Every finding on record at Louisburg Healthcare & Rehabilitation Center

Based on observation, record review and staff interviews, the facility failed to store an unknown white cream in a locked cart. A white cream was observed on top of an empty barrier dressing package on the resident's bedside table. This occurred for 1 of 1 resident reviewed for medication storage. (Resident #52) The findings included:Resident #52 was readmitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.Review of active physician's orders dated 4/23/26 revealed an order for Calcium alginate with silver dressing to right buttocks daily.Review of active physician's orders dated 4/23/26 revealed an order for ammonium lactate lotion 12% apply to both legs daily.An observation and interview were conducted with Resident #25 on 5/31/26 at 12:18 PM. Resident #25 was sitting up in bed and there was an empty barrier dressing package sitting on the bedside table. A glob of cream that was the size of a silver dollar, white in color and had a thick creamy consistency was sitting on top of the packaging. Resident #25 denied that he knew what the cream was. Resident #25 reported that the cream had been sitting on the bedside table since the previous day. Resident #25 stated the nurse had been in earlier and completed his dressing change. The resident reported that the cream was on the bedside table then. Resident #25 could not give an approximate time of when the cream was placed on the table the previous day.An observation was conducted on 05/31/2026 at 12:49 PM with the Director of Nursing (DON). The DON confirmed that the glob of white cream sitting on an empty barrier dressing on Resident #52's bedside table should not have been left in the room. The DON inspected the cream and removed both the empty barrier dressing package and cream from the resident's bedside and discarded it. An interview was conducted with Nurse #2 on 05/31/2026 at 1:20 PM. Nurse #2 confirmed that she was the nurse responsible for caring for Resident #25 on the 7:00 AM to 3:00 PM shift. Nurse #2 stated she had cared for Resident 25 on the 7:00 AM to 3:00 PM on 5/30/2026 also. Nurse #2 stated she had changed Resident #25's dressing that morning but she did not recall there being an empty barrier dressing package with white cream on the bedside table. Nurse #2 stated the nurse assigned to the resident was responsible for dressing changes when the wound care nurse was not present. The nurse stated the wound nurse was not there that day, but she did work and complete Resident #25's dressing change on 5/30/26. Nurse #2 stated she had applied the ammonium lactate lotion to Resident #25's legs but denied placing the cream on the empty dressing and placing it on the bedside table. During an interview with the Wound Nurse on 6/2/26 at 1:15 PM she stated that she had completed Resident #25's dressing to his right buttocks on 5/30/26. The Wound Nurse stated she did not apply any creams on Resident #25's body. She further stated that the application of cream to Resident #25's leg was the day shift nurse caring for the resident's responsibility.An interview was conducted with the DON on 6/3/26 at 4:15 PM. The DON stated all medications and creams were to be removed when the nurse exited the resident's room.An interview was conducted with the Administrator on 6/3/26 at 4:17 PM. The Administrator stated that she expected that leftover medications would be discarded prior to leaving the resident's room.

Based on record review, and staff interviews, the nurse failed to provide care according to professional standards when she borrowed and administered Resident #35's Potassium Chloride Extended Release (ER) tablets to Resident #8 and left the room without ensuring the resident had taken the medication for 1 of 5 residents reviewed for medications (Resident #8). Findings: Resident #8 was admitted on [DATE] with diagnoses including kidney disease, peptic ulcer, and constipation. A review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact.A review of Resident #8's current physician's orders revealed an order for Potassium Chloride ER Tablet 20 mEq (milliequivalents) to be given one (1) tablet by mouth one time a day for supplement and to take with food and a full glass of water.An observation was conducted on 6/2/26 at 1:22 PM as Resident #8 was lying in bed holding a candy wrapper that contained a yellow pill. The Director of Nursing (DON), who was in Resident #8's room at the time of the observation stated that the medication was Potassium Chloride Extended Release (ER) Tablet 10 mEq. An interview conducted on 6/2/26 at 1:22 PM with Resident #8 revealed that he had a pill in his hand because he felt Nurse #1 gave him too many pills. Resident #8 stated that he only takes one white pill, but Nurse #1 gave him two yellow pills today, and he decided to save one. Resident #8 stated that Nurse #8 handed him two pills in a cup and a cup of water and she walked out before he could take his medication. The resident revealed he took one pill and saved the other because he always took one pill for supplement and did not understand why the nurse gave him two yellow tablets this time. An interview was conducted on 6/2/26 at 1:39 PM with Nurse #1. Nurse #1 revealed that Resident #8's prescribed Potassium Chloride ER Tablet Extended Release 20 mEq had run out that morning, and she borrowed Resident #35's Potassium Chloride ER Tablet Extended Release 10 mEq and administered them to Resident #8. Nurse #1 stated that she was aware the facility has back up medication, but she did not have the time to go fetch the medication or to call the pharmacy. Nurse #1 revealed that she committed a mistake and was apologetic for borrowing Resident #35's medications to give to Resident #8. Nurse #1stated that she borrowed two 10 mEq tablets and gave them to Resident #8. Nurse #1 stated that she did not stay in the room until Resident #8 took his medication because she was behind in passing medications and was rushing through. During an interview with the Physician Assistant (PA) on 6/03/26 at 3:09 PM she stated that Resident #8 taking half of the dosage of the prescribed Potassium Chloride ER 20 MEQ tablet had no adverse effect on him and that the error was not a significant issue. An interview was conducted on 6/2/26 at 1:43 PM with the DON. The DON stated that nurses are not allowed to borrow other residents' medications to administer on another resident. The DON stated that Nurse #1 was supposed to retrieve the Potassium Chloride ER Tablet 20 mEq from the emergency medications in the facility or call the pharmacy immediately she noted Resident #8 had run out of his medications. The DON revealed that nurses are required to observe the residents taking their medications before leaving the room. In an interview with the Administrator on 6/2/26 at 2:12 PM she revealed that the facility has back up emergency medications in the facility for nurses to use in the event a resident runs out of their medications.

Based on observation, record review, resident and staff interviews, the facility failed to assess a resident's ability to keep a rescue albuterol inhaler (a medication used to rapidly open airways and relief breathing difficulties) at bedside for self-administration for 1 of 2 residents reviewed for self-administration of medications (Resident #25). The findings included:Resident # 25 was admitted to the facility 4/2/26 with diagnoses that included chronic obstructive pulmonary disease (COPD) (a progressive lung disease that blocks airflow and makes it difficult to breathe) and dependence on supplemental oxygen.The admission Minimum Data Set (MDS) dated [DATE] revealed Resident # 25 was cognitively intact. Resident #25 was readmitted to the facility on [DATE]. A physician's order dated 5/28/26 revealed an order ProAir (Albuterol Sulfate) HFA Aerosol Solution - one (1) inhalation orally every 4 hours as needed for shortness of breath. An observation was conducted of Resident #25 on 6/1/2026 at 9:18 AM. Resident #25 was lying in the bed with the head of bed elevated. An albuterol sulfate inhaler was observed in the box of tissues sitting on the resident's bedside table.Resident #25's care plan dated 4/4/26 did not include any goals or interventions for self-administering medications.Review of Resident #25's medical record did not show an assessment for self-administration of medications.During an interview and observation with Resident #25 on 6/1/26 at 12:30 PM, the albuterol inhaler was sitting in a box of tissues box that was on the bedside table. Resident #25 stated he has always kept the rescue inhaler with him for shortness of breath (SOB). Resident #25 stated he had been keeping the rescue inhaler at the bedside since he was admitted to the facility back in April of 2026. Resident #25 stated the rescue inhaler was his personal inhaler from home. He denied that he had informed the staff that he had the inhaler. Resident #25 verbalized that he was to use the inhaler every 4 hours as needed for SOB. Nurse #2 was interviewed on 06/01/2026 12:49 PM and she confirmed she was assigned to Resident #25 on 6/1/26 during the 7:00 AM to 3:00 PM shift. Nurse #2 discussed she was not sure what the process was for a resident to self-administer medication because she had been working at the facility for short period of time. Nurse #2 stated she did not know that Resident #25 had the inhaler at his bedside. Nurse #2 stated she had administered Resident #25's morning medications and did not see an inhaler in the box of tissues on the bedside table. Nurse #2 stated if she saw any medication left in a resident's room, she would remove it immediately.During an interview with the Director of Nursing (DON) on 6/3/26 at 4:10pm, the DON stated she was not aware Resident #25 had the inhaler at bedside. She explained if a resident wanted to self-administer their medication, the facility would need to do an assessment to ensure the resident was safe to self-administer their medication. The DON stated once a resident was able to self-administer their medication the resident would have a plan of care to self-administer their medication. She explained Resident #25 had the potential to self-administer his own medication due to the resident's cognition. The DON stated if a nurse saw medication at a resident's bedside, she would expect that the nurse would remove the medication. The DON further stated she expected a conversation to be held with the resident about self-administering, an assessment to be completed, and an order obtained. The Administrator was interviewed on 6/3/26 at 4:12 pm. The Administrator stated she was not sure if there were any residents in the facility who self-administered their own medication. She explained if a resident wanted to self-administer their medication, the nurse would need to complete an evaluation. The Administrator stated if a nurse saw medication at a resident's bedside, she expected the nurse to remove the medication and then an evaluation completed to see if the resident was safe to self-administer.

Based on record review and interviews with staff, the facility failed to ensure the medical record was complete regarding documentation of wound care for 1 of 3 residents reviewed for pressure ulcers (Resident # 17).The findings included:Resident #17 was admitted to the facility on [DATE] with diagnoses that included Stage IV pressure ulcer of the sacral region.A physician's order initiated 4/23/2026 revealed an order for Sodium Hypochlorite External Solution 0.25 % (Dakins Solution). Apply to sacrum topically every day shift for wound care. Cleanse with Dakins. Apply Dakins wet to moist dressing. Apply dry dressing. Apply to sacrum topically as needed for wound care. Change dressing if soiled, or dressing comes off.Review of Resident #17's Treatment Administration Record (TAR) revealed in May 2026, nurse initials were missing for the dressing change for the sacral pressure ulcer on 5/10/26, 5/18/26, 5/23/26, and 5/28/26. An interview was conducted with Nurse #1 on 6/3/26 at 2:48 PM. Nurse #1 confirmed she had worked with Resident #17 on 5/10/26 and 5/23/26 during the 7:00 AM to 3:00 PM shift. Nurse #3 stated she completed the dressing change for Resident #17 both days. Nurse #3 stated she was not sure why she did not document the dressing changes since she usually documented the treatment as soon as the dressing was complete.Nurse #4 who worked with Resident #17 on 5/18/26 and did not document completion of the treatment was not available by phone for interview. A telephone interview was conducted with Nurse #3 on 6/3/26 at 2:45 PM. Nurse #3 confirmed she had worked with Resident #17 on 5/28/26 during the 7:00 AM to 3:00 PM shift. Nurse #3 stated she completed the dressing change for Resident #17 on 5/28/26. Nurse #3 further stated the laptop she was using to document her treatments cutoff before she had an opportunity to chart so she plugged the laptop in for it to charge. Nurse #2 reported she did not realize she had not gone back and documented the dressing change.An interview was conducted with the Director of Nursing (DON) on 6/3/26 at 4:18 PM. The DON stated she expected the nurses would have completed dressing change documentation as soon as the dressing was completed. An interview with the Administrator on 6/3/26 at 4:19 PM revealed she expected staff to complete wound care documentation as soon as they completed the dressing change or treatment.

Based on record review, and staff and resident interviews, the facility failed to provide resolution of Resident Council Meeting grievances for 4 of 11 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding a wider variety of drink options and clothes/items not coming back from laundry (7/24/24, 8/28/24, 9/23/24, and 10/29/24). The findings included: a. On 7/24/24 the Resident Council Meeting Minutes noted a dietary concern that there were not enough beverage options. A housekeeping concern was also discussed about clothes/items not being returned from laundry. The follow-up/intervention section of the form was blank. b. On 8/28/24 the Resident Council Meeting Minutes noted a housekeeping concern was discussed about clothes/items not being returned from laundry. Previous concerns from the July 2024 Resident Council Meeting were not discussed, and the follow-up/intervention section of the form was blank. c. On 9/23/24 the Resident Council Meeting Minutes noted a housekeeping concern that clothes were not being returned from laundry, and a dietary concern that there were not enough beverage options. Previous concerns from the August 2024 Resident Council Meeting were not discussed, and the follow-up/intervention section of the form was blank. d. On 10/29/24 the Resident Council Meeting Minutes noted a housekeeping concern that clothes were not being returned from laundry, and a dietary concern that there were not enough beverage options. Previous concerns from the September 2024 Resident Council Meeting were not discussed, and the follow-up/intervention section of the form was blank. Interviews conducted with Resident #3, Resident #29, Resident #32, Resident #43, Resident #57, and Resident #68 during the Resident Council Meeting on 3/4/25 at 10:29 AM revealed no resolution with the ongoing concerns of not enough beverage options at meals and clothes/items not being returned from the laundry. The residents indicated the housekeeping issue of clothes/items not being returned was still a concern. The Activities Director (AD) was interviewed on 3/05/25 at 11:27 AM. She stated that from July through September 2024, she and the Social Worker (SW) held Resident Council Meetings together. Every complaint from Resident Council was communicated with a grievance. If a concern was raised by one of the residents from July through September 2024, the SW wrote a grievance for follow-up. She could not say why the issues in the 10/29/24 Resident Council Meeting were not addressed. During an interview with the SW on 3/05/25 at 2:36 PM, she confirmed that she assisted the AD with Resident Council Meetings from July through September 2024. The issues during the July Resident Council Meeting should have been communicated via the grievance form. The SW indicated that the issues from the 7/24/24 and 8/28/24 meetings were not addressed, and she could not provide a reason why. During the September 2024 Resident Council meeting, the SW stated that the nursing issues were not addressed or communicated for an unknown reason. An interview was conducted with the Administrator on 3/06/25 at 12:52 PM. She indicated that all complaints from Resident Council should be followed by a grievance, which then was distributed to the appropriate department head and responded to in a timely manner.

Based on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 2 of 181 days reviewed for staffing (9/15/24 (Sunday) and 12/07/24 (Saturday). The findings included: A review of the Payroll Based Journal (PBJ) staffing data report for the first quarter of 2024 (October, November, and December) reported excessively low weekend staffing. Review of the facility's daily staff posting and staffing schedules from 9/01/24 through 2/28/25. revealed the following: a. On 9/15/24 the daily staff posting indicated a daily census of 69 on all three shifts. Review of the staffing schedule revealed there was no RN working on any shift that day. b. On 12/07/24 the daily staff posting indicated a daily census of 82 on all three shifts. Review of the staffing schedule revealed there was no RN working on any shift that day. In an interview on 3/06/25 at 11:57 AM the Director of Nursing (DON) indicated that if there was a hole in the staff schedule, they would call other staff in to fill the position. The DON reported 9/15/24 was a Sunday and 12/07/24 was a Saturday and the Minimum Data Set (MDS) nurse, who was an RN, would come in and fill the open position. She indicated she would look for timecard evidence of RN coverage for 9/15/24 and 12/07/24. In an interview on 3/06/25 at 1:58 PM the Administrator revealed she had looked for timecards to support RN coverage and there was no documentation for RN coverage for 8 consecutive hours in the facility on 9/15/24 or 12/07/24.

Based on observation, record review, and Responsible Party (RP), staff and Nurse Practitioner interviews, the facility failed to provide foot care as ordered for 1of 1 resident reviewed for foot care (Resident #17). The findings included: Resident #17 was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease and dementia. Review of physician orders for Resident #17 dated 8/24/24 revealed that the application of lotion to both feet for 90 days due to dry skin was ordered. A review of Resident #17's August 2024 through current, 3/3/25 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed no documentation for the application of lotion to Resident #17's feet. Resident #17's care plan last revised on 10/8/24 indicated that she had episodes of refusing to see the podiatrist with risk for complications. Interventions included: Allow the resident to have a choice in her care as much as possible, consult with the physician regarding refusal of care to determine if changes in prescribed care may be appropriate, encourage and allow the resident to remain in as much control over her own care as possible, explain procedures and care to the resident before care is performed, if she refuses do not argue and return at a later time to attempt again. Lastly, report all refusals of care to the nurse and document each episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required substantial/maximal assistance with bathing/personal hygiene. She was not coded for rejection of care behavior. Review of a health status note dated 1/30/25 at 12:12 PM and completed by Nurse #1 revealed Resident #17 was out of the facility at a doctor's appointment with her RP. Review of a Podiatry visit summary dated 1/30/25 revealed Resident #17's skin findings were severe dry/peeling/flaky skin to both feet. There was evidence of poor pedal hygiene with dry, crusty skin between 1-4 interspaces of both feet. The crusty, dead skin was removed between the toes with dry gauze. It was recommended nursing staff apply over the counter lotion twice daily to Resident #17's feet for 90 days due to dry skin. Follow-up appointment in 3 months. The RP was interviewed via telephone on 3/03/25 at 1:48 PM. He revealed that Resident #17's feet have been an issue since her admission. He stated the application of lotion to her feet would provide moisture, especially in between her toes, to prevent further dryness, crusty, and aide in dead skin removal. An observation of Resident #17's feet was done in conjunction with an interview with Nurse #1 on 3/05/25 at 9:50 AM. Nurse #1 took off the left sock first and the foot appeared extremely dry with excess dry skin that fell on to the bed sheet. The left sock was then replaced. The right sock was then removed and appeared drier than the left foot as evidenced by more flaking skin and cracks observed on the skin of the foot. Excessively dried and dead skin fell from her foot and remained on the bed sheet. Nurse #1 stated she was not sure if there was an order for lotion to be applied to Resident #17's feet. She further stated Resident #17 sometimes refused for her socks to be taken off or to receive care related to her feet. The resident was not observed to be resistant to having her socks removed at the time of the observation. The Nurse Practitioner (NP) was interviewed on 3/05/25 at 9:59 AM. She stated she had just assessed Resident #17's feet, and they appeared to be extremely dry with excessive skin that fell from the feet when the socks were removed. The NP indicated she could not say if lotion had been applied to Resident #17's feet regularly. She stated if lotion was applied, and then her socks were replaced, the lotion would most likely rub off. During a follow-up interview with Nurse #1 on 3/05/25 at 10:06 AM, she stated that there was not a current order to apply lotion twice daily to Resident #17's feet. Nurse #1 indicated that she was unaware of the podiatry appointment on 1/30/25 or the recommendations that resulted from that visit to apply lotion twice daily to Resident #17's feet. Nurse Aide (NA) #1 was interviewed on 3/05/25 at 10:05 AM. She stated application of lotion to Resident #17's feet was not included in the care plan; however, she normally applied lotion to Resident #17's feet when she gave the resident a bed bath. NA #1 stated she was a part-time employee, and the last time she applied lotion to Resident #17's feet was 6 days ago. She stated Resident #17 often refused care (including a bath), and it was normally a hit or miss when it came to refusal of bathing. During a follow-up interview with NA #1 on 3/05/25 at 10:07 AM, she stated Resident #17 refused a bed bath that morning. Resident #17 told NA #1 she would get sick if water touched her. NA #1 stated she was going to ask if Resident #17 would allow lotion to be applied to her feet. The NA returned at 10:10 AM, and she stated that Resident #17 accepted for lotion to be applied to her feet. The Director of Nursing (DON) was interviewed on 3/05/25 at 3:01 PM. She revealed after a resident returns from an outside appointment, the paperwork for the facility should be given to the nurse on duty, who would need to take note of recommendations or instructions and follow through as needed. The DON indicated Resident #17's feet needed more attention when she observed them today. Resident #17 often refused care, and with that, there may be times where she seemed to comply, but the entire task was not always fulfilled. Applying lotion should be a daily routine/task as well as needed. The DON stated the application of lotion should not need to be entered as an order, even though it could not be monitored without an order. The application of lotion twice daily to her feet should have been included in the care plan and activities of daily living (ADL) activity for nurse aides. During an interview with the Administrator on 3/06/25 at 12:31 PM, she revealed all outside consultations should be reviewed by the nurse on duty. If a summary did not come back with the resident, the nurse on duty should call the appropriate doctor's office. All residents assisted with personal hygiene and bathing should have lotion applied on every shift and as needed. The information from the 1/30/25 podiatry appointment should have been communicated to nursing, and lotion should have been administered to Resident #17's feet twice daily as recommended.

Based on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills by failing to clean the convection oven during two kitchen observations. This practice had the potential to affect food served to the residents who resided in the facility. The findings included: During a kitchen tour on 03/03/25 at 10:27 AM, the following observations were made with the Dietary Manager: The convection oven had a large volume of grease buildup inside of the oven, inside the door and on the seals. The grease buildup was encrusted on doors and on shelves where food would be cooked. A second observation of the convection oven on 3/06/25 at 11:03 AM revealed a large volume of grease buildup inside of the oven, on the door and gasket seals. The grease buildup was encrusted on doors and on shelves where food would be cooked. In an interview on 3/06/25 the Certified Dietary Manager revealed they cleaned the convection oven once a month and it was last cleaned on 2/06/25. In an interview on 3/06/25 at 11:06 AM [NAME] #1 stated they cleaned the convection oven once a month and the charred food was apples that spilled over two weeks ago. In an interview on 3/06/25 at 11:25 AM the Administrator stated they would clean the convection oven and create a cleaning schedule.

Based on observation, record review, and resident and staff interviews, the facility failed to assess a resident for self-administration of medication for 1 of 5 residents reviewed for medication administration (Resident #57). The findings included: Resident #57 was admitted to the facility on [DATE]. The resident's care plan dated 7/29/24 did not include self-administration of medication. There was not an assessment of Resident #57 in the medical record to determine if it was safe for the resident to self-administer medications. Review of the quarterly Minimum Data Set (MDS) 1/7/25 revealed Resident #57 was cognitively intact. On 03/04/25 at 09:19 AM Resident #57 was observed in the bed with two cups containing medication on the table at the bedside. One cup had multiple pills, and the second cup contained powder. Resident #57 stated she had asked the staff to place the medications on the bedside table because she was in the middle of eating when she brought in the medication. Resident #57 stated she had forgotten to take her medication. Resident #57 stated the staff usually left her medicines at the bedside and she would go ahead and take it. Resident #57 stated powdered substance in the second cup on the bedside table was a medicated powder she placed beneath her breast when she was ready. An interview was conducted with Medication Aide (MA) #1 on 03/04/25 at 09:23 AM. MA# 1 stated she left the medications on the bedside tablet and told Resident #57 she would be right back. MA #1 stated she normally stood at the bedside and watched the residents take their medication. MA #1 stated she forgot to go back to Resident #57's room. MA #1 stated Resident #57 did not self administer her medication. An interview was conducted with the Director of Nursing on 03/04/25 at 09:25 AM. The DON stated medication should have been administered to the residents immediately. If the resident refused the medication, it should have been removed and the DON notified. The DON stated Resident #57 had not been assessed for self administration of medication. The DON further stated that all treatments should be completed by the nursing staff and not residents. An interview was conducted with the Administrator on 3/6/25 at 9:30 AM. The Administrator stated she expected that staff would make sure all medications were taken prior to leaving the resident. The Administrator further stated she expected all treatments to be completed by staff before leaving the resident room.

Based on observations, record reviews and interviews, the facility failed to maintain Resident #14's dignity by failing to remove a urinal from the overbed table while the resident's meal was in front of him (Resident #14). The facility also failed to promote resident independence and dignity when staff stood over Resident #35 while assisting him to eat. These deficient practices occurred for 2 of the 2 residents reviewed for dignity and respect. The findings included: 1. Resident #14 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the Resident #14 had severe cognitive impairment. He was able to feed himself with set up help and was totally dependent on staff for toilet use. An observation was conducted on 3/3/25 at 12:47 PM. Resident #14 was observed eating his meal with a urinal containing urine sitting on the overbed table with his meal. An interview was conducted on 3/3/25 at 12:30 PM with Nurse Aide #5. NA #5 stated she was unsure of who had placed the meal tray on the residents overbed table. An observation was conducted with the Support Nurse on 3/6/25 at 12:03 PM. Resident #14 was observed eating his meal with a urinal sitting on the overbed table with his meal. The Support Nurse removed the urinal with Resident #35's permission. An interview conducted with Resident #14 on 3/6/25 at 12:15 PM revealed he preferred to have his urinal within reach but not on the overbed table with his meal. An interview was conducted with the Director of Nursing (DON) on 3/6/25 at 2:38 PM. The DON stated she had completed education on 3/3/25 with all floor staff regarding making sure urinals were not sitting on the bedside tables while residents were eating. The DON stated the urinal should have been emptied and placed away from the table. An interview was conducted with the Administrator on 3/6/25 at 2:40 PM. The Administrator stated she expected staff to remove urinals from the overbed table while residents were eating their meal. 2. Resident #35 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact and required limited assistance plus one-person physical assistance for eating. An observation was conducted on 3/3/25 at 12:45 PM. Resident #35 was lying on the bed with the head of bed elevated. Nurse Aide (NA) #5 was seen standing while feeding Resident #35. There was a chair in the room at the bedside. The MDS Coordinator was observed to go in the room to speak to NA #5 about standing while feeding Resident #35. An observation was conducted on 3/5/25 at 11:54 AM. Resident #35 was lying in the bed with the head of the bed elevated. NA #3 was seen standing while feeding resident. NA #3 was observed conversing with Resident #35. There was a chair in the room at the bedside. An interview was conducted with NA #3 on 3/6/25 at 11:56 AM. NA #3 stated she knew she was supposed to be sitting while feeding Resident #35, but she was having a conversation with the resident. An interview was conducted with the Director of Nursing (DON) on 3/6/25 at 2:38 PM. The DON stated the NA should have been seated and at eye level while assisting Resident #35 with his meal. An interview was conducted with the Administrator on 3/6/25 at 2:40 PM. The Administrator stated she expected that staff would be seated when assisting residents that required assistance with eating their meal.

Based on record review, and resident and staff interviews, the facility failed to provide a written grievance summary for 2 of 6 grievances (9/23/24, 1/29/25) on behalf of Resident Council and 1 of 1 resident (Resident #57) reviewed for grievances. The findings included: Review of the facility's Grievance Policy and Procedure effective February 2025 read in part: As soon as possible after the filing of a grievance report, the Grievance Officer or designee will interview the grievant, interview appropriate other parties, examine relevant records and take any other action which will enable a full understanding of the issue. The inquiry, disposition and decision will be completed within seven (7) days of receipt of grievance .A written response to the grievance will be required within 14 calendar days of the grievance being filed that should include the results of the investigation. 1a. Review of the Grievance Report Form dated 9/23/24 indicated a concern that was reported by the Social Worker (SW) on behalf of Resident Council regarding housekeeping not mopping daily. The facility response was that someone spoke to housekeeping staff about mopping rooms daily after the nursing staff removed dirty linen from the floors. There was no evidence a written summary was provided to Resident Council members. The SW was interviewed on 3/05/25 at 2:36 PM. She indicated that the grievance about the daily mopping issue on 9/23/24 should have been addressed by the appropriate department head, and then she would follow up with the complainant and offer a written copy of the findings. The SW could not give a reason why a written summary of the grievance was not provided to Resident Council members. 1b. Review of the Grievance Report Form dated 1/29/25 indicated a concern that was reported by the Activity Director (AD) on behalf of Resident Council regarding missing socks, 2 sinks that were broken, and a clogged toilet. The facility response was that the missing socks were found, the sinks and toilet were repaired. There was no evidence a written summary was provided to Resident Council members. Additionally, a Grievance Report Form dated 1/29/25 indicated a concern that was reported by the AD on behalf of Resident Council regarding first and third shift nurse aides not responding to call lights, nursing staff not announcing themselves upon entry to resident rooms, medicine not given on second or third shift, snacks not given at night, and meals delivered cold. The facility response was that snacks were given on first and second shifts for residents who requested them, nursing staff were educated on customer service/communication/resident rights/abuse, nurses were reminded that they can assist with call lights, and residents should be asked about pain and medications should be given. There was no evidence a written summary was provided to Resident Council members. An interview was conducted with the AD on 3/04/25 at 12:40 PM. She stated that she submitted grievances from Resident Council Meetings in January and February 2025 to the Director of Nursing (DON) and the Assistant DON (ADON). The DON was interviewed on 3/05/25 at 2:51 PM. She stated that she was not informed of the grievance policy or the 7-day grievance resolution requirement until February 2025 during a mock survey. The DON indicated that for the January 2025 grievances filed by Resident Council, she did not provide a written response within 14 days, only had a verbal discussion with the residents. The DON acknowledged that according to the grievance policy, a written response should have been offered for all grievances within 14 days of when it was filed. During an interview with the Administrator on 3/06/25 at 12:52 PM, she stated that all grievances from Resident Council should have been addressed and offered a written response in a timely manner. 2. Resident #57 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #57 was assessed as cognitively intact. Review of the Grievance Report Form dated 2/7/25 indicated a concern that was reported by the Activities Director (AD) on behalf of Resident #57 regarding a nurse aide who refused to change/assist with changing a resident on third shift. This was the second occurrence with the same nurse aide, and care from this nurse aide was no longer wanted by Resident #57. The facility response was that when Resident #57 was interviewed, she could not recall which nurse aide was the accused. The nursing team was educated on abuse and customer service. There was no evidence a written summary was provided to Resident #57. The DON was interviewed on 3/05/25 at 2:51 PM. She stated that she was not informed of the grievance policy or the 7-day grievance resolution requirement until February 2025 during a mock survey. The 2/7/25 grievance involving Resident #57 was handled by the Assistant Director of Nursing (ADON), who was involved in many tasks at the same time the grievance was filed. The DON acknowledged that according to the grievance policy, a written response should have been offered to Resident #57 within 14 days of when it was filed. The ADON was unavailable for interview during the survey. During an interview with the Administrator on 3/06/25 at 12:52 PM, she stated that the grievance from Resident #57 should have been addressed and offered a written response in a timely manner.

Based on record review, resident, staff, and Medical Director Interview, the facility failed to prevent a significant medication error by not following physicians order and failing to administer Aripiprazole (an antipsychotic medication used to treat schizophrenia and Letrozole (an antineoplastic medication used to treat breast cancer) for 1 of 3 residents (Resident #2) reviewed for significant medication error. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the left breast and bipolar schizoaffective disorder. Review of Resident #2 ' s most recent quarterly Minimum Data Set (MDS) 6/6/24 revealed the resident was cognitively intact. The MDS also revealed the resident had received antipsychotics for 7 days of the lookback period. Review of Resident #2 ' s care plan dated 12/15/23 revealed the resident had a care plan for receiving antipsychotic medication related to her diagnosis of Schizophrenia. The interventions included in part administer medication as ordered by the physician. Review of the care plan also revealed a focus area of diagnosis of left breast cancer. The interventions included give medications as ordered. a. Review of a physician ' s order dated 2/22/23 revealed Resident #2 was to receive Aripiprazole 5 MG (milligram): Give 1 tablet by mouth one time a day for schizophrenia at 9:00 AM. An interview with Resident #2 on 8/27/24 at 2:36 PM revealed she had missed some medication for two days in July and two days in August due to the medication being out. Resident #2 stated she was concerned about missing this medication because it was important she take it daily. Review of Resident #2 ' s electronic Medication Administration Record (MAR) for July 2024 and August 2024 revealed she had not received Aripiprazole as ordered on the following dates: On 7/20/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 7/20/24 written by Nurse #1 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. An interview was conducted with Nurse #1 on 8/28/24 at 9:13 AM. Nurse #1 stated she had not received education on the process for missing medications. The nurse stated she had attempted to order the medication from the pharmacy and was made aware that the medication would be arriving that evening in the pharmacy delivery. On 7/21/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 7/21/24 written by Nurse #2 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. Multiple attempts to reach Nurse #2 were unsuccessful. On 8/12/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 8/12/24 written by Nurse #3 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. An interview was conducted with Nurse #3 on 8/27/24 at 3:13 PM. Nurse #3 stated she was able to reorder a medication through the electronic MAR. The nurse stated she did not follow up with the pharmacy to see when the medication would arrive. Nurse #3 stated she had not been made aware of the use of a backup pharmacy. On 8/13/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 8/13/24 written by Nurse #4 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. Multiple attempts to reach Nurse #4 were unsuccessful. During an interview with the Medical Director on 8/27/24 at 4:18 PM, she stated there were no side effects if the resident missed doses of the medication Aripiprazole. b. Review of a physician ' s order dated 2/22/23 revealed Resident #2 was to receive Letrozole 2.5 MG (milligram) -Give 1 tablet by mouth one time a day for Breast Cancer at 9:00 AM. Review of Resident #2 ' s electronic Medication Administration Record (MAR) for August 2024 revealed she had not received Letrozole as ordered on the following date: On 8/12/24 at 9:00 AM, the MAR showed no dose of Letrozole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 8/12/24 written by Nurse #3 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. An interview was conducted with Nurse #3 on 8/27/24 at 3:13 PM. Nurse #3 stated she was able to reorder a medication through the electronic MAR. The nurse stated she did not follow up with the pharmacy to see when the medication would arrive. Nurse #3 stated she had not been made aware of the use of a backup pharmacy and she did not report the missing medication to the charge nurse or Director of Nursing. During an interview with the Medical Director on 8/27/24 at 4:18 PM, she stated there were no side effects if the resident missed doses of the medication Letrozole. During an interview with the Director of Nursing on 8/27/24 at 3:40 PM. The DON stated she expected that the nurse assigned to a resident with missing medications would notify the charge nurse and DON. The DON explained the pharmacy should have been notified and the missing medication picked up from the backup pharmacy until the medication refill could be received at the facility.

Based on record review, resident, staff, Pharmacist and Medical Director Interview, the facility failed to ensure medication was available as ordered for 1 of 3 residents reviewed for administration of medication to meet needs of the resident. (Resident #2) The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the left breast and bipolar schizoaffective disorder. a.Review of a physician ' s order dated 2/22/23 revealed Resident #2 was to receive Aripiprazole 5 MG (milligram): Give 1 tablet by mouth one time a day for schizophrenia. Review of Resident #2 ' s electronic Medication Administration Record (MAR) for July 2024 revealed she had not received Aripiprazole as ordered on the following dates: On 7/20/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 7/20/24 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. The note did not indicate the pharmacy or Director of Nursing was notified. An interview was conducted with Nurse #1 on 8/28/24 at 9:13 AM. Nurse #1 stated she had not received education on the process for missing medications. The nurse stated she had attempted to order the medication from the pharmacy and was made aware that the medication would be arriving that evening in the pharmacy delivery. Nurse #1 stated she did not notify the charge nurse or Director of Nursing that Resident #2 did not have the medication. On 7/21/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 7/21/24 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. The note did not indicate the pharmacy or Director of Nursing was notified. Multiple attempts to reach Nurse #2 were unsuccessful. Review of Resident #2 ' s electronic Medication Administration Record (MAR) for August 2024 revealed she had not received Aripiprazole as ordered on the following dates: On 8/12/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 8/12/24 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. The note did not indicate the pharmacy or Director of Nursing was notified. An interview was conducted with Nurse #3 on 8/27/24 at 3:13 PM. Nurse #3 stated she was able to reorder a medication through the electronic MAR. The nurse stated she did not follow up with the pharmacy to see when the medication would arrive. Nurse #3 stated she had not been made aware of the use of a backup pharmacy and she did not report the missing medication to the charge nurse or Director of Nursing. On 8/13/24 at 9:00 AM, the MAR showed no dose of Aripiprazole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 8/13/24 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. The note did not indicate the pharmacy or Director of Nursing was notified. Multiple attempts to reach Nurse #4 were unsuccessful. An interview was conducted with the Pharmacist on 8/27/24 at 4:14 PM. The Pharmacist stated the first medication request for Aripiprazole for Resident # 2 was entered into the electronic system on 7/19/24. A second request for Aripiprazole was entered on 7/22/24. The Pharmacist stated there was no documentation in the system stating anyone from the facility had called about the medication not being available. The Pharmacist reported that a 30-day supply of Aripiprazole was sent to the facility on [DATE]. Further interview with Pharmacist revealed there was a local backup pharmacy to aid in the administration of resident ' s medications. During an interview with the Medical Director on 8/27/24 at 4:18 PM, she stated there were no side effects if the resident missed doses of the medication Aripiprazole. b. Review of a physician ' s order dated 2/22/23 revealed Resident #2 was to receive Letrozole 2.5 MG (milligram) -Give 1 tablet by mouth one time a day for Breast CA. Review of Resident #2 ' s electronic Medication Administration Record (MAR) for August 2024 revealed she had not received Letrozole as ordered on the following date: On 8/12/24 at 9:00 AM, the MAR showed no dose of Letrozole was administered. A chart code of 9 was documented on the MAR to indicate other/see nurses notes. A nurses note dated 8/12/24 revealed Resident #2 did not receive her Aripiprazole due to medication being on order. An interview was conducted with the Pharmacist on 8/27/24 at 4:14 PM. The Pharmacist stated the medication request for Letrozole for Resident # 2 was entered into the electronic system on 8/12/24. The Pharmacist stated the request was filed too soon to be filled. The Pharmacist stated there was no other documentation of request for the medication. The Pharmacist reported that a 30-day supply of Letrozole was sent to the facility on [DATE]. Further interview with Pharmacist revealed there was a local backup pharmacy to aid in the administration of resident ' s medications. During an interview with the Medical Director on 8/27/24 at 4:18 PM, she stated there were no side effects if the resident missed doses of the medication Letrozole. During an interview with the Director of Nursing on 8/27/24 at 3:40 PM. The DON stated she expected that the nurse assigned to a resident with missing medications would notify the charge nurse and DON. The DON explained the pharmacy should have been notified and the missing medication picked up from the backup pharmacy until the medication refill could be received at the facilit

Based on observations, record review, staff and resident interviews, pest control technician interviews, and Nurse Practitioner interviews, the facility failed to maintain an effective pest control program to protect vulnerable residents from ants. On 6/23/24 Resident #1 was observed in bed with small black ants all over the floor, bedside table, bed linens, her gown, inside her incontinence brief, and on her body. Resident #1 complained of itching everywhere and had numerous small, reddened areas spread across the back and sides of her body. On 6/26/24 Resident #2 was observed in bed with small black ants all over the floor, furniture, bed linens, and clothing of Resident #2. Fire ants inject venom when they bite that causes a burning sensation and can cause localized sterile blisters, whole body allergic reactions such as anaphylactic shock, and, occasionally, death. Individual ants can bite and sting several times and because large numbers of ants are often together, incidents usually involve multiple stings. High numbers of stings can lead to severe medical reactions even in people with normal immune systems. The elderly and immobile individuals are at a higher risk of multiple stinging incidents. A reasonable person would experience serious adverse psychosocial outcomes that would include feeling helpless, intense anxiety, humiliation, and panic during the incident and fear of recurrence after the incident from being covered with ants on their body and clothing while in bed and being unable to leave the bed without assistance. This deficient practice was for 2 of 3 residents reviewed for pest control (Resident #1 and Resident #2). Immediate jeopardy began on 6/23/24 when the facility failed to maintain an effective pest control program. The immediate jeopardy was removed on 7/10/24 when the facility 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 education is completed and monitoring systems put in place are effective. The findings included: Review of fire ant information titled Medical Problems and Treatment Considerations for the Red Imported Fire Ant, which was provided by the Entomological (scientific study of insects) Program Manager with the North Carolina Department of Agriculture and Consumer Services and the State Public Health Entomologist (a scientist who studies insects and related animals) with the North Carolina Division of Public Health, Communicable Disease Branch revealed the following: When a fire ant bites it injects venom that can cause localized sterile blisters, whole body allergic reactions such as anaphylactic shock, and, occasionally, death. The intense burning sensation that occurs from the injected venom accounts for the popular name of fire ant. Individual worker ants can bite and sting several times and the site of the sting hurts for a few minutes and then reddens. The bite will then swell into a bump or hive within 20 minutes and within several hours to a day after being stung, most people will develop a white fluid-filled sterile pustule (small, inflamed, pus-filled sores that look like blisters) which are a characteristic of the fire ant sting. Because large numbers of worker ants are often together stinging incidents usually involve multiple stings and the ants can crawl rapidly (1.6 centimeters per second) and within seconds, they begin stinging almost simultaneously. People vary greatly in their sensitivity to fire ant stings with some people being hypersensitive to it may have other medical conditions (such as a heart condition or diabetes) that can result in serious medical problems or even death from a single sting. High numbers of stings can lead to severe medical reactions even in people with normal immune systems. The elderly, infants, neurologically compromised people, and otherwise immobile or unaware individuals are at a higher risk of multiple stinging incidents and should be supervised carefully. The information further stated fire ant workers can easily enter structures through even tiny cracks and crevices. Occasionally, entire colonies will migrate into structures and nest in wall voids or other locations. This is particularly common when outdoor conditions become very hot and dry or when flooding occurs in the immediate landscape. Review of the facility's pest control logs revealed the facility had a contract which was dated 6/23/22 for monthly inspection of all exterior and interior areas of the facility for pest activity and emergency calls were available 24 hours a day 7 days a week. The pest control log with a service date of 6/17/24 revealed that all interior and exterior areas were inspected and serviced by Pest Control Technician #1 with no ant activity noted in the report. An observation of the 400 Hall was conducted on 7/09/24 at 10:05 am which revealed Resident #1's and Resident #2's rooms were located on the same side of the hall (400 Hall) and were the immediate next door to each other on the hall. a. Resident #1 was admitted to the facility on [DATE] and resided on the 400 Hall on the side of the hall located on the back exterior of the facility. The weekly skin assessment completed on 6/18/24 revealed Resident #1 had no skin issues noted. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment, adequate vision without corrective lenses, and required staff assistance to get out of bed during the 7-day lookback period. The nursing progress note dated 6/23/24 at 6:25 am by Nurse #1 revealed there was an ant infestation in Resident #1's bed and room. Resident #1 was observed to have several small, reddened areas on the skin across the back and sides of the body and Resident #1 reported itching all over. Resident #1 was observed by Nurse #1 to be scratching the skin a lot. The nursing progress note further noted Resident #1 was moved to a new room and the provider was notified. A telephone interview was conducted on 7/09/24 at 11:32 am with Nurse #1 who revealed she had entered Resident #1's room during rounds and found Resident #1 to be covered in ants. Nurse #1 stated she was unable to say exactly how many ants were on Resident #1 but stated there were a lot of ants and that they were everywhere. Nurse #1 stated the ants were small, black ants and they were on the bed linens, the floor, tables, and on Resident #1's body including inside the incontinence brief. She stated Resident #1 was removed from the bed by staff because she was not able to get out of bed by herself. Nurse #1 stated Resident #1's gown was removed, her skin was wiped with the personal care wipes, and her body and scalp were checked to make sure there were no more ants. Nurse #1 stated they attempted to move Resident #1 to the empty room on the same side of the hall, which was along the back of the building, but she stated when they checked the room the small black ants were in that room as well, so they moved Resident #1 across the hall. Nurse #1 reported that she completed a thorough skin assessment of Resident #1 and noted there were so many tiny red marks on the back, sides, and buttock area of the body and Resident #1 reported she was so itchy and was scratching herself all over. Nurse #1 stated she had never seen ants like this in the resident rooms prior but had reported that at times would see one or two ants here or there. Nurse #1 stated she notified the Administrator, Director of Nursing (DON), the on-call medical provider, and the Maintenance Supervisor of the ants. A physician order dated 6/23/24 for diphenhydramine 25 milligram (mg) tablet every 6 hours as needed for itching for 3 days. A physician order dated 6/23/24 for calamine lotion to apply to red areas topically every 8 hours as needed for red areas for 7 days. Review of the Maintenance Log dated 6/23/24 Nurse #1 noted ant infestation in Resident #1's room. The Nurse Practitioner (NP) progress note dated 6/24/24 revealed Resident #1 recently complained of itching everywhere, was noted to have numerous small, reddened areas spread across the back and sides. The NP progress note further stated Resident #1's room was noted to have an ant infestation and was moved to another room. The NP noted that Resident #1 did not report pruritis (itching) during the visit. A telephone interview was conducted on 7/09/24 at 3:45 pm with the NP who revealed she saw Resident #1 on 6/24/24 as a follow-up to the on-call provider notification of the ant infestation and reported itching. The NP reported that Resident #1 was unable to get out of bed without staff assistance based on her observations and knowledge of the resident. The NP stated Resident #1 was alert and oriented and had never reported itching prior to the ant infestation. She reported that based on the time frame of the ant infestation, Resident #1's noted reddened marks, and reported itching, the reddened marks and itching were due to the ant bites. An interview was conducted on 7/09/24 at 10:02 am with Resident #1 who was identified as alert and oriented by the Administrator, revealed that about two weeks ago, unable to recall exact date, she thought she saw ants on the floor and on the furniture in her room and told someone who came in and killed the ants. Resident #1 stated sometime later that night the nurse woke her and told her she had ants all over her and she needed to get out of the bed quickly. Resident #1 stated the staff got her out of bed and into her wheelchair then moved her to another room. Resident #1 stated she did see a lot of ants on her bed, the floor, and on the furniture when she got out of the bed. Resident #1 stated she could not tell that she was bitten but she stated the nurse told her she had bites from the ants. Resident #1 reported her body and arms were itchy for a few days from the bites. Resident #1 stated she had difficulty repositioning in the bed to get comfortable that night, but she was unable to get out of bed without help and she didn't realize the ants were in the bed or she would have called staff for help. Resident #1 stated she had not seen ants in her room prior to that night. A telephone interview was conducted on 7/09/24 at 2:37 pm with Nurse Aide (NA) #1 who revealed she was assigned to Resident #1 on 6/22/23 from 3:00 pm until 6/23/24 at 7:00 am. NA #1 stated Resident #1 had told her about the ants in her room during the 3:00 pm shift and she killed and cleaned up the ants. NA #1 stated she saw a few ants on the floor around some crumbs and did not see any more ants at that time, so she did not report the ants to anyone. NA #1 stated she provided incontinence care to Resident #1 throughout both of her shifts and did not observe ants in her room until she was called to the room by Nurse #1 in the morning. NA #1 reported when she entered Resident #1's room there were a lot of ants, not sure how many, just a lot of ants and they were all around the room. She stated they were small black ants and they were on Resident #1's body, bed, floor, and tables in Resident #1's room. NA #1 stated when they tried to find another room for Resident #1 to go to since her room had so many ants she stated the empty rooms on the same side of the hall, along the back of the building, also had ants in them so they moved Resident #1 across the hall. NA #1 stated Resident #1 required assistance to get out of bed. She indicated Resident #1 was able to turn a little bit in bed but needed help to fully turn in bed. NA #1 stated she had not seen that many ants before, but she stated she had seen small amounts of ants in the facility around food crumbs on the floor. A telephone interview was conducted on 7/10/24 at 9:44 am with Nurse #3 who revealed she was new to the facility and was on orientation with Nurse #1 on the morning of 6/23/24 when Resident #1's room was infested with ants. Nurse #3 stated she and Nurse #1 entered Resident #1's room in the morning for rounds and first noticed ants on top of the blanket but when the blanket was lifted, oh my goodness they were all over. Nurse #3 reported small black ants were all over the room, floor, tables, bed, and Resident #1. Nurse #3 stated they got Resident #1 out of the bed and cleaned her up to make sure no more ants were on her. She stated she did not do the actual skin assessment, so she was unable to state if any bites were present. Nurse #3 stated Resident #1 was alert and oriented and reported that her whole body itched, and she was scratching herself. Nurse #3 reported when they tried to move Resident #1 to another room on the same side of the hall, she saw ants in two empty rooms, so they had to move her across the hall. Nurse #3 stated there were just so many ants, that she felt itchy herself just seeing how many ants were on Resident #1. During an interview with the Maintenance Supervisor on 7/9/24 at 3:30 pm he revealed he was called by a Nurse from the facility about the ants in Resident #1's room on 6/23/24 and he came in the same day and sprayed the ant spray he had used at the facility in Resident #1's room and thoroughly cleaned and sanitized the room. The Maintenance Supervisor stated he did not see any other areas on the hall that Resident #1 was located on when he came in on 6/23/24, but he sprayed the entire hall as a precaution with the same spray. The Maintenance Supervisor stated he did not call for the Pest Control Company to come because he treated the room and did not observe any further ant activity in any other rooms on Hall 400. The Maintenance Supervisor stated the ants that were in Resident #1's room were small black ants. During an interview on 7/09/24 at 3:19 pm the Administrator revealed she did not recall being notified by Nurse #1, but she recalled the progress note about the ants and discussed it with the Maintenance Supervisor on 6/24/24. The Administrator stated Resident #1 was moved to a new room and the room was cleaned and sprayed. The Administrator stated she believed the Maintenance Supervisor called for the Pest Control Company to treat the facility, but she would have to speak to the Maintenance Supervisor to confirm. b. Resident #2 was admitted to the facility on [DATE] and resided on the 400 Hall on the side of the hall located on the back exterior of the facility. The care plan initiated on 6/07/24 revealed Resident #2 required extensive staff assistance to turn and reposition in bed and for transfers from bed to chair. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #2 was cognitively intact, had adequate vision without corrective lenses, and required staff assistance to get out of bed. The nursing progress note dated 6/26/24 at 6:01 am by Nurse #2 revealed Resident #2 was moved from her room due to an ant infestation. Nurse #2 noted that multiple ants were swept from Resident #2's room at the beginning of the shift but Resident #2 refused to change rooms. Nurse #2 further noted that by the end of the shift there were even more ants in the room and Resident #2 was moved to another room. Nurse #2 noted that Resident #2 did not have any areas of concern noted on the skin at this time. A telephone interview was conducted on 7/09/24 at 11:29 am with Nurse #2 who revealed she was notified by Nurse Aide (NA) #2 around 6:00 am on the morning of 6/26/24 that ants were all over Resident #2's room. She stated when she entered Resident #2's room she observed small black ants everywhere. She explained they were on the bed, floor, tables, sheets, bed pad, clothes, and few on the outside of the incontinence brief. She stated she brushed the ants from Resident #2's body with her hands. Nurse #2 stated the ants were all over everything and it was unsafe for Resident #2 to remain in the room. She stated Resident #2 did not want to change rooms, but she did agree at that time to move to another room since there were so many ants. Nurse #2 clarified that Nurse #5 had observed the ants, cleaned up the ants, and attempted to have Resident #2 change rooms prior to her shift and that was reported to her at shift change. Nurse #2 stated she had not observed ants in Resident #2's room during her shift until notified by NA #2 at approximately 6:00 am. She reported she completed a skin check of Resident #2 and did not observe any bites and Resident #2 did not report any complaints of itching. Nurse #2 stated she had seen a few ants in the facility in the past but never had seen that many ants before. An attempt to conduct a telephone interview with Nurse #5 on 7/10/24 at 11:28 am and 1:05 pm was unsuccessful. An attempt to conduct a telephone interview with NA #2 on 7/10/24 at 9:30 am was unsuccessful. An interview was conducted on 7/09/24 at 9:44 am with Resident #2 who revealed about one week ago her room was infested with small black ants, and she needed to change her room. Resident #2 stated she saw the black ants on her hands, gown, floor, and bed linens. Resident #2 stated she saw ants in her room earlier that day, but she didn't want to move to another room and the nurse had cleaned the ants up. Resident #2 stated she didn't think the ants would have been on the bed later, so once that happened she was okay being moved. Resident #2 stated the staff helped her get out of bed and they moved her to another room. Resident #2 stated she did not have any bites or itchiness from the ants being on her and she stated she had not seen ants in her room since that day. An interview was conducted on 7/09/24 at 1:56 with the Maintenance Supervisor who revealed he was notified of the ants in Resident #2's room on the morning of 6/26/24 and notified the Pest Control Company that an emergency visit was needed. He stated he sprayed Resident #2's room prior to the Pest Control Company's arrival and observed quite a few small black ants in the room around the baseboards and air conditioning unit. The Maintenance Supervisor reported the ants entered the facility from the outside normally around the air conditioning units, and he stated the ants were worse at this time of the year. The Maintenance Supervisor stated when the Pest Control Company arrived on 6/26/24 he was told that the small black ants in Resident #2's room were sweet ants the kind that were normally in homes and were attracted by food. Review of the pest control visit log dated 6/26/24 revealed a visit was conducted for ants. Pest Control Technician #2 observed dead ants in the resident care area reported for ants. Pest Control Technician #2 also reported live fire ant mounds on the exterior building perimeter were identified, and they were treated at that time. A telephone interview was conducted on 7/09/24 at 3:00 pm with Pest Control Technician #2 who reported he was notified on 6/26/24 that two resident rooms were reported to have ants prior to his arrival. He stated he did not see any live ants in the two resident rooms, but it was reported that the Maintenance Supervisor had sprayed the ants prior to his arrival. Pest Control Technician #2 stated that he believed the dead ants he saw in Resident #2's room were odorous house ants (also known as sweet or sugar ants) which were small ants that were black in color. He stated the odorous house ants were very small and were not normally known to bite or be aggressive. Pest Control Technician #2 stated he walked the perimeter of the building and observed several active live fire ant mounds around the back of the building on the side of the hall where the two resident rooms were located. He stated he treated all the live fire ant mounds he observed at that time. Pest Control Technician #2 stated fire ants were aggressive in nature and did bite. He stated fire ants were able to access a building through gaps in doors, around windows, or air conditioner units. An interview was conducted on 7/09/24 at 1:27 pm with the Rehabilitation Director who revealed that she observed approximately 10-12 small black ants on the floor in the rehabilitation office on either 6/29/24 or 6/30/24. She stated she first saw one on the desk which was why she looked on the floor and observed the other ants. She stated she killed the ants and then swept to make sure no more ants were present. The Rehabilitation Director stated she had not seen ants in the rehabilitation office prior and had not observed any ants in the rehabilitation gym. Review of the pest control visit log dated 7/01/24 revealed Pest Control Technician #1 completed a routine visit and inspected the Physical Therapy room for ants and live ants were observed and treated. A telephone interview was conducted on 7/09/24 at 2:33 pm with Pest Control Technician #1 who revealed he received the call from the facility on 6/26/24 for a visit due to ants but he was unavailable that day, so Pest Control Technician #2 went to the facility. He stated he received the report from Pest Control Technician #2 that fire ant mounds were identified and treated on the exterior back of the facility. He stated he returned to the facility on [DATE] for the routine visit and he observed one active fire ant mound located at the exterior rear of the facility near the rehabilitation office and the previously reported resident hall, which he treated. He stated he also observed dead ants in the rehabilitation office on this visit, which he identified as fire ants. Pest Control Technician #1 stated fire ants were small (not tiny) dark reddish to black in color, they were aggressive in nature, and more prone to biting and stinging than odorous house ants. A walking tour and interview was conducted on 7/10/24 at 10:50 am with Pest Control Technician #1 and the Maintenance Supervisor of the perimeter of the facility. Pest Control Technician #1 identified the previous fire ant mounds that were treated on 6/26/24 to this surveyor. The area was observed as a hard, dry area of dirt with multiple ant holes along the side/rear exterior wall which was identified by the Maintenance Supervisor as the rehabilitation gym. No live fire ants were noted at this location. The tour continued around the rehabilitation gym where Pest Control Technician #1 identified the fire ant mound that was treated on 7/01/24 which was located approximately four feet from the back exterior wall of the resident hall where Resident #1 and Resident #2 were located. The area was observed as a hard, dry area of dirt with no live fire ants observed. An additional active fire ant mound was identified by the Pest Control Technician #1 at this time which was approximately eight feet from the back exterior of the resident hall. He agitated the fire ant mound with his foot, and live fire ants were observed to be small, dark reddish brown to black in color. Pest Control Technician #1 treated the active fire ant mound. Pest Control Technician #1 stated fire ants were known to move long distances for food sources and were capable of entering the facility from the locations of the mounds that were treated. An interview was conducted with the Administrator on 7/10/24 at 2:46 pm who revealed resident room rounds were completed daily by the Administrative team and the ant infestation was not identified during the rounds prior to the incident. The Administrator was notified of immediate jeopardy on 7/09/24 at 4:33 pm. The facility provided the following credible allegation of immediate jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 6/23/24 Resident #1 was observed in bed by Nurse #1 with small black ants all over the floor, bedside table, bed linens, gown, inside the incontinent brief, and on her body. Resident #1 was unable to get out of bed without staff assistance. On 6/23/24 Resident #1's skin assessment by Nurse #1 revealed several small, reddened areas across her back and sides, resident complained of itching and was observed scratching. Nurse #1 removed the ants from the resident and the resident was moved to another room. On 6/23/24 Nurse #1 called the Medical provider; orders were given for Benadryl 25 mg 1 tab by mouth every six hours PRN x three days and Calamine lotion to red areas three times a day as needed for 7 days. Resident #1 is her own responsible party. On 6/24/24 the resident was seen by the Nurse Practitioner and resident had no reports of pruritis during her visit and resident currently is not experiencing any skin irritation, itching or discomfort per nursing assessment on 7/9/24. On 6/23/24 the Maintenance Supervisor cleaned and sanitized the room. He checked the adjoining rooms with no observed pests on 6/23/24. On 6/24/24 the Maintenance Supervisor initiated daily inspection of 100% of all rooms on 400 hall for any signs of pests. On 6/26/24 the Maintenance Supervisor called Pest control to come to the facility as his daily inspection did identify ants observed in a vacant room which he cleaned and sanitized. On 6/26/24 Resident #2 was observed in bed by Nurse #2. Nurse #2 observed small black ants all over the floor, furniture, bed linens, and clothing of Resident #2. Resident #2 was unable to get out of bed without staff assistance. Nurse #2 did not observe any signs of physical injury from the ants on Resident #2 and resident was immediately moved into another room. Pest control came to the facility on [DATE] and sprayed rooms 405,407,409. There were some dead ants but there were no live pests noted by pest control. Pest control proactively treated 100% of the exterior perimeter of 400 hall. Pest Control identified and treated fire ant mounds on the exterior of the facility on 6/26/24. The Maintenance Supervisor has completed ongoing pest control monitoring of 100% of 400 hall 5x weekly since 6/26/24 without additional identification of pests. All residents are at risk of harm due to this deficient practice. On 7/9/24 licensed nurses did skin checks on 100% of the residents and there were no identified skin concerns associated with pest/insect bites. On 7/9/24 the Admissions Coordinator, Therapy Director, Nurse Secretary, Human Resources, Maintenance Supervisor, Activity Coordinator, and the Business Office Manager did 100% room checks and did not identify any pests in the facility. On 7/9/24 the Maintenance Supervisor was educated to notify pest control immediately upon identifying any pests by the Administrator. On 7/9/24 the Maintenance Supervisor called pest control to come to the facility on [DATE] and do a thorough inspection and provide treatments as needed. 2. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 7/9/24 the Administrator began in servicing all staff (full time, part time, and prn including agency) on the need to provide effective Pest management to ensure residents are safe from ants and pests. This education will be provided to new hires during the orientation process by Human Resources. No staff shall work without this education effective 7/10/24. The Administrator, Director of Nursing, and Human Resources will monitor to ensure no staff works without completing the education. This education included: The facility maintains high standards of cleanliness and sanitation throughout the facility to eliminate food and water sources that attract pests. The facility will ensure proper storage and disposal of waste to prevent attracting pests. Educate staff to ensure food is stored properly, waste is disposed of properly, and we maintain cleanliness to reduce the risk of pest infestations. The Maintenance Supervisor weekly inspects and repairs (as needed) any structural issues, such as cracks, holes, or gaps that could allow pests to enter the building. The Maintenance Supervisor and the Department Heads conduct regular inspections of all areas of the facility, including resident rooms, common areas, kitchens, and storage areas to identify any signs of pest activity. The Maintenance Supervisor will maintain detailed records of all pest control activities, including inspection reports, treatment records, and any actions taken to address identified issues. Staff will need to recognize signs of pest activity, they were educated on what pests are, and understand the importance of maintaining a pest free-free environment. Staff should know how to report any pest sightings or concerns immediately. Any pest sightings should be reported immediately to the Maintenance Supervisor or the on-call Administration. Always address any concerns or complaints from residents or their families regarding pest control promptly and effectively. The alleged date of immediate jeopardy removal is 7/10/24. The credible allegation of immediate jeopardy removal was validated by onsite verification on 7/10/24 as evidence by staff interviews, alert and oriented resident interviews, record review, and observations. Interviews were conducted with those residents identified as alert and oriented by the facility with no additional concerns regarding ants. The Maintenance Supervisor's education dated 7/09/24 presented by the Administrator and signed by the Maintenance Supervisor was reviewed. Interviews were conducted with staff which included nursing, housekeeping, laundry, dietary, and administration to confirm education had been completed regarding identification and notification when ants or other pests were identified, ensuring the area was clean, proper waste disposal, and food storage. Staff education logs dated 7/09/24 and 7/10/24 were reviewed for all departments including dietary, rehabilitation, housekeeping, administrative, and nursing. Those staff that have not received education in person or via telephone on 7/09/24 will be educated prior to the beginning of their next scheduled shift by the Administrator, Director of Nursing, or Human Services. Administrative room round logs dated 7/09/24 were reviewed with no newly identified concerns. Skin assessment sheets dated 7/09/24 were reviewed with no newly identified concerns. Observations were conducted on 7/09/24 and 7/10/24 with no identified active ants or pests in the resident rooms, common areas, or bathrooms. The facility's Immediate Jeopardy removal date of 7/10/24 was validated.

Based on record review, staff interviews, Nurse Practitioner, Consultant Pharmacist, and Medical Director interviews the facility failed to attempt a gradual dose reduction (GDR) per Consultant Pharmacist recommendations of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses which included anxiety, insomnia, and major depressive disorder. Resident #38 did not have a diagnosis of schizophrenia upon admission to the facility. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #38 was cognitively intact and was not coded for behaviors. Resident #38 was coded for anxiety, depression, and schizophrenia and they received antipsychotic, hypnotic, and antidepressant medications. The MDS annual assessment noted Resident #38 had not had a gradual dose reduction (GDR) of the antipsychotic medication and there was no documentation of clinical contraindications (inadvisable because of harm to person) related to a GDR attempt. A review of Resident #38's hospital discharge summary dated 2/02/23 revealed Resident #38 was discharged from the hospital with the following medications: paliperidone (an antipsychotic medication used to treat schizophrenia and schizoaffective disorder) 1.5 milligrams (mg) 3 tablets every morning, bupropion extended release (an antidepressant medication) 300 mg daily, and zolpidem (hypnotic, sedative medication used for insomnia) 5 mg at night. Review of Resident #38's active physician orders on 3/06/24 revealed the following: An active physician order with a start date of 2/03/23 for paliperidone 1.5 mg tablet give 3 tablets daily. An active physician order with a start date of 2/03/23 for bupropion extended release 300 mg daily. An active physician order with a start date of 2/03/23 for zolpidem 5 mg tablet at bedtime. An active physician order dated 2/21/24 for outpatient psychiatric appointment for routine follow-up. Review of the Note to Attending Physician/Prescriber dated 8/23/23 revealed the Consultant Pharmacist notified the attending physician that it was time to evaluate psychoactive medications for a GDR. The following medications were listed for possible GDR: zolpidem 5 mg at night, bupropion extended release (ER) 300 mg daily for depression, and paliperidone 4.5 mg daily for depression. The Nurse Practitioner (NP) response to the GDR recommendation was that Resident #38 was followed by outpatient psychiatry. Review of the Note to Attending Physician/Prescriber dated 11/15/23 revealed the Consultant Pharmacist sent a follow-up to the 8/23/23 notification regarding GDR recommendation for Resident #38. The Consultant Pharmacist notified the attending physician that it was time to evaluate psychoactive medications for a GDR for the following medications: zolpidem 5 mg at night, bupropion extended release (ER) 300 mg daily for depression, and paliperidone 4.5 mg daily for depression. The NP response to the GDR recommendation was that Resident #38 was followed by outpatient psychiatry. Review of the Note to Attending Physician/Prescriber dated 12/13/23revealed the Consultant Pharmacist notified the provider that a signed note in Resident #38's medical record in November 2023 regarding GDR review for psychoactive medications, that the resident was seen by outside psychiatric provider. Please send the GDR request to their office for review and return to the facility. The Consultant Pharmacist reported it was time to evaluate Resident #38's psychoactive medications for a GDR. The following medications were listed for possible GDR: zolpidem 5 mg at night, bupropion extended release 300 mg daily for depression, and paliperidone 4.5 mg daily for depression. The NP response to the GDR recommendation was that Resident #38 was followed by outpatient psychiatry. Review of the Medication Regimen Review dated 1/16/24 revealed the Consultant Pharmacist notified the provider that according to documentation in the medical record, Resident #38 received outpatient psychiatric services. The Consultant Pharmacist requested the provider follow-up on obtaining the most recent consultations for review. The Consultant Pharmacist further noted they needed the documentation to ensure GDRs were monitored for hypnotic and antidepressant medication. Review of the Medical Director Progress Note dated 2/02/24 revealed Resident #38 was seen for a regulatory visit with chronic health problems being addressed which included schizophrenia. The Medical Director noted Resident #38 was under the care of an outpatient psychiatrist with no new symptoms or exacerbations reported during the visit. Review of the care plan revised on 2/24/24 revealed Resident #38 received antipsychotic medication related to diagnosis (no diagnosis noted) and received an antidepressant medication related to depression. Resident #38 was at risk for adverse side effects with interventions for the Consultant Pharmacist to review my psychotropic medication quarterly and as needed for possible changes or reductions. Review of Resident #38's electronic medical record revealed no documentation of outpatient psychiatric appointments or supporting clinical documentation regarding contraindications for GDR attempts from the outpatient psychiatric provider. Interviews were conducted on 3/06/24 at 8:45 am and 10:15 am with the Support Nurse who revealed Resident #38 was followed by an outpatient psychiatrist, but the facility had not received any documentation regarding his care. The Support Nurse stated she had tried to call the outpatient psychiatrist and was unable to make contact. The Support Nurse stated Resident #38 was reportedly seen by the outpatient psychiatrist via telehealth in July of 2023, but the facility was unable to locate any information regarding the visit and was unable to determine who assisted Resident #38 with the telehealth call. A telephone interview was conducted on 3/06/24 at 10:09 am with the Consultant Pharmacist who revealed the facility was notified that the notation that Resident #38 was followed by outpatient psychiatry was not a sufficient response to the GDR recommendation. The Consultant Pharmacist stated they were unable to locate any outpatient psychiatric documentation on Resident #38's medical record to state a GDR was clinically contraindicated and had asked the facility on multiple occasions to obtain documentation to ensure Resident #38's psychotropic medications were being monitored. An interview was conducted on 3/06/24 at 11:35 am with the Nurse Practitioner (NP) who revealed she was told Resident #38 was followed by outpatient psychiatrist. The NP stated she had asked the facility many times to obtain the outpatient psychiatrist visit records so she could review the information, but she had not received any documentation. An attempt to interview the Medical Director via telephone was unsuccessful on 3/06/24 at 11:53 am. The Medical Director returned the call on 3/07/24 2:31 pm and reported she had requested Resident #38's outpatient psychiatrist documentation but the facility had not received the information. The Medical Director stated the normal process for residents that were prescribed psychotropic medication was to be followed by the in-house psychiatric provider, but she was told Resident #38 was followed by outpatient provider. During an interview on 3/06/24 at 12:30 pm the Administrator stated the Support Nurse worked with the NP regarding Resident #38's outpatient psychiatric visits. The Administrator stated she would have to speak to the Support Nurse regarding the issue of obtaining Resident #38's outpatient psychiatric information.

Based on observations, record review, resident and staff interviews, and Medical Director interview, the facility failed to obtain and implement physician orders for the care and monitoring of a resident on hemodialysis for 1 of 2 residents for dialysis (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) with dependence on dialysis. Review of the care plan last revised on 8/31/23 revealed Resident #15 received hemodialysis (a machine filters waste from the body when the kidneys no longer work adequately) three times a week due to renal disease. The interventions included applying firm and direct pressure using two fingers to bleeding shunt or port site, and do not draw blood or take blood pressure on the arm with shunt or graft (catheter access area for delivery of hemodialysis). Resident #15 had an active physician order dated 10/19/23 for dialysis on Tuesday, Thursday, and Saturday. Review of the arteriovenous graft (AVG) surgery discharge summary dated 1/15/24 revealed Resident #15 had an arteriovenous (AV) fistula (an artery and vein joined surgically to administer dialysis) placed in the right upper arm. An attempt to interview Nurse #3, who was assigned to Resident #15 on 1/15/24, via telephone on 3/04/24 at 2:04 pm was unsuccessful. Review of the dialysis communication note to nurse dated 1/16/24 revealed the dialysis center requested the facility to note on resident chart for no intravenous (IV) or blood pressure (BP) in the right arm. A review of Resident #15's active physician orders revealed no orders for monitoring of the right arm AV fistula, no IV in the right arm, and no blood pressure check on the right arm. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #15 was cognitively intact and was coded for dialysis. An interview and observation was conducted on 3/04/24 at 12:40 pm with Resident #15 who revealed she received her dialysis through the right arm AV fistula. Resident #15 stated the nursing staff did not check her right arm AV fistula site every shift. Resident #15's AV fistula site was observed to be in the upper right arm and there was no documentation observed in the resident medical record about no blood pressures or IV from the right arm. An interview was conducted on 3/04/24 at 12:53 pm with Nurse #2 who revealed when a resident returned from dialysis the access site was checked for bleeding, vital signs were obtained, and the post-dialysis weight from the dialysis communication binder was entered into the medical record. Nurse #2 reported she did not see a physician order to check the AV fistula site for Resident #15. Nurse #2 stated she believed an AV fistula site was assessed once a shift for bruit (a whooshing sound heard at the fistula site with a stethoscope) and thrill (vibration caused by blood flow felt with fingers) but stated she would have to check to be sure since there was not a physician order. During an interview on 3/04/24 at 1:20 pm the Registered Nurse (RN) Supervisor stated when Resident #15 returned from the surgical procedure for the AV fistula the nurse that received the discharge information should have entered physician orders for the fistula site care which would include shunt procedures for bleeding, monitoring for bruit and thrill, and no BP or IV in the arm that the fistula was in. She further stated the dialysis communication book was to be reviewed upon Resident #15's return from dialysis and the nurse should have completed the recommendations as requested by dialysis regarding no BP or IV in the right arm. The RN Supervisor stated the dialysis communication books were reviewed during the morning clinical meeting, but she was unable to state how the communication from dialysis regarding no blood pressure or IV in the right arm was missed for Resident #15. Interviews were conducted on 3/05/24 at 9:41 am and 3/06/24 at 8:53 am with the Support Nurse who revealed the nurse that received the dialysis communication book was responsible for the review and completion of the recommendations for no BP or IV for Resident #15's right arm. The Support Nurse further reported when Resident #15 returned from the AV fistula procedure the instruction sheet should have been reviewed by the receiving nurse and if any orders were needed the nurse should have contacted the physician. The Support Nurse was unable to state how the orders for Resident #15's AV fistula site monitoring and no BP or IV in the right arm were missed. An interview with the Medical Director was conducted on 3/05/24 at 10:24 am. The Medical Director stated she was not aware there were no orders for monitoring of the AV fistula site and did not know how the orders to monitor the site were overlooked. The Medical Director stated Resident #15's AV fistula should have had orders in place which included monitoring for bruit and thrill. An interview was conducted on 3/05/24 at 3:20 pm with Nurse #5 who revealed she was aware of Resident #15's right arm AV fistula but did not realize there were not physician orders to monitor the fistula, and for no BP or IV in right arm. Nurse #5 stated when Resident #15 returned from dialysis she often left her room right away to go visit with other residents or go outside so she was not always able to check her fistula, but she would try. Nurse #5 stated she was aware the fistula site had to be checked every day, and that no BP or IV was to be done in the right arm but she did not check to see if the physician orders were entered for Resident #15. An interview was conducted with the Director of Nursing (DON) on 3/06/24 at 10:34 am who revealed the nurse assigned to Resident #15 was responsible to review the surgical discharge summary upon the residents return and leave the summary to be reviewed by the DON for follow-up to make sure all necessary orders were entered. The DON stated she believed Resident #15's AV fistula surgical discharge summary was received by the nurse but was not left for her to review. The DON further stated the nurses were to monitor the AV fistula site for bleeding, and the bruit and thrill were to be checked every shift. The DON stated the nurse who was assigned to Resident #15 should have reviewed the dialysis communication binder when she returned from treatment and completed the recommendations sent for no BP or IV in the right arm in the resident record and in the room. The DON was unable to state how the physician orders for the AV fistula site monitoring and the dialysis communication recommendations were missed for Resident #15. During an interview on 3/06/24 at 10:34 am the Administrator stated Resident #15's AV fistula surgical discharge summary was to be reviewed by the nurse that was assigned when the resident returned and if any orders were needed, they were expected to obtain the orders. The Administrator stated the discharge summary was to be left for the DON to review and follow-up as needed during the daily clinical meeting.

Based on record review and staff interviews, the facility failed to refer residents with serious mental health diagnoses for a Preadmission Screening and Resident Review (PASRR) level II screening for 1 of 3 residents reviewed for PASRR (Resident #38). The findings included: Review of Resident #38's Hospital Discharge Summary dated 2/02/23 revealed no diagnosis of schizophrenia. Resident #38 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder and anxiety. Review of Resident #38's Preadmission Screening and Resident Review (PASRR) Level I Determination Notification dated 3/24/23 revealed Resident #38 required no further screening unless a significant change occurred which suggested a diagnosis of mental illness. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #38 was cognitively intact and was coded for anxiety, depression, and schizophrenia. Resident #38 was not coded for behaviors. Review of Resident #38's active diagnosis list on 3/03/24 revealed Resident #38 had a diagnosis of schizophrenia which was created on 10/20/23 with an active date of 6/23/23. An interview was conducted on 3/05/24 at 9:10 am with the Social Worker who revealed she was responsible to submit notification for PASRR review for Resident #38, but she stated she was unable to recall being notified of Resident #38's schizophrenia diagnosis. The Social Worker stated she would have submitted a review of Resident #38's PASRR Level I based on the new diagnosis of schizophrenia. An interview was conducted with the Administrator on 3/06/24 at 10:37 am who revealed the Social Worker was responsible for Resident #38's PASRR review.

Based on interviews with staff and record review the facility failed to ensure a baseline care was completed within 48 hours after admission and failed to complete all sections of the baseline care plan for a new admission for 1 of 3 residents (Resident #63) reviewed. The findings included: Resident #63 was admitted into the facility on [DATE] with diagnoses of cancer, dialysis, and diabetes. A review of Resident #63's medical record showed that the baseline care plan was started on 2/1/24 and had only one section completed, which was medication regimen section. The general information section was completed on 2/3/24. Resident #63's health conditions, dietary, therapy and social services were not completed. A review of Resident #63's admission Minimum Data Set, dated dated dated [DATE] noted he was severely cognitively impaired, was dependent on staff for his activities of daily living, was incontinent of bowel and was receiving dialysis. In an interview on 3/5/24 at 8:20 AM the Director of Nursing (DON) indicated the Social Worker (SW) was responsible for the care plans, as the MDS Nurse was part time. In an interview on 3/5/24 at 9:24 AM the Administrator indicated that the base line care plan begins with the Social Worker. In an interview on 3/5/24 at 11:15 AM the Minimum Data Set (MDS) Nurse stated that she works part time to help out. She indicated for a new admission; she checks the care plan to see if the nursing team has entered the resident care details. The MDS nurse indicated the Social Worker handled the baseline care plans.

Based on record review, staff interviews, Consultant Pharmacist, Nurse Practitioner, and Medical Director interviews, the facility failed to obtain outpatient psychiatrist visit notes for a resident prescribed psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #38) The findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses which included anxiety, insomnia, and major depressive disorder. Review of the Medication Regimen Review dated 1/16/24 revealed the Consultant Pharmacist notified the provider that according to documentation in the medical record, Resident #38 received outpatient psychiatric services. The Consultant Pharmacist requested the provider follow-up on obtaining the most recent consultations for review. Review of Resident #38's medical record revealed no documentation of outpatient psychiatric appointments or supporting clinical documentation from the outpatient psychiatric provider. An interview was conducted on 3/06/24 at 8:45 am with the Support Nurse who revealed Resident #38 was followed by an outpatient psychiatrist, but the facility did not have any documentation regarding his outpatient psychiatric appointments. She stated Resident #38 was reportedly seen by the outpatient psychiatrist via telehealth in July of 2023, but the facility was unable to locate any information regarding the visit and was unable to determine who assisted Resident #38 with the telehealth call. The Support Nurse stated she was unable to contact the outpatient psychiatric provider to obtain the records for Resident #38 because the office does not answer the phone. A telephone interview was conducted on 3/06/24 at 10:09 am with the Consultant Pharmacist reported they were unable to locate any outpatient psychiatric documentation on Resident #38's medical record and had asked the facility on multiple occasions to obtain documentation to ensure Resident #38's psychotropic medications were being monitored. An attempt to contact the outpatient psychiatrist provider on 3/06/24 at 10:21 am was unsuccessful. An interview was conducted on 3/06/24 at 11:35 am with the Nurse Practitioner (NP) who revealed she was told Resident #38 was followed by outpatient psychiatrist, but the facility did not have any of the records from the outpatient psychiatrist. The NP stated she had asked the facility many times to obtain the outpatient psychiatrist visit records so she could review the information, but she stated she had not received any documentation.

Based on observation and staff interviews the facility failed to label and date an open bottle of eye drops for one of two medication carts observed for medication storage (Hall 400). The findings included: During an observation of the 400 Hall medication cart on 3/04/24 at 8:59 am in the presence of Nurse #1 a squeeze bottle of prednisolone acetate ophthalmic suspension 1% (steroid medication used to treat inflammation of the eyes caused by certain conditions) was in the top drawer, opened, with no open date noted on bottle, and there were no resident identifiers on the bottle. At the time of the observation, an interview was conducted with Nurse #1 who confirmed the squeeze bottle of the prednisolone acetate ophthalmic suspension 1% medication was opened, did not have the date the bottle was opened, and had no resident identifiers. Nurse #1 stated she did not know when the medication was opened or where the bag that had the resident name on it went. She stated the medication was for a resident on the hall and she confirmed she had already administered the medication. Nurse #1stated she knew which resident the medication belonged to because there was only resident prescribed the medication on her cart. Nurse #1 removed the prednisolone acetate ophthalmic suspension 1% from the medication cart. An interview was conducted on 3/06/24 at 9:20 am with the Director of Nursing (DON) who revealed Nurse #1 should not have used the eye drops without resident identification on the bottle. The DON stated Nurse #1 should have reordered the medication from the pharmacy. During an interview on 3/06/24 at 10:57 am the Administrator stated Nurse #1 should have discarded the medication without the resident information available.

Based on record review, and staff, Emergency Medical Services (EMS) personnel, and Medical Director interviews, the facility failed to identify the urgent need for medical attention for a resident with new onset seizure activity on 8/12/23 at approximately 10:30 am which is a medical emergency. They did not immediately initiate EMS (Emergency Medical Services) to transfer the resident to an acute care hospital for medical evaluation and interventions for 1 of 2 residents reviewed with a medical emergency. EMS was contacted at 10:58 am and upon their arrival Resident #1 continued with seizure activity and required 3 doses of Versed (a medication used to stop a seizure) for seizure activity to cease. Upon arrival at the hospital Resident #1 was unresponsive and in status epilepticus (a seizure lasting for more than 5 minutes), a medical emergency that may lead to brain damage or death. A CT (computerized tomography) scan revealed a subarachnoid hemorrhage (bleeding in the space that surrounds the brain), Resident #1 required intubation (a tube inserted into the airway) and was admitted to the ICU (intensive care unit). Immediate Jeopardy began on Saturday, 8/12/23, when the facility failed to initiate EMS immediately when Resident #1 was observed with onset of seizure activity. The immediate jeopardy was removed on 8/31/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and that monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses did not indicate any history of seizures. Review of the quarterly Minimum Data Set (MDS) completed on 7/1/23 identified Resident #1 as severely cognitively impaired. The MDS did not reveal a diagnosis of seizures. Resident #1's physician's order summary for August 2023 revealed Resident #1 had no orders for seizure medication. On 8/23/23 at 9:47 AM Nurse Aide (NA) #2 (agency staff) was interviewed and stated on Saturday 8/12/23 she took Resident #1's breakfast meal tray away around 9:30 AM and did not remember anything unusual with Resident #1. On 8/29/23 at 9:24 AM NA #1 was interviewed and stated she was coming up the hall on 8/12/23 at 10:30 AM and saw Resident #1 had movement of her head, like a seizure. The NA stated she had never worked with the resident before but knew she did not look right and went to tell Nurse #2 right away. A phone interview was conducted with Nurse #1 (agency staff) on 8/23/23 at 3:48 PM. She indicated on 8/12/23 she saw Resident #1 with a mild twitch of her lips and continued to observe her for about one minute. When the twitch did not stop she stepped to the doorway and saw Nurse #2 (who was the weekend Supervisor) on the hall and reported the resident's head was moving like a little twitch. Nurse #1 revealed she could not remember what time she observed the resident and notified Nurse #2. Nurse #1 indicated that Nurse #2 took over and contacted the On Call Physician. Nurse #1 indicated Resident #1's breathing was normal/regular and she denied observing any other changes with the resident. Nurse #2 was interviewed on 8/23/23 at 11:13 AM. She indicated on 8/12/23 around 10:30 AM, NA #1 came and reported to her Resident #1 was twitching. Nurse #2 stated she went to Resident #1's room and when she saw the resident her head was twitching left to right. Nurse #2 revealed Nurse #1 joined her in the resident's room and she (Nurse #2) indicated it appeared the resident was having a seizure. Nurse #2 stated the resident did not have a diagnosis of seizures. She reported she told Nurse #1 to stay with resident until she returned with her electronic tablet to contact the On Call Physician. Nurse #2's triage note documentation for 8/12/23 revealed the following information related to Resident #1: - At 10:38 AM Nurse #2 contacted the on-call physician group via electronic tablet communication. The On Call Physician requested information on any history of seizures and if the resident was on seizure medication. Nurse #2 indicated no to both questions and was instructed to get vital signs (VS) to include blood pressure (BP). - At 10:46 AM Nurse #2 responded back to the On Call Physician with VS as heart rate 118 and temperature of 96.9. The nurse indicated she was not able to get a BP due to Resident #1's arm movement. The On Call Physician ordered Ativan intramuscular (IM) (used as a rescue medication to stop a seizure). Ativan IM was not available in the facility and the order was given to send Resident #1 to the emergency room (ER). The EMS report dated 8/12/23 indicated a call was received from the facility at 10:58 AM and they were dispatched to the facility at 10:59 AM. A Health Status note completed by Nurse #2 dated 8/12/23 at 11:03 AM revealed the writer observed Resident #1 having constant seizure like activity. Nurse #2 contacted the On Call Physician through tablet communication and an order to send to the ER was obtained. In a follow up phone interview on 8/24/23 at 1:21 PM Nurse #2 indicated on 8/12/23 she followed the facility's normal protocol for physician communication and used her tablet to email the On Call Physician. She indicated the resident was laying on her back with her head turned to the right and her head was twitching back and forth. Nurse #2 indicated the resident was not having convulsions, her body was shaking more like a tick, and had no thrashing. She reported this information to the On Call Physician. Nurse #2 indicated the On Call Physician asked for VS and BP, she indicated she was able to get VS but not able to obtain BP as Resident #1 had to be completely still for an accurate BP. After providing information on the VS and inability to obtain a BP, the On Call Physician wanted to know if the resident was on any seizure medications. She revealed at first she answered yes to the On Call Physician and then checked the medical record and realized Resident #1 was not ordered any seizure medication and informed the On Call Physican of the correct information (no ordered seizure medication). Nurse #2 indicated the On call Physician ordered Ativan IM, but the facility did not have any in stock and she received the order to send Resident #1 to the ER prior to calling EMS. A phone interview was conducted on 8/28/23 at 11:02 AM with the On Call Physician who took the call from the facility related to Resident #1 on 8/12/23. The On Call Physician revealed the facility called to report Resident #1 was having seizure activity. The On Call Physician indicated staff were asked to get VS, BP and if the resident was receiving any seizure medications. Staff reported VS and there was initially some confusion with staff as to whether the resident did or did not receive seizure medication. She indicated when staff clarified the resident did not have orders for seizure medication an order was given for Ativan IM. Staff reported back that there was no Ativan IM in the facility. The On Call Physician stated if the resident had received Ativan IM, it could have resolved her seizures. The On Call Physician indicated that most facilities had liquid Ativan available for emergency situations. The EMS Report dated 8/12/23 indicated they arrived at the facility at 11:07 AM. The report revealed on arrival at the facility, Nurse stated that [Resident #1] had been seizing for approximately an hour and they had no standing orders or medication. [Resident #1] was found sitting [on] her bed obvious seizure, right side, facial droop, irregular, respirations. Staff advised that Resident #1 was seen at approximately 9:30 AM this morning for medication administration. A 2.5 mg dose of Versed was first administered in a previously established IV (intravenous) at 11:13 AM and the Resident 's response was documented as unchanged. A second 2.5 mg dose was administered at 11:22 AM and the Resident's response was documented as unchanged. Oxygen was applied via a non-rebreather mask (a face mask that gives you oxygen). Resident #1 left the facility with EMS at 11:20 AM. The resident was noted to continue to seize and a third 2.5 mg dose of Versed was administered at 11:30 AM (while enroute to the hospital) and the Resident's response was documented as improved. During transport Resident #1 continued to have irregular breathing and a nasopharyngeal airway (NPA) was inserted (a thin, clear, flexible tube that is inserted into a patient's nostril to bypass upper airway obstruction) and breathing became more regular. EMS arrived at the hospital at 12:01 PM. In a phone interview on 8/28/23 at 2:57 PM EMS personnel revealed on arrival at the facility on 8/12/23, she observed Resident #1 with seizure activity. EMS reported that Nurse #2 indicated the resident had been having seizures for about an hour. EMS stated the resident had an established IV line and had facial droop on her right side. She indicated she gave the Resident a dose of medication (Versed) to help with seizures and moved the resident onto their ambulance. EMS stated before they left the facility she administered a second dose of seizure medication, and while on route to the hospital, she gave a third dose. She indicated after the third dose Resident #1's condition improved. The hospital record revealed Resident #1 presented on 8/12/23 for status epilepticus. She was noted with tonic-clonic seizure activity (involves a loss of consciousness with stiffening of muscles and twitching/jerking muscle contractions) with duration of one hour and right-sided gaze deviation (abnormal movement of the eyes). On arrival she had a Glasgow Coma Scale (scale used to describe the extent of impaired consciousness) score of 3 (the lowest possible score indicating the resident was completely unresponsive). Resident #1 was intubated for airway protection. A CT scan showed an acute subarachnoid hemorrhage. The hospital course indicated on 8/13/23 Resident #1's gaze deviation that was previously to the right was now on the left. An MRI (magnetic resonance imaging) of Resident #1's brain was conducted on 8/14/23 and showed no acute signs of stroke. Resident #1 was hospitalized until 8/23/23 at which time she was transferred to an inpatient hospice. On 8/28/23 at 12:12 PM during a phone interview the Medical Director indicated that the conversation on 8/12/23 with the On Call Physician group was through electronic messaging/tablet (emailing back and forth) and not on the phone. The Medical Director further stated that this was a new onset of seizures for Resident #1, and the delay was in trying to see if there was anything staff could do to stop or treat the seizures in the facility. The Medical Director said they did treat the situation as a medical emergency and the nurse called the On Call Physician group and followed their directions/orders to send Resident #1 out. The On Call Physician was trying to do the right thing for a resident with first time seizures which included getting the resident's history and trying to see if they could treat/resolve in house before sending out. She indicated she believed their response was appropriate. An interview on 8/24/23 at 1:11 PM the Nurse Support Staff stated if a resident were having seizures, staff should call the physician and send the resident out immediately. The Administrator was notified of immediate jeopardy on 8/30/23 at 11:00 AM. 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. Resident #1 was discharged to the care of Emergency Medical Service on 08/12/2023 and is no longer a resident of the facility. No further corrective action could be completed specific to Resident #1. All residents are at risk of requiring emergency medical services. On 08/30/2023, the Nurse Consultant, Interim Director of Nursing (DON), and Licensed Practical Support Nurse (LPN) completed an audit of 100% of hospital transfers for current and discharged residents for the last 3 months from 05/30/2023 - 08/30/2023. This audit consisted of review of each hospital transfer to identify any residents with any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where immediate emergency medical services was required and not initiated when physician response time was delayed, or if emergent care needs couldn't be met at the facility. This audit was completed on 08/30/2023. The audit identified that 1 of 30 hospital transfers had an acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where immediate emergency medical services was required and not initiated when physician response time was delayed, or if emergent care needs couldn't be met at the facility. Resident #1 was the resident identified as a result of the audit. No corrective actions were required for Resident #1 as the resident remains out at the hospital. On 08/30/2023, the Interim DON met with all floor nurses and initiated assessment of all current residents to identify any residents with any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where immediate emergency medical services was required and not initiated when physician response time was delayed, or if emergent care needs couldn't be met at the facility. No current residents were identified as having any acute change in condition. No other residents were impacted. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 08/30/2023 the DON began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN) and certified nursing assistants (full time, part time, and prn including agency) on any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Additionally, education included activation of emergency services when physician response time was delayed, or if emergent care needs couldn't be met at the facility. Additional education included that if conditions worsened and nurse's assessment warrants, activate emergency medical services, call the attending physician and resident's family or responsible party, as appropriate to ensure resident receives emergent care needs to address the change in condition. The DON will ensure that all licensed nurses, RN's, LPN's, and CNA's (full time, part time, and prn including agency) who do not complete the in-service training by 08/30/2023 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency.) Alleged date of immediate jeopardy removal: 08/31/2023 Onsite validation was completed on 9/1/23 through interviews and record review. Inservice sign in sheets and staff interviews verifed in-services were completed on any change in condition and activation of emergency services when physician response time was delayed, or if emergent care needs couldn't be met at the facility. Education was confirmed for agency nursing staff, facility nursing staff through interviews and any staff who did not complete the in-service training by 8/30/23 will not be allowed to work until the training is completed. Evidence of audits were reviewed for hospital transfers for current and discharged residents. Resident interviews were conducted with no issues identified. The facility's immediate jeopardy removal date was validated as 8/31/23.

Based on record review and interviews with Orthopedic Surgeon, Nurse Practitioner (NP), Medical Director, and staff, the facility failed to safely transfer a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 12/23/22 Resident #1, a resident totally dependent for 2 staff's assistance and a mechanical lift for transfers, fell while being transferred by Nursing Assistant #1 and Nursing Assistant #2 without a mechanical lift. Resident #1 experienced pain rated a 10 out of 10 (with 10 representing the worst pain imaginable), she suffered femur (thigh bone) fractures to both legs, and she underwent two orthopedic surgeries to address the fractures. Findings included: Resident #1 was most recently readmitted to the facility on [DATE] with diagnoses that included dementia, end stage renal disease with dialysis, difficulty in walking, and muscle weakness. Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as being moderately cognitively impaired and totally dependent on two persons for transfers. She was not steady and only able to stabilize with staff assistance when moved from seated to standing position and with surface-to-surface transfers. Resident #1 was not coded for any falls since the prior assessment. Review of Resident #1's care plan active care plan on 12/23/22 revealed the following: - A focus area dated 4/8/21 revealed she was at increased risk for falls and had a fall in the past related to confusion, deconditioning, gait/balance problems, and poor communication/comprehension. Interventions included a stand-up lift with 2-person assistance for all transfers. - A focus area was added on 11/23/20 for activities of daily living (ADL) self-care performance deficit related to confusion, dementia, weakness, deconditioning, and impaired balance. Interventions included total assistance of 2 staff members using a mechanical lift for all transfers. Review of the Nursing Assistant task list history active on 12/23/22 for Resident #1 concerning transfers (last updated on 8/13/22) revealed the following: - Sit to stand lift required for transfers on non-dialysis days - Total mechanical lift required for transfers on dialysis days with dialysis pad - Use 2 staff members for designated lift transfer. A health status note written by Nurse #1 dated 12/23/22 at 6:01 AM read in part; she heard Resident #1 yelling and when she went to the room, she observed her in front of the wheelchair with Nursing Assistant (NA) #1 and NA #2 on either side of her. Resident #1 told her she was trying to slide back in the wheelchair, but her leg gave out on her. NA #1 and NA #2 stated they had assisted the resident to the floor. A pain assessment was performed with a 4/10 and Tylenol 650 milligrams (mg) was administered. Resident #1 stated she was hurt, but not that bad. There were no open areas or bleeding observed. After she was wheeled up to the front door for dialysis transportation, Resident #1 stated her knee was hurting worse. When Nurse #1 picked up her pant leg to assess, Resident #1 yelled out in pain. She requested to go to the hospital. An order was obtained, and Emergency Medical Services (EMS) was called. An Emergency Department (ED) report dated 12/23/22 revealed a computerized tomography (CT) scan (x-ray images from different angles) of Resident #1's right leg showed a distal (away from the center) femur acute extra-articular (outside of the joint) fracture with mild posterior medial (back midline) displacement. There was not any documentation regarding a scan performed to the left leg and no irregularities were documented of the left leg during the physical examination. A health status note written by a Nurse #5 on 12/23/22 at 2:31 PM indicated, in part, the nurse spoke with the hospital regarding Resident #1 and was told the resident had a femur fracture. Surgery was planned for the next day. A phone interview was conducted with Nurse #1 on 1/12/23 at 10:32 AM. She revealed she was getting ready to start passing medication on the morning of 12/23/22, and she heard Resident #1 scream. Nurse #1 stated she went to her room and saw Resident #1 on her knees on the floor. NA #1 and NA #2 were in the room with the resident. After she performed an assessment of Resident #1, NA #1 and NA #2 told her they were trying to transfer her from the bed to the wheelchair. Resident #1 started to slide, so they assisted her to the floor. At the time (12/23/22), Nurse #1 revealed she did not know what assistance and equipment was required for transferring Resident #1. Right after the fall, Nurse #1 indicated Resident #1 was able to perform range of motion but did complain of pain (4/10) to her right knee. All 3 staff members assisted her up into the wheelchair, and Nurse #1 went back to passing medications. Resident #1 ate a snack and watched TV until NA #1 went into her room and wheeled her up to the front for transport to dialysis. When Nurse #1 was wheeling her medication cart to the front area, she stated she had heard Resident #1 moan and said her knee pain had increased to 10/10. Nurse #1 indicated that she had tried to perform another assessment to the right knee, but when she pulled the pant leg up Resident #1 grimaced/yelled with pain. Nurse #1 stated she contacted the physician on call because Resident #1 requested to go to the hospital. When Nurse #1 received the order for transfer, she called 911 and Resident #1 was picked up by EMS. During a follow-up interview with Nurse #1 on 1/12/23 at 12:44 PM, she revealed she may have seen a mechanical lift outside the door to Resident #1's room but not inside the room when she entered after the incident on 12/23/22. During a phone interview with NA #1 on 1/12/23 at 10:57 AM, she revealed she gave Resident #1 a bath the morning of 12/23/22. She then dressed her and asked for help from NA #2 to transfer Resident #1 to the wheelchair. NA #1 indicated that she and NA #2 were getting ready to put Resident #1 in the wheelchair, and she started to yell/resist, so they guided her to the floor. Nurse #1 then came into the room and helped put Resident #1 in the wheelchair. After she was in her chair, Resident #1 seemed fine. Nurse #1 and NA #2 left the room, and she placed Resident #1 in front of the TV. After about 10 minutes, NA #1 stated she brought the resident in the wheelchair to the front door for dialysis transport. At that time, Resident #1 did not complain of any pain/discomfort, and that was the last time she saw the resident. NA #1 stated prior to transferring the resident on 12/23/22 she found care details for Resident #1 in the electronic care plan where it instructed for the mechanical lift to be used for all transfers. Before she asked for help from NA #2, she retrieved the mechanical lift and placed it in Resident #1's room. However, NA #2 told her that they did not use the lift for Resident #1, and he did not tell her why. NA #1 stated this was her first-time asking NA #2 for assistance and guidance. NA #2 was interviewed on 1/12/23 at 2:23 PM. He revealed on Resident #1's scheduled dialysis days, he assisted the NA assigned to Resident #1 with transfers. On 12/23/22, NA #2 stated Resident #1 was on the edge of her bed, and he performed a 2-person assist with NA #1 to the wheelchair like he had always done for the past 3 years. When they got her up to turn from the bed, her leg gave out and he and NA #1 assisted her to the floor. He stated he then went to get Nurse #1, who assessed Resident #1, and all 3 staff members helped her get back into the wheelchair. NA #2 indicated he then left the room and went back to his assignment. He stated there was a mechanical lift in the room, but he never had to use a lift when transferring Resident #1 in the last 3 years he had worked with her. NA #2 indicated he told this to NA #1 on 12/23/22 before transferring Resident #1. NA #2 stated he had heard of the care plan but never looked at Resident #1's care plan before, and no one had ever instructed him to use a mechanical lift with Resident #1. Hospital #1's record dated 12/24/22 indicated Resident #1 was sent to a secondary hospital (Hospital #2) for surgery on 12/24/22. Hospital #2's record from 12/24/22 through 12/29/22 revealed that on 12/24/22 the initial physical exam performed on Resident #1 noted no lower extremity edema, swelling of the right knee, and sensation/motion intact distally (away from where the bone or muscle is attached). An x-ray of Resident #1's right knee and right femur (leg) was performed on 12/24/22 and showed an impacted fracture of the distal femoral diaphysis (central part of the bone). Surgery was performed on 12/27/22 of the closed bicondylar (2 plateaus of the bone) fracture of the right distal femur. After the initial physical therapy evaluation on 12/28/22, x-rays of the left lower extremity revealed a closed left distal femur fracture. It was initially discovered during the tertiary trauma survey (a prospective study of missed injury) on 12/28/22. Orthopedic surgery was performed on 12/29/22. A Review to Ensure Quality (the facility's investigation for review of risk management) initiated on 12/23/22 and signed/completed by the Director of Nursing on 12/29/22 was reviewed. It revealed Resident #1 sustained a fall with a femur fracture. Nurse #1, NA #1, and NA #2 were interviewed and suspended pending the investigation. The RP and physician were notified on 12/23/22 at the time of the incident. Nurse #1 completed and documented her assessment of the resident after the incident. Resident #1 received medication for pain of 4/10 and sent to the ED for complaint of right knee pain. The following timeline of the fall incident on 12/23/22 was included: - 4:30 AM: NA #1 had resident dressed and ready for transfer to wheelchair - 4:40 AM: While transferring, Resident #1 began resisting and/or went limp. She was assisted to the floor. - 4:50 AM: Resident #1 was assisted back to the wheelchair. - 5:00 AM: Resident #1 was left in her room to watch television. - 5:20 AM: Resident #1 complained of knee pain 4/10. She was given Tylenol by Nurse #1 without Medication Administration Record (MAR) documentation. Corrective action included an in-service that began on 12/26/22 by the Director of Nursing to all nursing staff regarding safe transfers, utilizing the care plan/Kardex (a task list for NAs), falls, and handling residents with challenging behaviors. All staff who had not participated in the training as of 12/30/22 were not allowed to return to work until completed. A telephone interview was conducted with the NP on 1/12/23 at 10:42 AM. She revealed Resident #1 did not typically stand and bear weight, and she was not sure if that was because she did not want to or was not capable. The NP stated she had called over to the ED on 12/23/22 and was informed Resident #1 had a right leg fracture but was then sent out to another hospital. At that time, medical staff had not found the left leg fracture yet. After the right leg surgery, Resident #1 began physical therapy at the second hospital, the NP indicated she complained of pain and an x-ray was performed where a fracture in the left leg was found as well. During a telephone interview with the Medical Director on 1/12/23 at 11:49 AM, she revealed she could not confirm the left leg fracture was a result of the fall, since it was not discovered initially. An interview was conducted on 1/18/23 at 2:24 PM with the Orthopedic Surgeon, who operated on Resident #1 in the secondary hospital (Hospital #2) on 12/27/22. He stated he believed with great certainty the left femur fracture was related to the fall on 12/23/22, and the second injury was missed by both hospitals. Physician #1 stated he had fixed the right femur and noticed Resident #1 was having pain on the other side. During follow-up exams, Resident #1 was having pain on the left side as a result, which was an identical injury to the right leg fracture. Physician #1 stated a fracture would begin to heal within 2-4 weeks (subacute), which could be identified with imaging. From Resident #1's operation and imaging results, both leg fractures appeared fresh (acute) with similar timelines. Resident #1 did not want anyone touching her anywhere, and all the medical attention was placed on her right leg. Usually, Physician #1 indicated that localized pain to a leg held the focus of the treatment. An interview was attempted with the Radiologist who performed an x-ray on 12/24/22 of Resident #1's right leg at Hospital #2, but she was unable to be reached during the investigation. The Director of Nursing (DON) was interviewed via telephone on 1/13/23 at 4:28 PM, and she revealed her expectation was that all nursing assistants be skilled on how to use the mechanical lift and to utilize the care plan/task list before assisting with any ADL care. During a telephone interview with the Administrator on 1/13/23 at 4:19 PM, she revealed her expectation was for all nursing staff to follow the care plan in each resident's medical record and to follow the tasks as listed. The Administrator stated Resident #1's care plan listed mechanical lift with transfers, but she was not sure if the care plan was updated properly. She reported that the lift was added for Resident #1 after she underwent a mastectomy surgery in April of 2021. She explained that the mastectomy surgery caused Resident #1 to have more difficulty with using a bar to stand up. The Administrator revealed the NA care tasks did specify a 2-person assist and the use of the mechanical lift on dialysis days and that nursing staff assigned to Resident #1 were to use the mechanical lift only on dialysis days. She reported that the dialysis center where Resident #1 was treated required a lift pad underneath all patients prior to entry. She acknowledged that on that 12/23/22, the day of the fall, NA #1 and NA #2 were preparing the resident for dialysis when they transferred her from the bed to her wheelchair without the mechanical lift. The Administrator was notified of Immediate Jeopardy on 1/18/23 at 4:56 PM. The facility provided the following Plan of Correction (POC) with a completion date of 12/31/22: Resident #1 was discharged from the facility; therefore, no further corrective action could be obtained for Resident #1. On 12/28/2022 and 12/29/2022, a meeting to discuss Root Cause Analysis was held with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Support Nurse, Administrator, Nurse Consultant, and Regional Director of Operations. Results of the investigation were discussed during the root cause meeting and shared with Quality Assurance Committee (QA) members and with the facility Medical Director (MD). On 12/29/2022 a final root cause was identified as: employee knowledge of residents transfer status, efficiency while providing resident care, and residents medical complexities and diagnosis related to weak and brittle bones. On 12/29/2022 a final root cause was identified. On 12/28/2022, the DON, ADON, and the Unit Support Nurse reviewed 100% of the current resident's most recently completed nursing assessments and observations to identify the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. This audit was completed on 12/28/2022. On 12/28/2022, the DON reviewed the care plans for 100% of current residents. This audit consisted of a review to ensure the identified transfer status was accurately reflected on the resident's plan of care including the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. This audit was completed on 12/29/2022. The results included: 5 out of 68 care plans required updating. On 12/29/2022, the DON implemented corrective action for those residents which included: Updating the 5 resident care plans that required updating to include the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. This care plan update was completed on 12/29/2022 by the DON. On 12/28/2022, the Nurse Consultant audited the falls for the last 30 days. This audit consisted of review of falls to identify if there were any other residents who had a fall where the plan of care wasn't followed for transfers. This audit was completed on 12/28/2022. The results included: There were no other residents who had a fall where the plan of care wasn't followed. No corrective action was required. On 12/26/2022, the Director of Nursing in serviced all Licensed Nurses, Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) and Certified Nursing Assistants (Full time, Part time, and PRN staff) on Safe Transfers, falls process which included falls prevention, falls risk, and what to do if a fall occurs. This training included all current staff including agency. This training included education on: Safe Transfers, Utilizing the Kardex, when to utilize the Kardex, and the falls process. Additionally, on 12/26/2022, the DON began validation of competency of certified nursing assistants and nurses on how to access the Kardex and care plan. This competency included staff demonstration of how to view the plan of care/Kardex and verbalization of the need to review the plan of care prior to providing care. This was completed on 12/30/2022 by the DON. Since 12/28/2022, the DON, ADON, Unit Support Nurse, and the Minimum Data Set nurse (MDS) and the nurse management team have reviewed residents at the time of admission, quarterly, and with significant changes to ensure that the transfer status was accurately reflected on the resident's plan of care including the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. The Director of Nurses has ensured that all licensed nurses, RN's and LPN's and CNA's (full time, part time, and as needed) who do not complete the in-service training will not be allowed to work until the training is completed. This information has been integrated into the standard orientation training. As of 12/30/2022, any staff required to receive scheduled in-service training will not be allowed to work until training has been completed. On 01/02/2023, the Director of Nurses or a designee began monitoring for compliance to identify if staff could verbalize or demonstrate how to access the plan of care, direct observation of the care provided, and if the correct number of caregivers was used to provide the care. The monitoring is being completed using the Transfers QA Tool weekly for 4 weeks and monthly for 2 months monitoring 5 random staff completing transfers/care on various shifts and days to ensure care is being complete according to the plan of care. There have been no concerns identified from any of the monitors that were completed. The monitoring will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Additionally, reports will be presented at the quarterly QA Meeting. The Quarterly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, Health information Manager (HIM), Medical Director, Infection Preventionist, and the Dietary Manager. Onsite validation was completed on 1/23/23 through staff interviews, observation, and record review. Staff were interviewed to validate in-services completed on safe transfers, fall prevention, falls risk, and fall intervention/reporting/notification/action. Observation of a transfer with mechanical lift for Resident #4 revealed no issues, and a review of audits for transfers/lifts/staff required for transfers with lifts/care plans and Kardex were implemented. Review of residents audited for falls/transfers and resident interviews verified no additional issues were identified. The facility's action plan was validated to be completed as of 12/31/22.

Based on facility staff, Nurse Practitioner (NP), physician, and pharmacy interviews, and facility and hospital record reviews, the facility failed to administer an anticoagulant medication for a period of 30 days after admission to the facility for one of one newly admitted residents reviewed with a [DIAGNOSES REDACTED].#1). Resident #1 developed [MEDICAL CONDITIONS] and a [MEDICAL CONDITION] embolism (PE), requiring hospitalization for his evaluation and treatment. Immediate jeopardy began on 5/31/18 when Resident #1 was discharged from the hospital and initially admitted to the facility. The resident ' s hospital discharge orders indicated Eliquis (an anticoagulant medication) was included in his medication regimen due to a [DIAGNOSES REDACTED]. The order for Eliquis was verified by Nurse #5 but it was not among the admission medications included on the resident ' s physician orders [REDACTED]. Immediate jeopardy was removed on 8/23/18 when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the hospital on [DATE] after experiencing a fall at home. His discharge [DIAGNOSES REDACTED]. The resident was discharged from the hospital and admitted to the facility on [DATE]. A review of Resident #1 ' s paper chart included a fax from the hospital dated 5/31/18 at 7:59 (AM or PM was not designated). The fax included a list of the resident ' s hospital discharge medications with a handwritten checkmark next to each medication listed under the heading, Start taking these medications. This medication list included 5 milligrams (mg) Eliquis was to be given by mouth twice daily. The facility ' s Nurse Practitioner signed and dated (5/31/18) each of the two pages listing the resident ' s discharge medications. A review of Resident #1 ' s (MONTH) (YEAR) and (MONTH) (YEAR) Physician order [REDACTED]. A review of the resident ' s Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had intact cognitive skills for daily decision making. The resident required extensive assistance for all of his Activities of Daily Living (ADLs), with the exception of needing limited assistance from staff for walking, locomotion on the unit, and supervision only for locomotion off of the unit and for eating. Section I of the assessment did include [MEDICAL CONDITION] as an active diagnosis. Section N of the MDS assessment did not indicate the resident received an anticoagulant medication. A review of Resident #1 ' s Provider Progress Notes included notes written by the NP on 6/8/18, 6/14/18, and 6/22/18. Each of the progress notes indicated the resident was to continue with Eliquis for [MEDICAL CONDITION]. On 6/29/18 at 7:30 AM, a telephone order was written by the NP to obtain an X-ray to the resident ' s left hip, left knee and left ankle secondary to pain and [MEDICAL CONDITION]. A venous Doppler ultrasound to the left lower extremity was also ordered to rule out a [MEDICAL CONDITION] secondary to pain and [MEDICAL CONDITION]. A review of the results of the 6/29/18 x-ray showed Resident #1 did not have an acute fracture or dislocation. The results noted he did have moderate [MEDICAL CONDITION], predominantly involving the knee. Results of Resident #1 ' s left lower extremity venous ultrasound (signed 6/29/18 at 8:19 PM) included the following: Findings: Absent compression and absent (blood) flow extending from the common femoral vein through the popliteal vein. Visible thrombus (blood clot). (Blood) Flow is seen in the calf veins. Impression: Extensive obstructive [MEDICAL CONDITION]. On 6/29/18, a physician's order [REDACTED]. Resident #1 was admitted to the hospital on [DATE]. A review of his hospital records included the following list of Hospital Problems: Principal problem: Acute [MEDICAL CONDITION] embolism; Active problems: Acute [MEDICAL CONDITION] of his lower extremity; [MEDICAL CONDITION]; [DIAGNOSES REDACTED]; [MEDICAL CONDITION] reflux disease; and, [MEDICAL CONDITIONS]. Further review of the records from Resident #1 ' s 6/29/18 hospital admission included his History of Present Illness and read, in part: In brief, this (patient) presented with acute PE/[MEDICAL CONDITION], notably he was off his Eliquis which he was supposed to be on for his [MEDICAL CONDITION]. The hospital records also provided information on his Hospital Course dated 7/2/18: (Patient) with acute [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. **Acute PE/[MEDICAL CONDITION] – [MEDICATION NAME] gtt (an intravenous anticoagulant drip) initially as was thought to be Eliquis failure. Contacted facility and found out this medication had been stopped .so he was not taking any anticoagulant. Restarted Eliquis tonight given he was not on the medication. Family and case management to discuss with facility. A review of the resident ' s hospital discharge medication list dated 7/2/18 included 5 mg Eliquis to be given as two tablets (10 mg) by mouth twice daily. The resident was readmitted to the facility on [DATE]. His re-admission medications did include 5 mg Eliquis to be given by mouth as two tablets (10 mg) twice daily. A physician ' s clarification order was written on 7/3/18 which read: Eliquis 10 mg po (by mouth) twice a day x 7 days then Eliquis 5 mg po BID (twice daily). Documentation on Resident #1 ' s (MONTH) (YEAR) and (MONTH) (YEAR) MAR revealed the resident received the Eliquis as ordered by the physician from 7/2/18 up until the date of review on 8/23/18. An interview was conducted on 8/23/18 at 2:56 PM with the facility ' s Quality Assurance (QA) Nurse. The QA Nurse stated she also assumed responsibilities for staff development and education. During the interview, the QA Nurse reported the facility first became aware of the medication error involving Resident #1 not receiving his Eliquis as ordered when there was a suspicion he had developed a [MEDICAL CONDITION] and/or PE on the day the resident was sent out to the hospital (6/29/18). In outlining the steps the facility took to minimize the risk of this happening again, the QA Nurse reported, We did some in-servicing with the nurses. The records indicated two in-services were conducted to educate nurses on the procedures they would be expected to follow for each resident ' s admission/re-admission: 1) An In-Service Education Report (dated 6/28/18) covered the following topic(s): admission orders [REDACTED]. A typed notation under the heading of Attendees Name and Title read, Attendance is accepted by Employee ' s Signature only. Nine (9) nurses ' signatures were on the report. 2) An In-Service Education Report (dated 6/29/18) covered the following topic(s): Discharge Summary. With each admission or re-entry the discharge summary must be faxed to (Name of the contracted pharmacy). A typed notation under the heading of Attendees Name and Title read, Attendance is accepted by Employee ' s Signature only. Five (5) nurses ' signatures were on the report. Upon review of the in-service information provided, the QA Nurse was questioned why the first in-service (on the admission orders [REDACTED]. The QA Nurse stated, may have been my mistake, I dated them. The QA further clarified the day the error was discovered was the day the in-services were done; she stated the facility procedures outlined in the in-services were implemented immediately on 6/29/18. When asked why there was a discrepancy as to how many nurses attended each in-service, the QA Nurse responded by saying the in-service information had also been posted for review. During a follow-up interview with the QA Nurse on 8/23/18 at 3:53 PM, the nurse was asked how new nurses and agency nurses (temporary staffing nurses) received education on the facility ' s required procedures for ordering medications when a resident was admitted /readmitted . The QA Nurse stated that she herself conducted the orientation for new nurses and included this information in the orientation. She also reported that at this time, only two agency nurses were used by the facility and these nurses attended both of the in-services. The QA Nurse reported that other than the new nurses, Just a couple (of nurses) have not been signed off (on the in-services). Upon request, a listing of nurses currently on staff was provided. This listing identified 19 Licensed Practical Nurses (LPNs) and 4 Registered Nurses (RNs). Upon review of the staff listing, the QA Nurse reported 7 of the LPNs were new nurses and one LPN was currently on leave; one (1) of the RNs was identified as a new nurse. On 8/23/18 at 4:55 PM, the QA Nurse provided appended copies of the two in-services documented as conducted on 6/28/18 and 6/29/18. The QA Nurse reported the facility ' s Director of Nursing (DON) had her own lists that added signatures to the original In-Service Education Report previously provided. 1) The appended In-Service Education Report (dated 6/28/18) covered the following topic(s): admission orders [REDACTED]. A typed notation under the heading of Attendees Name and Title read, Attendance is accepted by Employee ' s Signature only. A total of fourteen (14) nurses ' signatures were on the report, including the 1st 9 nurses ' signatures as listed on the original In-Service Education Report previously provided. 2) An In-Service Education Report (dated 6/29/18) covered the following topic(s): Discharge Summary. With each admission or re-entry the discharge summary must be faxed to (Name of the contracted pharmacy). A typed notation under the heading of Attendees Name and Title read, Attendance is accepted by Employee ' s Signature only. A total of twelve (12) nurses ' signatures were on the report, including the 1st 5 nurses ' signatures as listed on the original In-Service Education Report previously provided). A telephone interview was conducted on 8/24/18 at 4:55 PM with Nurse #5. Nurse #5 was identified as the nurse who had admitted Resident #1 to the facility on [DATE] and input his admission medication orders into the computer. Upon inquiry, the nurse reported that she must have missed putting the Eliquis into the computer along with his other admission medications. She stated she felt really bad about the error and since that time has triple checked any orders she has put into the computer for a resident. When Nurse #5 was asked if she had faxed the hospital discharge orders over to the pharmacy when Resident #1 was admitted to the facility on [DATE], the nurse stated she thought more than likely she had called and talked with the pharmacy versus sending a fax. Nurse #5 thought she probably called the pharmacy to be sure they had received the orders and were sending the medications to the facility. When asked what in-service education she received on 8/23/18, the nurse reported it was in regards to the need to fax hospital discharge orders to the pharmacy for admissions and re-admissions. The nurse stated she was in-serviced by the facility ' s Director of Nursing (DON) and signed the in-service report on 8/23/18. A review of the original In-Service Education Report dated 6/28/18 revealed Nurse #5 ' s signature was included as having received this education. However, Nurse #5 ' s signature was not on the original In-Service Education Report dated 6/29/18 and only appeared on the appended In-Service Education Report as signature #12 of 12. An interview was conducted on 8/23/18 at 2:05 PM with the NP who had helped to care for Resident #1 after his initial admission to the facility on [DATE]. This NP also wrote the order to do a Doppler ultrasound and to send the resident out to the hospital on [DATE]. During the interview, The NP stated the day the resident was sent out to the hospital (6/29/18) was the day she found out that the resident had not been receiving Eliquis since his admission to the facility. It was an error. At that point, she talked with the facility about a plan to reduce errors. She reported the facility planned to fax the hospital discharge list to the pharmacy when a resident was admitted , the nurse would put the orders into the computer and the pharmacy would verify the orders. The NP stated she was unsure whether or not this was a new process for the facility. However, she also reported the admission orders [REDACTED]. Upon inquiry as to when the new verification process was supposed to take effect, the NP stated, I thought it was right away. A telephone interview was conducted on 8/23/18 at 5:15 PM with the facility ' s Medical Director. Upon inquiry, the Medical Director reported the NP had contacted her and told her about the concerns of this resident having a [MEDICAL CONDITION] and possible PE. She was made aware of the Eliquis not being given and the resident being sent to the hospital. During the discussion, the Medical Director confirmed both she and the NP thought the resident was receiving the Eliquis during the month of June. When asked what her thoughts were in regards to the Eliquis not being given during the month of (MONTH) prior to the resident ' s development of PE/[MEDICAL CONDITION], the Medical Director reported there were risks of the resident not having the Eliquis and she would have hoped he had been anticoagulated due to his [DIAGNOSES REDACTED]. She reported a PE/[MEDICAL CONDITION] could have occurred even for a patient who was not anticoagulated. The Medical Director added, Of course we expect the patient to be on the Eliquis as ordered. An interview was conducted on 8/23/18 at 1:55 PM with Nurse #1. Nurse #1 had not been identified as a new nurse by the QA Nurse. During the interview, the nurse was asked to describe the process for obtaining physician orders [REDACTED]. Once the orders were verified, the nurse would put the orders into the computer and his/her name would be documented electronically as having input them. The nurse would then print out a physician's order [REDACTED]. Both nurses would sign this. Nurse #1 stated she would put this physician's order [REDACTED]. When asked if there had been a change in the process followed for admission/re-admission orders [REDACTED]. During a follow-up interview conducted with Nurse #1 on 8/23/18 at 2:00 PM, the nurse was asked if she faxed anything to the pharmacy upon a resident ' s admission/re-admission to the facility. Nurse #1 stated she would generally only fax an order for [REDACTED]. A review of the original In-Service Education Report dated 6/28/18 revealed Nurse #1 ' s signature was included as having received education. A review of both the original and the appended In-Serviced Education Reports (dated 6/29/18) revealed Nurse #1 ' s signature was not included as having received education on faxing a resident ' s Discharge Summary to the pharmacy upon admission/re-admission to the facility. An interview was conducted with Nurse #2 on 8/23/18 at 2:30 PM. Nurse #2 reported she had only worked at the facility for about 2 and ½ weeks and had been identified by the QA Nurse as a new nurse at the facility. Upon inquiry, the nurse described the process of initiating medication orders for new admissions/re-admissions. She stated that because she was new, she had not yet done the entire admission process herself. Nurse #2 reported the resident ' s hospital discharge orders were used to call, verify, and obtain physician orders [REDACTED]. The nurse stated once the orders were obtained, she would put them into the computer system and those would be sent electronically to the pharmacy. Nurse #2 stated she thought she was supposed to send a fax to the pharmacy as well. When asked what she would fax to the pharmacy, the nurse reported she was not sure and questioned whether or not this would be necessary because the pharmacy would get the orders directly via the computer system. An interview was conducted with Nurse #3 on 8/23/18 at 2:45 PM. Nurse #3 reported she had worked at the facility for approximately 4-5 months. Upon inquiry, the nurse described the process of initiating medication orders for new admissions/re-admissions. She stated the hospital discharge orders would be provided by the Admission ' s staff member at the facility, the nurse would call the provider to verify the orders, and put the orders into the computer. Once the orders were in the electronic system, she would print out the resident ' s MAR and a 2nd nurse would verify the MAR compared to the hospital discharge med list. She reported both nurses would then sign the MAR. Also, Nurse #3 stated she would fax the hospital discharge orders to the pharmacy. The nurse noted she would follow the same process for a resident being readmitted to the facility. A follow-up interview was conducted on 8/24/18 at 9:35 AM with Nurse #3. When asked, the nurse stated she signed the in-service reports (dated 6/28 and 6/29) on 8/23/18. Her signature was number (#) 11 of 14 on the appended In-Service Education Report dated 6/28/18 and #8 of 12 on the appended In-Service Education Report (dated 6/29/18). An interview was conducted on 8/23/18 at 5:55 PM with Nurse #4. Nurse #4 had not been identified as a new nurse by the QA Nurse. Nurse #4 reported she began working at the facility in July. Nurse #4 was observed to be working on a hall cart at the time of the interview. When shown the two In-service Reports dated 6/28/18 and 6/29/18, the nurse was asked when she was in-serviced on these topics. Nurse #4 stated she received and signed the in-service reports on this date (8/23/18). When asked if there was anything new presented to her in the in-service education provided, the nurse stated the printing out of the orders was new to her and something that she did not know was required. Nurse #4 ' s signature was number #13 of 14 on the appended In-Service Education Report dated 6/28/18 and #1 of 12 on the appended In-Service Education Report (dated 6/29/18). A telephone interview was conducted on 8/24/18 at 9:08 AM with Pharmacist #1. Pharmacist #1 was the facility ' s former consultant pharmacist who assumed responsibility for the facility ' s medication regimen reviews in (MONTH) of (YEAR). During the interview, the pharmacist did not recall reviewing Resident #1 ' s chart. Pharmacist #1 reported she was in-house the afternoon he was sent out to the hospital on [DATE] and thought he was on her list to review that day. The pharmacist stated she called the dispensing pharmacy the afternoon of 6/29/18 and found out the pharmacy had not received an order to dispense Eliquis for Resident #1 upon his admission to the facility on [DATE]. A telephone interview was conducted on 8/24/18 at 4:00 PM with Pharmacist #2. Pharmacist #2 was a staff pharmacist who worked at the dispensing pharmacy. Pharmacist #2 confirmed she had completed an Interim Drug Regimen Review on 6/1/18 for Resident #1. The pharmacist reviewed Resident #1 ' s pharmacy records and reported she would have had access to any electronic orders that came over from the facility (Eliquis was not among the medications ordered). Pharmacist #2 stated she did not have access to the resident ' s medical [DIAGNOSES REDACTED]. For this reason, she requested the facility provide a [DIAGNOSES REDACTED]. The pharmacist reported the Interim Drug Regimen Review was completed for every resident admitted on Medicare to a skilled facility. An interview was conducted on 8/24/18 at 4:45 PM with Nurse #6. Nurse #6 had not been identified as a new nurse by the QA Nurse. During the interview, Nurse #6 was asked if she had been in-serviced on the required procedures to order medications for a newly admitted resident. The nurse stated she was in-serviced on 8/23/18 and she signed the in-service sheet on that date as well. Nurse #6 ' s signature was number #10 of 14 on the In-Service Education Report dated 6/28/18 and #7 of 12 on the appended In-Service Education Report (dated 6/29/18). When asked if there was anything new or different that she learned when in-serviced on 8/23/18, the nurse stated printing out a copy of the resident ' s orders was new to her. A follow-up interview was conducted with Nurse #6 on 8/24/18 at 7:45 PM. During the interview, the nurse confirmed she first learned the facility required a copy of a newly admitted resident ' s orders to be printed out on 8/23/18. When asked if this in-service information had been shared with her prior to 8/23/18, the nurse reported it had not. An interview was conducted on 8/24/18 at 10:07 AM with the facility ' s Administrator. During the interview, the error that caused the medication order for Resident #1 ' s Eliquis to be missed upon his admission to the facility was discussed. Upon inquiry, the Administrator indicated she would have expected the nursing staff to use the hospital discharge medication list as a basis for verifying and ordering a newly admitted resident ' s medications. On 8/24/18 at 10:15 AM, the Administrator was informed of the immediate jeopardy. The facility ' s allegation of Immediate Jeopardy removal indicated: Louisburg Healthcare and Rehabilitation Allegation of Compliance F760 The process that lead to the deficiency cited: Resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Take 1 tablet (5mg total) by mouth Two (2) times a day. The admitting nurse failed to include the medication on the MAR or to order the medication from the pharmacy. As a result, the resident did not receive the Eliquis as ordered from 05/31/2018 through 06/29/2018. The nurse verified the order with the physician, but failed to put it in the computer. The nurse admits it was an oversight. A human error. As a result, the second nurse checking orders and discharge summaries was implemented on 06/29/218. On 06/29/2018, the resident was referred to be seen by the Nurse Practitioner related to increased confusion, poor appetite and a physical decline. Nurse Practitioner ordered an x-ray and venous ultra sound of his left lower extremity. Results were obtained at 11:26am on 06/29/2018 (Positive for [MEDICAL CONDITION] and Negative for fracture). The Nurse Practitioner gave orders to the Director of Nursing to increase Eliquis dose to 10mg twice daily. The Director of Nursing discovered the missing order when she tried to discontinue the old order of 5mg. twice daily. The Nurse Practitioner voided the medication change order and gave an order to send the resident to the emergency room . The procedure for implementing the plan of correction for the specific deficiency cited: Two in-services were conducted on 06/29/2018. The Director of Nursing and Quality Assurance Nurse in-serviced nursing staff on: 1). 8 of 11 facility nurses received training on admission orders [REDACTED] 2) 5 of 11 facility nurses were in-serviced on how to include the hospital discharge summary for all admits/readmits with fax to pharmacy. On 08/23/2018, the Director of Nursing trained new nurses and nurses that had not received the training on admission/readmission orders [REDACTED]. Any nurse that has did not receive the training on will not be allowed to work until they have completed the training. On 08/23/2018, the Director of Nursing trained new nurses and nurses that had not received the training on how to including the hospital discharge summary for all admits/readmits with fax to pharmacy. Any nurse that has did not receive the training on will not be allowed to work until they have completed the training. The Director of Nursing and Quality Assurance Nurse conducted an audit of new admits/readmits for second signatures and discharge summary faxed to pharmacy as a second check to ensure all discharge meds are included in orders on 06/29/218. These audits conducted daily during morning clinical meetings. A 100% audit of all residents on anti-coagulants was completed by the Quality Assurance Nurse on 06/29/2018 to ensure medications were available. The Nurse Practitioner reviewed all [DIAGNOSES REDACTED]. One resident was found to meet the criteria, however his physician did not want him on medication due to frequent [MEDICAL CONDITION] and the benefits out way the risk. The computer software alerts the DON, and the QA Nurse daily as to medication omissions. Any omissions are communicated to the nurse responsible for correction. The facility chose to review (MONTH) ' s orders admits/readmits from 06/01/2018 – 06/29/2018 to audit orders by the Director of Nursing/Treatment Nurse and Quality Assurance Nurse to ensure all medications were available and in the med cart/discharge summaries matched the Medication Administration Record on 06/29/2018. Since 06/29/2018, each admit/readmit record is reviewed during the daily morning clinical meeting by the Director of Nursing, RN Supervisor or Quality Assurance nurse to ensure all medications are ordered per the discharge summary and recorded on the MAR. The procedure for ensuring the plan of correction is effective and that the specific cited deficiency cited remains corrected and/or in compliance with the regulatory requirements. Effective 06/29/2018 any newly hired nurses will be trained during orientation by the Director of Nursing or Quality Assurance Nurse on 1) all admission orders [REDACTED]. On 06/29/2018 the QA committee recommended five time per week audits times six months of all new admissions and re-admissions will be completed by the Director of Nursing/Quality Assurance nurse or RN Supervisor to ensure second signatures and that discharge summaries are faxed to the pharmacy utilizing a Physician order [REDACTED]. On 06/29/2018, the decision was made to complete audits and forward to the QAPI committee monthly for review and recommendations times six months. Title of the person responsible for implementing the acceptable plan of correction. Director of Nursing/QA Nurse. The facility alleges compliance 08/23/2018. The facility ' s credible allegation of Immediate Jeopardy removal was validated on 8/24/18 at 7:45 PM. On 8/23/18 from 5:55 PM through 8/24/18 at 7:45 PM, LPNs and RNs working at the facility were interviewed in regards to the in-service education received. Staff were able to describe the education received on the facility ' s procedures regarding the initiation of medication orders for newly admitted or readmitted residents. The nurses reported all admission orders [REDACTED]. Additionally, the nurses reported a resident ' s hospital discharge medication list needed to be faxed over to the pharmacy when a resident was admitted or readmitted to the facility. Administrative staff, including the Director of Nursing, the QA Nurse, and the Administrator were also interviewed. The DON and QA Nurse were able to describe their respective role in the monitoring process to assure continued compliance. The immediate jeopardy was removed on 8/23/18.

Based on record review, observation, resident, staff and nurse practitioner interviews, the facility failed to secure a resident in the van during transport according to manufacturer's recommendations causing the resident to fall for 1 of 3 sampled residents who were transported using a contracted van service and failed to notify a supervisor or call 911 for assistance when 1 of 1 fell to the van floor and remained on the van floor for the duration of her transport to a physician ' s visit (Resident #3). Resident #3 slid out of the wheelchair when the driver abruptly stopped and then swerved to avoid hitting the vehicle in front of him resulting in the resident landing on her buttocks and sliding forward on the van floor. The driver was unable to place her back in the wheelchair and she was left on the van floor for the remainder of the trip, which was approximately 7-9 minutes until she reached her appointment destination. There were no injuries sustained. Findings included: Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) Assessment date 1/25/18 identified Resident #3 as cognitively intact with a Brief Interview for Mental Status score of 14. Review of the medical record indicated Resident #3 had a physician ' s appointment on 2/1/18 at 7:15 AM. The manufacturer's instructions for restraining the occupant in the van was reviewed. The instruction illustrated six (6) restraints to be used during wheelchair transportation including left rear wheel, right rear wheel, left front wheel, right front wheel, waist, and upper body. The instruction read, BE CERTAIN THAT ALL PASSENGERS ARE PROPERLY SECURED BEFORE MOVING THE VEHICLE. Review of the contracted van service policy read, in part, if an incident results in injury or suspected injury, it is important that employees report the incident immediately and secure the appropriate assistance. Of course, if the incident results in a serious trauma or emergency medical condition, call 911 immediately. The record of the van driver was reviewed. The record indicated that the driver was trained on transportation safety using the manufacturer's instruction on how to secure the wheelchair and the resident in the van in April 2017 and the facility had a copy of his certificate for this training. Review of the contract van company ' s supervisor ' s accident investigation report dated 2/1/18 indicated the driver was travelling too fast for the road conditions and too close to the vehicle in front of him. The report also indicated the seat belt was not checked properly when put on the resident and the driver failed to do his job as he was trained by not calling 911 to help place Resident #3 back into her wheelchair at the time of the incident. Review of the nursing note dated 2/1/18 indicated Resident #3 had left for an appointment earlier in the day via a contract ambulance service. The facility staff received a phone call notifying them Resident #3 had been in an incident. When the resident arrived back to the facility she was assessed for injuries. Resident #3 had complaints of pain around her sacral area and was given a pain medication. The Nurse Practitioner was in the facility and assessed the resident and ordered x-rays. Resident #3 was sitting in a chair and talking at this time. Review of the facility resident incident report dated 2/1/18 indicated Resident #3 was off facility grounds in a private vehicle and involved in an automobile accident. Resident #3 had left the facility to go to an appointment. The facility was notified later that the resident had been in an incident and had fallen on the floor of the transport van. The resident return to the facility after the appointment and was assessed for injuries and x-rays were performed. The resident was given PRN (as needed) pain medication for complaints of pain. Review of the Nurse Practitioner ' s note dated 2/1/18 indicated Resident #3 was seen following a motor vehicle accident and complaints of back pain. Resident #3 was noted to be alert and verbal and in no acute distress with mild anxiety. Her vital signs were stable and her pain was controlled. The note indicated x-rays of the lumbar and sacral regions would be ordered. Review of the [MEDICATION NAME] Spine x-ray results, dated 2/1/18, revealed mild [MEDICAL CONDITION] disc disease of the [MEDICATION NAME] spine. Review of the Sacrum/Coccyx x-ray results, dated 2/1/18 revealed no fracture or significant destructive osseous lesion seen. Review of the Pelvis x-ray dated 2/1/18 revealed modest [MEDICAL CONDITION], but no pelvic or [MEDICAL CONDITION]. Review of the Lumbar Spine x-ray dated 2/1/18 revealed No compression fracture or bone lesion was noted. Review of the Ankle x-ray dated 2/1/18 revealed no acute fracture, dislocation or destructive osseous lesion. Review of the written statement from the driver dated 2/1/18 was reviewed. The report indicated he approached a merge in the road and realized the traffic was stopping so he braked hard and swerved to avoid hitting the car in front of him and heard a clunk which he realized was the seat belt buckle of the van hitting the floor. The report further indicated the gel pad on which the resident was sitting on slid from the wheelchair. The driver stopped the van in the median to check on Resident #3. She voiced no complaints. The driver attempted to place Resident #3 back in the wheelchair but was unable to do so. The report indicated he made her as comfortable as I could and proceeded to the destination which was only 7-9 minutes away. When the driver arrived at the destination a family member came outside and assisted by telling the driver how to place Resident #3 into her wheelchair. The written statement from Resident #3 was reviewed. The statement from Resident #3 was dated 2/5/18 and read Resident #3 was put on the bus and her wheelchair was fastened but not her. The driver was driving and to keep from hitting a car he slammed on the brakes. When he hit the brakes Resident #3 slid out of her wheelchair landing on her back feeling like she bruised her ankle as well as hurting her backside. She stated she slid all the way from the back of the bus to the front of the bus while on the floor. The driver then stopped and pulled the bus over and attempted to pick the resident up off the floor but was unable to do so. The driver told her that he could not get her up, so he got back into the bus and drove while she was on the floor. When arriving at her appointment the driver pulled her by her leg trying to get her out of the bus and off the floor. A family member met the resident at the appointment and was at the scene when the driver placed the resident into her wheelchair. During an interview with the Administrator on 2/13/18 at 10:41 AM she stated the contracted van service took Resident #3 to an appointment on 2/1/18 and apparently the driver had to slam on the brakes and Resident #3 fell from her wheelchair. She further stated Resident #3 had a seat belt on that had not been applied correctly and she was not wearing a harness seat belt. She stated the resident ' s family member met Resident #3 at her appointment, learned what had happened and called the facility. She stated when she found out she called the ambulance service and stated she did not want that driver returning the resident to the facility and was informed by the service that the driver was already back in route to the facility. The Administrator then stated the Nurse Practitioner was in the building when the resident arrived and the resident was assessed and x-rays were done with no injuries noted. She also stated the family member had followed the transport van back to the facility and he told the facility he watched the van driver load the resident into the van and ensured the seat belts were applied correctly. The Administrator stated when she interviewed the resident the resident stated the wheelchair was locked down but she had no shoulder harness seat belt on. She stated the van driver should have applied the seat belt correctly and he should have notified 911 when the incident occurred and the resident was on the van floor. She stated on the day of the incident the facility began re-training all the of contract drivers for the named transport company when they arrived to transport any resident. She stated the first training started on 2/1/18 when the named transport company came to the facility at 9:30 AM. The Facility Environmental Services Director checked that the wheelchair was secure and the seat belt and shoulder harness were in working condition and applied correctly. She stated on 2/5/18 the facility transport personnel were in-serviced on transport van safety including proper lock down of the wheelchair and pulling over in case of emergencies and calling 911 and the facility. She stated the Environmental Services Director was keeping a log of all of the named transport appointments and in-servicing each driver and checking to ensure each resident was secured properly. During an interview with Resident #3 on 2/13/18 at 11:25 AM she stated she had a doctor ' s appointment and the driver from the van company put her in the van. She stated she was sitting towards the back of the van and the driver locked in the wheelchair but did not put the seatbelt harness over her. She stated the van was traveling down the road and the driver slammed on the brakes to not hit the car in front of him. She stated she came out of the wheelchair and slid on her back to the front of the van. She stated she was quite shook up to be in your wheelchair one minute and on the floor the next and this was frightening. She stated the driver pulled over and tried to get her up but could not and said she would have to stay on the floor until they arrived at her appointment. She continued by stating when she arrived at the physician ' s office the driver opened the side door and her feet were towards the door. She stated her family member was there waiting and helped get me into my wheelchair. She stated that after her appointment her family member made sure she was locked in and the seatbelt on before the driver brought her back to the facility. She stated she was not really complaining of too much pain but her buttocks was hurting and she had x-rays which were all ok. She stated it was just scary. During an interview with the supervisor of the driver of the named ambulance service on 2/13/18 at 12:56 PM he stated as far as he knew the driver was going down the road and he heard the seat belt strap hit the floor and the Resident #3 slid out the chair with her gel cushion. The driver pulled over and tried to pick Resident #3 up and could not so he then drove another 7 to 8 minutes to the physician ' s office to get help. He stated on this particular transport van the patient enters from the rear of the van. There are four wheelchair locks to secure the base of the wheelchair, two in the front of the chair and two in the rear. He stated there was a harness seatbelt that crosses over the patient and a lap seat belt. He stated he could only figure that the seat belt was not snapped in all the way. He stated all drivers take an online course in van safety and they receive a certificate stating they understand how to secure a wheelchair in the van. He stated he checked the van when the driver returned to the company and both the waist seat belt and harness were in working condition. He stated his expectation would have been for the driver to properly secure the patient in the van and to call 911 to get help when he could not place the patient back into the wheelchair in route to the appointment. He stated their policy read that the driver should have notified his supervisor and 911. During an interview with transport driver on 2/13/18 at 1:00 PM, who transported Resident #3 on 2/01/18, he stated Resident #3 was sitting next to the nursing station at the time of the pickup. Resident #3 was going to an appointment in Raleigh near the hospital. He stated he put her in the van from the back while she was seated in her wheel chair. He stated he rode up on the lift with the wheelchair after wheels were locked on the platform and once the wheelchair was up he unlocked the wheels and pushed the wheelchair into the van. At this time he aligned the wheelchair wheels to the straps mounted on the floor and secured the wheels. He stated there are four (4) hooks used to secure the wheelchair frame in four (4) areas. He then stated there was a lap seat belt that was connected from the bottom of the van and that was placed around Resident #3 ' s waist and attached to the other side of the floor. He stated he did not use a harness seatbelt because he had never been able to find the attachment that made this part of the seat belt work. He stated he was told that the lap seatbelt was sufficient sometime during his training in April 2017. He then stated while driving and merging near Capital Boulevard in Raleigh he noticed traffic breaking hard. He stated he applied the brakes hard and realized he could not bring the van to a stop before hitting the car in front of him. He noticed the median and made a decision to turn the van right to miss the car in front and swerved over. At this time he heard a clunk sound and heard Resident #3 say, whoa, whoa, whoa. He stated he knew the clunk sound was the seatbelt hitting the floor because he hears that sound multiple times a day when he unlatches the belt and drops it to the floor. He stated he looked in his mirror and saw Resident #3s head drop down slowly and he glanced back to see that she had slipped out of her seat. He stated he brought the van to a stop, put it in park, put the hazard lights on and jumped out and came around the van. When opening the van door the resident stated she was ok. He stated he tried to get her up but could not. He stated she had been sitting on a gel pad that slid out of the wheelchair onto the van floor. He stated he really did not remember what he was thinking at the time but decided the best thing was to continue on to her appointment where he could get help. When they arrived at the appointment he stated someone came out from inside that knew the resident and the resident suggested opening the side door and sliding her to the side so she could put her legs down and then get into her wheelchair. He stated he lifted her and she pivoted to the chair. He stated he waited for her until the appointment was finished and then put her back into the van to return to the facility. He stated he really did not know if the strap was hooked correctly or what happened but that he did push the two pieces of the seatbelt together but could not say if he ever heard the belt click closed in retrospect. During an interview with the Nurse Practitioner on 2/13/18 at 1:24 PM she stated she evaluated Resident #3 upon her return to the facility on [DATE]. She stated the resident was alert and oriented. She stated Resident #3 complained of some back pain so she ordered multiple x-rays which were negative. She stated the resident did have a [DIAGNOSES REDACTED]. She also stated she would expect that the residents are seat belted in properly when being transported. During an interview with the nurse consultant on 2/14/18 at 12:16 PM she stated it was 30 minutes from the time of the incident until the driver was able to get the resident out of the van at the physician appointment based on her interview with the family member in which he stated Resident #3 was approximately 30 minutes late for her appointment. During an interview with Resident #3 ' s family member on 2/14/18 at 12:33 PM he stated the driver of the company didn ' t have Resident #3 tied in so when the driver had to make a quick stop Resident #3 came out of the chair and hit the floor. He stated apparently the driver could not get her back into the wheelchair so he drove her to the doctor ' s office on the floor. He stated when he saw the van pull up he went out to meet her and the driver told him what happened. The driver opened the side door and the resident was on the floor. He stated the driver and he put her feet on the ground and the driver went inside the van and unbuckled the wheelchair. The driver then got her up by placing his arms under her arms and lifted her a little just enough to turn so she could sit in the wheelchair. The resident was supposed to be at her appointment at 7:15 AM and she arrived around 7:30-7:35 AM and it took about 5 minutes to get her off the floor into her wheelchair. He stated she was quite shook up. He stated after the appointment he watched the driver buckle the resident in and then he followed the van back at the nursing home. CORRECTIVE ACTION The Administrator and Regional Nurse Consultant were interviewed on 2/13/18 at 10:41 AM. They stated they had done an investigation, initiated re-training, in-services and audits for transportation staff and put a Plan of Correction (P(NAME)) in place that began on 2/1/18. The Administrator added that she strongly suggested the named Ambulance transport service re-train their employees and that she would expect her residents to be safe during a transfers. She stated the driver of the van had been terminated by the named transport service. On 2/1/18 the Administrator, Quality Assurance Nurse, Regional Nurse Consultant and the Facility Environmental Services Director had an impromptu Quality Improvement Executive Committee Meeting to specifically review the facility plan related to the re-training, in-services and audit tool. On 2/1/18 the facility began requiring all drivers from the named Ambulance transport service to be checked off by the facility Environmental Services Director for properly securing the wheelchair and resident with four point floor straps, waist and chest harnesses before the transport occurs. This training had been recorded in the Transport Log Book. On 2/2/18 the facility received requested training/policies from the named Ambulance transport service. This training included certifications of all named Ambulance transport drivers according to their van manufacturer ' s specifications. On 2/5/18 100% of the facility employed van drivers were re-trained on the facility policy for van safety according the van manufacturers ' specification, proper lock down of wheelchairs and pulling over in case of an emergency or incident that may cause injury to the resident and calling 911 and the facility. The Administrator will forward the results of the Transport Log book audit to the Executive QI Committee for monthly review and recommendations times one month. Final date of compliance 2/6/2018. The Administrator and Environmental Services Director will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the credible allegation of compliance for prevention of accidents. As part of the validation process on 2/14/18, the plan of correction was reviewed including the re-education of staff and observations of interventions put into place to ensure wheelchairs were properly secured in the transport van with four point floor straps, waist and chest harnesses intact. Observations were made of other residents who required the use of the transport van for correct application of the wheelchair straps and seatbelts according to manufacturer's instructions. Interviews with transport drivers revealed they were retrained to ensure the wheelchair was securely locked down using four straps and the waist and shoulder harness seatbelts were applied to the resident correctly. A review of the monitoring tool revealed that the facility completed the audits and re-training of van drivers. The facility alleges full compliance with this plan of correction effective 2/6/18.

Based on observation, record review and staff, family and nurse practitioner interviews the facility failed to identify a side rail as an accident hazard for 1 of 5 sampled residents (Resident #1) that resulted in entrapment of the resident's arm in the side rail. The facility also failed to identify the use of a side rail as a potential accident hazard for 2 of 5 sampled residents that was not immediate jeopardy (Resident #5 and Resident #2). The findings included: The Immediate Jeopardy began on 2/8/17 with the entrapment of the arm of Resident #1 between the side rail and the mattress of the bed and was removed on 2/15/17 at 6:30 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimum harm that is not immediate jeopardy) to complete employee education, to ensure monitoring systems are in place that are effective and due to examples 2 and 3 for Resident #2 and Resident #5. 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] noted the resident was admitted to the facility at 12:10 PM and was accompanied by family members who provided the admitting information. The assessment noted the resident was disoriented to time and place, had clear speech and was sometimes understood with ability limited to making concrete requests. The Assessment further noted the resident had active range of motion, was dependent on staff for transfers, required the assistance of 2 persons for ambulation, was dependent on staff for locomotion in a wheelchair and had a history of [REDACTED]. Under Sleep Patterns the assessment noted the family stated the resident did not sleep well. The Assessment contained an electronic signature of Nurse #1 at 2:49 PM. A Skin assessment dated [DATE], completed by Nurse #1, noted a discoloration on the resident's left thigh. There was not a side rail assessment completed on 2/7/17. A Resident Incident Report dated 2/8/17 at 3:50 AM completed by Nurse #2 revealed the resident was noted with the left arm between the side rail and the bed. The report noted the arm was removed from the area and the only abnormality noted of the arm was red discoloration. The report did not provide a specific location of the area of red discoloration on the arm. A Side Rail Screen completed on 2/8/17 at 10:17 AM noted the resident used the side rail for support or positioning and revealed side rails were indicated and served as an enabler to promote independence. The assessment did not specify the length of the side rails appropriate for the resident. A Physical Therapy note dated 2/8/17 at 12:29 PM noted activity limitations and participation restrictions included dementia, weakness, decreased endurance and poor standing balance. The note revealed the resident required heavy verbal and tactile cuing along with demonstration in order to follow even basic 1-step commands. A Physical Therapy note documented on 2/8/17 at 2:47 PM revealed the resident required maximum assistance of 2 persons for rolling in bed, supine to sitting position and moderate assistance of 2 persons to transfer from the bed to the chair and much extra time with poor command following. The note revealed the left arm was bruised but she was able to elevate the left arm above 90 degrees and denied pain. She did not demonstrate facial grimacing or other pain behaviors. A nurse's note dated 2/8/17 at 2:47 PM noted Resident #1 had been transported to the hospital (The resident did not return to the facility). A follow-up note on the Resident Incident Report dated 2/8/17 revealed the arm had areas of discoloration (no location provided) with no edema or pain and physical therapy evaluated the resident who had full range of motion of the arm. It was noted the primary care physician was in the facility and assessed the resident and ordered an X-ray to ensure no occult injury. The note further revealed the family requested the resident be sent to the Emergency Department (ED) for further evaluation instead of a mobile X-ray. Review of the ED Record for Resident #1 dated 2/8/17 revealed a physician's note that a family member found the resident wedged between the bed and the bed rail and had some new bruises on her left arm, forearm and leg. The physician's exam revealed the following: Extremities revealed no obvious deformity though she does have bruising over the left arm and left forearm. This bruising is red and does not have the appearance of an abrasion with the limb trapped between 2 surfaces. There is a small bruise on the distal shin on the left. Grossly normal passive range of motion at all major joints. All peripheral pulses symmetrical and equal. The ED record revealed the resident was admitted to the hospital related to her increased altered mental status. X-rays were completed at the hospital on [DATE] for Resident #1 and reported as follows: Left Humerus-No evidence of fracture. Left Forearm-No evidence of acute bony abnormality. Left tibia/fibula-Degenerative changes without acute fracture. ED final impression: Altered Mental Status and left upper arm injury. On 2/13/17 at 11:45 AM, Nurse #1 stated in an interview Resident #1 was admitted to a bed that had 3/4 length rails on the bed. The Nurse stated a family member told her the resident had sundowning (increased confusion and agitation at night) and would get out of bed and pull her clothes off. The Nurse stated the family wanted the side rail up so the resident would not fall out of bed. The Nurse stated she explained to the family that side rails were not safe and explained she would put the bed in the low position with a fall mat beside the bed. The Nurse stated a family member insisted the side rails be put up on the bed so she put the side rails up. The Nurse stated she did not notify any of the management staff the family wanted the side rails up. On 2/13/17 at 12:50 PM an interview was conducted with NA (Nursing Assistant) #1 who was assigned to Resident #1 on the 11 PM to 7 AM shift on 2/7-8/17. The NA stated during the night the resident was agitated and kept trying to get out of the bed. The NA stated she checked on the resident every time she went by the room and the resident would roll from side to side trying to put her feet over the side of the bed and sometimes the resident would have her feet hanging off of the bed and she would put the resident's feet back on the bed and tell the resident not to get up. The NA stated a family member entered the facility between 3:00 and 4:00 AM to check on the resident. The NA stated the family member came and told her the resident's arm was stuck in the side rail. The NA stated she had checked on the resident about 10 minutes prior to this and had gone to assist another resident to the bathroom. The NA stated the resident's left upper arm was stuck in between the rail and the bed and she went and got the nurse who came and got the resident's arm out. The NA stated there was some redness of the resident's arm. On 2/13/17 at 2:15 PM an interview was conducted with the Director of Nursing (DON) and the Administrator. The Administrator stated when she came to work on the morning of 2/8/17 she was notified that Resident #1 got her arm caught between the side rail and the mattress of the bed. The Administrator stated there was not much space between the side rail and the mattress and they could not figure out how she got her arm stuck between the mattress and the side rail. The Administrator stated they had some beds with full length and 3/4 length side rails and the staff had been trained on the use of side rails in the facility. The Administrator stated she could not take the rails off of the beds because she did not have anywhere to store them. On 2/13/17 at 3:14 PM an interview was conducted with Nurse #2 who was assigned to Resident #1 on the 11 PM to 7 AM shift on 2/7-8/17. The Nurse stated the NA called her to the room and when she entered the room she observed the resident lying on the left side of the bed and her arm was straight down between the mattress and near the end of the side rail closest to the head of the bed. The Nurse further stated she slid the resident's arm out from the mattress and the bed rail and noted some red areas on her arm but the skin was intact. The Nurse stated she asked the resident if her arm hurt and she told her it did so she gave the resident some Tylenol and propped the arm up on a pillow. The Nurse stated there was not a gap between the mattress and the side rail. The Nurse stated the family member left the facility and approximately 30 minutes later another family member came in and stayed with the resident the rest of the night. On 2/13/17 at 5:00 PM the Administrator stated in an interview on this date she had instructed the Maintenance Director to remove all the 3/4 length and full length side rails from the beds in the facility and some had been removed and would be completed by the next day. On 2/14/17 at 11:37 AM Nurse #1 stated in an interview she checked the resident over prior to going to the hospital on [DATE] and did not see any bruises other than the ones on the arm. The Nurse further stated she did note a small circular bruise to the resident's upper, lateral thigh near the hip on admission and she documented this on the skin assessment when admitted on [DATE]. On 2/14/17 at 2:35 PM an interview was conducted with the family member who found the resident between 3:00 and 4:00 AM on 2/8/17 with an arm between the side rail and the mattress. Family Member #1 stated she found the resident lying flat on her back with her left arm down in the rail about 1/3 of the way down from the beginning of the rail near the head of the bed. The Family Member stated the resident's body was somewhat sideways the bed and she was uncovered. On 2/14/17 at 2:57 PM the Administrator stated in an interview she spoke with the resident's family on the morning of 2/8/17 and advised them the facility did not encourage the use of side rails as there could be worse injury with the rails than without them. The Administrator stated the family wanted side rails on the bed and a seat belt on the resident. The Administrator stated she explained to the family they could not do this. On 2/15/17 at 10:48 AM the Administrator stated in an interview when she came in on the morning of 2/8/17 she learned of the problem with Resident #1 regarding the side rail. The Administrator stated she and the maintenance director looked at the bed and the mattress covered the bed frame. The Administrator stated some of their beds were old and the beds and the mattresses were ordered separately and the manufacturer's instructions did not specify the type of mattress to be used. The Administrator stated they used FDA (Federal Drug Administration) guidelines for dimensional limits between the side rail and the mattress and the space between the mattress and the bed rail for Resident #1 was within those guidelines. On 2/15/17 at 11:07 AM the Maintenance Director stated in an interview without the resident on the bed the space between the bed and the 3/4 length side rails was 1/8-1/2 an inch. The Maintenance Director stated the side rails were fully functional and were not broken, bent or damaged in any way. The Maintenance Director stated he was instructed to remove the 3/4 length rails and put on 1/4 length rails on the bed of Resident #1 which he did. The Maintenance Director stated he had been instructed to remove all full length and 3/4 length side rails from the beds of residents whose side rails were not to be used and this had been done. On 2/15/17 at 11:20 AM, an observation of the bed for Resident #1 was conducted with the Maintenance Director who stated as far as he knew, the mattress on the bed had not been changed. There were 1/4 side rails near the head of the bed. The mattress fully covered the bed frame to approximately 1/8 inch beyond the edge of the bed. The Administrator was notified of the Immediate Jeopardy on 2/14/17 at 3:15 PM. The facility provided a credible allegation of compliance on 2/15/17 at 6:00 PM. The Allegation of Compliance indicated: Resident #1 with arm discoloration due to side rail had arm released and assessed for injury at time of event. No significant injury identified. Resident had 3/4 rails raised prior to having arm caught between mattress and side rail. (The assessed gap between mattress and rail found acceptable space of 0.5 inches between mattress and 3/4 rail per FDA guidelines for all beds in facility prior to use in any resident rooms). Upon release of the residents arm, a pillow was placed between side rail and resident by the charge nurse to prevent reoccurrence of catching arm between mattress and rail. On the morning of 2/8/17 a side rail assessment was done and Environmental Services was contacted to remove the 3/4 rails from the bed and was provided upper 1/4 rails to assist with turning and positioning. This was done after Resident #1 was assisted to a wheelchair. The Admissions Coordinator had explained to family that the use of side rails can pose more of a hazard than nonuse and side rail use required a physician's orders [REDACTED]. The resident had not yet been identified as needing side rails and made no effort to exit bed per nursing staff. At approximately 7:30 AM on 2/8/17, Physical Therapy evaluated the left arm of Resident #1 and noted no loss of range of motion, no evidence of pain verbally or nonverbally. Physical Therapy also evaluated for potential structural injury such as fracture, limited range of motion. Resident #1 denied pain when asked and smiled with relaxed facial features and posture during and post evaluation for further injury. The Nurse Practitioner was asked to evaluate resident which was done at approximately 10:30 AM on 2/8/17 and noted discoloration to the left upper extremity and no change in range of motion. The Nurse Practitioner requested mobile X-ray to evaluate for fracture but family requested resident be sent out to the hospital for evaluation. The Family remained with the resident, meals offered and staff assisted resident with ADL (activities of daily living) needs. Ambulance service picked up resident for transfer after lunch and resident was transported to the hospital. On the evening of 2/8/17 the hospital reported the resident had been admitted . Resident did not return to this facility. On 2/13/17 all 1/4 side rails used on the beds of residents were assessed and needed for turning and repositioning and were determined not to be a restraint for these residents. These assessments were completed by the Director of Nursing, Administrator and the MDS Nurses. These residents were assessed for potential injury related to the use of the 1/4 side rails and no associated injuries were noted. FDA guidelines were used in the absence of manufacturer's instructions to determine appropriate fit of mattress to bed frame to prevent injury. Only one resident had 3/4 side rails in use with appropriate assessment, physician order, and care plan for use. This resident had no evidence of injuries correlating with use of the side rail. 2/13/17 After discussion with corporate Vice President and the Interdisciplinary Team (IDT) which consists of nursing, social worker, dietary, activities and rehabilitation services, the decision was made to remove all 3/4 side rails (except for the one resident) and full side rails from the beds. On 2/14/17 at 6:00 PM 3/4 and full side rails been removed from beds (with exception of one resident). Those residents utilizing upper 1/4 rails for turning and repositioning support have care plans and the side rail is not a restraint per RAI (Resident Assessment Instrument) Assessments. The use of side rail assessments (completed by licensed nurses) with consideration of resident's needs and the care plan update was done by MDS nurses with reference to Resident Assessment Instrument Manual. All nursing staff in-serviced on appropriate assessment and use of side rails per facility side rail policy and procedure as well as side rail assessment as guided by RAI instrument. The Administrator and Director of Nursing educated All Licensed Nursing and Nurse Aide Staff on when and why residents are assessed for the use of side rails. If a decision is made to utilize a side rail, there must be a physician's orders [REDACTED]. The IDT will meet at least quarterly to review and recommend appropriate changes such as the need for implementation of side rails or continued non-use of side rails. The Administrator and Director of Nursing have in-serviced the Nurses and Nurse Aide staff on monitoring for potential entrapment issues and potential associated injuries such as bruising, skin tears, sprains, soft tissue damage and broken bones. The NAs will report to the charge nurse if identifying any situation that may require use of a side rail for further interventions. If a resident or family members request a side rail the Administrator, DON, Care Plan Coordinator, Social Worker, Admissions Coordinator and/or Charge Nurse is to be promptly notified for education on the use of side rails with the resident and/or family members. Nurses and Nurse Aide Staff will not be scheduled on duty until in-serviced on the use of side rails, restraints and potential for accidents related to use. Staff in-service will be completed by 4:00 PM on 2/15/17. On 2/15/17 at 6:00 PM, the credible allegation was validated by a tour of the facility to ensure there were no full length or ¾ length side rails on the beds of residents who were not assessed and care planned for the rails. There was one resident in the facility with padded 3/4 side rails who had been assessed as having a medical need for the rails, had a physician's orders [REDACTED]. All other residents had no side rails or had a ¼ length to 1/2 length side rail or a grab bar used for turning and positioning. Resident #1 was no longer in the facility. Interviews with the nurses revealed they had received an in-service regarding side rails and that no resident was to have a side rail without having an assessment for the side rail. The Nurses knew if a resident or family member insisted on full length or 3/4 length side rails to notify the management staff and that the rails could not be put on the bed without an assessment, a physician's orders [REDACTED]. Interviews with the NAs revealed they had received in-services regarding side rails and rails were only to be used for the residents with care plans for the side rails. Interviews with the NAs revealed they were aware to notify the nurse if a resident or family member requested ¾ length or full length side rails to be put on the bed. 2. Resident #5 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The most recent side rail assessment was dated 2/6/16 and noted that side rails did not appear to be indicated at that time. There were no additional side rail assessments on the medical record. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory loss and severe cognitive impairment. The assessment noted the resident required total assistance from staff for bed mobility and transfers and ambulation did not occur during the 7 day assessment period. The MDS revealed the resident had impaired range of motion of both upper and lower extremities. The Care Area Assessment (CAA) dated 12/22/16 for Cognitive Loss/Dementia revealed the resident was alert and oriented only to self and was unable to make needs known. The CAA noted the resident required total care for all daily needs. A CAA was not required for falls. A Resident Incident Report dated 1/13/17 at 3:00 PM revealed a Nursing Assistant (NA) reported discoloration to the foot of Resident #5. The report indicated the discoloration was a result of the side rail. The report noted Nurse Practitioner (NP) #1 was notified. A nurse's note dated 1/13/17 at 3:11 PM revealed discoloration was noted to the top and bottom of the resident's left foot. The note revealed a nurse practitioner went in to see the resident. The incident report was completed by the Director of Nursing (DON). The Immediate Post-Incident Action noted the side rail was removed from the bed. The Immediate Actions Taken noted the staff was educated on not using side rails. There was not a nurse practitioner note found regarding the discoloration of the resident's foot. The Care Plan for Resident #5 revealed an updated entry dated 1/17/17 that noted the side rail was removed from the bed to prevent injury. On 2/13/17 at 5:25 PM the Administrator stated in an interview when the incident happened the NAs were in-serviced to make sure they looked at the care plan to see if a resident was supposed to have a side rail. The Administrator stated they had not had issues with this kind of thing and did not feel they needed to do a full house investigation or take it to the Quality Assurance Committee. On 2/14/16, MDS Nurse #1 stated in an interview, Resident #5 would move around in bed and would get restless if there was activity going on in the hall. The MDS Nurse stated the family wanted the side rail and after the incident on 1/13/17 they decided to remove the side rail. On 2/14/17 at 10:46 AM the DON stated in an interview the resident had full length side rails on the bed but were not supposed to be used. The DON further stated the NA called her to the resident's room and she observed the resident lying on her right side and the left foot was near the raised side rail but not in the side rail. The DON stated the nurse practitioner looked at the resident and told her the cause of the bruise was most likely from the side rail and the side rail was removed from the bed. On 2/14/17 at 11:24 AM an interview was conducted with the NA that first saw the bruise on the resident's foot. The NA stated she went in to provide care and the resident was lying in a fetal position and the top of her left foot was lying against the padded full length side rail. The NA further stated when she repositioned the resident she noted bruising on the top of the left foot and notified the DON who went in the room to look at the resident's foot. The NA stated the side rail was removed from the bed. On 2/15/17 at 1:35 PM, an interview was conducted with Nurse Practitioner (NP) #1 who saw the resident on 1/13/17. The NP stated the resident had an ecchymotic (bruised) area on the foot and by looking at the foot and the side rail she thought the foot likely got caught in the side rail but did not recall seeing the foot caught in the side rail. 3. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Activities of Daily Living (ADLs) 10/27/16 revealed the resident required extensive to total assist with most of ADL care and required total assist with bed mobility. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance with bed mobility and required total assistance of 2 persons for transfers. The MDS revealed the resident had no impairment in range of motion of the upper extremities and impaired range of motion of one side of the lower extremities. The resident's Care Plan updated on 1/17/17 noted impaired thought processes associated with visual loss which also caused decline in safety awareness. The approaches included the following: Ensure needs are met before leaving the room to reduce risk for falls by reducing impulsive behaviors. Check frequently throughout day for unmet/anticipated needs related to pain, toileting needs, repositioning, comfort, wanting to lie down or get out of bed to minimize impulsive behaviors to reduce the risk for falls. The Care Plan also noted the resident required assistance for all ADLs. Review of the clinical record revealed no side rail assessment and the Care Plan did not include information regarding side rails. Review of the clinical record revealed no injuries for the resident related to the side rails. On 2/13/17 at 9:30 AM the resident's bed was observed with a 3/4 length side rail on the left side of the bed (side rail down and resident not in the bed) and the right side of the bed was up against the wall. On 2/13/15 at 2:00 PM rounds were made with the Administrator. Resident #2 was observed lying in bed with the left 3/4 length side rail in the up position. The Administrator stated the side rail was not supposed to be up for this resident and did not know why the rail was being used. On 2/13/17 at 2:15 PM the Administrator stated in an interview that some residents have 3/4 length side rails on their beds but were not used and the staff had been trained on the use of the side rails in the facility. The Administrator further stated she could not take the side rails off the beds because she did not have anywhere to store them. On 2/13/17 at 5:00 PM the Administrator stated she had instructed the Maintenance Director to remove all the full and 3/4 length side rails except for one resident who had been assessed and care planned for the side rail. On 2/15/17 at 3:25 PM the Director of Nursing (DON) stated in an interview that Resident #2 did not move around very much but could use the side rail to pull himself up into a sitting position. The DON further stated the staff had advised the resident to call for assistance as he has vision problems and the resident had been compliant with this. On 2/15/17 at 5:05 PM NA (Nursing Assistant) #2 who cared for the resident stated in an interview the resident could turn from side to side and could use the side rail to sit up in the bed but required assistance and did not transfer himself. The NA stated the resident could not get in an upright position to sit on the edge of the bed without assistance.

Based on observation, record review and staff interviews, the facility failed to keep a resident free from physical restraint and did not identify a medical symptom that was being treated with the use of a restraint. The facility also failed to evaluate the need for a side rail for the bed that restricted the resident's movement. Resident #1's arm was trapped between the side rail and the mattress of the bed. This affected 1 of 5 resident's reviewed for side rails as restraints (Resident #1). The Immediate Jeopardy began on 2/8/17 with the entrapment of the arm of Resident #1 between the side rail and the mattress of the bed and was removed on 2/15/17 at 6:30 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimum harm that is not immediate jeopardy) to complete employee education and to ensure monitoring systems are in place that are effective. Resident #1 was admitted to the facility on [DATE] and had diagnoses of diabetes, bilateral [MEDICAL CONDITION] of the knees, generalized muscle weakness and urinary tract infection. The Nursing Admission assessment dated [DATE] noted the resident was admitted to the facility at 12:10 PM and was accompanied by family members who provided the admitting information. The assessment noted the resident was disoriented to time and place, had clear speech and was sometimes understood with ability limited to making concrete requests. The Assessment noted there were no problem behaviors observed during the admission/assessment process. The Assessment further noted the resident had active range of motion, was dependent on staff for transfers, required the assistance of 2 persons for ambulation, was dependent on staff for locomotion in a wheelchair and had a history of [REDACTED]. Under Sleep Patterns the Assessment noted the family stated the resident did not sleep well. The Assessment contained an electronic signature of Nurse #1 at 2:49 PM. There was not a side rail assessment completed on 2/7/17. There were no diagnoses or medical symptoms listed to indicate the resident needed a ¾ length side rail. A Resident Incident Report dated 2/8/17 at 3:50 AM completed by Nurse #2 revealed the resident was noted with the left arm between the side rail and the bed. The report noted the arm was removed from the area and the only abnormality noted of the arm was red discoloration. The report did not provide a specific location of the area of red discoloration of the arm. A Side Rail Screen completed on 2/8/17 at 10:17 AM noted the resident used the side rail for support or positioning and revealed side rails were indicated and served as an enabler to promote independence. The assessment did not specify the length of the side rails appropriate for the resident and did not provide a medical symptom for the side rails. A Physical Therapy note documented on 2/8/17 at 2:47 PM revealed the resident required maximum assistance of 2 persons for rolling in bed, supine to sitting position and moderate assistance of 2 persons to transfer from the bed to the chair and much extra time with poor command following. The note revealed the left arm was bruised but she was able to elevate the left arm above 90 degrees and denied pain. She did not demonstrate facial grimacing or other pain behaviors. A nurse's note dated 2/8/17 at 2:47 pm noted Resident #1 had been transported to the hospital (The resident did not return to the facility). A follow-up note on the Resident Incident Report dated 2/8/17 revealed the arm had areas of discoloration (no location provided) with no [MEDICAL CONDITION] or pain and physical therapy evaluated the resident who had full range of motion of the arm. It was noted the primary care physician was in the facility and assessed the resident and ordered an X-ray to ensure there was not a hidden fracture. The note further revealed the family requested the resident be sent to the Emergency Department (ED) for further evaluation instead of a mobile X-ray. Review of the ED Record for Resident #1 dated 2/8/17 revealed a physician's note that a family member found the resident wedged between the bed and the bed rail and had some new bruises on her left arm, forearm and leg. The physician's exam revealed the following: Extremities revealed no obvious deformity though she does have bruising over the left arm and left forearm. This bruising is red and does not have the appearance of an abrasion with the limb trapped between 2 surfaces. There is a small bruise on the distal shin on the left. Grossly normal passive range of motion at all major joints. All peripheral pulses symmetrical and equal. The ED record revealed the resident was admitted to the hospital related to her increased altered mental status. X-rays were completed at the hospital on [DATE] for Resident #1 and reported as follows: Left Humerus-No evidence of fracture. Left Forearm-No evidence of acute bony abnormality. Left tibia/fibula-[MEDICAL CONDITION] changes without acute fracture. ED final impression: Altered Mental Status and left upper arm injury. On 2/13/17 at 11:45 AM, Nurse #1 stated in an interview Resident #1 was admitted to a bed that had 3/4 length side rails on the bed. The Nurse stated a family member told her the resident had sundowning (increased confusion and agitation at night) and would get out of bed and pull her clothes off. The Nurse stated the family wanted the side rail up so the resident would not fall out of bed. The Nurse stated she explained to the family that side rails were not safe and explained she would put the bed in the low position with a fall mat beside the bed. The Nurse stated a family member insisted the side rails be put up on the bed so she put the side rails up. The Nurse stated she did not notify any of the management staff the family wanted the side rails up. On 2/13/17 at 12:50 PM an interview was conducted with NA (Nursing Assistant) #1 who was assigned to Resident #1 on the 11 PM to 7 AM shift on 2/7-8/17. The NA stated during the night the resident was agitated and kept trying to get out of the bed. The NA stated she checked on the resident every time she went by the room and the resident would roll from side to side trying to put her feet over the side of the bed and sometimes the resident would have her feet hanging off of the bed and she would put the resident's feet back on the bed and tell the resident not to get up. The NA stated a family member entered the facility between 3:00 and 4:00 AM to check on the resident. The NA stated the family member came and told her the resident's arm was stuck in the side rail. The NA stated she had checked on the resident about 10 minutes prior to this and had gone to assist another resident to the bathroom. The NA stated the resident's left upper arm was stuck in between the rail and the bed and she went and got the nurse who came and got the resident's arm out. The NA stated there was some redness of the resident's arm. On 2/13/17 at 2:15 PM an interview was conducted with the Director of Nursing (DON) and the Administrator. The Administrator stated when she came to work on the morning of 2/8/17 she was notified that Resident #1 got her arm caught between the side rail and the mattress of the bed. The Administrator stated there was not much space between the side rail and the mattress and they could not figure out how she got her arm stuck between the mattress and the side rail. The Administrator stated they had some beds with full length and 3/4 length side rails and the staff had been trained to check the care plan to see if a resident was supposed to use the side rail prior to putting the side rails up. The Administrator stated she could not take the rails off of the beds because she did not have anywhere to store them. On 2/13/17 at 3:14 PM an interview was conducted with Nurse #2 who was assigned to Resident #1 on the 11 PM to 7 AM shift on 2/7-8/17. The Nurse stated the NA called her to the room and when she entered the room she observed the resident lying on the left side of the bed and her arm was straight down between the mattress and near the end of the side rail closest to the head of the bed. Nurse #2 further stated she slid the resident's arm out from the mattress and the bed rail and noted some red areas on her arm but the skin was intact. The Nurse stated she asked the resident if her arm hurt and she told her it did so she gave the resident some Tylenol and propped the arm up on a pillow. The Nurse stated there was not a gap between the mattress and the side rail. Nurse #2 stated the family member left the facility and approximately 30 minutes later another family member came in and stayed with the resident the rest of the night. On 2/13/17 at 5:00 PM the Administrator stated in an interview on this date she had instructed the Maintenance Director to remove all the 3/4 length side rails from all but one of the beds in the facility and some had been removed and would be completed by the next day. The Administrator stated they had one resident with 3/4 padded side rails that had been assessed as needing the side rails, had a physician's orders [REDACTED]. On 2/14/17 at 2:35 PM an interview was conducted with the family member who found the resident between 3:00-4:00 AM on 2/8/17 with her arm between the side rail and the mattress. Family Member #1 stated she found the resident lying flat on her back with her left arm hanging down between the rail and the mattress about 1/3 of the way down from the beginning of the rail near the head of the bed. The Family Member stated the resident's body was somewhat sideways the bed and she was uncovered. On 2/14/17 at 2:57 PM the Administrator stated in an interview she spoke with the resident's family on the morning of 2/8/17 and advised them the facility did not encourage the use of side rails as there could be worse injury with the rails than without them. The Administrator stated the family wanted side rails on the bed and a seat belt on the resident. The Administrator stated she explained to the family they could not do this. On 2/15/17 at 10:48 AM the Administrator stated in an interview when she came in on the morning of 2/8/17 she learned of the problem with Resident #1 regarding the side rail. The Administrator stated she and the maintenance director looked at the bed and the mattress covered the bed frame. The Administrator stated some of their beds were old and the beds and the mattresses were ordered separately and the manufacturer's instructions did not specify the type of mattress to be used. The Administrator stated they used FDA (Federal Drug Administration) guidelines for dimensional limits between the side rail and the mattress and the space between the mattress and the bed rail for Resident #1 were within those guidelines. On 2/15/17 at 11:07 AM the Maintenance Director stated in an interview without the resident on the bed the space between the bed and the 3/4 length side rails was 1/8-1/2 inch. The Maintenance Director stated the side rails were fully functional and were not broken, bent or damaged in any way. The Maintenance Director stated he was instructed to remove the 3/4 length rails and put on 1/4 length rails on the bed of Resident #1 on the morning of 2/8/17 which he did. The Maintenance Director stated he had been instructed to remove all full length and 3/4 length side rails from the beds of residents whose side rails were not to be used and this had been done. On 2/15/17 at 11:20 AM, an observation of the bed for Resident #1 was conducted with the Maintenance Director who stated as far as he knew, the mattress on the bed had not been changed. There were 1/4 length side rails near the head of the bed. The mattress fully covered the bed frame to approximately 1/8 inch beyond the edge of the bed. The Administrator was notified of the Immediate Jeopardy on 2/14/17 at 3:15 PM. The facility provided a credible allegation of compliance on 2/15/17 at 6:00 PM. The Allegation of Compliance indicated: Resident #1 with arm discoloration due to side rail had arm released and assessed for injury at time of event. No significant injury identified. Resident #1 had 3/4 side rails raised prior to having her arm caught between mattress and the side rail (The assessed gap between mattress and rail found acceptable space of 0.5 inches between mattress and 3/4 rail per FDA (Federal Drug Administration) guidelines for all beds in the facility prior to use in any resident rooms). Upon release of the resident's arm, a pillow was placed between the side rail and the resident by the charge nurse to prevent reoccurrence e of catching arm between the mattress and the rail. On the morning of 2/8/17 a side rail assessment was done and Environmental Services was contacted to remove the 3/4 rails from the bed and was provided 1/4 side rails to assist with turning and positioning. This was done after Resident #1 was assisted to a wheelchair. The Admissions Coordinator had explained to the family that the use of side rails can pose more of a hazard than nonuse and side rail use required a physician's orders [REDACTED]. The resident had not yet been identified as needing side rails and made no effort to exit the bed per nursing staff. At approximately 7:30 AM on 2/8/17, Physical Therapy evaluated the resident's left arm and noted no loss of range of motion and no evidence of pain verbally or nonverbally. Physical Therapy also evaluated for potential structural injury such as fracture and limited range of motion. The Resident denied pain when asked and smiled with relaxed facial features and posture during and post evaluation for further injury. The Nurse Practitioner was asked to evaluate the resident which was done at approximately 10:30 AM on 2/8/17 and noted discoloration to the left upper extremity with no change in range of motion. The Nurse Practitioner requested a mobile X-ray to evaluate for fracture but the family requested the resident be sent out to the hospital for evaluation. The family remained with the resident, meals offered and staff assisted the resident with ADL (activities of daily living) needs. The ambulance service picked up the resident for transfer after lunch and the resident was transported to the hospital. On the evening of 2/8/17 the hospital reported the resident had been admitted . The resident did not return to the facility. On 2/13/17 all 1/4 side rails used on the beds of residents were assessed and needed for turning and repositioning and were determined not to be a restraint for these residents. These assessments were completed by the Director of Nursing, Administrator and the MDS Nurses. These residents were assessed for potential injury related to the use of the 1/4 side rails and no associated injuries were noted. FDA (Federal Drug Administration) guidelines were used in the absence of manufacturer's instructions to determine appropriate fit of mattress to be frame to prevent injury. Only one resident had 3/4 side rails in use with appropriate assessment, physician's orders [REDACTED]. This resident had no evidence of injuries correlating with the use of the side rail. If a new admission assessment including side rail assessment indicates a need for restrictive side rails, a physician order [REDACTED]. (The Resident Assessment Instrument process will be completed at least quarterly and reviewed for continued use of side rail) A request for side rails will be made, the bed evaluated for side rail acceptance and if appropriate, side rails will be implemented. If the bed frame cannot accommodate side rails an alternate bed with side rail accommodation will be provided. On 2/13/17 after discussion with the corporate Vice President and the Interdisciplinary Team (IDT) which consisted of nursing, social worker, dietary, activities and rehabilitation services, the decision was made to remove all 3/4 side rails (except for the one resident) and full side rails from the beds. On 2/14/17 at 6:00 PM all 3/4 and full side rails had been removed from the beds (with the exception of the one resident). Those resident's utilizing upper 1/4 rails for turning and repositioning support have care plans and the side rail is not a restraint per RAI (Resident Assessment Instrument) Assessments. The use of side rail assessments (completed by licensed nurses) with consideration of the resident's needs and the care plan update was done by the MDS nurses with reference to the Resident Assessment Instrument Manual. All nursing staff was in-serviced on appropriate assessment and use of side rails per facility side rail policy and procedure as well as side rail assessment as guided by the RAI. The Administrator and Director of Nursing educated all Licensed Nursing and Nurse Aide Staff on when and why residents are assessed for the use of side rails. If a decision is made to utilize a side rail, there must be a physician's orders [REDACTED]. The IDT will meet at least quarterly to review and recommend appropriate changes such as the need for implementation of side rails or the continued non-use of side rails. The Administrator and Director of Nursing have in-serviced the Nurses and Nurse Aide staff on monitoring for potential entrapment issues and potential associated injuries such as bruising, skin tears, sprains, soft tissue damage and broken bones. The NAs will report to the charge nurse if identifying any situation that may require the use of a side rail for further interventions. If a resident or family members request a side rail the Administrator, DON, Care Plan Coordinator, Social Worker, Admissions Coordinator and/or Charge Nurse is to be promptly notified for education on the use of side rails with the resident and/or family members. Nurses and Nurse Aide Staff will not be scheduled on duty until in-serviced on the use of side rails, restraints and potential for accidents related to their use. Staff in-service will be completed by 4:00 PM on 2/15/17. On 2/15/17 at 6:00 PM, the credible allegation was validated by a tour of the facility to ensure there were no full length or 3/4 length side rails on the beds of residents who were not assessed and care planned for the rails. There was one resident in the facility with padded 3/4 side rails who had been assessed as having a medical need for the rails, had a physician's orders [REDACTED]. All other residents had no side rails or had a 1/4 length to 1/2 length side rail or a grab bar used for turning and positioning. Resident #1 was no longer in the facility. Interviews with the nurses revealed they had received an in-service regarding side rails and side rails as restraints and that no resident was to have a side rail without having an assessment for the side rail. The Nurses knew if a resident or family member insisted on full length or 3/4 length side rails to notify the management staff and that the rails could not be put on the bed without an assessment, a physician's orders [REDACTED]. Interviews with the NAs revealed they had received in-services regarding side rails and rails were only to be used for the residents with care plans for the side rails. Interviews with the NAs revealed they were aware to notify the nurse if a resident or family member requested 3/4 length or full length side rails to be put on the bed.