse and respirations. Neglect included nursing staff ' s lack of knowledge of the resident ' s code status, staff not immediately initiating cardiopulmonary resuscitation (CPR) and calling 911, and staff not knowing how to call a code when a resident required immediate medical treatment. Resident # 1 was pronounced dead in the facility. The Immediate Jeopardy (IJ) began on [DATE] for Resident #1 when the resident was found not breathing and without a pulse by staff in the resident ' s room and staff neglected to immediately initiate CPR and call 911 for the resident. Immediate jeopardy was identified on [DATE] at 4:57 PM. The immediate jeopardy was removed on [DATE] at 1:50 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of remedies put in place are effective. Findings included: A review of the facility's resident care policy, effective [DATE], titled Medical Emergencies in part read: All medical emergencies involving residents shall be responded to in a timely manner according to established procedures. All physicians, registered nurses, licensed practical nurses, and health care technicians are trained and competent in cardiopulmonary resuscitation (CPR), the [MEDICATION NAME] maneuver, and automated external defibrillator (AED) use. Further review of the resident care policy revealed that in the event of a cardiac/respiratory arrest/life-threatening situation (Code Blue), the first staff member on the scene is to summon initial assistance by shouting EMERGENCY or pulling the call bell from the electrical socket for a continuous ring. The staff member deciding that immediate measures are needed will send a staff member to announce CODE BLUE and location three (3) times and call Emergency Medical Services (EMS) and tell the emergency situation, facility floor, room number, resident ' s name, age, and diagnosis, if known. Trained staff members are to initiate emergency first-aid measures and basic life support as indicated, including CPR (unless a Do Not Resuscitate (DNR)), AED, [MEDICATION NAME] Maneuver, and/or insert airway, start oxygen 4L/minute, suction, and perform venipuncture. Record review revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review of Resident #1 ' s medical record revealed a physician order [REDACTED]. A social worker admission note dated [DATE] at 11:09 AM stated that Resident # 1 had been admitted on [DATE] with a family member serving as Guardian of Person (GOP) and was considered a full code. The Resident Care Plan, dated [DATE], showed that Resident # 1 was care planned as a full code with no living will or treatment limitation. The most recent Minimum Data Set prior to Resident # 1 ' s death was dated [DATE] and showed that the resident was cognitively intact, exhibited behaviors of rejection of care and physical and verbal behavior towards others, was occasionally incontinent of urine, was receiving oxygen (O2) therapy, and required only supervision with activities of daily living (ADLs), except bathing which required extensive assistance. Review of a nursing note written by Nurse # 1, dated [DATE] at 2:30 PM, showed that, at approximately 1:10 PM, health care tech (HCT) # 1 informed Nurse # 1 that there was something wrong with Resident # 1. Upon assessing Resident # 1, Nurse # 1 found the resident unresponsive and palpated no pulse. The note stated that Nurse # 1 called for help and sent for Resident # 1 ' s chart to determine the resident ' s code status. Nurse # 1 then documented that she called the House Supervisor on duty and for staff to get the crash cart. The note also stated that Nurse # 1 auscultated Resident # 1 for heart rhythm and utilized the pulse oximeter and blood pressure with no reading. She reported that the resident ' s skin was cool to touch and CPR was initiated and automated external defibrillator (AED) was applied until emergency medical services (EMS) arrived. Nurse # 1 ' s note also indicated that staff from other units responded to the code and assisted with CPR. In an interview with Nurse # 1 at 2:30 PM on [DATE], she stated that Resident # 1 could communicate her needs and was fine on the morning of [DATE], but had chosen to stay in her room most of the day, which was not unusual. Nurse # 1 reported that Resident # 1 had been talking that morning and was up and down out of bed to go to the bathroom and was found on [DATE] right before lunch by HCT # 1 laying on her back on her bed. HCT # 1 reported to her that Resident # 1 did not look right and she went into the room to assess the resident. Nurse # 1 stated she found the resident on the bed with no pulse and no respirations noted. The resident ' s skin was warm in parts, but there were areas that were cooler than others like the feet and hands. Resident # 1 ' s color was the same, mouth was open, and eyes were closed. Nurse # 1 reported that she called for help to the House Supervisor while another staff member went to get the resident ' s chart to find out the code status and get a crash cart. She then stated that she initiated CPR and the AED was placed on the resident, but there was no heart rhythm present. Nurse # 1 stated that she made a mistake by leaving the room, not knowing the resident ' s code status, and not initiating CPR for Resident # 1. She reported that she should have stayed in the room and just called out for help, but she did not feel that Resident # 1 had any signs of life when she entered the room and that she should have initiated CPR, but she did not feel that would have prevented the resident ' s death. In a follow up interview with Nurse # 1 at 2:16 PM on [DATE], she stated she was CPR certified, but did not initiate chest compressions because she was unsure of the resident ' s code status because she did not write it down from the shift change meeting and could not remember. She reported that compressions were begun after the code was called and the crash cart arrived. Nurse # 1 reported there was a backboard and Ambu bag on the crash cart. In an interview with HCT # 1 on [DATE] at 1:27 PM, she stated that she cared for Resident # 1 on a regular basis and the resident was fine in the morning of [DATE] and before she went lunch. She reported when she got back from her lunch break, she went to the resident ' s room to get the resident ready for lunch and the resident did not respond when name was called and when she tapped the resident. HCT # 1 then stated that she checked her pulse and there was no pulse so she called another HCT (HCT # 2) into the room while she went to get the nurse. She reported that the nurse entered the room and checked for pulse, but the resident was not responding. Nurse # 1 went to get the chart and she and HCT # 2 stayed in the room. Nurse # 1 came back into the room and stated that the resident was a full code, but no one started chest compressions. Nurse # 1 left the room again to call a code, but there was a problem with the overhead paging system, so Nurse # 1 called the House Supervisor who was able to call the code overhead. HCT # 1 stated she knew how to do CPR, but did not initiate CPR because she was waiting for direction from the nurse. There was a crash cart on the way to the room and other nurses responding to the code started to enter the room. HCT # 1 stated she was not in the room when chest compressions were initiated so she could not say how long it took for someone to start CPR on Resident # 1, but the incident started around 1:00 PM when she found the resident unresponsive. At 6:31 PM on [DATE], via telephone, HCT # 2 reported that HCT # 1 approached her and asked her to go to Resident # 1 ' s room to see if the resident was breathing. She stated she checked the resident ' s pulse and saw no chest rise and hollered for the nurse to come to the room. She recalled that the House Supervisor called the code and when she got to the unit, she told HCT # 2 to go get the crash cart. HCT # 2 said she went to get the crash cart and took it to the resident ' s room. On [DATE] at 3:42 PM, HCT #3 stated that Resident# 1 ' s behavior on [DATE] was normal. The resident stayed in bed that day. During lunch, he saw HCT # 1 go into Resident # 1 ' s room and looked out of the room to get HCT # 2 ' s attention. HCT # 3 reported that later he saw several people go into Resident # 1 ' s room and he was looking for Nurse #1, so he looked in the room for her and she told him to get the resident ' s chart and bring it to the room and that the House Supervisor was on the way down to the room. HCT # 3 stated that he was not sure who had called the code, but the resident was never left alone after she was found. He reported that he was CPR certified and that he was aware that residents ' code status was kept on the chart and on a list at the nurses ' station. Review of a nursing note by House Supervisor # 1, dated [DATE] at 4:00 PM revealed that House Supervisor # 1 arrived to the unit at approximately 1:15 PM and found Resident # 1 non-responsive with no heart rated noted per auscultation, no pulse palpitated, no reading on the pulse oximeter, and no blood pressure reading. House Supervisor # 1 ' s note then indicated that CPR was initiated, the AED was used and the code and EMS were called in addition to the on-call doctor. House Supervisor # 1 also documented that she attempted to start an intravenous (IV) line without success. EMS arrived at approximately 1:25 PM and took over the code by continuing CPR without success. It was noted that EMS contacted the doctor and medical examiner, time of death was pronounced at 1:32 PM. A follow up telephone order was received to pronounce expiration at 1:35 PM. In an interview with House Supervisor # 1 at 4:20 PM on [DATE], she stated that she was on another floor when Nurse # 1 called her and stated that something was wrong with Resident # 1 and she wasn ' t sure, but she thought the resident was gone . House Supervisor # 1 stated she called the code and left the 4th floor to go to the 1st floor to assess Resident # 1. She reported that when she arrived on the unit, Nurse # 1 was at the nurses ' station and she wondered why she was not in the room with the resident, but she didn ' t have time to ask because she was heading straight to the resident ' s room. House Supervisor # 1 reported that she told someone to get the crash cart while she was walking to the resident ' s room and once she entered the resident ' s room she found the resident lying on the bed on her back and other staff that had responded to the code had entered the room and immediately initiated CPR. She stated that while they were administering CPR, she called EMS. She also reported that she tried to start an IV, but was unsuccessful. EMS arrived and took over the CPR and put the resident on their machine, but the resident registered as a flat line. House Supervisor # 1 stated that Resident # 1 was non-responsive, with no respiration, no pulse, cold skin in some place, and skin coloration had begun to change when she entered the resident ' s room. She reported that she had been involved in several codes before and knew when there were no signs of life present and Resident # 1 did not look like there was life present when she entered the room. The House Supervisor stated that the HCT who found the resident should not have left the room, but should have yelled out for help and that Nurse # 1 should have known the resident ' s code status and initiated CPR. She felt that Nurse # 1 panicked as it was her first code and she did not appear to know what to do. House Supervisor # 1 stated that all nursing staff should know the resident ' s code status because it was given during report at shift change, it was located at the nurses ' station, there was a coded dot on the chart for the DNR residents, and there was a page in the front of each resident ' s chart indicating their advanced directives including their code status. She reported that Nurse # 1 had told her that she tried to call the code herself, but was unable to do so because she did not know how to work the overhead paging system. During a phone interview with House Supervisor # 1 at 4:03 PM on [DATE], she stated that she was on the 4th floor when Nurse # 1 called her and said she thought something was wrong with Resident # 1 and she thought the resident might be gone. House Supervisor # 1 stated that when she arrived on the 1st floor unit, Nurse # 1 was on the phone at the nursing station and she proceeded to the resident ' s room and found the resident supine in bed. House Supervisor # 1 reported that she asked the resident ' s code status while feeling for a pulse and told staff in the room to get the crash cart. Nurse # 1 entered the room and told the House Supervisor that she had tried to call a code, but was unable. House Supervisor # 1 stated that she then when out of the room and called the code and 911. Staff began responding from other units and asked if the resident was supposed to be given CPR. The House Supervisor informed them that Resident # 1 was supposed to be receiving CPR and the back board was placed under the resident and staff initiated CPR. She reported that she did not call the code prior to arrival on the unit and that no one was doing chest compressions when she arrived on the unit. House Supervisor # 1 informed that it was approximately 8 to 10 minutes from the time she received the call from Nurse # 1 until CPR was initiated. In a follow up phone interview with House Supervisor # 1 on [DATE] at 5:45 PM, she recalled that she called code blue and EMS before she left the 2nd floor in route to the resident ' s room on the 100 hall. She estimated that the time between receiving Nurse # 1 ' s call and the start of chest compressions (CPR) was approximately 8 to 10 minutes. In an interview with Nurse # 2 at 2:58 PM on [DATE], she stated that she was on the 5th floor on [DATE] when the code was called for a resident on the 1st floor. She reported that she and another nurse responded to the code, which took approximately 2 minutes, and there were multiple staff standing in Resident # 1 ' s room when they arrived, but no one was doing CPR on the resident. Nurse # 2 stated that the crash cart was in the resident ' s room when she arrived to the unit, but it was unopened. The nurse who came from the 5th floor with her asked if the resident was a Do Not Resuscitate (DNR) and Nurse # 2 reported that she initiated CPR once she found out the resident was a full code. She stated that they did put the AED on the resident, but there was no heart rhythm. She reported that at some point during CPR, Nurse # 1 did assist with chest compressions, but there had been no one doing CPR prior to her getting to the resident ' s room. She stated that she would have expected to see CPR being done when they entered the room and that nurses should have known the resident ' s code status because it is given at report for all residents on the unit and there are other places where the residents ' code statuses were located including a list at the nurses ' station and an orange dot on the residents ' charts who had a DNR in place. In a follow up interview with Nurse # 2, via telephone, on [DATE] at 5:50 PM, she reiterated that when she responded to the code and arrived in Resident# 1 ' s room there were no chest compressions being done. She stated that Nurse # 1 stated the resident was not a DNR, so the back board was placed under the resident and CPR was initiated. The House Supervisor was on the phone calling EMS and Nurse # 1 relieved her with the chest compressions while a nurse, who is no longer employed at the facility, was providing oxygen through the Ambu bag. In an interview with Nurse # 3 on [DATE] at 2:53 PM, she stated that she was working on the 2nd floor of the unit when she heard the code. She reported that she put her meds away to prepare to respond to the code when HCT # 2 came to the 2nd floor to retrieve the crash cart. HCT # 2 took the elevator back to the 1st floor while she took the stairs and made it to the unit before the HCT did with the cart. Nurse # 3 reported that when she entered resident ' s room there was staff present, but no CPR was being done. Other nurses responding to the code entered the room and initiated CPR immediately upon entry. Nurse # 3 stated that if a resident was DNR they were listed at the nurses ' station, it was on their Medication Administration Record [REDACTED]. On [DATE] at 6:09 PM, Nurse # 4 reported that she heard the code called overhead and she and another nurse, who is no longer employed at the facility, responded and confirmed that the resident was a full code. The nurse from the 5th floor, Nurse # 2, did chest compressions and AED pads were put on Resident # 1. The House Supervisor entered and tried to start an IV, but could not get it started. EMS entered, confirmed full code status, and took over with the CPR. At 6:42 PM on [DATE], Nurse # 5 reported that she was on the 3rd floor with the House Supervisor when the House Supervisor received the call from Nurse # 1. She reported that House Supervisor # 1 immediately left the unit and she heard a code being called over the overhead system a few minutes later. Nurse # 5 stated that when she arrived on the unit, there was a whole group of staff in the room and Nurse # 2 was doing compressions. She reported that she went to get the IV pole. Nurse # 5 stated that she was never aware of a problem with the overhead system and that there was a dot that would be on the chart of residents who were a DNR and there was also a list of DNR resident on the report sheets and the DNR status of all resident on the unit should be specified during shift change. In an interview with the Standards Management Director at 5:15 PM on [DATE], she stated that Resident # 1 was found unresponsive in the resident ' s bedroom so it was recorded in the facility ' s incident report as are any incidents involving a code. She reported that the event was reviewed as a part of their patient safety review process and some opportunities for improvement were identified such as the procedure for calling a code, knowing residents ' code status, and having a crash cart readily available on the 1st floor of the unit. The facility initiated emergency response retraining for all staff on that unit, a requisition was completed for an additional crash cart to be placed on the unit for the 1st floor since the only crash cart for the unit was located on the 2nd floor, and they put stickers on each phone, on each unit in the facility, that gave step-by-step directions on how to use the overhead paging system used to call an emergency code. The Standards Management Director also stated that the facility had requested funding for additional training for all nursing staff regarding emergency response and codes as well as implementing a program where the facility would start holding mock code drills. In an interview with the Director of Nursing (DON) on [DATE] at 7:57 PM, he stated that all nursing staff was responsible for knowing resident code status and any staff who was trained should initiate CPR. He reported that the facility had implemented sheets of all residents for staff to use to keep on them with their code status and other pertinent information for the duration of their shift and to be shredded at the end of each shift. The DON stated that it was his expectation that staff should not leave the room of an unresponsive resident, they should call out and initiate CPR, if they are trained, and the resident is a full code. In an interview with the Standards Management Director on [DATE] at 2:02 PM, she stated there were orange sticker on the name label on each chart of resident with a DNR status and staff were trained regarding this sticker during orientation. In addition, during every shift report staff was to tell what residents were DNR. The Standards Management Director confirmed Resident #1 ' s medical record was correctly designated the resident as being a full code, but nursing staff did not initiate CPR to Resident #1 on [DATE]. Facility administration decided all staff should have been re-educated, so they had a meeting on [DATE] and again on [DATE] to address action items. They started re-education of entire facility staff on night shift on [DATE] and asked staff what the orange sticker on the charts meant and asked them to explain how the overhead paging system worked. They also asked staff what they would do if they found a resident unresponsive. There was also a mock code drill done on [DATE] in the AM. On [DATE] at 08:20 AM, the DON reported that he felt the nurse (Nurse # 1) panicked and the HCT (HCT # 1) was unsure if she should give CPR and wanted the nurse to verify the resident ' s status before she did anything. Nurse # 1 ran out of the room to call the House Supervisor and was unsure if the overhead paging system was working. He stated that nurses need to know the code status of their residents and there were measures in place for them to know because it had been addressed months prior. The code status was relayed during shift report, there was a dot on the chart for residents with DNR, and a list of DNRs was kept at the nursing station. He reported that the overhead paging system had changed at the end of April and it was discussed in a supervisors ' meeting and an email was sent out alerting staff of the change. The DON stated that the code status for Resident # 1 as a full code should have been known by staff and CPR should have been initiated immediately upon finding the resident without a pulse and respirations, but he did not feel the location of the crash cart on the 2nd floor of the unit contributed to the resident expiring. The Center Director was notified of the immediate jeopardy at 4:57 PM on [DATE]. The facility presented a credible allegation on [DATE] at 1:39 PM. The credible allegation read: The main resident cited in this Immediate Jeopardy citation has expired. A review of code status for all residents at the facility was completed on [DATE] by the Director of Nursing, Assistant Director of Nursing and RN Supervisors. Code status was based on physician orders. Of the 197 residents who are currently at the facility, 120 are full codes and could be at risk for the same deficient practice The resident who expired had a history of [REDACTED]. There was a delay in calling a Code Blue and a delay in initiating CPR. The resident expired. Four staff members were directly involved in the situation which included two HCTs and two RNs. A Nurse Preceptor completed retraining of the four staff members, on response to medical emergencies, on [DATE]. Retraining included review of the facility ' s Medical Emergency Policy (AM ,[DATE]) which states the first person on the scene will summon for help and initiate CPR if resident is not a DNR. The death was reported to the state on [DATE]. The following corrective actions were implemented: A 24 hour report for alleged neglect was submitted to DHSR, Healthcare Personnel Investigations, on [DATE]. As a plan of protection, the four staff members involved will be placed on investigatory placement with pay, pending an investigation. According to the work schedule, all four staff members are currently scheduled off and will be placed on investigatory placement with pay when they return to duty. One HCT and two RNs will be placed on investigatory leave on [DATE] and one HCT will be placed on investigatory leave on [DATE]. None of the four staff members will have contact with the residents prior to placement on investigatory leave. A review of the Code Blue was initiated on [DATE]. The review was conducted by the Director of Standards Management, in conjunction with the Assistant Director of Nursing. The event was discussed in the facility ' s Event Review Committee on [DATE]. The Event Review Committee is an extension of the facility ' s Quality Improvement Committee. Based on the event analysis, an action plan was developed and forwarded to the Center Director and Director of Nursing. On [DATE], the Event Review Committee reviewed the action items and recommended additional items to improve resident care, which included enhanced monitoring processes to validate staff competency. All staff members on the Alzheimer Unit, where the Code Blue occurred, were retrained on emergency response on [DATE] and [DATE] by the Nurse Preceptors. The training included a review of the Medical Emergency Policy (AM ,[DATE]) and a power point presentation covering steps for initiating a code blue, review of the emergency paging instructions, AED demonstration and code status information. The training covered the requirement for the staff member who finds an unresponsive resident to remain with the resident, call for help and immediately start chest compressions if the resident is not a DNR. Retraining of all facility Nursing Staff by the Nurse Preceptors and Staff Development Nurses, on Emergency Medical Response was initiated on [DATE] and continued through [DATE]. The training included a review of the Medical Emergency Policy (AM ,[DATE]) and a power point presentation covering steps for initiating a code blue, review of the emergency paging instructions, AED demonstration and code status information. The training covered the requirement for the staff member who finds an unresponsive resident to remain with the resident, call for help and immediately start chest compressions if the resident is not a DNR. 210 staff members were trained on [DATE], [DATE] and [DATE]. Retraining will continue each shift until all nursing staff are trained, with a target completion date of [DATE].Any staff not trained will be trained before working on the hall again. New Employees will receive training in New Employee Orientation and will complete training prior to having a resident care assignment. Per facility policy (NM #1), all direct care nursing employees (e.g. HCTs, LPNs, RNs) are required to complete BLS training as part of New Employee Orientation and annually. As part of the training, HCTs, RNs, and LPNs are required to initiate CPR if the resident is not a DNR and call 911. The Staff Development Director/designee tracks employee completion of required training and provides each Department Manager with a report of compliance. Department Managers are responsible for ensuring their assigned employees complete BLS as required by facility policy. Mock Code Drills were identified as an enhanced training opportunity for staff on [DATE]. Planning was initiated and a Mock Code Blue drill was conducted on [DATE]. A schedule for monthly mock Code Blue drills on each shift, was finalized on [DATE]. Mock Code Blue drills will be conducted monthly, starting [DATE] on each shift to evaluate staff ' s response to emergencies. An emergency cart was obtained for Alzheimer 1st floor on [DATE]. An AED was purchased on [DATE] and added to the emergency cart on Alzheimer 1st floor. The emergency cart for 1st floor Alzheimer was added to an existing quality assurance process, under the direction of the Director of Nursing, which requires that AEDs are checked every shift to verify they are operational. A sticker with Code Blue paging instructions were added to all telephones in resident care areas on [DATE]. Audits were conducted on [DATE] and [DATE] to validate nursing staff members (e.g. RNs, LPNS, and HCTs) had knowledge of the paging instructions posted on the telephones and how to call a Code Blue. 174 employees were audited and all employees were able to respond affirmatively. The facility implemented a process in [DATE] in which code status is reviewed at each shift report and DNR status is noted on the resident ' s medical record, via an orange dot. The orange dot is used to identify residents who are DNR. When a physician order [REDACTED]. Physician orders [REDACTED]. To enhance staff awareness of each resident ' s code status, the Director of Nursing implemented a worksheet on [DATE] to be used by staff members during each shift. During shift report, code status will be verified and written on the worksheet for quick access throughout the shift. The worksheets will be shredded at the end of each shift. Debriefing of the Code Blue event with the Alzheimer Unit nursing staff was conducted by the Director of Nursing on [DATE] and [DATE] to review the event and review expectations for emergency response for any future Code Blues. The Alzheimer Unit Nurse Manager communicated expectations regarding timely response to medical emergencies with the Alzheimer nursing staff, in a staff meeting on [DATE]. All other facility nursing staff were informed on the expectation for timely response to medical emergencies in a meetings conducted by their Nurse Managers/Nurse Supervisors on [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 1:50 PM, the credible allegation was validated. Staff interviews with HCTs and licensed nurses revealed the facility implemented corrective measures, including in-servicing of nursing staff regarding knowing residents ' code statuses and where to find the code statuses, the proper procedure and protocol for calling a Code Blue, and how to respond when a resident is found unresponsive.

Based on observation, record review, and staff interviews, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) and call Emergency Medical Services (EMS) for 1 of 1 resident, Resident # 1, found without a pulse or respirations. Resident # 1 was pronounced dead in the facility. Findings included: The immediate jeopardy began on [DATE] when Resident # 1 was found lying on the bed, without pulse or respirations, and facility staff did not immediately initiate CPR and contact EMS. Immediate jeopardy was identified on [DATE] at 4:57 PM. A credible allegation was presented by the facility and was accepted on [DATE] at 1:39 PM. The immediate jeopardy was lifted on [DATE] at 1:50 PM. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of remedies put in place are effective. Findings included: A review of the facility's resident care policy, effective [DATE], titled Medical Emergencies in part read: All medical emergencies involving residents shall be responded to in a timely manner according to established procedures. All physicians, registered nurses, licensed practical nurses, and health care technicians are trained and competent in cardiopulmonary resuscitation (CPR), the [MEDICATION NAME] maneuver, and automated external defibrillator (AED) use. Further review of the resident care policy revealed that the facility provides on-site Basic Life Support (BLS) which includes CPR, the [MEDICATION NAME] maneuver, and AED. The facility does not provide Advanced Cardiac Life Support. Review of the history and physical (H&P), completed by the facility ' s physician and dated [DATE], revealed Resident # 1 was admitted with a [DIAGNOSES REDACTED]. A Physician order [REDACTED].# 1 had no Advance Directives in place. A social worker admission note, dated [DATE] at 11:09 AM, stated that Resident # 1 had been admitted on [DATE] with a family member serving as Guardian of Person (GOP) and was considered a full code. The Resident Care Plan, dated [DATE], showed that Resident # 1 was care planned as a full code with no living will or treatment limitation. The most recent Minimum Data Set prior to Resident # 1 ' s death was dated [DATE] and showed that the resident was cognitively intact, exhibited behaviors of rejection of care and physical and verbal behavior towards others, was occasionally incontinent of urine, was receiving oxygen (O2) therapy, and required only supervision with activities of daily living (ADLs), except bathing which required extensive assistance. Review of the facility ' s incident/accident log from [DATE] showed that a code was called for Resident # 1 and the resident expired in the facility on [DATE]. In a nurse ' s note, dated [DATE] at 2:30 PM, Nurse # 1 wrote that at approximately 1:10 PM, health care tech (HCT) # 1 informed Nurse # 1 that there was something wrong with Resident # 1. Upon assessing Resident # 1, Nurse # 1 found the resident unresponsive and palpated no pulse. The note stated that Nurse # 1 called for help and sent for Resident # 1 ' s chart to determine the resident ' s code status. Nurse # 1 then documented that she called the House Supervisor on duty and for staff to get the crash cart. The note also stated that Nurse # 1 auscultated Resident # 1 for heart rhythm and utilized the pulse oximeter and blood pressure with no reading. She reported that the resident ' s skin was cool to touch and CPR was initiated and automated external defibrillator (AED) was applied until emergency medical services (EMS) arrived. Nurse # 1 ' s note also indicated that staff from other units responded to the code and assisted with CPR. In an interview with Nurse # 1 at 2:30 PM on [DATE], she stated that Resident # 1 could communicate her needs and would often refuse care and treatment. She reported that the resident was fine on the morning of [DATE] and had chosen to stay in her room most of the day, which was not unusual. Nurse # 1 reported that Resident # 1 had been talking that morning and was up and down out of bed to go to the bathroom and was found right before lunch by HCT # 1 laying on her back on her bed. HCT # 1 reported to her that Resident # 1 did not look right and she went into the room to assess the resident. Nurse # 1 stated she found the resident on the bed with no pulse and no respirations noted. The resident ' s skin was warm in parts, but there were areas that were cooler than others like the feet and hands. Resident # 1 ' s color was the same, mouth was open, and eyes were closed. Nurse # 1 reported that she called for help to the House Supervisor while another staff member went to get the resident ' s chart to find out the code status and get a crash cart. She then stated that she initiated CPR and the AED was placed on the resident, but there was no heart rhythm present. Nurse # 1 stated that she made a mistake by leaving the room, not knowing the resident ' s code status, and not initiating CPR for Resident # 1. She reported that she should have stayed in the room and just called out for help, but she did not feel that Resident # 1 had any signs of life when she entered the room and that she should have initiated CPR, but she did not feel that would have prevented the resident ' s death. In a follow up interview with Nurse # 1 at 2:16 PM on [DATE], she stated she was CPR certified, but did not initiate chest compressions because she was unsure of the resident ' s code status because she did not write it down from the shift change meeting and could not remember. She reported that compressions were begun after the code was called and the crash cart arrived. Nurse # 1 reported there was a backboard and Ambu bag on the crash cart. In an interview with HCT # 1 on [DATE] at 1:27 PM, she stated that she cared for Resident # 1 on a regular basis and the resident was fine in the morning of [DATE] and before she went lunch. She reported when she got back from her lunch break, she went to the resident ' s room to get the resident ready for lunch and the resident did not respond when name was called and when she tapped the resident. HCT # 1 then stated that she checked her pulse and there was no pulse so she called another HCT (HCT # 2) into the room while she went to get the nurse. She reported that the nurse entered the room and checked for pulse, but the resident was not responding. Nurse # 1 went to get the chart and she and HCT # 2 stayed in the room. Nurse # 1 came back into the room and stated that the resident was a full code, but no one started chest compressions. Nurse # 1 left the room again to call a code, but there was a problem with the overhead paging system, so Nurse # 1 called the House Supervisor who was able to call the code overhead. HCT # 1 stated she knew how to do CPR, but did not initiate CPR because she was waiting for direction from the nurse. There was a crash cart on the way to the room and other nurses responding to the code started to enter the room. HCT # 1 stated she was not in the room when chest compression were initiated so she could not say how long it took for someone to start CPR on Resident # 1, but the incident started around 1:00 PM when she found the resident unresponsive. At 6:31 PM on [DATE], via telephone, HCT # 2 reported that HCT # 1 approached her and asked her to go to Resident # 1 ' s room to see if the resident was breathing. She stated she checked the resident ' s pulse and saw no chest rise and hollered for the nurse to come to the room. She recalled that the House Supervisor called the code and when she got to the unit, she told HCT # 2 to go get the crash cart. HCT # 2 said she went to get the crash cart and took it to the resident ' s room. On [DATE] at 3:42 PM, HCT #3 stated that Resident# 1 ' s behavior on [DATE] was normal. The resident stayed in bed that day and would refuse meals at times. During lunch, he saw HCT # 1 go into Resident # 1 ' s room and looked out of the room to get HCT # 2 ' s attention. HCT # 3 reported that later he saw several people go into Resident # 1 ' s room and he was looking for Nurse #1, so he looked in the room for her and she told him to get the resident ' s chart and bring it to the room and that the House Supervisor was on the way down to the room. HCT # 3 stated that he was not sure who had called the code, but the resident was never left alone after she was found. He reported that he was CPR certified and that he was aware that residents ' code status was kept on the chart and on a list at the nurse ' s station. In a nursing note by House Supervisor # 1, dated [DATE] at 4:00 PM, House Supervisor # 1 revealed that she arrived to the unit at approximately 1:15 PM and found Resident # 1 non-responsive with no heart rated noted per auscultation, no pulse palpitated, no reading on the pulse oximeter, and no blood pressure reading. House Supervisor # 1 ' s note then indicated that CPR was initiated, the AED was used and the code and EMS were called in addition to the on-call doctor. House Supervisor # 1 also documented that she attempted to start an intravenous (IV) line without success. EMS arrived at approximately 1:25 PM and took over the code by continuing CPR without success. It was noted that EMS contacted the doctor and medical examiner, time of death was pronounced at 1:32 PM and received permission to move the body was received at 1:55 PM. A follow up telephone order was received to pronounce expiration at 1:35 PM. In an interview with House Supervisor # 1 at 4:20 PM on [DATE], she stated that she was on another floor when Nurse # 1 called her and stated that something was wrong with Resident # 1 and she wasn ' t sure, but she thought the resident was gone . House Supervisor # 1 stated she called the code and left the 4th floor to go to the 1st floor to assess Resident # 1. She reported that when she arrived on the unit, Nurse # 1 was at the nurses ' station and she wondered why she was not in the room with the resident, but she didn ' t have time to ask because she was heading straight to the resident ' s room. House Supervisor # 1 reported that she told someone to get the crash cart while she was walking to the resident ' s room and once she entered the resident ' s room she found the resident lying on the bed on her back and other staff that had responded to the code had entered the room and immediately initiated CPR. She stated that while they were administering CPR, she called EMS. She also reported that she tried to start an IV, but was unsuccessful. EMS arrived and took over the CPR and put the resident on their machine, but the resident registered as a flat line. House Supervisor # 1 stated that Resident # 1 was non-responsive, with no respiration, no pulse, cold skin in some place, and skin coloration had begun to change when she entered the resident ' s room. She reported that she had been involved in several codes before and knew when there were no signs of life present and Resident # 1 did not look like there was life present when she entered the room. The House Supervisor stated that the HCT who found the resident should not have left the room, but should have yelled out for help and that Nurse # 1 should have known the resident ' s code status and initiated CPR. She felt that Nurse # 1 panicked as it was her first code and she did not appear to know what to do. House Supervisor # 1 stated that all nursing staff should know the resident ' s code status because it was given during report at shift change, it was located at the nurses ' station, there was a coded dot on the chart for the DNR residents, and there was a page in the front of each resident ' s chart indicating their advanced directives including their code status. She reported that Nurse # 1 had told her that she tried to call the code herself, but was unable to do so because she did not know how to work the overhead paging system. During a phone interview with House Supervisor # 1 at 4:03 PM on [DATE], she stated that she was on the 4th floor when Nurse # 1 called her and said she thought something was wrong with Resident # 1 and she thought the resident might be gone. House Supervisor # 1 stated that when she arrived on the 1st floor unit, Nurse # 1 was on the phone at the nursing station and she proceeded to the resident ' s room and found the resident supine in bed. House Supervisor # 1 reported that she asked the resident ' s code status while feeling for a pulse and told staff in the room to get the crash cart. Nurse # 1 entered the room and told the House Supervisor that she had tried to call a code, but was unable. House Supervisor # 1 stated that she then when out of the room and called the code and 911. Staff began responding from other units and asked if the resident was supposed to be given CPR. The House Supervisor informed them that Resident # 1 was supposed to be receiving CPR and the back board was placed under the resident and staff initiated CPR. She reported that she did not call the code prior to arrival on the unit and that no one was doing chest compressions when she arrived on the unit. House Supervisor # 1 informed that it was approximately 8 to 10 minutes from the time she received the call from Nurse # 1 until CPR was initiated. In a follow up phone interview with House Supervisor # 1 on [DATE] at 5:45 PM, she recalled that she called code blue and EMS before she left the 2nd floor in route to the resident ' s room on the 100 hall. She estimated that the time between receiving Nurse # 1 ' s call and the start of chest compressions (CPR) was approximately 8 to 10 minutes. In an interview with Nurse # 2 at 2:58 PM on [DATE], she stated that she was on the 5th floor and the code was called for a resident on the 1st floor. She reported that she and another nurse responded to the code, which took approximately 2 minutes, and there were multiple staff standing in Resident # 1 ' s room when they arrived, but no one was doing CPR on the resident. Nurse # 2 stated that the crash cart was in the resident ' s room when she arrived to the unit, but it was unopened. The nurse who came from the 5th floor with her asked if the resident was a Do Not Resuscitate (DNR) and Nurse # 2 reported that she initiated CPR once she found out the resident was a full code. She stated that they did put the AED on the resident, but there was no heart rhythm. She reported that at some point during CPR, Nurse # 1 did assist with chest compressions, but there had been no one doing CPR prior to her getting to the resident ' s room. She stated that she would have expected to see CPR being done when they entered the room and that nurses should have known the resident ' s code status because it is given at report for all residents on the unit and there are other places where the residents ' code statuses were located including a list at the nurses ' station and an orange dot on the residents ' charts who had a DNR in place. In a follow up interview with Nurse # 2, via telephone, on [DATE] at 5:50 PM, she reiterated that when she responded to the code and arrived in Resident# 1 ' s room there were no chest compressions being done. She stated that Nurse # 1 stated the resident was not a DNR, so the back board was placed under the resident and CPR was initiated. The House Supervisor was on the phone calling EMS and Nurse # 1 relieved her with the chest compressions while a nurse who is no longer employed at the facility was providing oxygen through the Ambu bag. In an interview with Nurse # 3 on [DATE] at 2:53 PM, she stated that she was working on the 2nd floor of the unit when she heard the code. She reported that she put her meds away to prepare to respond to the code when HCT # 2 came to the 2nd floor to retrieve the crash cart. HCT # 2 took the elevator back to the 1st floor while she took the stairs and made it to the unit before the HCT did with the cart. Nurse # 3 reported that when she entered resident ' s room there was staff present, but no CPR was being done. Other nurses responding to the code entered the room and initiated CPR immediately upon entry. Nurse # 3 stated that if a resident was DNR they are listed at the nurses ' station, it is on their Medication Administration Record [REDACTED]. On [DATE] @ 6:09 PM, Nurse # 4 reported that she heard the code called overhead and she and another nurse, who is no longer employed at the facility, responded and confirmed that the resident was a full code. The nurse from the 5th floor, Nurse # 2, did chest compressions and AED pads were put on Resident # 1. The House Supervisor entered and tried to start an IV, but could not get it started. EMS entered, confirmed full code status, and took over with the CPR. At 6:42 PM on [DATE], Nurse # 5 reported that she was on the 3rd floor with the House Supervisor when the House Supervisor received the call from Nurse # 1. She reported that House Supervisor # 1 immediately left the unit and she heard a code being called over the overhead system a few minutes later. Nurse # 5 stated that when she arrived on the unit, there was a whole group of staff in the room and Nurse # 2 was doing compressions. She reported that she went to get the IV pole. Nurse # 5 stated that she was never aware of a problem with the overhead system and that there was a dot that would be on the chart of residents who were a DNR and there was also a list of DNR resident on the report sheets and the DNR status of all resident on the unit should be specified during shift change. In an interview with the Standards Management Director at 5:15 PM on [DATE], she stated that Resident # 1 was found unresponsive in the resident ' s bedroom so it was recorded in the facility ' s incident report as are any incidents involving a code. She reported that the event was reviewed as a part of their patient safety review process and some opportunities for improvement were identified. The facility initiated emergency response retraining for all staff on that unit, a requisition was completed for an additional crash cart to be placed on the unit for the 1st floor since the only crash cart for the unit was located on the 2nd floor, and they put stickers on each phone, on each unit in the facility, that gave step-by-step directions on how to use the overhead paging system used to call an emergency code. The Standards Management Director also stated that the facility had requested funding for additional training for all nursing staff regarding emergency response and codes as well as implementing a program where the facility would start holding mock code drills. In an interview with the Director of Nursing (DON) on [DATE] at 7:57 PM, he stated that all nursing staff were responsible for knowing resident code status and any staff who was trained should initiate CPR. He reported that the facility had implemented sheets of all residents for staff to use to keep on them with their code status and other pertinent information for the duration of their shift and to be shredded at the end of each shift. The DON stated that it was his expectation that staff should not leave the room of an unresponsive resident, they should call out and initiate CPR, if they are trained, and the resident is a full code. The DON reported that all HCTs and nurses were trained and certified in CPR. From 8:05 PM through 8:25 PM on [DATE], observations were made of the stickers that were placed on each phone after Resident # 1 ' s Code Blue on [DATE], on each unit, with the step-by-step instructions of how to use the overhead paging system to call a code. In an interview with the Standards Management Director on [DATE] at 2:02 PM, she stated there were orange stickers on the name label on each chart of resident with a DNR status and staff were trained regarding this sticker during orientation. In addition, every shift report staff was to tell what residents were DNR. Facility administration decided all staff should have been re-educated, so they had a meeting on [DATE] and again on [DATE] to address action items. They started re-education of entire facility staff on night shift on [DATE] and asked staff what the orange sticker on the charts meant and asked them to explain how the overhead paging system worked. They also asked staff what they would do if they found a resident unresponsive. There was also a mock code drill done on [DATE] in the AM for all nursing staff in the building at the time. On [DATE] at 08:20 AM the DON reported that he felt the nurse panicked and the HCT (HCT # 1) was unsure if she should give CPR and wanted the nurse to verify the resident ' s status before she did anything. Nurse # 1 ran out of the room to call the House Supervisor and was unsure if the overhead paging system was working. He stated that nurses need to know the code status of their residents and there were measures in place for them to know because it had been addressed months prior. The code status was relayed during shift report, there was a dot on the chart for residents with DNR, and a list of DNRs was kept at the nursing station. He reported that the overhead paging system had changed at the end of April and it was discussed in a supervisors ' meeting and an email was sent out alerting staff of the change. The DON stated that staff should have known the code status for Resident # 1 and CPR should have been initiated immediately upon finding the resident unresponsive, but he did not feel the location of the crash cart on the 2nd floor of the unit contributed to the resident expiring. The Center Director was notified of the immediate jeopardy at 4:57 PM on [DATE]. The facility presented a credible allegation on [DATE] at 1:39 PM. The credible allegation read: The main resident cited in this Immediate Jeopardy citation has expired. A review of code status for all residents at the facility was completed on [DATE] by the Director of Nursing, Assistant Director of Nursing and RN Supervisors. Code status was based on physician orders. Of the 197 residents who are currently at the facility, 120 are full codes and could be at risk for the same deficient practice. The resident who expired had a history of [REDACTED]. There was a delay in calling a Code Blue and a delay in initiating CPR. The resident expired. Four staff members were directly involved in the situation which included two HCTs and two RNs. A Nurse Preceptor completed retraining of the four staff members, on response to medical emergencies, on [DATE]. Retraining included review of the facility ' s Medical Emergency Policy (AM ,[DATE]) which states the first person on the scene will summon for help and initiate CPR if resident is not a DNR. The death was reported to the state on [DATE]. The following corrective actions were implemented: A review of the Code Blue was initiated on [DATE]. The review was conducted by the Director of Standards Management, in conjunction with the Assistant Director of Nursing. The event was discussed in the facility ' s Event Review Committee on [DATE]. The Event Review Committee is an extension of the facility ' s Quality Improvement Committee. Based on the event analysis, an action plan was developed and forwarded to the Center Director and Director of Nursing. On [DATE], the Event Review Committee reviewed the action items and recommended additional items to improve resident care, which included enhanced monitoring processes to validate staff competency. All staff members on the Alzheimer Unit, where the Code Blue occurred, were retrained on emergency response on [DATE] and [DATE] by the Nurse Preceptors. The training included a review of the Medical Emergency Policy (AM ,[DATE]) and a power point presentation covering steps for initiating a code blue, review of the emergency paging instructions, AED demonstration and code status information. The training covered the requirement for the staff member who finds an unresponsive resident to remain with the resident, call for help and immediately start chest compressions if the resident is not a DNR. Retraining of all facility Nursing Staff by the Nurse Preceptors and Staff Development Nurses, on Emergency Medical Response was initiated on [DATE] and continued through [DATE]. The training included a review of the Medical Emergency Policy (AM ,[DATE]) and a power point presentation covering steps for initiating a code blue, review of the emergency paging instructions, AED demonstration and code status information. The training covered the requirement for the staff member who finds an unresponsive resident to remain with the resident, call for help and immediately start chest compressions if the resident is not a DNR. 210 staff members were trained on [DATE], [DATE], and [DATE]. Retraining will continue each shift until all nursing staff are trained, with a target completion date of [DATE]. Any staff not trained will be trained before working on the hall again. New Employees will receive training in New Employee Orientation and will complete training prior to having a resident care assignment. Per facility policy (NM #1), all direct care nursing employees (e.g. HCTs, LPNs, RNs) are required to complete BLS training as part of New Employee Orientation and annually. As part of the training, HCTs, RNs, and LPNs are required to initiate CPR if the resident is not a DNR and call 911. The Staff Development Director/designee tracks employee completion of required training and provides each Department Manager with a report of compliance. Department Managers are responsible for ensuring their assigned employees complete BLS as required by facility policy. Mock Code Drills were identified as an enhanced training opportunity for staff on [DATE]. Planning was initiated and a Mock Code Blue drill was conducted on [DATE]. A schedule for monthly mock Code Blue drills on each shift, was finalized on [DATE]. Mock Code Blue drills will be conducted monthly, starting [DATE] on each shift to evaluate staff ' s response to emergencies. An emergency cart was obtained for Alzheimer 1st floor on [DATE]. An AED was purchased on [DATE] and added to the emergency cart on Alzheimer 1st floor. The emergency cart for 1st floor Alzheimer was added to an existing quality assurance process, under the direction of the Director of Nursing, which requires that AEDS are checked every shift to verify they are operational. A sticker with Code Blue paging instructions were added to all telephones in resident care areas on [DATE]. Audits were conducted on [DATE] and [DATE] to validate nursing staff members (e.g. RNs, LPNS, and HCTs) had knowledge of the paging instructions posted on the telephones and how to call a Code Blue. 174 employees were audited and all employees were able to respond affirmatively. The facility implemented a process in [DATE] in which code status is reviewed at each shift report and DNR status is noted on the resident ' s medical record, via an orange dot. The orange dot is used to identify residents who are DNR. When a physician order [REDACTED]. Physician orders [REDACTED]. To enhance staff awareness of each resident ' s code status, the Director of Nursing implemented a worksheet on [DATE] to be used by staff members during each shift. During shift report, code status will be verified and written on the worksheet for quick access throughout the shift. The worksheets will be shredded at the end of each shift. Debriefing of the Code Blue event with the Alzheimer Unit nursing staff was conducted by the Director of Nursing on [DATE] and [DATE] to review the event and review expectations for emergency response for any future Code Blues. The Alzheimer Unit Nurse Manager communicated expectations regarding timely response to medical emergencies with the Alzheimer nursing staff, in a staff meeting on [DATE]. All other facility nursing staff were informed of the expectation for timely response to medical emergencies in a meetings conducted by their Nurse Managers/Nurse Supervisors on [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 1:50 PM, the credible allegation was validated. Staff interviews with HCTs and licensed nurses revealed the facility implemented corrective measures, including in-servicing of nursing staff regarding knowing residents ' code statuses and where to find the code statuses, the proper procedure and protocol for calling a Code Blue, and how to respond when a resident is found unresponsive.