Every finding on record at Magnolia Gardens Center for Nursing and Rehabilita

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours per day, 7 days per week for 13 out of 36 days reviewed for staffing (4/27/25, 5/4/25, 5/25/25, 6/1/25, 6/15/25, 6/22/25, 8/23/25, 8/31/25, 9/6/25, 9/7/25, 9/14/25, 9/20/25, and 9/21/25). The findings included:Review of the staffing data submitted by the facility through the CMS (Centers for Medicare and Medicaid Services) Payroll-Based Journal (PBJ) system for quarter 3 (April 1, 2025, through June 30, 2025) indicated there was no RN coverage for eight consecutive hours on 4/27/25, 5/4/25, 5/25/25, 6/1/25, 6/15/25, and 6/22/25. Review of the facility's nurse staffing sheets for 8/19/25 through 9/29/25, revealed there was no RN coverage for eight consecutive hours on 8/23/25, 8/31/25, 9/6/25, 9/7/25, 9/14/25, 9/20/25, and 9/21/25. During an interview with the Scheduling Coordinator on 9/25/25 at 2:29 PM, she stated she had been in her role at the facility for 2 weeks. The Scheduling Coordinator could not provide a reason why there was no RN coverage for the listed dates and stated that September's schedule was already completed before she started working. She stated she was aware of the regulation stating there needed to be RN coverage for at least 8 hours in a 24-hour period. The Scheduling Coordinator stated the facility had trouble hiring registered nurses.During an interview with the Director of Nursing (DON) on 9/25/25 at 2:45 PM, she stated the PBJ report and the September days with no RN on the schedule were correct. The DON explained the facility had been without a Staffing Coordinator for several months and the DON completed the nursing schedule. The DON stated they had trouble hiring registered nurses and the facility currently doesn't use any staffing agencies. She reported the facility currently had a pool of 8 to 15 RNs; some full-time and some part-time, and it was difficult to find weekend coverage. The DON reported they were actively trying to hire more registered nurses for weekend shifts.During an interview with the Administrator on 9/25/25 at 3:29 PM, he stated he was not aware the facility was not meeting the federal regulation for RN hours. He stated the facility did not use agency staff and was in the process of trying to hire more registered nurses.

Based on record reviews and staff interviews, the facility failed to revise the care plan for 1 of 2 sampled residents reviewed for advance directive status (Resident #46). The findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses which included: other sequelae of cerebrovascular disease and malignant neoplasm of urinary organ. The resident's portable medical form in the Advance Directive notebook, maintained at the 100 hall nurses' station was reviewed. The Medical Orders for Scope of Treatment (MOST) form with the effective date of 4/4/24 documented Resident #46's Advance Directive as Do Not Resuscitate (DNR) with the following interventions: comfort measures; antibiotics if indicated; intravenous fluids for a defined trial period; and no feeding tube. The notebook also consisted of a medical transfer form documenting the resident's Advance Directive status as DNR with the effective date of 9/4/25. The care plan dated 4/27/24 documented Resident #46's Advance Directive status as Full Code (cardiopulmonary resuscitation required). Interventions included: advanced directive wishes to be honored through the review period. Review of the physician's order dated 8/5/24 documented Resident #46's Advance Directive status as DNR. Continued review of Resident # 46's care plan revealed it was not revised with the change in Resident #46's advance directive status as ordered by the physician on 8/5/24. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #46 was cognitively intact. During an interview on 9/24/25 at 11:42 a.m., Unit Manager #1 revealed if a resident was experiencing a medical emergency, the nurse would refer to the 24-report which is updated every shift and included every residents' advance directive status, or the Advance Directive notebook which is maintained at each nurses' station, or the special instructions section of each resident's profile page in the electronic record. Unit Manager #1 stated the advance directive status was also documented in each resident's care plan, but nurses did not routinely refer to the care plan for the advance directive of a resident who was actively in dire medical distress. On 9/25/25 at 11:53 a.m., the Director of Nursing (DON) revealed the MDS Nurse was unavailable for interview. The DON stated Resident #46's care plan should have been revised when the physician's order changed the resident's Advance Directive status from Full Code to DNR. She further stated the MDS Nurse should have updated the resident's care plan as soon as notified of the physician's order change.

Based on record review and staff interviews, the facility failed to ensure a resident had a physician's order to receive hospice services for 1 of 1 resident reviewed for hospice (Resident #3).Findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses of stroke with right sided hemiplegia and hemiparesis (paralysis and weakness respectively), vascular dementia and adult failure to thrive.Review of records revealed hospice nurse progress notes which indicated Resident #3 was admitted to hospice on 7/3/25 and was receiving regular hospice orders, care and services.A significant change Minimum Data Set (MDS) assessment on 7/14/25 indicated that Resident #3 was severely cognitively impaired and was coded for hospice services. Further review of Resident #3's medical record revealed no physician order for hospice services. On 9/23/25 at 1:10 PM an interview with Unit Manager #1 was conducted. Unit Manager #1 said hospice orders should be placed in the electronic medical record for a resident by the ordering provider. Unit Manager #1 said there was a binder which at times contained orders from hospice but the binders did not contain the actual Medical Director's order for hospice.An interview with the Director of Nursing (DON) was conducted on 9/23/25 2:11 PM. The DON said when staff received a hospice referral or recommendation, staff called the hospice provider to let them know about the referral, then staff reached out to the physician or nurse practitioner to obtain an actual order if they did not already have one, which could be obtained over the phone. The DON said sometimes a written order could be kept in a hospice binder at the nurses' station but otherwise the order should be entered into the electronic medical record. The DON confirmed there was no written order in the hospice binder for Resident #3 and confirmed there was no hospice order placed in the electronic medical record.In an interview with the Administrator on 9/24/25 at 9:45 AM, the Administrator said that Residents receiving hospice care should have an order placed in the electronic medical record.

Based on observation, record review, and interviews with facility staff, resident, and the Contracted Van Transportation Company Owner, the facility failed to ensure Resident #1's wheelchair was secure on the contract transportation van lift by the Contract Van Driver before the lift platform was raised to the elevated position. On 3/7/25, Resident #1 was loaded onto the van lift by the Contract Van Driver. The lift was positioned at the rear entrance of the van and Resident #1 was facing out away from the van. When the lift platform was at the floor level of the van, Resident #1's wheelchair rolled forward, away from the van, and Resident #1 fell forward, off of the lift, landing on the asphalt parking lot. Resident #1 fell approximately 48 inches from the raised lift platform onto the ground. According to the resident, she had tried to put her arms out to catch herself as she was falling. Resident #1 was transported to the hospital via Emergency Medical Services (EMS) and at the hospital, Resident #1 was found to have sustained fractures to both upper arms, multiple lumbar vertebrae (lower back) fractures, and a fracture to her right foot. Resident #1 also sustained a laceration to her right forehead measuring 4 centimeters in length which required 4 sutures to close. Resident #1 was receiving a blood thinner which increased her risk of bleeding. There is a high likelihood of a serious adverse outcome, including death or injury, when the manufacturer's instructions for loading residents onto the transportation van lift are not followed. This deficient practice was found for 1 of 3 residents reviewed for accidents.The findings included:Review of the manufacturer's operating instructions showed the following instructions for the use of the contract transportation van lift to load a resident in a wheelchair.1. Stand clear and press the unfold switch until the platform stops (reaches floor level of the vehicle - unfold fully).2. Press the DOWN switch until the entire platform reaches ground level and the roll stop (a piece of metal attached to the lift which unfolds to a flat position when the lift is on the ground but is in an upright position when the lift is not in contact with the ground) unfolds fully (ramp position).3. Load passenger onto platform, lock wheelchair brakes, and buckle handrail belt (if equipped). Ensure passenger is fully positioned inside the yellow boundaries.4. Press UP switch and raise platform to floor level; approximately 48 inches from ground level to floor of van per lift manual specifications. 5. Unlock wheelchair brakes and unload passenger from platform and move into the van.Resident #1 was admitted to the facility on [DATE] with diagnoses included polyneuropathy (numbness and weakness in extremities), severe obesity, and a history of deep venous thrombosis. Resident #1's quarterly Minimum Data Assessment (MDS), dated [DATE], coded the resident as having no cognitive impairment. The resident was coded to use a wheelchair for ambulation and was dependent on staff for all activities of daily living except Resident #1 was independent with eating and oral hygiene. The MDS showed Resident #1 weighed 415 pounds. Review of the physician orders showed Resident #1 had an active order last reviewed and dated for 1/5/25 for apixaban (a blood thinner) 2.5 milligrams, take one tablet twice daily. Review of the February and March 2025 Medication Administration Record showed Resident #1 was administered the apixaban twice daily including a dose on the morning of 3/7/25. There had been no documented dose omissions from 2/1/25 to 3/7/25. Review of a statement provided to the facility by the Contract Van Driver dated 3/7/25 read in part, I loaded the resident on the lift facing outward due to her size and the size of the wheelchair. The lift is appropriate for facing outward loading. After loading her on the lift I locked the brakes and checked them, then raised the lift to the van floor level. The statement continued to document the driver walked around to the right side of the van to enter via the side passenger doorway. As the Contract Van Driver was walking up the steps, he noticed her (Resident #1's) chair began to roll forward toward the outside of the van. Contract Van Driver had documented he immediately moved toward her, but her chair hit the roll stop. Her momentum carried her and her wheelchair over the end of the lift where she landed on the pavement and her chair was resting on top of her. The Contract Van Driver documented he removed the wheelchair without moving the resident and at that time two unknown people arrived at her side.Contract Van Driver was unavailable for interview.An interview was conducted with Resident #1 on 7/17/25 at 10:20 AM. Resident #1 stated she was leaving the facility in a wheelchair for an appointment right after lunch on 3/7/25. Resident #1 stated the Contract Van Driver pushed her to the end of the sidewalk of the main facility entrance and loaded her onto the van lift at the back of the van. Resident #1 stated she was in a large wheelchair and felt like it took up the entire platform. Resident #1 stated she was facing the parking lot when the Contract Van Driver began to raise the lift. Resident #1 reported she felt like the wheelchair was stable on the platform but wasn't sure if the Contract Van Driver engaged the wheelchair brakes. Resident #1 explained she was trying to get the Contract Van Driver attention as the lift began to raise because she felt like the chair was beginning to roll forward as the lift was rising, but he did not hear her yelling for him. Resident #1 stated, the next thing she knew, her wheelchair began rolling forward, she fell forward off of the van lift, as she was falling she tried to catch herself with outstretched arms and hands, and she landed onto the pavement. Resident #1 did not know how far she fell but felt like it might have been several feet. Resident #1 reported she felt pain in both her arms and lower back immediately after the fall. Resident #1 stated the Director of Nursing came out and sat down on the ground with her and waited for the ambulance to arrive. Resident #1 reported she didn't want anyone to touch her-she just wanted the ambulance to get there and take her to the hospital. An interview was conducted with the Director of Nursing (DON) on 7/17/25 at 11:48 AM. The DON stated, on 3/7/25 around lunchtime, Facility Van Driver #2, who was not involved with the Contract Van Driver, or the incident, came around the corner from the front lobby to her office and stated Resident #1 appeared to have just fallen off of the van lift out front due to the resident being on the ground. The DON reported she told Facility Van Driver #2 to call 911 and she immediately went outside to assess Resident #1. The DON stated she found Resident #1 lying face down on the pavement, both of the resident's arms were under her and her wheelchair was off to the side. There was also a small laceration to the right side of her forehead. The DON stated Resident #1 was conscious, alert, crying, and stated she didn't want anyone to touch her. The DON further stated Resident #1 told her both arms and her back were hurting, therefore, the decision was made to not to move her and not assess her further until the Emergency Medical Services (EMS) arrived. The DON stated she applied a bandage to control the bleeding to the resident's forehead wound. The DON stated there were a couple of other staff members who came over to see if they could assist but she did not remember who they were.Facility Van Driver #2 was no longer employed at the facility and was unavailable for interview.An interview was conducted by phone with the Van Transportation Company Owner 7/17/25 at 12:50 PM. The Van Transportation Company Owner stated he received a call on 3/7/25 about 12:30 PM from the Contract Van Driver who told him a resident (Resident #1) just fell off the lift of the van. The Van Transportation Company Owner stated he arrived at the facility shortly after the driver called him to let him know what had happened and inspected the van and lift for any abnormalities and did not find any. Van Transportation Company Owner stated Contract Van Driver reported to him he put Resident #1 on the lift facing outward, locked the wheelchair brakes and then raised the lift up fully. The Contract Van Driver then told the Van Transportation Company Owner he walked around to the passenger side to get in the van and saw Resident #1 rolling forward out of the corner of his eye. The Contract Van Driver stated to the Van Transportation Company Owner he observed Resident #1 fall face first over the roll stop and onto the pavement below. The Van Transportation Company Owner reported the Contract Van Driver had been driving for his company for a while and completed training on using the van lift and there had no issues with the Contract Van Driver.A review of Emergency Medical Services (EMS) record showed the call was received by dispatch at 12:37 PM and EMS arrived at the facility on 3/7/25 at 12:53 PM. The record read, Resident #1 was alert and oriented and lying face down in the parking lot next to a transport bus with a superficial laceration noted to her forehead. The record further read, The attendant apparently dropped her off the side of the ramp while she was in the wheelchair and she landed face first on the parking lot.No loss of consciousness per staff. Noted to be on a blood thinner. The record further read, assistance was needed by the local fire department in getting the resident transitioned to the stretcher and into the ambulance. Resident #1 remained alert during transport to the hospital for evaluation.A review of the hospital records for Resident #1 for the hospitalization period of 3/7/25 through 3/10/25 revealed the following: Resident # 1 was seen in the emergency room (ER) on 3/7/25 following the fall out of a van. The physician noted Resident #1 was alert and in no acute distress at the time of the physician's assessment. The physician's head to toe assessment of Resident #1 showed pain reported in both arms (splints were applied), mild back pain, and right foot pain. A 4 centimeter laceration on the forehead above the right eyebrow was closed with 4 simple sutures. Pain medication was provided. Resident #1 required no surgeries due to fractures. Diagnostic x-rays done on 3/7/25 in the emergency room showed Resident #1 had sustained the following fractures: 1) comminuted (fragmented) intra-articular distal humerus fracture, right elbow, 2) comminuted intra-articular distal humerus fracture, left elbow, 3) mildly displaced fractures of the left transverse processes of Lumbar (L)1 and L2 (bones which make up the lower portion of the spine), and nondisplaced fractures of the distal second and third metatarsals (the long bones of the midfoot) of the right foot. Further review of radiology reports completed on 3/7/25, indicated that a computed tomography (CT) (a CT is a noninvasive medical imaging procedure that uses x-rays to create cross-sectional detailed pictures of the inside of the body) scan of the head and neck were negative for any abnormalities. Resident #1 was admitted to the hospital on [DATE] for observation and was discharged back to the facility on 3/10/25 with both arms splinted and support to her right foot.A joint interview was conducted with Occupational Therapist #1 and Physical Therapist #1 on 7/17/25 at 3:30 PM. Both Occupation Therapist #1 and Physical Therapist #1 stated they had assessed Resident #1's wheelchair on 3/7/25 following the incident and found it to be in excellent working order, including the brakes working properly. Both therapists agreed that no repair issues were discovered. Occupational Therapist #1 reported, Resident #1, prior to the fall from the liftgate of the wheelchair van, was independent with both upper extremities but became dependent on staff for eating and oral hygiene following the accident on 3/7/25. Occupational Therapist #1 reported she was currently still working with Resident #1 on her hand grip and mobility. The interview further revealed Resident #1 had gained significant mobility back although the resident still required some staff assistance with reaching and picking up items.An interview was conducted with the Medical Director on 7/17/25 at 1:15 PM and she stated the DON called her immediately after the incident on 3/7/25. The Medical Director stated the DON did the right thing by not moving Resident #1 based on her presentation, her complaints of pain, and it would have taken several extra staff members to move her. The Medical Director stated she had reassessed Resident #1 several days after she was readmitted to the facility and had provided new orders to follow-up with her orthopedist in 6-8 weeks and occupational therapy as tolerated. During an interview with the Administrator on 7/18/25 at 4:30 PM, he stated the facility had not used the contract van company since the incident with Resident #1 on 3/7/25. He stated the facility transport van was unavailable that day, so they had to use an outside company. On 7/17/25 at 4:15 PM, the Administrator was notified of immediate jeopardy. The facility implemented the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;Free of Accidents: Contract company failed to prevent fall from the van lift by not staying with the resident on the lift and not ensuring the wheelchair brakes were fully engaged. On 3/7/25 The contract van driver arrived to pick up resident #1 at approximately 12:30pm for an appointment. The contract van driver loaded resident #1 on the lift facing outward due to her size and the size of the wheelchair. Per manufacturer's instructions the lift is appropriate to load facing outward. After loading resident #1 on the lift the contract van driver stated he locked the wheelchair brakes and checked them by pushing on the wheelchair to ensure there was no movement, he then raised the lift to the van floor level. The contract driver proceeded to walk into the van via the passenger doorway. As the driver was walking up the steps of the van, he noticed Resident #1's chair began to roll forward toward the outside of the van. He immediately moved toward her on the outside of the van, but the resident's wheelchair hit the roll stop of the liftgate. Her momentum carried the resident and her wheelchair over the end of the lift where she landed on the pavement and her chair was resting on top of her. The driver removed the chair without moving resident #1 and at that time two staff members arrived at her side. The van driver asked one of them to call 911. The County Emergency Medical Service (EMS) arrived at the facility within 10 minutes and the local fire department staff arrived shortly thereafter. No injuries were identified at the scene. Resident #1 was in the hospital for 3 days for right comminuted intra-articular distal humerus fracture, left comminuted intra-articular distal humerus fracture, mildly displaced fractures of the left transverse processes of L1 and L2, non displaced fractures of the distal second and third metatarsals of the right foot, and superficial linear laceration to the right forehead measuring 4 centimeters in length requiring 4 sutures to repair. Resident required bilateral splints for left and right elbow fractures and was totally dependent on staff upon return to the facility. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Residents that require transport have the potential to be affected by the deficient practice.The Director of Nursing identified residents that have been transported in the last 30 days. On 3/7/25 alert and oriented residents identified were interviewed by the Administrator and asked if they had any safety concerns during transport. No residents reported having safety concerns. On 3/7/25 the Director of Nursing performed a skin check on the non interviewable residents that were identified. No injuries or signs of safety concerns were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; The contract van company owner inspected the contract van vehicle lift, tie downs, lap, and shoulder restraints for proper operation on 3/7/25. All were mechanically sound and working as intended.Education was provided per manufacturers guidelines to all 5 transportation drivers for the facility on 3/7/25 by the Director of Plant Operation about providing supervision/contact with the resident while the resident is on the lift. In addition, the Director of Plant Operations observed the transportation drivers through the loading and unloading process to show full compliance and understanding of providing constant supervision and contact with a resident when the resident is on the lift, this included safely securing a resident in the van. These observations were completed on 3/7/25. The contract van company is no longer being used. No other contract van company is being used. Newly hired transportation drivers will be required to receive the same education and return demonstration with the Regional Maintenance Director or Maintenance Director during orientation. The Administrator will be responsible for tracking the education. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; The Maintenance Director or Administrator will observe five residents being loaded into the van prior to transport at the facility and unloaded from the van upon return to the facility from the transport per week for four weeks then three residents a week for eight weeks to ensure that facility van drivers are following manufacturer's instructions for loading and unloading a resident on and off the van. This includes ensuring wheelchair brakes are locked when using the wheelchair lift, having constant supervision/contact with the resident while they are on the wheelchair lift, and safely securing the resident in the van per manufacturer's instructions.The decision was made on 3/7/25 to complete training and education, monitor the system, and to take to Quality Assurance Committee.This plan was taken to the Quality Assurance and Performance Improvement (QAPI) committee on 3/20/25 by the Administrator. The QAPI committee, which consists of the interdisciplinary team will review the audits to identify if there are any trends that need to be addressed or require an extension of the audits. Include dates when corrective action will be completed. Alleged date of IJ removal: 3/21/25. The facility's corrective action plan was validated by the following:Only 2 of the 5 facility van drivers were still employed by the facility. The facility provided documentation of Transportation Aide/Driver #3 and Transportation Aide/Driver #4 web-based training courses on driving basics, how to anticipate potential hazards and how to react to them, and a checklist that included return demonstrations on how to load and unload residents from the transportation van. The facility provided evidence of their audits as outlined in their plan of correction. Their audits included observation of Facility Van Driver #3 and Facility Van Driver #4 to ensure both followed lift and van safety instructions regarding boarding safety, patient securement, and patient assistance. Monitoring of all residents using the transport van lift was being conducted and that information was presented in the facility's QA meeting. On 7/17/25 at 5:05 PM Facility Van Driver #3 was observed loading and unloading a staff member, who was seated in a wheelchair, from the facility van using the lift. Facility Van Driver #3 explained in detail the steps she took and the safety measures she followed when using the lift as she was loading and unloading the staff member. The observation included verification that wheelchair brakes were engaged, and the chair was secure on the lift. An interview conducted with a resident who had been recently transported to an appointment revealed he had no concerns with being loaded or unloaded from the van, being secured safely in the van, and felt the transport was safe. Facility Van Driver #3 stated she completed the refresher course as part of the facility plan of correction on 3/8/25. Facility Van Driver #3 provided a copy of a checklist which showed she used when loading and securing a resident for transport. The facility's IJ removal date and compliance date for the corrective action plan of 3/21/25 was validated. The IJ removal date was 3/21/25.

Based on record review and resident and staff interviews, the facility failed to ensure staff implemented their abuse policy and procedure in the area of reporting when facility staff had knowledge of an allegation of sexual abuse. This failure resulted in a delay in the facility initiating a thorough investigation of the allegation, implementing protective measures, and reporting the allegation to the State Agency, Law Enforcement and Adult Protective Services. This deficient practice was found for 1 of 3 residents reviewed for abuse (Resident #1). Findings included: The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation reviewed/revised 1/1/25, read in part: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. During an interview on 3/4/25 at 2:04 p.m., Nursing Assistant (NA) #1 revealed Resident #1 reported to her on Sunday (2/16/25) that she was touched inappropriately by a male staff member, but did not know his name and did not provide a description of the male or date of the incident. She recalled there were two male nursing assistants working on that unit. NA #1 stated she reported the allegation to the Staff Nurse #1 but was unsure if Staff Nurse #1 interviewed Resident #1. An interview was conducted with Staff Nurse #1 on 3/4/25 at 2:37 p.m. Staff Nurse #1 stated no one had reported abuse to her since she began working at the facility (approximately three months ago). She recalled three to four days prior to Resident #1's recent hospitalization (2/20/25), she and the Director of Nursing (DON) were standing at the nurse's station when they overheard NA #1 repeatedly, advising NA #2 to not enter Resident#1's room unless he had someone with him. Staff Nurse #1 stated she overheard NA #1 tell NA #2 that Resident#1 was saying that somebody was messing with her. Staff Nurse #1 revealed she did not interview Resident #1 and did not know if the DON interviewed the resident. An interview was conducted on 3/5/25 at 2:51 p.m. with the Director of Nursing (DON). The DON stated she first learned of the sexual abuse allegation on the morning of Friday, 2/21/25. The DON stated she did not recall overhearing any conversation at the nursing station between a female NA and male NA about not providing care to Resident #1. During an interview on 3/5/25 at 1:36 p.m., the Occupational Therapist (OT) recalled on 2/17/25, as she was escorting Resident #1 from the 200-hall unit's common area to start the resident's therapy session, the resident was agitated and insisted that she needed to talk with the Administrator. The OT revealed the resident informed her she was being molested at the facility since her admission. The OT stated that she calmed the resident and immediately escorted Resident #1 to the Admission's Coordinator's office where the resident repeated the allegation. The OT stated at that time she was unaware who was the Abuse Coordinator. The Admission's Coordinator later explained to her that the Administrator was the Abuse Coordinator, but she (Admissions Coordinator) did write the report and submitted it to the Administrator. On 3/5/25 at 2:19 p.m., the Admission's Coordinator stated on the morning of 2/17/25, the OT escorted Resident #1 to her office. She revealed Resident #1 told her she had been molested at the facility. The Admission's Coordinator stated she excused herself and went to the Administrator's office and informed him of the resident's allegation. She was instructed by the Administrator to take Resident #1's statement, which she did. She stated Resident #1 informed her that a tall, skinny black guy (no name provided) had been molesting her. She stated the resident reported every morning the male staff would remove all of her clothes, rub her private area, then bathe and dress her before transferring her to her wheelchair and escort her to the dining table in the common area. The resident reported this happened the previous Wednesday, Thursday, Friday, Saturday, and Sunday. The Admission's Coordinator revealed when asked if there was anything else she needed to report about the incident, the resident replied, No, that was it, but he's a nice guy. The Admission's Coordinator stated she submitted the statement to the Administrator. She further revealed she had not heard any more about the allegation. During an interview on 3/6/25 at 5:54 p.m., the Administrator revealed on 2/17/25, the Admission's Coordinator reported to him there was a potential allegation of abuse (she did not specify the type of abuse) which he directed her to document the witness statement. He stated the Admission's Coordinator handed him the statement later, which he placed on his desk to review after completion of what he was working on. However, he did not remember the statement. He stated that when the police arrived at the facility on 2/21/25 at 8:30 a.m. to investigate a report of employee to resident sexual abuse, he recalled receiving a written statement of abuse earlier that week. The Administrator indicated he did not read the statement of abuse when it was placed on his desk on 2/17/25. He stated after locating and reading the witness statement on his desk on 2/21/25, he contacted the Regional Chief Nursing Officer and together they began working on the investigation on 2/21/25. The alleged perpetrator (NA#2) was immediately suspended on 2/21/25. The Administrator sent an initial report to the Division of Health Service Regulation and notified Adult Protective Services on 2/21/25. During an interview on 3/6/25 at 11:26 a.m., NA #2 stated the first time he was made aware Resident #1 alleged that he inappropriately touched her was the morning of 2/21/25. The Administrator also informed him he was suspended until the investigation of the alleged abuse was complete. NA #2 stated he had not worked at the facility since 2/21/25. He further revealed that he was informed via phone today (3/6/25) that he was cleared to return to work at the facility. The facility initially reported the incident to the State Agency on 2/21/25 as an alleged employee to resident abuse of sexual assault. The facility reported it became aware of the incident on 2/21/25 at 8:30 a.m. Resident #1 was currently in the hospital and reported to the police a description which fit one of the two male nurse aides that worked on the resident's hall. The male aide was suspended on 2/21/25 until completion of the investigation. Review of the facility's staffing records revealed NA#2 worked at the facility on 2/16/25 from 7:00 a.m. through 11:00 p.m. but did not work at the facility on 2/17/25 through 2/20/25. The facility provided the following corrective action plan with a compliance date of 2/22/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 2/17/25 Admission Coordinator presented Administrator with a written statement from the therapist stating that Resident #1 alleged sexual assault during care by a staff member. The administrator laid the statement on the desk before reading and completed the task he was previously working on. The Administrator became distracted by other events in the facility and failed to read the statement and report in the two-hour window. The Administrator failed to report the allegation as required. The failure of the Administrator to report led to not reporting to law enforcement, Adult Protective Services, not starting an investigation, lack of protection. Adult Protective Services was notified on 2/21/2025. Resident #1 did not readmit to the facility after hospitalization and is no longer residing in the facility. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All Residents residing in the facility have the potential to be affected by the deficient practice. On 2/21/25 the Regional Nurse Consultant reviewed reportable incidents for the last 30 days to identify if reporting was completed per policy to include appropriate reporting to the administrator and that law enforcement, APS, and state agency were notified. On 2/21/2025 Director of Nursing, Assistant Director of Nursing, Unit Manager, and Social Worker completed interviews with alert and oriented residents regarding abuse and skin checks on not alert and oriented residents for signs of abuse; with no indications of abuse discovered. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 2/21/2025 the Director of Nursing and Assistant Director of Nursing educated current staff, including agency on identifying and reporting abuse. Education included verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, involuntary seclusion, exploitation, misappropriation of resident property and mistreatment. The staff members, including agency staff, that have not received the education will not be able to work until they have received this education. The Director of Nursing is responsible for ensuring this is enforced. In the event abuse is witnessed the staff member should stay with the resident providing protection from the abuse. Immediately after removing the abuse the abuse must be reported to the Administrator. The Administrator was educated by the Regional Nurse Consultant on 2/21/2025 on how he should confirm the abuse, ensure the protection of the resident, confirm the perpetrator is removed, and submit an initial investigation to the State, contact the police department and Adult Protective Services and complete a thorough investigation prior to submitting the five-day report to the State. Staff were asked to return information verbally to confirm understanding of education. The Director of Nursing is responsible for ensuring newly hired staff, including agency staff, will receive the education in orientation. Education completed 2/21/2025. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Regional Nurse Consultant will audit all submitted reportables in person weekly for twelve weeks to ensure protection of the resident was provided, perpetrator was removed, and appropriate reporting to the administrator and notification to law enforcement, APS, and state agency was completed timely by the Administrator. The decision was made on 2/21/2025 to complete education, to monitor the system, and to take to Quality Assurance Committee. The Regional Nurse Consultant or designee will bring these audits to the Quality Assurance Committee meeting monthly for 3 consecutive months. The Quality Assurance Committee will evaluate the effectiveness of the above plan and will make additional interventions and recommendations based on the audits to ensure continued compliance. Date of alleged compliance: 2/22/2025 Validation of the facility's corrective action plan was conducted from 3/4/25 through 3/6/25. Review of facility documents revealed alert and oriented residents were interviewed regarding abuse by facility staff with no abuse reported and no concerns were discovered. Skin audits of residents were reviewed with no findings indicating abuse. Reviewed the education provided to staff (including sign-in sheets) on following the facility's policy on the types of abuse, protecting the resident, and reporting abuse immediately to nurse, DON, and Administrator and time frames for submitting initial report and the investigation report to the State Agency. Facility staff were interviewed during the survey on the facility's abuse policy including: identifying abuse, reporting abuse immediately, and protecting residents. The Administrator was interviewed and verbally demonstrated an understanding of the facility's abuse policy and the importance of taking immediate action on allegations of abuse. Other sampled residents' abuse allegations (most recent was 12/24/24) indicated the facility's abuse policy was followed. Interviews with residents and observations of residents indicated they had no concerns with abuse or if abuse was reported, it was investigated. The facility's compliance date of 2/22/25 was validated.

Based on record review and interviews of staff, the resident, and the nurse practitioner, the facility failed to correctly transcribe the resident's (Resident #57) nephrology order for sterile saline flush 15 to 30 milliliters of the suprapubic urinary catheter every 12 hours. The resident's order was put in as a one-time order and only one sterile saline flush was completed. This deficient practice affected 1 of 3 residents reviewed for urinary catheter. Findings included: Resident #57 was admitted to the facility on [DATE] with the diagnosis of neurogenic bladder. Resident #57's quarterly Minimum Data Set, dated dated dated [DATE] documented the resident's cognition was intact. The resident had a suprapubic urinary catheter and the diagnosis of neurogenic bladder. The care plan dated 5/23/24 for Resident #57 had a planned area for suprapubic urinary catheter. The interventions were monitor/document for signs and symptoms of urinary tract infection and report to the physician and to position the catheter bag and tubing below the level of the bladder. Resident #57's nephrology consultation visit note dated 7/5/24 documented for staff to flush her suprapubic urinary catheter with 15 to 30 milliliters of sterile saline every 12 hours. The resident was to return for follow up after 7/28/24. Resident #57 had an order entered on 7/5/24 by Nurse #1 for a one time order to flush the suprapubic urinary catheter every 12 hours with 15 to 30 milliliters of sterile water. A review of Resident #57's Medication Administration Record (MAR) documented on 7/5/24 day shift one flush of the suprapubic urinary catheter. The remaining dates for the month of July to the 30th had no signatures. There was an x in the place to sign. On 7/9/24 at 10:30 am an interview was conducted with Resident #57. Resident #57 stated she saw the urologist and he ordered her suprapubic urinary catheter to be flushed twice a day. She further stated that the staff had not flushed her catheter twice a day. When she asked the staff about the catheter flush the nurse still had not flushed the catheter. Resident #57 commented that she had no signs or symptoms of urinary tract infection (UTI) at this time. On 7/9/24 at 1:30 pm an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that Resident #57's suprapubic urinary catheter flush order was incorrectly placed into the system as a one-time order. Nurse #1 incorrectly entered the order for one-time order to flush the catheter every 12 hours on 7/5/24. At 2:30 pm the ADON checked with Nurse #1 and the resident's MAR, the resident's catheter was only flushed once by Nurse #1 who entered the order on 7/5/24 day shift. There were no continued flushes after this date/shift. On 7/9/24 at 3:35 pm an interview was conducted with the Corporate Nurse Consultant. During the interview Resident #57's medical record was displayed to read. The Corporate Nurse stated the resident's order to flush the suprapubic urinary catheter every 12 hours was placed in the order system for one-time only in error. The order reflected as completed and there would not have been an order for the nurses to follow for every 12 hours ongoing. The Corporate Nurse stated she would correct this, and the resident would have her catheter flushed now. Resident #57 had an order entered on 7/9/24 second shift by the Assistant Director of Nursing to flush the suprapubic urinary catheter every 12 hours with sterile water (15-30 ml) every day and evening shift for UTI for 28 Days. On 7/10/24 at 9:00 am an interview was conducted with Nurse #1. Nurse #1 stated she was regularly assigned to Resident #57 on day shift. Nurse #1 stated she entered Resident #57's order in the electronic medical record for suprapubic urinary catheter flush on 7/5/24. Nurse #1 was not sure if the order was entered as a one-time order. Nurse #1 stated there was not currently a place/order in the MAR to document the catheter flush. The order was showing as completed (7/5/24). Nurse #1 stated she would document any catheter flushes completed in the nurses' notes because it was no longer in the resident's orders. Nurse #1 stated she had not documented in the nurses notes a catheter flush. Nurse #1 stated if she needed to flush the catheter, she would use a prior order that was not discontinued. A review of Resident #57's orders, including discontinued orders, had not revealed an order to flush the catheter in the past six months (1/8/24). A review of Resident #57's nurses' notes had not revealed any documentation of the suprapubic urinary catheter flush for the past 90 days (4/8/24). On 7/10/24 at 9:11 am an interview was conducted with the Nurse Practitioner (NP). The NP stated she was very familiar with Resident #57. The resident saw the urologist on 7/5/24 with sterile saline suprapubic urinary catheter flush every 12-hours order. The NP stated she asked staff and reviewed the resident's chart and there was no standing order for urinary catheter flush or prior order in place to flush the catheter. The NP was not aware the resident had not received the ordered urinary catheter flushes after 7/5/24. The resident was oriented and could ask when the new order from urology was not completed (catheter flush) because she was aware of the order. The NP was made aware that the order was corrected on 7/9/24 in the evening for the catheter flush. At 11:30 am the NP assessed the resident and stated the resident had no signs or symptoms of a UTI from the missed urinary catheter flushes from 7/5/24 to 7/9/24. On 7/11/24 at 9:30 am an interview was conducted with Resident #57. She stated her urinary catheter was now being flushed twice a day.

Based on record review, observations, resident, and staff interviews the facility failed to provide care in a manner to maintain the resident ' s dignity by not answering call bells for residents that need extensive assistance with activities of daily living (ADLs). This was evident for 3 of 6 residents (Resident #10, Resident #3, and Resident #4) reviewed for dignity. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, diabetes mellitus, and osteoarthritis of right knee. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 ' s cognition was intact. She required moderate assistance with toileting, shower/baths, and personal hygiene. She required maximum assistance with dressing and was dependent on staff for transfers. She was always incontinent of bowel and bladder. An interview on 05/08/24 at 10:21 AM with Resident #10 was conducted. She stated she had waited up to 2 hours for her call light to be answered, which resulted in her sitting in urine and bowel movement. She indicated she did not want to sit in a soiled brief. She did not recall the dates of the occurrences. She then stated she can time how long the call light had been on according to what she ' s watching on TV at the time. Resident Council minutes reviewed for 09/07/23, 10/03/23, 11/02/23, and 01/04/24 revealed concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care. On 12/07/23, 02/08/24, 03/07/24, and 04/24/24 concerns related to Nursing Assistants (NAs) call light response time were voiced. An interview was conducted on 05/09/24 at 1:08 PM with the Assistant Director of Nursing (ADON). The ADON stated she did pull NA #1 to assist with transportation during the morning of 05/09/24 and she made the nurses and other NAs know she would be off the hall. She stated the other NAs on the hall would assist in covering the section until the NA returned. An interview was conducted on 05/09/24 at 1:10 PM with the Director of Nursing (DON). The DON stated she was unaware of the wait times and staff not answering call bells. She also stated her expectations is for the call lights to be answered in a timely manner by all staff. 2. Resident #3 was admitted to the facility on [DATE] with diagnosis that included Parkinson ' s Disease, diabetes mellitus, and Dementia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 cognition was moderately impaired. She required set-up/clean-up assistance with toileting, minimal assistance with eating, oral hygiene, and personal hygiene. She also required moderate assistance with shower/baths and dressing. She had limited range of motion (ROM) to one side of her upper extremities. A continuous observation and interview on 05/09/24 from 9:44 AM through 10:13 AM revealed call lights were activated. Nursing Assistant (NA) #2 was noted sitting at the nurses ' station in front of the computer. NA #2 was asked if she was aware the call lights were activated and she stated, They ' re not my residents and then stated, I thought that nursing assistant had returned to the hall. She indicated she normally answered any call lights that were activated, and she should not have assumed NA # 1 was going to do so. An interview was conducted on 05/09/24 at 11:40 AM with Nursing Assistant (NA) #1. She verified she was the direct care Nursing Assistant (NA) for Resident #3 ' s room. She stated she answered the call bells as timely as she could however this morning she had been pulled to assist with transportation and was not on the floor for a period of time. She stated the nurses and other NAs knew she would be off the hall for transportation. She stated she did not tell other staff she was leaving her assignment, but the ADON was on the floor, and she did. Resident Council minutes reviewed for 09/07/23, 10/03/23, 11/02/23, and 01/04/24 revealed concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care. On 12/07/23, 02/08/24, 03/07/24, and 04/24/24 concerns related to Nursing Assistants (NAs) call light response time were voiced. An interview was conducted on 05/09/24 at 1:08 PM with the Assistant Director of Nursing (ADON). The ADON stated she did pull NA #1 to assist with transportation during the morning of 05/09/24 and she made the nurses and other NAs know she would be off the hall. She stated the other NAs on the hall would assist in covering the section until the NA returned. An interview was conducted on 05/09/24 at 1:10 PM with the Director of Nursing (DON). The DON stated she was unaware of the wait times and staff not answering call bells. She also stated her expectations is for the call lights to be answered in a timely manner by all staff. An interview was conducted on 05/09/24 at 1:55 PM with Resident #3. She revealed that when she activated her call light to request assistance on 05/09/24 at about 09:45 AM, it took staff 30 minutes to come to her room. She did not recall why she activated the call light at that time. She indicated she often had to wait up to an hour for help after she activated the call light. She also stated she got frustrated and helpless when staff do not respond timely. She further stated it doesn ' t feel good to be wet that long. She indicated when the State was in the building, the staff answered the call bell a lot faster than if they were not. 3. Resident #4 was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive pulmonary disease (COPD), difficulty walking, history of falls, and unsteadiness on feet. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 ' s cognition was intact. She required set-up/clean-up assistance with toileting, personal hygiene, and dressing. She required minimal assistance with showing/bathing and was occasionally incontinent of bladder. A continuous observation and interview on 05/09/24 from 9:44 AM through 10:13 AM revealed call lights for rooms [ROOM NUMBERS] were activated. Nursing Assistant (NA) #2 was noted sitting at the nurses ' station in front of the computer. NA #2 was asked if she was aware the call lights were activated and she stated, there not my residents and then also stated, I thought that NA had returned to the hall. She indicated she normally answered any call lights that were activated, and she should not have assumed NA # 1 was going to do so. An interview was conducted on 05/09/24 at 11:40 AM with Nursing Assistant (NA) #1. She verified she was the direct care Nursing Assistant (NA) for rooms [ROOM NUMBERS]. She stated she answered the call bells as timely as she could however this morning she had been pulled to assist with transportation and was not on the floor for a period of time. She stated the nurses and other NAs knew she would be off the hall for transportation. She stated she did not tell other staff she was leaving her assignment, but the ADON was on the floor, and she did. Resident Council minutes reviewed for 09/07/23, 10/03/23, 11/02/23, and 01/04/24 revealed concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care. On 12/07/23, 02/08/24, 03/07/24, and 04/24/24 concerns related to Nursing Assistants (NAs) call light response time were voiced. An interview was conducted on 05/09/24 at 1:08 PM with the Assistant Director of Nursing (ADON). The ADON stated she did pull NA #1 to assist with transportation during the morning of 05/09/24 and she made the nurses and other NAs know she would be off the hall. She stated the other NAs on the hall would assist in covering the section until the NA returned. An interview was conducted on 05/09/24 at 1:10 PM with the Director of Nursing (DON). The DON stated she was unaware of the wait times and staff not answering call bells. She also stated her expectations is for the call lights to be answered in a timely manner by all staff. An interview was conducted on 05/09/24 at 1:45 PM with Resident #4. She revealed that when she activated her call light to request assistance on 05/09/24 at about 09:45 AM, it took staff 30 minutes to come to her room. She indicated she needed ice at that time, but it should not matter what the need was. She then stated it made her mad and upset when staff are heard talking about personal things, but they wouldn ' t answer the call light.

Based on record review, resident, and staff interviews, the facility failed to communicate the facility's efforts to address group concerns verbalized during Resident Council meetings and to resolve repeat concerns for 8 of 9 consecutive months (September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, and April 2024). Findings included: a. Resident Council minutes dated 09/07/23 indicated residents had voiced concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care (not following the bath schedule) and food being cold when served. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. b. Resident Council minutes dated 10/03/23 indicated residents had voiced concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care (NAs leaving residents soiled for extended period) and food being cold when served. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. c. Resident Council minutes dated 11/02/23 indicated residents had voiced concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care and food not being on time. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. d. Resident Council minutes dated 12/07/23 indicated residents had voiced concerns related to Nursing Assistants (NAs) call light response time and food being cold when served. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. e. Resident Council minutes dated 01/04/24 indicated residents had voiced concerns related to Nursing Assistants (NAs) not providing activity of daily living (ADL) care (not following the bath schedule) and food being cold when served. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. d. Resident Council minutes dated 02/08/24 indicated residents had voiced concerns related to Nursing Assistants (NAs) call light response time slow and food not coming out on time. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. e. Resident Council minutes dated 03/07/24 indicated residents had voiced concerns related to Nursing Assistants (NAs) call light response time slow and food being cold when served. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. f. Resident Council minutes dated 04/24/24 indicated residents had voiced concerns related to Nursing Assistants (NAs) call light response time slow. There was no evidence of the facility ' s response to the concerns voiced during the previous meeting had been reviewed or discussed. The facility ' s concern log revealed no documented concerns from the Resident Council from September 2023 through April 2024. An interview was conducted on 05/08/24 at 12:45 PM with the Administrator. He indicated the concerns that were reported in resident council meetings would be written up by the Activity Director and given to the department head responsible so an investigation could be conducted. He was unaware the resident concerns were not addressed from September 2023 through April 2024. An interview was conducted on 05/09/24 at 12:45 PM with Resident # 11, Resident Council President, and Resident #12, Resident Council Co-President, was conducted. Resident # 11 stated they did not receive feedback from staff when group concerns were voiced. Resident # 11 further voiced they have complained multiple times regarding receiving activity of daily living (ADL) care and call bell response time being slow, however, nothing gets resolved. He then stated the Nursing Assistants (NAs) stand around at the nurses ' station and gossip and talk about personal things until 7:45-8:00 AM when they should be starting work at 7:00 AM. He indicated he did not know if the old Activity Director was giving the concerns to the Director of Nursing (DON) or the Administrator. Resident # 12 agreed with Resident # 11 ' s comments. Multiple phone calls to contact the Previous Activities Director were unsuccessful. The Previous Activities Director was employed from 08/02/23 through 04/09/24.

Based on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation surveys completed on 09/01/22 and 07/20/23. This was for 2 deficiencies that were cited in the areas of Resident Rights/Exercise of Rights and Reasonable Accommodation of Needs/Preferences. Resident Rights/Exercise of Rights was cited on the recertification and complaint survey on 09/01/22 and recited on the current complaint survey of 05/09/24. Reasonable Accommodation of Needs/Preferences was cited on 07/20/23 and recited on the current complaint survey of 05/09/24. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QA). The findings included: This citation is cross referred to: 1. F550-Based on record review, observations, resident, and staff interviews the facility failed to provide care in a manner to maintain the resident's dignity by not answering call bells for residents that need extensive assistance with activities of daily living (ADLs). This was evident for 3 of 6 residents (Resident #10, Resident #3, and Resident #4) reviewed for dignity. During the facility's recertification and complaint survey of 9/1/22, the facility failed to promote dignity by not providing privacy cover over a urinary catheter drainage bag for one resident. This occurred for 1 of 6 residents reviewed for dignity. 2. F558-Based on observation, record review, resident interviews, and staff interviews, the facility failed to place a resident's call light (Resident #5 and #7) within reach to allow for the residents to request staff assistance this was for 2 of 3 residents reviewed for accommodation of needs. During the facility's recertification and complaint survey of 07/20/23, the facility failed to provide a dependent resident with a wheelchair to accommodate her size and inability to sit up. The resident was unable to get out of bed unless the staff borrowed a wheelchair from another resident with the same accommodation needs for 1 of 2 residents reviewed for accommodation of needs. A phone interview was conducted on 05/21/24 at 3:23 PM with the Administrator. He stated the citations repeated, but the same issues did not repeat. He indicated he felt the current interventions in place are effective for the issues being cited in previous surveys.

Based on observation, record review, resident interviews, and staff interviews, the facility failed to place a resident's call light (Resident #5 and #7) within reach to allow for the residents to request staff assistance this was for 2 of 3 residents reviewed for accommodation of needs. The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnosis that included epilepsy and epileptic syndromes, history of falls, traumatic brain injury and traumatic subdural hemorrhage with loss of consciousness. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 ' s cognition was severely impaired. He had no behavior and no rejection of care. He required minimum assistance of 1 for toileting hygiene and personal hygiene and required maximum assistance with shower/baths. He was occasionally incontinent of bladder and always continent of bowel. He had no functional limitation with range of motion of her extremities. Resident #5's active care plan, last revised on 04/23/24, indicated he had an activities of daily living (ADL) self-care performance deficit related to a history of traumatic subdural hemorrhage with loss of consciousness from a fall downstairs and cognitive impairment. The interventions included for staff to encourage him to use his bell to call for assistance. Another focus read Resident #5 had an actual fall and was at risk for additional falls related to confusion and history of a fall with serious injury prior to admit to facility. The interventions included for staff to be sure his call light was within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. An observation was conducted on 05/08/24 at 9:55 AM of Resident #7 lying in bed resting with eyes closed. His call bell was tied onto the bottom of the grab rail on the left side of bed out of the residents ' reach. Resident #7 declined to be interviewed. An interview was conducted with Nursing Assistant (NA) #1 on 05/09/24 at 11:40 AM. She verified she was the direct care NA for Resident #7 ' s room. She indicated she checked call bell placement prior to leaving the rooms. NA #1 verified Resident #7 does utilize his call bell for assistance at times. She indicated she did not check his call bell placement upon leaving his room today. An interview was conducted on 05/09/24 at 10:52 AM with Nurse #1. She verified that Resident #7 ' s call bell was tied on the bottom of the grab rail where the resident could not reach it. She indicated he gets up unassisted and ambulated but had used the call bell in the past. She stated Resident #7 does require assistance with his activities of daily living (ADLs). An interview was conducted on 05/09/24 at 1:10 PM with the Director of Nursing (DON). She stated the call bell device should always be within the resident ' s reach. 2. Resident #5 was admitted to the facility on [DATE] with diagnosis that included chronic osteomyelitis (inflammation of bone or bone marrow) of right thigh and difficulty walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 ' s cognition was intact. She had no behavior and no rejection of care. She required moderate assistance of 1 for toileting hygiene and minimal assistance with shower/baths. She was always continent of bowel and bladder. She had no functional limitation with range of motion of her extremities. Resident #5's active care plan, last revised on 04/23/24, indicated she had an activities of daily living (ADL) self-care performance deficit related to pain in her right hip. The interventions included for staff to encourage the resident to use bell to call for assistance. Another focus read Resident #5 had an actual fall and was at risk for additional falls related to generalized muscle weakness and poor safety awareness. The interventions included for staff to be sure her call light was within reach and encourage the resident to use it. An observation and interview were conducted on 05/08/24 at 10:15 AM. Resident #5 ' s call bell was located on the floor behind a box at the head of bed. Resident indicated she could not locate her call bell. She stated she did not know how the call bell got up against the wall under the box, it had been there a while. She also stated she would use her call bell if she needed to. An interview was conducted on 05/08/24 at 10:18 AM with NA #3. She verified she was the direct care NA for Resident #5 and that her call bell was on floor behind a box at head of bed. She stated Resident #5 does not use her call bell, but she does require assistance with her activities of daily living (ADLs). She stated she checks for call bell placement prior to leaving a room but she did not recall if she checked Resident #5 ' s call bell the last time she was in the room. An observation was conducted on 05/09/24 at 10:10 AM. Resident #5 ' s call bell was located on the floor behind a box at head of bed. Resident stated the call bell was under a box and she could not currently reach it. She stated she did not know how the call bell got under the box; it had been there a while. She indicated she did not use the call bell often, but she would if it was within reach, and she needed to do so. An interview was conducted on 05/09/24 at 10:52 AM with Nurse #1. She verified that the Resident #5 ' s call bell was on floor behind a box at head of bed. She stated Resident #5 did not normally use her call bell, but she does require assistance with her activities of daily living (ADLs). An interview was conducted on 05/09/24 at 1:10 PM with the Director of Nursing (DON). She stated the call bell device should always be within the resident ' s reach.

Based on record review and staff interviews, the facility's administration failed to investigate and complete a root cause analysis for a fall for 1 of 4 residents reviewed for accidents. (Resident #8). The deficient practice led to the inability to implement effective interventions to prevent a reoccurrence. The findings included: Resident # 8 was admitted to the facility on [DATE] with diagnosis that included disorder of the brain, repeated falls, and paranoid schizophrenia. Resident #8 ' s significant change Minimum Dat Set (MDS) assessment dated [DATE] indicated her cognition was severely impaired. She had one fall with major injury since admission or reentry. She required moderate assistance for bed mobility and minimal assistance for transfers. Resident #8 ' s care plan, last revised 04/23/24, indicated she was at risk for falls related to confusion, deconditioning, impaired balance during transitions; poor safety awareness, and she does not call for assistance. The interventions included for staff to anticipate and meet the resident's needs, be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needed a prompt response to all requests for assistance and to ensure that the resident is wearing appropriate footwear when ambulating. An incident report, dated 04/25/24, revealed a fall with no injury. Resident #8 was noted to be sitting upright in hall. Resident #8 stated she was trying to go backwards in her wheelchair and fell out of it. The report also revealed she was alert and oriented to person, place, time, and situation with predisposing factor being gait imbalance. The nursing notes reviewed from 04/25/24 through 05/08/24 there was no at risk meeting related to fall that occurred on 04/25/24. An interview was conducted on 05/08/24 at 1:32 PM with the Director of Nursing (DON). She stated falls are discussed every morning in the meeting and then documented in the nurses ' notes. She indicated she did not have an actual at risk meeting. She also indicated she was responsible for completing a root cause analysis for falls. She further stated if there were no notes documented in the nursing notes regarding a fall then there were not any. She was unable to provide documentation of root cause analysis for Resident #8 ' s fall on 04/25/24.

Based on observation, record review, and interviews of staff and a resident, the facility failed to provide a dependent resident a wheelchair to accommodate her size and inability to sit up. The resident was unable to get out of bed unless the staff would borrow a wheelchair from another resident with the same accommodation needs (Resident #93) for 1 of 2 residents reviewed for accommodation of needs. Findings included: Resident #93 was admitted to the facility on [DATE] with the diagnosis of progressive neurological disease. Resident #93's discharge with return anticipated Minimum Data Set, dated dated dated [DATE] documented she had an intact cognition. The resident required total dependence for bathing, transfer, and mobility. Her diagnosis was progressive neurological disease. Resident #93's care plan dated 7/20/21 had a focus for identified activity of daily living self-care deficit. The intervention was to discuss with the resident or family any loss of independence. On 7/17/23 at 10:10 am Resident #93 was observed to be sitting in her bed. There were no wheelchairs in the room that would accommodate her size and need for support while sitting. The resident was concurrently interviewed. The resident stated that she had been without a wheelchair for over a month and was not able to get out of bed unless another resident's wheelchair that fit her and could support her was borrowed since about 4/23/23. A new wheelchair was delivered yesterday but had no pressure reduction cushion so the wheelchair could not be used until the cushion was obtained. The resident stated she was informed by Physical Therapy there were not enough large wheelchairs for all the residents in the building. Resident #93 stated she had not gotten out of bed for over a week, and wanted to visit her family. On 7/1723 at 12:15 pm an interview was conducted with the Therapy Manager. She stated that there were not enough bariatric and supportive wheelchairs (when a resident cannot sit up on their own) for all residents who required the support. She ordered wheelchairs when the corporate office provided the funding and approval. Resident #93's wheelchair funding was approved about 2 weeks ago and a wheelchair was ordered. She stated that Resident #93 had been without a wheelchair that fit her for about a month. When a resident was discharged , their wheelchair would be reassigned to another resident. A bariatric wheelchair was ordered about 2 weeks ago and had arrived yesterday. The pressure reduction cushion had not arrived, and the wheelchair cannot be used until the cushion was available. The resident had a sacral pressure ulcer. She stated the residents' shared wheelchairs so they can get out of bed and sometimes there were not enough to go around, and residents would remain in bed. On 7/20/23 at 11:30 am an interview was conducted with the Administrator. The Administrator stated he was not aware Resident #93 required a specialty wheelchair and that one was not available. He stated that there was funding for wheelchairs, and one should have been ordered when first identified. The Administrator further stated he was not aware there were not enough bariatric wheelchairs that provide sitting support for each resident that required one.

Based on staff interviews and medical record review, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare part A services to 2 of 3 residents (Resident #36 and Resident # 29) reviewed for SNF Beneficiary Protection Notification Review. Findings included: a. Resident #36 was admitted to the facility on [DATE]. Medicare part A services began on the date of admission. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #36 on 4/4/23. The notice indicated that Medicare coverage for skilled services was to end 4/4/23. Resident #36 remained in the facility when Medicare coverage ended and had not exhausted the Medicare benefit. The medical record further revealed a CMS-10055 SNF ABN was not provided to the resident or resident representative on 4/4/23. b. Resident #29 was admitted to the facility on [DATE]. Medicare part A services began on the date of admission. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #29 on 3/20/23. The notice indicated that Medicare coverage for skilled services was to end on 3/20/23. Resident #29 remained in the facility when Medicare coverage ended and had not exhausted the Medicare benefit. The medical record further revealed that a CMS-10055 SNF ABN was not provided to the resident or resident representative on 3/20/23. An interview was conducted with the Social Worker on 7/20/23 at 11:24 AM. She shared staff (Social Work, Business Office Manager, Therapy Director, and Minimum Data Set Nurse) met weekly and discussed each resident who received services under Medicare part A. She explained the team discussed the anticipated last covered day of Medicare services and she completed the NOMNC form but was not aware that she was responsible for issuing the SNF ABN form and had not issued this form since she began her position at the facility in April of 2023. During a telephone interview with the former Social Worker on 7/20/23 at 11:26 AM and she revealed that she was not employed at the facility after November of 2022. An interview was conducted with the [NAME] Office Manager on 7/20/23 at 11:28 AM and she revealed that she was responsible for submitting the NOMNC forms when there was not a social worker employed but was not aware of the SNF ABN form. The Administrator was interviewed on 7/20/23 at 11:33 AM and he revealed that it was the social worker's responsibility to issue the NOMNC and SNF ABN forms as applicable and was not aware that the SNF ABN forms were not provided to the resident and/or resident representatives.

Based on observations, and resident and staff interviews, the facility failed to repair the walls in the resident's room after under-sink cabinets were removed leaving holes in the wall and no floor tile in two residents rooms (rooms [ROOM NUMBERS]) and failed to maintain the wall behind a bed in good repair (room [ROOM NUMBER]). The deficient practice was observed on 1 of 2 halls (200 hall). Findings included: a. On 7/17/23 at 11:50 am an observation and interview of was done of Resident #93 in room [ROOM NUMBER] while sitting up in her bed. The wall under the sink was damaged/missing the plaster and paint and floor tile was missing. There were two 2 inch holes in the wall next to the bed. Resident #93 stated the under-sink cabinet was removed for resident handicapped access months ago and the wall and floor were not repaired. She stated this was disappointing to the resident they have left the hole in the wall for months and there was no storage. The hole next to the bed was fixed. The resident stated she would like the wall and floor to be fixed because it was her home. An interview was conducted on 7/18/23 at 11:45 am with the Maintenance Director. He stated the facility was required to provide a handicapped sink, so the under-sink cabinet was removed in all resident's rooms. He stated the facility was not spending the money for cement plaster to fix the walls. Due to the age and neglect of the plaster, it needed to be completely replaced. The plaster breaks easily when bumped with furniture or wheelchairs. There was constantly damage to the walls and all the walls below the sink where the cabinets were removed had not been repaired. 20670 b. During the tour of the residents' rooms on the 200 hall on 7/17/23 at 11:51 a.m., there were missing sections of floor tile and the baseboard observed beneath the handwashing sink in room [ROOM NUMBER]. A second observation of room [ROOM NUMBER] on 7/20/23 at 9:50 a.m. revealed the floor and baseboard beneath the sink continued to be in disrepair. An interview with the Maintenance Director on 7/20/23 at 9:51 a.m., revealed floor tile was ordered to repair the area beneath the sink in room [ROOM NUMBER] on 4/17/23, but at the time of this interview had not been received. c. On 7/17/23 at 12:49 p.m., the wall behind the headboard of bed A in room [ROOM NUMBER] had multiple large, scratched marks with torn plaster. During a second observation of room [ROOM NUMBER] on 7/20/23 at 9:42 a.m. accompanied by the Maintenance Director, the wall behind the headboard of bed A continued to be badly damaged. On 7/20/23 at 9:43 a.m., the Maintenance Director stated that he was unaware of the damaged wall in room [ROOM NUMBER]. He indicated he had not received a work order from the staff concerning the wall in room [ROOM NUMBER]. He revealed he placed instructions on how to place work order requests for maintenance in the computer for staff and provided instructions to new hires. The Maintenance Director stated he frequently repaired the walls in residents' rooms when observed during his room audits due to nursing assistants pushing the beds against the walls and raising or lowering the heads of the beds. He indicated the heads of the beds should be at least six inches from the walls. The Maintenance Director revealed he had reported this issue to the Administrator. On 7/20/23 at 11:30 am an interview was conducted with the Administrator. He stated that all the under-sink cabinets were removed from the resident's room to provide handicapped access. Because the sinks started to fall down after cabinet removal, the sinks were repaired first, and the walls were not fixed, and tile floor was not replaced. He stated that the wall damage and missing plaster dated back to the previous recertification survey. During COVID, rooms were empty, and walls were repaired while empty. The Administrator provided a purchase order form dated 7/19/23 for 24 square feet of tile that had not been approved by corporate which would cover approximately 3 bathroom floors.

Based on staff interviews and medical record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change occurred for 1 of 4 residents (Resident #59) reviewed for significant change MDS assessments. Findings included: Resident #59 was admitted to the facility on [DATE]. Diagnosis included, in part, benign prostatic hyperplasia with urinary tract symptoms. The significant change MDS assessment with an assessment reference date (ARD) of 4/28/23 was reviewed and revealed the assessment was signed as completed on 5/16/23, 18 days after the determination that a significant change had occurred. Attempts to interview the former MDS Nurse by telephone were unsuccessful. During an interview with the Administrator on 7/19/23 at 3:32 PM, he acknowledged over the past several months MDS assessments had been late. He said the facility had tried some different options to help get caught up on the MDS assessments, which included the hiring of a part time/as needed MDS Nurse who assisted the full time MDS Nurse. The Administrator added the facility recently made a personnel change in the MDS department and there was a new MDS Nurse who had gotten MDS assessments caught up and current.

Based on observation, staff interviews and record review, the facility failed to develop a care plan that addressed the use of a urinary catheter for 1 of 3 residents (Resident #59) reviewed for urinary catheters. Findings included: Resident #59 was admitted to the facility on [DATE]. Diagnosis included, in part, benign prostatic hyperplasia with urinary tract symptoms. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact and had an indwelling urinary catheter. A Care Area Assessment (CAA) was completed by the former MDS Nurse on 5/17/23 for indwelling urinary catheter. The CAA indicated a care plan would be developed with approaches to avoid complications from urinary tract infections, minimize the risk for developing pressure injuries and ensuring the resident's needs were met. The comprehensive care plan, updated 5/25/23, was reviewed and did not include a care plan that addressed the use of a urinary catheter. Attempts to interview the former MDS Nurse by telephone were unsuccessful. On 7/19/23 at 3:47 PM, an interview was conducted with MDS Nurse #1. She was new to the facility (since 6/1/23) and said Resident #59's care plan should have included a focus area for urinary catheter. She explained the care plan should have included information about monitoring for signs/symptoms of infection, observing for kinks in the tubing and instructions for emptying the collection bag. During an interview with the Administrator on 7/19/23 at 3:32 PM, he shared the facility had recently made a personnel change in the MDS department. He added a care plan should have been developed to address the use of an indwelling urinary catheter for Resident #59.

Based on observations, resident and staff interviews and medical record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #59) reviewed for indwelling urinary catheters. Findings included: Resident #59 was admitted to the facility on [DATE]. Diagnosis included, in part, benign prostatic hyperplasia with urinary tract symptoms. The significant change Minimum Data Set assessment dated [DATE] revealed Resident #59 was cognitively intact and had an indwelling urinary catheter. The comprehensive care plan, updated 5/25/23, was reviewed and did not include a care plan that addressed the use of a urinary catheter. On 7/17/23 at 11:51 AM and 7/19/23 at 12:57 PM, observations were made of Resident #59. He was in bed and the bed was in the lowest position. The catheter collection bag was hung on the lowest bar of the bed and half of the bag touched the floor. An interview was conducted with Resident #59 on 7/19/23 at 2:34 PM. He shared staff members came in throughout the day and emptied the catheter collection bag. During the interview, Resident #59's bed was in the lowest position and the collection bag touched the floor. Nursing Assistant (NA) #1 was interviewed on 7/19/23 at 2:40 PM. He stated he typically worked second shift (3:00 PM-11:00 PM). He explained he emptied the catheter collection bag when he worked with Resident #59 and said the collection bag should hang below the level of the bladder and should not have touched the floor. An observation of Resident #59's catheter collection bag and interviews with NA #2 and the Assistant Director of Nursing (ADON) were completed on 7/19/23 at 2:43 PM. The resident was in bed. The bed was in the lowest position and the collection bag touched the floor. During an interview with NA #2, she verified she worked with Resident #59 on 7/17/23 and 7/19/23 during the first shift (7:00 AM-3:00 PM). She explained she typically emptied the collection bag in the morning and again at the end of her shift (around 2:45 PM). She stated the collection bag should be hung below the level of the resident's bladder and not come in contact with the floor. She added Resident #59's bed was in the lowest position and she hung the collection bag on the lowest bar of the bed which caused the bag to touch the floor. The ADON said if the collection bag was placed on the upper bar of the bed, it was still below the level of the resident's bladder and even when the bed was in the lowest position, the bag wouldn't come in contact with the floor.

Based on observation, record reviews, and staff interviews the facility failed have a physician order for a therapeutic diet per the Speech Therapist's evaluation for 1 of 5 residents (Resident #71) reviewed for nutrition. Findings included: Resident #71 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: ESRD (end-stage renal disease), diabetes mellitus, and dysphagia. The most recent Minimum Data Set, dated dated dated [DATE] indicated Resident #71 was cognitively intact, was independent with eating, required a mechanically altered diet, received dialysis services and speech therapy. The care plan dated 1/14/23 revealed Resident #71 had a potential nutritional problem related to ESRD and pureed renal diet with nectar thickened liquids. Interventions included: RD (Registered Dietitian) to evaluate and make diet change recommendations, when needed; provide and serve diet as ordered, Monitor intake and record every meal. The physician's order dated 6/29/23 indicated Resident #71 was to receive a diet of pureed texture (double portions) and nectar thickened fluids, related to ESRD, dependence on renal dialysis, and dysphagia. The resident was ordered a 1000 milliliter fluid restriction. The resident was cleared by speech therapy for soft sandwiches. The diet order also included the resident was not to receive salt packets, soups, fried foods, bananas, tomatoes, potatoes, oranges, juice, and citrus. During a dining observation on 7/17/23 at 1:30 p.m., Resident #71 received a meal of mechanical soft consistency which included ground pot roast, egg noodles, peas, dinner roll, and a brownie. The meal card located on the resident's meal tray from the dietary department indicated the resident was to receive a meal of mechanical soft consistency with double portion entree. An interview was conducted on 7/18/23 at 2:55 p.m. with the facility's Registered Dietician (RD). The RD revealed that after observing this Surveyor sitting with Resident #71 during the lunch meal service on 7/16/23 and noticed the resident was consuming a meal of mechanical soft texture. The RD stated that she reviewed the physician's orders which did not indicate the resident's diet was changed from pureed texture to mechanical soft texture. She revealed that earlier this day she was informed by the Speech Therapist (ST) that she upgraded the resident's diet from pureed to mechanical soft on 7/12/23 and provided a diet slip to the dietary department before the physician's order was completed. The RD revealed she in-serviced the ST on 7/18/23 concerning not providing a diet change slip to dietary until a signed physician's order of change was received and in place. During an interview on 7/19/23 at 10:35 a.m., the ST indicated Resident #71 received speech therapy services due to staff's concerns with meal consistency as evidenced by the resident's coughing while eating. On 5/24/23 the ST began working with the resident for safe trials while eating. The ST acknowledged she submitted a diet communication form to dietary to upgrade Resident #71's pureed soft diet to mechanical soft with ground meats on 7/12/23. She concluded she thought she had also placed the order in the electronic record prior to submitting the change to dietary.

Based on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification surveys completed on 9/1/22 and 4/22/21. This was for 4 deficiencies that were cited in the areas of Safe/Clean/Comfortable/Homelike Environment (F584), Comprehensive Assessment After Significant Change (F637) which were cited on 9/1/22 and recited on the current recertification and complaint survey 7/20/23. Develop/Implement Comprehensive Care Plan (F656) which was cited on 9/1/22, 4/22/21 and recited on the current recertification and complaint survey 7/20/23. Bowel/Bladder Incontinence, Catheter, UTI (F690) cited on 4/22/21 and recited on the current recertification and complaint survey 7/20/23. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QA). The findings included: This citation is cross referred to: F584: Based on observations, and resident and staff interviews, the facility failed to repair the walls in the resident's room after under-sink cabinets were removed leaving holes in the wall and no floor tile in two residents rooms (rooms [ROOM NUMBERS]) and failed to maintain the wall behind a bed in good repair (room [ROOM NUMBER]). The deficient practice was observed on 1 of 2 halls (200 hall). During the recertification survey on 9/1/22, the facility failed to maintain a clean and homelike environment by not ensuring room [ROOM NUMBER] had a working toilet for at least 3 days during the survey, not ensuring a clean resident room (room [ROOM NUMBER]A) and failed to label and cover urinals for 3 residents use in a shared bathroom (rooms [ROOM NUMBERS]) for 3 of 47 rooms on 2 of 2 halls reviewed for a clean, comfortable, and homelike environment. F637: Based on staff interviews and medical record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change occurred for 1 of 4 residents (Resident #59) reviewed for significant change MDS assessments. During the recertification survey on 9/1/22, the facility failed to complete a significant change assessment for 1 of 1 sampled resident reviewed for rehabilitation services. F656: Based on observation, staff interviews and record review, the facility failed to develop a care plan that addressed the use of a urinary catheter for 1 of 3 residents (Resident #59) reviewed for urinary catheters. During the recertification survey on 9/1/22, the facility failed to develop comprehensive care plans for 1 of 5 sampled residents reviewed for nutrition and 1 of 1 sampled resident reviewed for discharge planning. During the recertification survey on 4/22/21, the facility failed to develop and implement a comprehensive care plan for one of two residents reviewed for care plans. F690: Based on observations, resident and staff interviews and medical record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #59) reviewed for indwelling urinary catheters. During the recertification survey on 4/22/21, the facility failed to obtain orders regarding indwelling catheter care in 2 of 3 residents reviewed, orders to change the catheter in 2 of 3 residents reviewed and failed to secure the urinary catheter drainage tubing for 1 of 3 residents reviewed for indwelling urinary catheter. The Administrator was interviewed on 7/20/23 at 2:40 pm. He stated that the QA members were made up of Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Supervisor and the Medical Director were always invited to attend. He also stated that the QA committee usually meets quarterly but they have met monthly this year due to new staff. He also added that the facility has to utilized a lot agency staff since Covid began and he was happy to say that they have recently been able to eliminate all agency staff. He stated the facility has a whole will meet to discuss these issues and investigate new ways to achieve compliance.

Based on observations and staff interviews, the facility failed to ensure a potentially hazardous sandwich made with eggs and mayonnaise was stored within safe temperature range at or below 41 degrees Fahrenheit to prevent the potential for food borne illness; failed to ensure the wash and final rinse cycles of the dishwashing machine operated at the manufacturer's recommended temperatures; by not maintaining the food service equipment in clean and debris-free condition; and, failed to ensure the food items stored in the snack/nourishment refrigerators in 1 of 2 residents' nourishment rooms (100 hall nourishment room) were clean, and food items not provided by the facility were dated and labeled. These practices had the potential to affect food served to residents. Findings included: 1. During a kitchen observation with the dietary manager (DM) on 8/29/22 at 10:38 a.m., there were 2-large, resealable plastic bags containing a sandwich, an oatmeal cookie, and a can of soda on the shelf in the walk-in cooler. The DM identified the sandwiches as egg salad and revealed the bagged lunches were for residents who go out of the facility to their [CONDITION(S)] appointments. She stated there were 8 or 9 [CONDITION(S)] residents in the facility and dietary prepared each [CONDITION(S)] resident with a resealable plastic bag containing a sandwich, 2-snacks, and a juice or diet soda to carry with them to [CONDITION(S)]. The DM revealed the facility receptionist would collect the sealed lunch bags from the kitchen every morning and give one to each resident as they left the facility for [CONDITION(S)] center. During an interview on 8/31/22 at 8:50 a.m., Resident #17 revealed he went to the [CONDITION(S)] center three times a week after breakfast and usually ate his packed lunch at 12:30 p.m. while at the [CONDITION(S)] center. He stated that the dietary department supplied him with a packed lunch in a resealable plastic bag which included a sandwich which was always egg salad (his preference), a drink, and snacks. When asked if the packed lunch was refrigerated at the [CONDITION(S)] center due to the mayonnaise-based sandwich, he responded no, the lunch remained in his tote bag (observed in a non-insulated tote bag without an ice pack on back of Resident #17's wheelchair) until he was ready to eat it. An interview with the facility's receptionist on 8/31/22 at 9:20 a.m. revealed 4-residents were scheduled for [CONDITION(S)] this day (Wednesday): 2-residents were to leave the facility at 9:15 a.m. for their 10:15 a.m., [CONDITION(S)] appointment and 2-residents were to leave the facility at 10:15 a.m. for their 11:15 a.m. appointments at the [CONDITION(S)] center. She stated at 9:00 a.m. she collected the 4-resealable, plastic bags of lunches from the dietary department and stores the bagged lunches in a file cabinet next to her desk for each [CONDITION(S)] resident to take with them to the [CONDITION(S)] center. As a demonstration, the receptionist removed from the file cabinet (not temperature controlled) next to her desk 2-large, sealed plastic bags, each consisting of a sandwich, a soda, an oatmeal cookie and a bag of snack crackers. The receptionist revealed she monitored the temperature of the sandwiches by touching the lunch bag to ensuring the sandwiches remained cool. She also stated that after four hours any lunch bags remaining in her file cabinet were returned to the kitchen. 2. During three observations of the operation of the high temperature dishwashing machine in the kitchen on 8/29/22 from 10:21 a.m. to 10:35 a.m., the water temperatures during the wash cycle ranged from 154 degrees Fahrenheit to 174 degrees Fahrenheit; and the water temperatures during the rinse cycle were 174 degrees Fahrenheit during the first two observations and 176 degrees Fahrenheit during the third observation. The dietary staff revealed the wash and rinse temperature gauges were checked three times every day during the dishwashing operation. The dietary staff indicated the wash temperature should read 160 degrees Fahrenheit and the rinse temperature should read 180 degrees Fahrenheit. However, the dietary staff continued to send dishware through the dish machine when the rinse temperature read less than 180 degrees Fahrenheit then stacked the dishware on the storage racks and the meal trays at the food service tray line, ready for use. This surveyor informed the DM the rinse cycle was not meeting the required rinse temperature of 180 degrees Fahrenheit or above and the meal trays, plates, bowls, and silverware observed during the three observations would have to be rewashed. The DM directed the staff to stop the dishwashing machine and stated she would contact the dishwasher service technician. She revealed the service technician conducted monthly checks of the water temperature cycles on the machine every month and his last visit was a couple of weeks prior. 3. During the kitchen tour on 8/29/22 from 10:38 a.m. to 10:53 a.m., the following was observed: broken and missing floor tiles at the door of the walk-in cooler; dark black/brown grease in the deep fryer which the DM revealed was last used three days prior; badly scuffed/scratched wall next to the 3-compartment sink; the lids of the 3-bins (sugar, flour, rice) were stained with brown, sticky substances, and 1 of the bins filled with brown rice was not labeled. The inside bottom of both sides of the double plate warmer contained food debris and there was a large piece of a broken plate in the bottom of one side of the warmer. The DM revealed the plate warmer was last taken apart and cleaned approximately one and half weeks ago. 4. On 8/31/22 at 11:00 a.m., an observation of 1 of 2 nourishment rooms was conducted. The outside of the refrigerator/freezer was dirty with brown and dark gray stains and old pieces of tape. The inside of the refrigerator had no light, and one bottom vegetable bin contained a free-flowing, yellow colored liquid. The following items were observed in the refrigerator and not labeled with a resident's name, room number, and date stored: 3-4 resealed bottles of water, 1(16 ounce) resealed bottle of diet soda, 1-packaged pre-cooked breakfast sandwich, and 2(12 ounce) cans of grape soda. The freezer section had no thermometer, 6-flavored freeze pops that were not labeled with a resident's name, room number and date stored, and 1-travel thermos not labeled with a resident's name, room number and date stored. On a shelf of the ice cart there was an uncovered ice scoop next to the scoop holder.

Based on record review, observation, resident, facility staff, [CONDITION(S)] staff, and physician interviews, the facility failed to prevent significant medication errors for 1 of 8 residents reviewed for medication administration (Resident #42). The facility administered heart medication, insulin, blood thinner, blood pressure and diabetic medications to Resident #42 after Resident #68 ' s medications were transcribed in error for Resident #42. The facility failed to administer prescribed antipsychotic medication, heart medication, pain medication, tremor medication and insulin to Resident #42. Resident #42 had the high likelihood of additional adverse consequences to the medications he received that were not intended for him. Resident #42 experienced low blood sugar levels and increased tremors. Additionally, the facility failed to prevent significant medication errors for 2 of 8 residents reviewed for medication administration (Resident #46 and Resident #25) Medication aide (MA) #1 administered a blood pressure medication outside of prescribed parameters to Resident #46. and a MA administered an incorrect amount of insulin to Resident #25. Immediate Jeopardy began on 2/27/2021 when Resident #42 missed his first dose of [MEDICATION(S)] 12.5 milligrams (mg) for blood pressure, [MEDICATION(S)] 300 mg for pain, [MEDICATION(S)] 50 mg for tremors, [MEDICATION(S)] 5 mg for mood, and received [MEDICATION(S)] 25 mg (blood pressure), [MEDICATION(S)] 1000 mg (diabetes), and [MEDICATION(S)] insulin 32 units (elevated blood sugar). Immediate Jeopardy was removed on 4/16/2021 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) due to examples #2 and #3 to ensure monitoring systems put into place are effective. 1. Resident #68 was admitted to the facility on [DATE] from the hospital. The medical record for Resident #68 was reviewed and hospital discharge orders dated 2/26/2021 had the following medications ordered for Resident #68: [MEDICATION(S)] 400 mg (milligram) 1 tablet oral daily [MEDICATION(S)] 2 grams in [MEDICATION(S)] 100 milliliters intravenous every 12 hours [MEDICATION(S)] 0.125 mg oral daily [MEDICATION(S)] 5 mg oral twice per day [MEDICATION(S)] 45 mg oral daily [MEDICATION(S)] 40 mg oral daily Insulin [MEDICATION(S)] 32 units subcutaneously 3 times per day Insulin [MEDICATION(S)] sliding scale insulin before meals and bedtime [MEDICATION(S)] 1000 mg oral 2 times per day [MEDICATION(S)] [MEDICATION(S)] 25 mg oral 2 times per day [MEDICATION(S)] flextouch 120 units injected subcutaneously at bedtime [MEDICATION(S)] 1.8 mg injected subcutaneously daily Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #42 to be moderately cognitively impaired and he was receiving renal [CONDITION(S)]. The MDS documented Resident #42 received insulin, antipsychotic medications, antidepressant, diuretic and opioids during the 7-day lookback period. The medical record for Resident #42 was reviewed and included the hospital discharge orders. The orders were dated 2/27/2021 and had following medications listed for Resident #42: [MEDICATION(S)] 5 mg oral daily [MEDICATION(S)] 5 mg oral daily [MEDICATION(S)] insulin 35 units subcutaneously daily [MEDICATION(S)] 12.5 mg 2 tablets oral 2 times per day [MEDICATION(S)] 20 mg oral daily [MEDICATION(S)] 25 micrograms/hour patch, apply topically every 3rd day [MEDICATION(S)] 40 mg oral 2 times per day [MEDICATION(S)] 300 mg oral 2 times per day Insulin [MEDICATION(S)] 4 units subcutaneously 3 times per day before meals [MEDICATION(S)] 50 mg oral 2 times per day Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders were transcribed in error by Nurse #1. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 400 milligrams (mg) 3 doses (used for irregular heart rate) [MEDICATION(S)] 125 micrograms (mcg) 3 doses (used for heart failure and irregular heart rate) [MEDICATION(S)] 120 units 1 dose (long-acting insulin) [MEDICATION(S)] 1.8 mg 2 doses (used to control blood sugar) [MEDICATION(S)] 5 mg 5 doses (blood thinner) [MEDICATION(S)] 25 mg 6 doses (slows heart rate, decreases blood pressure) [MEDICATION(S)] 1000 mg 7 doses (used to control blood glucose) Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 5 mg 4 doses (blood pressure) [MEDICATION(S)] 100 mg 4 doses (gout) [MEDICATION(S)] 5 mg 4 doses (antipsychotic medication for mood stabilization) [MEDICATION(S)] 12.5 mg 7 doses (blood pressure) [MEDICATION(S)] 40 mg 7 doses (heart failure) [MEDICATION(S)] 300 mg 7 doses (used for pain control) [MEDICATION(S)] 50 mg 7 doses (for tremors) [MEDICATION(S)] 4 units 10 doses (short-acting insulin) [MEDICATION(S)] ([MEDICATION(S)]) patch: removed 2/27/2021, was not replaced until 3/3/2021. A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42 refused the medication due to a known [MEDICATION(S)] allergy. The medical record was reviewed, and Resident #42 received a [CONDITION(S)] treatment on 3/2/2021. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood glucose levels on 3/2/2021 were 67 at 4:00 PM. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 3/1/2021 written by the Unit Manager (UM) documented Resident #42 had episodes of low blood glucose during the shift and [MEDICATION(S)] 1 mg was administered at 10:00 PM for blood glucose results of 55. The note did not document the physician had been notified of the low blood glucose levels. A handwritten communication form from nursing staff to the physician dated 3/1/2021 reported several episodes of low blood glucose and questioned the amount of insulin prescribed for Resident #42. The physician initialed and signed the note on 3/2/2021. An interview was conducted with the UM on 4/15/2021 at 7:45 AM. The UM reported he had held the insulin for Resident #42 on 3/1/2021 and had given Resident #42 [MEDICATION(S)] on 3/1/2021 because he was shaking tremoring and had weakness and sweating. The UM reported he checked Resident #42 ' s blood glucose and it was low, but he was unable to recall the results. The UM reported he did not remember if he called the physician with Resident #42 ' s low blood glucose results. Resident #42 was interviewed on 4/13/2021 at 2:00 PM. Resident #42 reported that he returned from the hospital and he had many different medications. Resident #42 reported that he felt bad and his blood sugar dropped, but he wasn ' t certain of the date. Resident #42 reported he was told he had to take an intravenous antibiotic, but he was allergic to the medication and he refused to take the antibiotic. Resident #42 reported that when he took [MEDICATION(S)] type of medications, he became very sick to his stomach. The medical record was reviewed and lab work for Resident #42, performed on 3/4/2021 at the [CONDITION(S)] center revealed a glucose level of 43. Nurse #1 was interviewed on 4/19/2021 at 1:37 PM. Nurse #1 reported she completed the readmission for Resident #42 on 2/27/2021. Nurse #1 reported when Resident #42 was readmitted to the facility after hospitalization on [DATE], the transporters handed her a packet with all of Resident #42 ' s paperwork, including medication orders. Nurse #1 reported she had contacted the on-call physician to review the medications. Nurse #1 reported she did not know why Resident #68 ' s medications were transcribed for Resident #42. The [CONDITION(S)] nurse was interviewed on 4/14/2021 at 10:55 AM. The [CONDITION(S)] nurse reported Resident #42 had weakness related to the low blood sugar lab result on 3/4/2021. The [CONDITION(S)] nurse was interviewed on 4/15/2021 at 9:27 AM. The [CONDITION(S)] nurse reported Resident #42 was not very symptomatic with the low blood sugar on 3/4/2021, but the [CONDITION(S)] center nurses noticed that he was having more tremors and shaking. The [CONDITION(S)] nurse reported the [CONDITION(S)] center received the medication MAR for Resident #42 on 3/1/2021 but it was 3/8/2021 before [CONDITION(S)] was able to review the MAR. The [CONDITION(S)] nurse reported she had called the facility on 3/8/2021 to notify them there were medication discrepancies on the MAR, and she was told the facility corrected the medication errors and orders on 3/2/2021. The [CONDITION(S)] nurse reported that the facility had not called the [CONDITION(S)] center to notify of the medication errors for Resident #42. The facility physician (MD) was interviewed on 4/14/2021 at 12:49 PM. The MD reported she had visited Resident #42 on 3/2/2021 and when she reviewed his medications, she noted that medications were ordered for him that he had not had in the past and the orders did not match his hospital discharge note. The MD reported she contacted the Director of Nursing (DON) on 3/2/2021 and the DON came into the facility to make the order corrections. The MD reported because Resident #42 was on [CONDITION(S)] and had received the [MEDICATION(S)], [MEDICATION(S)] and other oral medications were most likely removed by the [CONDITION(S)] treatment. The MD reported that the most significant adverse reaction Resident #42 had was a low blood sugar that was treated with [MEDICATION(S)] (treats low blood sugar) on 3/1/2021. The MD reported that Resident #42 was allergic to the IV antibiotic, and Resident #42 had refused to take the medication. The MD reported the correct medication had been ordered and administered for Resident #42 effective 3/2/2021. An interview was conducted with the DON on 4/14/2021 at 2:57 PM. The DON reported she was called by the MD on 3/2/2021 to report transcription errors for Resident #42. The DON reported she had made the corrections to the medication orders on 3/2/2021 but she was not aware of the specific medications Resident #42 had received between 2/27/2021 and 3/2/2021. The DON reported she had not completed an incident report or medication error report for Resident #42. The DON was interviewed on 4/15/2021 at 1:09 PM. The DON reported she was not aware of the number of medications Resident #42 had received in error. The DON reported after she corrected the orders for Resident #42, she implemented a system to check for transcription errors on new admission residents, but she was not monitoring the process. The DON reported she was aware Resident #42 had experienced low blood sugars. The administrator was notified of the immediate jeopardy on 4/15/2021 at 2:54 PM. The facility provided a credible allegation for immediate jeopardy removal on 4/16/2021 that read: Credible Allegation of Removal of Immediate Jeopardy: Identify those residents who have suffered or are likely to suffer a serious adverse outcome because of the non-compliance. Immediate Action for those affected and potential to be affected. On 2/26/21, Resident #68 was admitted to the facility from the hospital. On 2/27/21 Resident #42 was readmitted to the facility from the hospital. Resident #68 medications were transcribed for Resident #42 resulting in medication errors. These medication errors caused [CONDITION(S)] with a low blood glucose of 43. Resident #42 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set assessment dated [DATE] assessed Resident #42 as Moderately Cognitively Impaired. Resident #68 did receive the correct medication administration. The Medical Director reported that she had visited Resident #42 on 3/2/21 and noted that the medications ordered for him did not match his previous orders. The Medical Director notified the Director of Nursing and the Director of Nursing made the order corrections. The Medical Director reported the resident was on [CONDITION(S)] and most like the medications were removed by the [CONDITION(S)] Treatment. Resident #42 experienced low blood glucose levels and increased tremors. Resident #42 had the high likelihood of additional adverse consequences to the medications he received that were not intended for him. For those Residents with potential to be affected: Residents admitted /readmitted since 2/1/21 had all Medications verified with Hospital Discharge Summary and current Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Director of Nursing and Nurse Designees started audit 4/15/21 and will be completed by 4/16/21. Specify the Action the Entity will take to Alter the Process or System Failure to Prevent a Serious Outcome from occurring reoccurring and when the action will be complete: ON 4/15/21-4/16/21 the Director of Nursing did in-service with all Nurses regarding: Admission/readmission and required procedures; Licensed Nurse will verify all orders with the physician, enter the orders after MD verification for the admitted resident and then have orders verified with second nurse to ensure the orders match the resident admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any Nurse that has not received the training will not work until training is received. Newly hired nurses will receive training during orientation by the Director of Nursing or Nurse Designee. Director of Nursing and Nurse Designee will continue daily surveillance of implemented process to assure ongoing compliance. Allegation of Immediate Jeopardy removal: The facility alleges Immediate Jeopardy removal as of 4/16/21. On 4/16/2021, the facility's credible allegation for immediate jeopardy removal was validated by the following: - Review of the in-services provided to nursing regarding admission/readmission and the required procedures including nurse will verify all orders with the physician, enter the orders into the electronic documentation system and then verify with a 2nd nurse - Audits of the admissions/readmissions medication verification with the hospital discharge orders - Corrections to errors found by the facility (17 out of 22 residents reviewed) - The facility ' s date of the immediate jeopardy removal plan of 4/16/2021 was validated on 4/16/2021. 2. Medication administration for Resident #46 was observed 4/15/2021 at 8:02 AM. Medication aide (MA) #1 checked Resident #46 ' s blood pressure with a wrist cuff and stated out loud Resident #46 ' s blood pressure was low, and she needed to get another blood pressure cuff. MA #1 rechecked Resident #46 ' s blood pressure with a different wrist cuff and reported the blood pressure was 97/61 and she would administer [MEDICATION(S)] 3.125 milligrams (mg). MA #1 was observed administering [MEDICATION(S)] 3.125 milligrams (mg) to Resident #46. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order specified that the [MEDICATION(S)] was to be held if the (systolic) blood pressure was less than 130. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . MA #1 was interviewed on 4/15/2021 at 11:58 AM. MA #1 reported she had misread the instructions and misunderstood the medication order for [MEDICATION(S)]. MA #1 reported she should have held the [MEDICATION(S)] and reported the low blood pressure to the nurse. MA #2 was interviewed on 4/16/2021 at 2:05 PM. MA #2 reported she had administered [MEDICATION(S)] to Resident #46 on 4/14/2021. MA #2 reported she documented Resident #46 ' s blood pressure after she administered the [MEDICATION(S)]. MA #2 reported she was not aware she should have documented the blood pressure prior to administering the medication. MT #2 reported she checked Resident #46 ' s blood pressure before and after the [MEDICATION(S)] administration and documented the blood pressure after the [MEDICATION(S)] was given. MT #2 reported she had been trained to administer blood pressure medications and to document the blood pressure after the medication was given. The Director of Nursing (DON) was notified of the medication error on 4/15/2021 at 10:56 AM. The DON checked Resident #46 ' s blood pressure and it was 130/78. The DON notified the physician and the Resident #46 ' s family. The DON was interviewed on 4/15/2021 at 10:56 AM. The DON reported she did not know why Resident #46 received the [MEDICATION(S)] with low blood pressures. The DON was interviewed again on 4/16/2021 at 3:47 PM. The DON reported MA needed to report changes and issues to the charge nurse. The DON reported that nurses on the floor should be providing active monitoring to the MA. The DON reported it was not a standard of care to document a blood pressure after a medication administration and MA #2 was incorrect. The DON reported she expected medications to be administered correctly and nurses to monitor MA activity with medication administration. The Administrator was interviewed on 4/16/2021 at 4:08 PM. The Administrator reported he expected medications to be administered correctly. 3.Resident # 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly minimum data set (MDS) dated [DATE] included that Resident # 25 had no cognitive impairment, made daily care decisions, was understood and was able to understand. Resident # 25 received 7 days of insulin injections during the review period. A record review revealed a physician ' s (MD) order that was originated on 12/03/2020 to administer [MEDICATION(S)] insulin 96 units injected every day at 10:00 PM for diabetes type 2. A review of Resident # 25 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note dated 12/11/2020 at 2:24 AM revealed that a medication aid (MA # 4) notified the nurse (nurse # 7) earlier in the evening of 12/10/2020 that Resident# 25 had been given 96 units of NovoLog (fast acting) insulin and not the ordered 96 units of [MEDICATION(S)] (slow acting ) insulin by MA # 4 as scheduled at 10:00 PM. Resident # 25 had no signs of [CONDITION(S)] or hyperglycemia; his blood sugar was 223 and his skin was warm and dry. A nurse note dated 12/11/2020 at 7:47 AM revealed that blood sugar checks of Resident # 25 the 11:00 PM to 7:00 AM shift were in normal limits and ranged as follows 164,163,115,130, 127, 111, 133,164 and 213. Resident # 25 did not show any adverse reaction after he received the incorrect insulin type. Resident # 25 was interviewed on 04/14/2021 at 10:48 AM. Resident # 25 revealed that one evening last December he was informed by the nurse staff that he received the incorrect insulin. Resident # 25 also reported that the nurse staff monitored him closely the entire night and he had no adverse effects from the insulin that he had been given. A phone interview with nurse # 7 on 04/14/2021 at 4:30 PM revealed that MA # 4 administered insulin to Resident #25, and it was the incorrect type of insulin that was ordered for Resident # 25. Nurse #7 revealed that the MA staff was only to check resident blood sugars and report results to the nurse and the nurse was to administer insulin. A phone interview was conducted with nurse # 6 on 04/14/2021 at 4:30 PM. Nurse # 6 revealed that Resident # 25 had ben administered the incorrect insulin on 12/10/2020 and that she monitored Resident # 25 closely through the night and that Resident # 25 showed no adverse medication effects and voiced no adverse effects. Resident # 25 remained stable. The facility MD was interviewed via phone on 04/15/2021 at 9:51 AM. The MD revealed that Resident # 25 had not sustained any adverse effects from an injection of the incorrect insulin type on 12/10/2020 and that the licensed nurses monitored him very closely and if Resident # 25 had experienced any adverse effects that there were MD orders in place to administer [MEDICATION(S)] if indicated and to call 911 to send Resident # 25 to the hospital immediately. A phone interview with MA #4 was conducted on 04/15/2021 at 2:59 PM and explained she did administer an insulin injection to Resident # 25 at around 10:00 PM on 12/10/2020 and that it was approximately 10 minutes after she gave the insulin injection she realized she had not administered the insulin type that was ordered for Resident # 25 and she reported the error to the licensed nurse.

Based on observation, record review, resident, staff and physician interviews, the facility neglected to notify the physician of an initial abnormal elevated potassium (K+) level of 5.4 millimoles per liter (mmol/L), report a change of condition to nursing staff at the oncoming shift, obtain a medication as ordered by the physician for an elevated K+ level of 6.9 mmol/L, and follow physician orders [REDACTED]. The resident was discharged from the hospital and readmitted to the facility on [DATE] (Resident #20). Immediate Jeopardy began on 10/12/19, when Resident #20 did not receive medical treatment for [REDACTED]. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings include: Resident #20 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #20 was cognitively intact. The MDS revealed he required setup assistance with bed mobility, extensive assistance with transfers, and setup assistance with eating of meals. Resident #20's K+, Blood Urea Nitrogen (BUN), and creatinine levels comparisons were made from a Complete Metabolic Panel (CMP) drawn on 09/11/19. The lab indicated Resident #20's K+ level of 4.5 mmol/L was found to be in the normal lab specified range (3.3-5.1 mmol/L). His BUN and creatinine level on 09/11/19 were elevated with a BUN level of 21.7 (mg/dl) milligrams per deciliter and a creatinine level at 2.52 mg/dl. The normal range for BUN is 6.0-20 mg/dl. The normal range for creatinine is between 0.50-1.20 mg/dl. On 10/11/19, a lab order for a Brain Natriuretic Peptide (BNP) to rule out dehydration was made by the physician. There were no nurses note to indicate the status of the resident on 10/11/19 that indicated potential for dehydration. The order for the BNP was not followed as ordered, but instead, a Basic Metabolic Panel (BMP) was obtained at 5:42 AM on 10/12/19 and sent to the lab. The BMP lab results were faxed to the facility on [DATE] at 11:19 AM. The lab reports indicated an elevate K+ level of 5.4 mmol/L, elevated Blood Urea Nitrogen (BUN) of 29.0 mg/dl, and an elevated creatinine level of 2.74 mg/dl. The nurses note on 10/12/19 nor the scanned lab indicated acknowledgement of the lab or notification of the physician on 10/12/19. The scanned lab was signed by the physician on 10/15/19 after the resident was admitted to the hospital. There was no documentation the night of 10/12/19 of a change of status in Resident #20's condition or indicating a change of lab orders from a BNP to a BMP. On 11/6/19, an unsuccessful attempt was made to contact Nurse #2 who was the nurse on duty during the night shift on 10/12/19 when the order for the BUN was not followed as written and a BMP was obtained in its place and sent to the lab for testing. A nurse's note, written by Nurse #3 on 10/12/19 at 2:09 PM did not indicate Resident #20 had a change in status and was given an as needed dose of [MEDICATION NAME] 10-325 mg for pain. Nursing assistant (NA) #4 was interviewed on 11/06/19 at 4:09 PM. NA #4 stated she worked with Resident #20 on 10/12/19 and revealed she had reported changes such as shortness of breath, the need for additional physical assistance, and lethargy to the nurse during her shift. An interview with NA #5 on 11/07/19 at 10:13 AM, NA #5 revealed she first noticed changes with Resident #20 on 10/12/19 during the second shift. She stated she observed him sitting outside on the front patio alone when she arrived for her shift. She attempted to speak to him, but he didn't respond as he normally would. She stated shortly after her shift began, she again observed him sitting alone near the nurses' station with his eyes rolled back in his head, saying he was dizzy, and needed to go back to bed. She further revealed she made the nurse on duty aware of her observation and was told it was just his medications and told to make sure she applied his oxygen once he was in bed. She said she assisted him to bed. Later in her shift, she reported he was more confused, speech slurred, and needing total assistance for his activities of daily living (ADL) care. She said the agency nurse told her not to be concerned it was just from his medications. An interview with NA #1 on 11/6/19 at 4:15 PM revealed NA #1 had worked with Resident #20 on both 10/12/19 and 10/13/19. She said she noticed he was needing a lot more assistance that usual and she had to use the mechanical lift to transfer him because he could not bear weight on 10/12/19. She stated she reported his changes to his nurse on both days. An interview with Nurse #3 on 11/06/19 at 3:00 PM, Nurse #3 stated she was the nurse who had worked with Resident #20 on 10/12/19 and 10/13/19 on both 1st and a portion of 2nd shift (7:00 AM- 7:00 PM). She stated on that weekend, Resident #20 was not himself. Nurse #3 stated when she came on duty on 10/12/19 at 7:00 AM Nurse #2 did not report to her that Resident #20 had a change in condition or an elevated potassium level. She further explained that several NAs had made her aware he was requiring more assistance on 10/12/19, but he otherwise appeared to be stable. Nurse #3 revealed she observed the resident in the morning of 10/13/19, he appeared lethargic, very confused, and not wanting to get up as he usually would. She revealed she thought the change may have been related to him getting used to his new pain medication that had recently been started. She reported later that day, he became increasingly confused and had shallow respirations, but would respond when called by name. She stated she called the on-call provider that evening and was given orders to obtain a complete blood count and a complete metabolic panel (CBC/CMP). She explained that although staff had reported he wasn't himself and had major changes in ability to complete his ADLs, she didn't think he was in acute distress and it was changes from his medication but made the provider aware anyway. She said the labs were drawn and she reported this to the oncoming shift nurse. A nurse's note dated 10/13/19 at 6:24 PM, written by Nurse #3, indicated Resident #20 was lethargic but he had voiced he was not feeling well. It stated he refused the Embeda (narcotic pain med used to treat moderate to severe pain) stating it was making him sick and that the on-call provider was notified and requested a CBC/CMP be drawn and gave orders to hold the Embeda pending lab results. Resident #20's lab report indicated the CBC and CMP were drawn on 10/13/19 at 08:25 PM and sent to the hospital. It further indicated a critical K+ level of 6.9 mmol/L was called by lab employee #1 to Nurse #4 on 10/13/19 at 10:31 PM. The lab results were signed by Nurse #4 and a note that the on-call provider was contacted was written on the scanned lab report. Review of physician orders [REDACTED].#20 to receive [MEDICATION NAME] (Sodium [MEDICATION NAME] Suspension 15 grams/60 milliliter) give 30 grams x 2. This medication used to treat elevated potassium in the blood. An interview with Nurse #4 on 11/7/19 at 8:57 AM revealed she worked with Resident #20 on 10/13/19 during the third shift when the critical potassium value was called to her by the lab. She stated she didn't recall the level, but when asked if 6.9 mmoL/L was accurate, she stated yes, I think that's right. She stated she called the on-call provider and was given orders to give [MEDICATION NAME] for the elevated K+ level. She stated when she looked for the medication, it was not found in the backup supply on the night of 10/13/19. Nurse #4 stated she did not see the urgency of obtaining the medication from the backup pharmacy as the facility pharmacy said they could send the medication in the tote on the following days delivery and therefore Nurse #4 did not notify the physician. When asked if Resident #20 had any signs and symptoms of distress on 10/13/19, she stated the vital signs provided by the NA were stable and he was already in bed sleeping. When asked specifically if she performed a physical assessment on the resident after receiving the abnormal lab values, she again said no, he was sleeping, and his vitals were stable. A nurse's notes written on 10/14/19 at 8:11 AM by Nurse #5 revealed a change of condition form titled Situation, Background, Assessment and Request (SBAR) was completed for Resident #20 which noted an altered level of consciousness, increase assistance with ADL's, slurred speech, weakness or [MEDICAL CONDITION] (numbness or paralysis of an extremity) with recommendations to go to the emergency room . An interview on 11/05/19 at 12:09 PM with Nurse #5, she stated she was the regular day shift nurse (7:00 AM-3:00 PM) on weekdays. She said she was the nurse on duty that obtained the order to send Resident #20 to the hospital on the morning of 10/14/19. She reported she went in to see the resident shortly after getting report on Monday morning 10/14/19 and noticed he was lethargic, had increased tremors, muscle weakness, slurred speech, and he had some difficulty breathing requiring oxygen. She stated he had rapid breathing and used his accessory muscles to facilitate breathing. She stated she applied oxygen when he refused his Bilevel Positive Airway Pressure (bi-pap) device due to anxiousness. She reported she had no report from the previous shift from Nurse #4 that indicated any change in the resident's condition. She further reported she checked his chart and recognized he had abnormal lab values over the weekend and orders weren't followed to give [MEDICATION NAME] for elevated K+ level. She notified the residents physician and received orders to send Resident #20 to the hospital for evaluation. She reported staff notified her that they had to feed him due to his lethargy on the morning of discharge to the hospital. She further stated she considered any value outside of the parameters given to be serious but very serious if the lab calls with a critical lab value. She stated she made the unit manager and the Director of Nursing (DON) aware of the abnormal lab and that the medication was not given as ordered. An interview with the Unit Manager on 11/05/19 at 12:45 PM revealed she was familiar with Resident #20's recent hospitalization . She reported he was pleasant and cooperative with care. He occasionally refused care when he did not feel well, but this occurred rarely. She was working on the morning of Resident #20's discharge on 10/14/19 and observed the resident to be increasingly confused, some respiratory difficulty, difficulty vocalizing his needs, and talking nonsense. She was aware the hall nurse was preparing the resident to be discharged . She stated she was made aware the orders for [MEDICATION NAME] for an elevated K+ level was not followed, but unclear why the back-up pharmacy was not utilized. She was unsure who the back-up pharmacy was since the facility had recently changed pharmacy services. She stated if a medication is unavailable, staff are to report the delay in administration to the provider and request order clarification. The (MONTH) 2019 Medication Administration Record [REDACTED]. A hospital emergency room history and physical (ER H&P) dated 10/14/19 at 10:39 AM indicated Resident #20 presented to the emergency room with an altered mental status of lethargy, was only alert and oriented x 1, but was able to answer to his name. He had gurgling with his breathing and a wet hacky cough of which he was protecting his airway upon initial exam and an ordered chest x-ray resulted in intravenous (IV) antibiotic treatment for [REDACTED]. emergency room labs included an ongoing elevated K+ level of 6.1 mmol/L, a BUN of 41 mg/dl, and a creatinine of 4.00 mg/dl. The assessment and plan note electronically signed by the hospital attending physician on 10/15/19 at 6:55 PM stated Resident #20's primary [DIAGNOSES REDACTED].#20 was critically ill with multiple life-threatening conditions including multiple organ system dysfunction/failure, oxygenation/ventilation instability requiring frequent modifications of support, fluctuations in neurological function requiring evaluation and intervention, correction and monitoring of serious electrolyte abnormalities and fluid volume titration. It further indicated Resident #20's [MEDICAL CONDITION] was treated in the emergency room with [MEDICATION NAME] and Calcium [MEDICATION NAME]. A hospital lab report dated 10/18/19 revealed Resident 20's K+ level was 3.9 mmol/L which is within the normal range. The hospital Intensive Care Unit- history and physical (ICU-HP) discharge summary dated 10/19/19 at 12:00 PM specified [MEDICAL CONDITION] was the primary discharge [DIAGNOSES REDACTED]. It further indicated Resident #20 spent several days (10/14/19 through 10/17/19) in the intensive care unit (ICU) where he underwent intubation with an endotracheal tube placement allowing increase aeration of the lungs and nasogastric tube, and bi-pap services. He was found to be in metabolic acidosis with a creatinine of 4.00 mg/dl which since improved to the resident's baseline. The medical record indicated Resident #20 was hospitalized from [DATE] to 10/19/19. He was readmitted to the facility on [DATE] in fair condition. An observation on 11/04/19 at 11:22 AM revealed Resident #20 lying in bed on his back. An interview with Resident #20 on 11/4/19 at 11:22 AM revealed he recalled being hospitalized twice recently, but unable to recall detailed reasons related to the hospitalization s. An observation of Resident #20 on 11/05/19 at 10:52 AM revealed the resident lying in bed on his back with the blind closed, lights off, and the door open. An interview with the Director of Nursing (DON) on 11/05/19 at 1:30 PM, the DON stated she was made aware of Resident #20's recent hospitalization s. She stated Resident #20 had experienced increased confusion, hypersomnolence, and even fallen a couple times during recent episodes of AMS. She further explained the resident had labs drawn over the weekend of 10/12/19-10/13/19 that resulted in an abnormally high K+ level and orders were given for [MEDICATION NAME]. She was aware the orders weren't followed by Nurse #4. She further explained she believed that [MEDICATION NAME] is normally a medication that is kept in their back up supply but stated if the facility was out on that night the nurse should have asked the pharmacy for alternative ways to obtain the medication to not delay administration. She stated the nurse should have notified the provider in the event the medication was unavailable in back-up stock and requested further direction. She revealed she was unsure who the back-up pharmacy was currently, but it should have been utilized to obtain this medication. She stated she would obtain an updated protocol since the facility had recently switched pharmacy suppliers. An interview conducted with Resident #20's physician on 11/05/19 at 3:00 PM revealed the physician believed the lack of following orders given for [MEDICATION NAME] was a major medication error and lack of awareness of abnormal labs on 10/12/19 prevented on-call physicians from treating Resident #20's condition timely. She further revealed failure to give this medication put the resident at increase cardiac risk. She stated she was not happy when she was made aware the medication had not been administered. She further revealed she was not notified until Monday morning when orders were given to send him to the hospital for evaluation of lethargy, slurred speech, breathing difficulties, and increase confusion. An interview with Director of Nursing (DON) on 11/07/19 at 4:17 PM, she revealed the nurses should have reported any labs drawn and their lab values for Resident #20 to the oncoming shift on the weekend of 10/12/19-10/13/19. She further stated the lab values for Resident #20's lab results on 10/12/19 should have been reviewed from the lab reporting system and Resident #20's physician notified of all abnormal lab values. She stated all of Resident #20's orders should have been entered and followed as directed. She stated the Nurse #4 should have reported the urgency of need for medications to pharmacy when new orders are obtained, and Nurse #4 should have requested alternative means to obtain the medication. She said Nurse #4 should have notified the physician when the order could not be followed as given on 10/13/19. She further revealed Nurse #4 should have performed ongoing assessments and document them accordingly in the medical record timely for Resident #20. She said all care changes should have been added to the plan of care with Resident#20's change of condition. The Administrator, DON, and Corporate consultants were made aware of the immediate jeopardy on 11/6/19 at 1:30 PM. _____________________________________________________________________________________ F 600 Credible Allegation of Removal of Immediate Jeopardy Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance According to the clinical record, Resident #20 was experiencing nausea and vomiting on 10/11/19. The physician ordered Give 4 mg ([MEDICATION NAME]) by mouth every 6 hours as needed for nausea and vomiting until 10/15/19. Take 1 tablet by mouth every 6 hours as needed for 5 days. The record indicates the first dose was given at 9:38 pm on 10/11/19 and the result was effective. While the record does not accurately portray, interview with the nurse indicates that a Basic Metabolic Panel was ordered by the physician when the [MEDICATION NAME] was ordered. This lab was received on 10/12/19 with a potassium value of 5.4. As the prescribed normal range was 3.3 to 5.1. The lab results were faxed at 11:12 am and the nurse did not act on this value, instead placing it in the physician's binder for later review. According to the record, the nurse #2 did not notify the physician of this first potassium lab value and upon interview with nurse #2 she did not communicate the potassium level with the next shift. Because the resident continued to be lethargic on 10/13/19, at approximately 6:11 pm, Nurse #3 completed a physical assessment and contacted the physician to report that the resident continued to be lethargic; less communicative. This assessment is not recorded in the clinical record but was described in interview with Nurse #3 and resulted in the order for the STAT (medical term used to define urgent) comprehensive metabolic panel and complete blood count which were drawn and submitted. The note at 6:11 pm on 10/13 supports this action. Nurse #3 reported that labs were ordered to oncoming nurse # 1 when giving report to leave for the day. The nurse's note states lethargic at 9:35 pm on 10/13/19. On 10/14/2019, at 02:52 AM, the clinical record indicated that Nurse #1 answered the facility phone and received a call from the laboratory reporting a critical Potassium value of 6.9 for Resident #20. Nurse #1 called the physician and reached the on-call physician. She informed the on-call physician of the potassium level and was given an order to administer 2 doses of 30 cubic centimeters (CC) of [MEDICATION NAME]. Nurse #1 went to the emergency kit and checked for [MEDICATION NAME] but did not find it. The nurse failed to check the Listing attached to the emergency kit which was also available in the notebook on each medication cart, and states [MEDICATION NAME]: then the generic name Sodium [MEDICATION NAME]. The bottle in the emergency kit included only the generic name, Sodium [MEDICATION NAME] which was not familiar to the nurse. She failed to realize the generic form of [MEDICATION NAME] was in the box. Nurse #1 then contacted the pharmacy and was advised the medication would be sent out on the next run which was expected to arrive between 4:00 am and 6:00 am on 10/14/19. The nurse did not notify the physician that she had not found the [MEDICATION NAME] or notify the Director of Nursing that she had a critical value and was unable to administer the ordered treatment. Neither did she contact the pharmacy by phone to request assistance or emergency back-up resources. The nurse's note at 2:52 am states writer called on-call with high potassium STAT lab of 6.9. Received orders to administer two doses [MEDICATION NAME] 30gm. Orders transcribed. Respirations were even and non-labored. Resident remained lethargic but readily responsive to verbal stimuli. And the vital sign is within normal limits. On the morning of 10/14/19 at the change of shift report nurse #1 communicated the status of resident #20 which was stable, according to the 2:52 am assessment note, although a critical lab was called to the on-call physician and the orders were received but the [MEDICATION NAME] had not been given. Nurse #1 also stated that pharmacy was going to deliver the [MEDICATION NAME]. Nurse # 2 went to resident #20 room at approximately 8:00 am completed an assessment and called the resident's primary care physician, to update her on the resident's status and the inability to administrator the [MEDICATION NAME]. The physician gave an order to send to emergency room for evaluation. Resident #20 was admitted to the hospital on [DATE] for treatment of [REDACTED]. Resident #20 was discharged back to the facility on [DATE] having fully recovered from the [MEDICAL CONDITION]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete To assure no other residents were impacted by the failure to recognize a condition that requires physician intervention, to notify the physician in a timely manner, and if unable to execute orders received the nurse has a responsibility to notify the physician. On 11/7/19 the Director of nursing and her team audited critical lab reports beginning with 10/14/19 and going forward to today, 11/7/19. No other examples of critical labs without appropriate response were noted. To assure all nurses respond to changes in condition with prompt reports to the physician and implementation of orders in a timely manner, on 11/7/19 the Director of Nursing assisted by the Regional Director of Operations, an RN, the Regional Director of Clinical Services, an RN, in-serviced all nurses on: 1) actions to be taken when critical lab values, as identified by the lab as critical values are received including notifying the Director of Nursing of the value and the orders given; 2) the signs and symptoms associated with [MEDICAL CONDITION] 3) the importance of following physician's orders [REDACTED]. 4) notifying the physician if, for any reason, the nurse is unable to carry out a physician's orders [REDACTED].>5) The process associated with using medications from the emergency kit including referring to the list provided and attached to the outside of the box that shows the name of the medications included in the kit in both generic and non-generic terms; 6) how to request and receive medications after hours that are needed for a STAT situation; 7) prevention, recognition, reporting of Abuse, neglect, misappropriation, mistreatment and exploitation of residents. 8) While the certified nursing assistant (CNA) responded as expected by notifying the nurse of the resident's declined condition, Reeducation for CNA's began on 11/8/19 to reinforce the importance of reporting any change in condition to their nurse as well as remaining aware of any further changes. No CNA will be permitted to take an assignment until re-education is completed. Any nurse who was not present in the facility at the time of this in-service will be contacted by telephone for the same in-service and asked to review and sign the in-service documents prior to being permitted to work in the facility. All new hires will receive this in-service as part of orientation. The facility alleges the removal of the immediate jeopardy on 11/8/2019. The Administrator is responsible for assuring corrective actions are sustained. Validation of the facility's immediate jeopardy removal plan was completed as evidenced by interviews with staff members and residents. Staff reported audits of critical lab values were performed and in-service training that was specified in the IJ removal plan was conducted as planned. Interviews with nursing staff indicated they were knowledgeable on the signs and symptoms of [MEDICAL CONDITION], how to respond when a resident experiences a change in condition, what to do when they receive abnormal laboratory results, the importance of following physician orders [REDACTED]. Interviews with nursing assistants revealed they were knowledgeable on notifying a nurse when a change in a resident's condition occurs. There were no concerns or reports of neglect by staff or residents interviewed. The facility's immediate jeopardy removal date of 11/08/19 was validated.

Based on record review, staff interviews and resident interview the facility failed to report a fall for one of three residents reviewed for falls (Resident # 8). Resident #8 experienced a fall when a nursing assistant transferred her from her bed to her wheelchair and the fall was not immediately reported. As a result of this fall Resident #8 experienced pain and a fracture of her distal femoral metaphysis (left thigh bone just above the knee). Findings included: Resident # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident # 8 had severely impaired vision, was cognitively intact and required limited assist of one staff for transfers and was non-ambulatory. Resident # 8 was unsteady with surface to surface transfer and was only able to stabilize self with staff assistance. Resident # 8 had no falls during the review period. A review of a fall risk assessment dated [DATE] revealed that Resident # 8 had a risk score of 8 and was a high risk for fall. A fall potential care plan had been initiated. A review of a care area assessment (CAA) dated 06/11/2018 revealed that Resident # 8 required limited to extensive assist with activities of daily living (ADLs). A CAA for Resident # 8 revealed that she was at risk for falls due to [MEDICAL CONDITION] and limited mobility. A review of an ADL care plan initiated on 07/18/2018 for Resident # 8 revealed that she would receive strengthening exercises and transfer training in restorative nursing by use of the omnicycle for 15 minutes 3 times a week. A care plan for Resident # 8 revealed that she had an ADL deficit with an intervention to provide limited to extensive assist with transfers. A care plan also revealed a risk for falls and the goal was that Resident # 8 would be free of falls with interventions that included to maintain a safe environment, to keep call light and other items within reach. A facility incident report note dated 07/21/2018 at 6:37 PM revealed that Resident # 8 alerted the nurse that she had pain her left knee and revealed that she fell on her knees that morning. The nurse asked Resident # 8 how she fell , and Resident # 8 replied it had happened that morning when the girl had tried to get her out of bed. The nurse attempted range of motion (ROM) and Resident # 8 responded by yelling and verbalized increased pain. The nurse applied ice to the left knee and notified the MD and the RP. New orders had been received and report given to the next nurse and the Director of Nurses (DON). The facility incident reports revealed that on 07/22/2018 Resident # 8 was alert, wheel chair bound, alert with some confusion. Currently full weight bearing status with imbalance without assist of staff. Resident # 8 stated on 07/21/2018 she fell when she was assisted to the wheel chair. Ice was applied to the left knee and Resident # 8 was medicated for pain. Resident # 8 rated her pain at a 6 out of 10. The MD (Physician) and RP (Responsible Party) aware and order an order was received for a muscle relaxer and left leg and knee x ray. The front of left knee was red in color. Resident # 8 to wear gripper socks when out of bed. A review of a Restorative Care Flow Record dated for (MONTH) (YEAR) revealed that Resident # 8 had received on level omnicycle for 15 minutes 3 times a week on 07/11/2018 through 07/13/2018, on 07/16/2018, 07/18/2018 and 07/20/2018 and for 6 minutes on 07/21/2018. Nurse assistant (NA) # 5 reported to the medication aid (MA) # 5 that Resident # 8 had complained of left leg pain and that restorative nursing stopped because of pain complaint by Resident # 8. Review of a nurse progress note dated 07/21/2018 at 6:37 PM revealed that Resident # 8 alerted nurse # 2 that her left knee hurt. A pain assessment revealed that Resident # 8 revealed that her pain rated a 6 out of 10 on a pain scale during range of motion (ROM) and that Resident # 8 yelled during the hands-on nurse assessment. The nurse notified the physician (MD) and received an order to obtain a left knee x- ray, administer [MEDICATION NAME] 5 mg orally (po) every 6 hours as needed (prn) for left knee pain and muscle pain. The resident and the RP were notified of the MD orders. A nurse progress note dated 07/22/2018 at 6:37 AM revealed that an x ray of the left knee of Resident # 8 had been obtained on 07/21/2018 and the x ray report revealed that Resident # 8 had a probable subtle [MEDICAL CONDITION] area of the distal femur, medially. On 07/22/2018 at 7:34 AM a nurse progress note revealed that Resident # 8 was transferred to the emergency room (ER) as per the MD order and the nurse phoned the RP to give an update. Resident # 8 revealed that at the time of transfer, her pain rated a 10 out of 10 and the vital signs of Resident # 8 were stable at the time of transfer. An ER MD note dated 07/22/2018 revealed that Resident # 8 arrived in the ER at 9:03 AM after a fall on 07/21/2018 with left knee pain and an x ray of a possible distal femur fracture. The ER performed a left leg and knee x ray that revealed that Resident # 8 had a [DIAGNOSES REDACTED]. A left knee immobilizer was ordered as well as [MEDICATION NAME]- [MEDICATION NAME] ([MEDICATION NAME]) 5- 325 mg (milligrams) per tablet was ordered. A nurse progress note dated 07/22/2018 at 2:37 PM revealed that Resident # 8 had returned from the ER at 12:40 PM with MD orders for pain medication and a left knee immobilizer. The RP and MD were made aware. An MD order dated 07/22/2018 at 3:00 PM was to administer [MEDICATION NAME] sodium ([MEDICATION NAME]) 40 mg/ 0.4 ml (milligrams/milliliters) subcutaneously 1 time a day for [MEDICAL CONDITION] ([MEDICAL CONDITION] prevention for 2 weeks. Resident # 8 was to follow up with the orthopedic MD as soon as possible. Resident # 8 was to wear the left knee immobilizer at all times except when bathing and the nurse was to assess the skin under the immobilizer every shift. An orthopedic consult dated 07/25/2018 revealed that Resident # 8 had a left femur fracture with minimal displacement and that Resident # 8 was a poor surgical candidate and was to be no weight bearing with a locked extension brace in place at all times with [MEDICATION NAME] 40 mg daily for 2 weeks recommended and to return in 3 weeks. The next appointment scheduled for 08/17/2018. An MD order dated 07/25/2018 was to maintain the left knee immobilizer on the left knee of Resident # 8 locked in extension at all times except for bathing and nurse to assess skin under the left knee immobilizer. An MD order dated 07/31/2018 was to administer [MEDICATION NAME] 10/325 mg po every 6 hours as needed, discontinue Tylenol and [MEDICATION NAME] 5- 325 mg. A review of the Medication Administration Record [REDACTED]. Resident # 8 also received [MEDICATION NAME] 5- 325 mg tablet orally every 12 hours as needed for moderate to severe pain. On 07/21/2018 the order was changed to administer [MEDICATION NAME] 10-325mg po every 8 hours prn moderate to severe pain. On 07/25/2018 Resident # 8 received [MEDICATION NAME] solution 40mg/0.4 ml subcutaneously 1 time a day for [MEDICAL CONDITION] prevention for 2 weeks. A pain assessment revealed that Resident # 8 complained of dull, tender pain at 7 out of 10 on 07/08/2018 and on 07/21/2018 through 07/31/2018, Resident # 8 complained of a dull tender pain of the left leg that had been rated from a 1 to a 10 out of ten and the pain was relieved by the [MEDICATION NAME]. A review of the treatment administration record (TAR) dated (MONTH) (YEAR) was reviewed and revealed that beginning on 07/22/2018, Resident # 8 had worn a knee immobilizer to the left knee at all times, and the immobilizer was removed for bathing. The nurses assessed the skin under the left knee every shift. A review of the MAR indicated [REDACTED]. The TAR dated (MONTH) (YEAR) revealed that Resident # 8 continued to wear the extended left knee immobilizer, locked in extension at all times except for bathing and the nurse checked the skin under the left knee immobilizer every shift. On 08/06/2018 at 2:41 PM a telephone interview conducted with nurse # 2 revealed that she worked 12 hours on 07/21/2018 and 07/22/2018 (7:00 AM to 7:00 PM). Nurse # 2 revealed that on 07/21/2018 she did not recall seeing Resident # 8 out of bed and that she had went to check the blood sugar of Resident # 8 at about 5: 00 or 5:30 PM, resident # 8 verbalized that her left knee hurt. Nurse # 2 revealed that she tried to reposition Resident # 8 for comfort and that Resident # 8 always complained of pain previously and that Nurse # 2 had given MA # 1 permission to give Resident # 8 her pain medication if it was time. Resident # 8 had revealed that her pain was rated at 10 of 10. MA # 1 or another staff member that Nurse # 2 could not recall stated that Resident # 8 had a fall earlier on 07/21/2018 when the nurse assistant (NA) # 3 was getting her out of bed. Nurse # 2 recalled that she had not seen Resident # 8 out of bed on 07/21/2018. Nurse # 2 then called the MD, RP and DON. An x ray order was obtained for Resident # 8. The DON told Nurse # 2 to keep her updated of any changes and report results received. Nurse # 2 revealed that on 07/22/2018, when she arrived at work an x ray report was received that Resident # 8 had a fractured femur. Nurse # 2 notified the MD, RP and DON and Resident # 8 was sent to the ER. Nurse # 2 completed an incident / accident report the morning of 07/22/2108. On 08/06/2018 at 3:55 PM an interview was conducted with MA #1. MA #1 revealed that she had worked on day shift 07/21/2018 and that NA # 3 had called her into the room of Resident # 8 for assistance. MA #1 and NA # 5 entered the room of Resident # 8 and observed Resident # 8 on the floor between her bed and her wheel chair and Resident # 8's feet were bent underneath her. Resident # 8 was alert and denied hitting her head and denied any pain. NA # 3 and MA # 1 lifted Resident # 8 off the floor and placed her in her wheel chair that was held steady by NA # 5. NA # 3 reported that Resident # 8 had not fallen and that she had been lowered down NA # 3's left leg to the floor.MA # 1 revealed that she could not recall what the exact time was, but that it had probably been around 9 or 9:30 AM. MA # 1 revealed that at about noon or so, Resident # 8 was taken to the rehabilitation gym for her restorative program. NA # 5 called MA #1 into the rehabilitation gym and reported that Resident # 8 was unable to ride the omnicycle any longer because she had complained of a lot of left leg pain. MA # 1 revealed that Resident # 8 was not due for pain medication at that time. MA #1 revealed that she had not reported the fall to Nurse # 2 because she thought that NA # 3 did. MA # 1 revealed that on 07/22/2018, she was directed to wait in the breakroom until the DON at that time, arrived to get her statement and begin an investigation. MA # 1 reported that the DON had taken a written statement from her, educated her about falls, safety and reporting falls. MA # 1 revealed that she had been suspended for 3 days pending an investigation. An interview conducted with NA # 5 was conducted on 08/06/2018 at 4:10 PM. NA #5 revealed that she had entered the room of Resident # 8 in the morning of 07/21/2018 with MA #1 when NA # 3 asked for assistance. Resident # 8 was observed on the floor and NA # 5 went to stand behind the wheel chair so that MA # 1 and NA # 3 could lift Resident # 8 into the chair. NA # 5 stated that she stood behind Resident # 8 and had not observed the placement of her legs. NA # 5 revealed that Resident # 8 made no complaints of any pain or discomfort. NA # 5 revealed that she also was the restorative nursing aid and had taken Resident # 8 to the Rehab gym later in the morning for her exercises and that when Resident # 8 was on the omnicycle, she had started to complain of left leg pain after 6 minutes. NA # 5 notified MA # 1 and assisted by a stand pivot transfer, Resident # 8 off the omnicycle and back to her wheel chair. NA # 5 wheeled Resident # 8 back to the unit to sit at the table in the common area. NA # 5 revealed that she had not informed Nurse # 2 of the fall earlier in the day because she had thought that NA # 3 or MA # 1 would have reported the fall. NA # 5 revealed that she knew she had been wrong not to report the fall to the nurse. On 07/22/2018 NA # 5 gave a written statement to the DON, received education related to falls and reporting falls by the DON. On 08/07/2018 at 7:58 AM an interview and observation was conducted with Resident # 8. Resident # 8 was awake, alert lying in bed. Resident # 8 revealed that she did recall a recent fall when she was transferred from her bed to her wheel chair. Resident # 8 reported that she did not really remember the details, but that she had ended up on the floor and did not hit or head or feel any pain at the time. Resident # 8 revealed that she had no left leg pain until later in the day and that she reported her pain to the nurse and did receive pain medication. Resident # 8 reported that she had a lot of pain all over her body for a long time, not just in her leg since she fell . Resident # 8 revealed that she did not walk and that right now she had to wear a leg immobilizer on her left leg all the time. Resident # 8 revealed that she had never had a fall before and that her knees just gave out on her that day and she did not know why. On 08/07/2018 at 9:24 AM a telephone interview was conducted with the previous DON. The DON reported that she had received a call from Nurse # 2 on 07/21/2018 and was informed that Resident # 8 had a fall during morning care and that the fall had not been reported to Nurse # 2 until later in the evening by Resident # 8. The DON was informed that the MD had ordered an x ray and that the RP had also been informed. The DON revealed that on the morning of 07/22/2018, Nurse # 2 had phoned the DON and updated her on the x ray report and that the MD had ordered that Resident # 8 be sent to the ER. The DON was informed that the 3 staff that were present at the time of the fall were waiting for the DON in the breakroom. The DON revealed that she came to the facility, received written statements from the staff, the DON educated the nurse staff about falls and reporting falls immediately. A telephone interview was conducted with NA # 3 on 08/07/2018 at 9: 53 AM. NA # 3 revealed that on 07/21/2018 she had provided ADL care to Resident # 8 for the first time. NA # 3 reported that she had been informed that Resident # 8 was a 1 staff stand- pivot transfer assist. NA # 3 revealed that she was about to transfer Resident # 8 into the wheel chair from the bed and that Resident # 8's legs became weak and that the NA had Resident # 8 lean against the NA's leg and that Resident # 8 was guided to the floor with her legs bent underneath her and the foot of NA # 3 also underneath Resident # 8. NA # 3 stated that she called her peers to help her and that MA #1 and NA # 3 lifted Resident # 8 into her wheel chair while NA # 5 stood behind the wheel chair. Resident # 8 had not hit her head and did not complain of any pain. NA # 5 revealed that she did not know or consider lowering any resident to the floor was considered a fall, she had never been educated about a fall of that type. NA # 3 revealed that she did not report the fall to Nurse # 2 because she thought that the MA (#1) reported the fall because MA # 1 was responsible for passing medications and NA # 5 thought that MA # 1 was also responsible for documentation and reporting to the nurse for all residents. NA # 3 revealed that on the morning of 07/22/2018, she had been informed to wait in the breakroom for the DON to arrive. The DON provided education of types of falls and the responsibility of all staff to report any type of fall to the nurse immediately. An interview was conducted with the interim DON on 08/07/2018 at 10:00 AM revealed that he had not been in employment at the time that Resident # 8 fell but his expectation was that any fall be immediately reported to the licensed nurse without exception and that the licensed nurse followed the policy and procedure and report all falls to the DON as soon as possible when the MD and RP were notified. A review of the facility in-service/education record dated 07/22/2018 revealed that all licensed nurses, MAs and NAs signed that they had received education that included that the charge nurse was to be immediately notified of any type of fall and that the resident could not be moved until the nurse completed an assessment and verified that the resident could be moved. The Nurse would conduct an investigation, complete a risk management assessment, assess for injury, notify the MD, RP and put immediate interventions in place. On 08/07/2018 at 1:13 PM an interview was conducted with the MD of Resident # 8. The MD revealed that she did not feel that a delay in the treatment of [REDACTED].# 8 made any difference in how the left femur fracture was handled because she was a nonsurgical candidate and the fracture was subtle. The MD revealed that participation in the restorative nursing program on 07/21/2018 did not cause any further injury or impairment for Resident # 8 in any way and that the situation was handled immediately and appropriately when this fall was identified, and the delay of any time caused no further injury or impairment. On 08/07/2018 at 1:34 PM an interview was conducted with the facility administrator that revealed the expectation is that all staff report any witnessed or unwitnessed fall immediately to the licensed nurse and this was to be done without exception.

Based on record review, staff interviews and observations the facility failed to have interventions in place to prevent 1 (Resident #2) of 4 sampled residents assessed to have exit seeking behaviors from exiting the facility while unsupervised. The Immediate Jeopardy began on [DATE] when the resident exited from the facility while unsupervised and was found by a bystander in the middle of the road in front of the facility. The immediate jeopardy was removed on [DATE] when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D), to ensure monitoring of systems put in place and 100 percent of employee training. Findings included: Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A record review of the physician's order [REDACTED]. A record review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. The MDS indicated no wandering behavior was exhibited for this quarter. The resident did not require any assistance with bed mobility, transfers, walking in room or corridor, or with locomotion on and off unit. The MDS also specified the resident had a steady gait. A record review of the care plans for Resident #2 included wandering related to cognitive impairment written on [DATE]. The goal was for the resident to remain in facility. Interventions included allowing resident to ambulate as desired on unit, check daily to ensure resident had a wanderer ' s bracelet on. This care plan was updated on [DATE] related to an exit out of facility on [DATE]. The Interventions included to have resident returned to facility, assessed for injury, wander guard checked for function, wander guard checked for placement, every 15-minute checks initiated, order obtained to medicate as needed for restlessness and the Social Worker (SW) to seek placement in a secured facility. A review of a nurse ' s note written on [DATE] at 3:45 pm revealed Resident #2 had a room change on this day from the 100 Wing to the 200 Wing. Medications and the Medical Administratior Records (MARs) were given to the day shift nurse on the 200 Wing. A report was given to the nurse and Dietary was made aware of the resident ' s room change. A review of a nurse's note written [DATE] at 6:00 pm revealed Resident #2 was found outside of the building and escorted back inside. The note specified the wander guard was defective and was replaced with a new one. The resident ' s vital signs were: blood pressure ,[DATE], heart rate 82, respiration rate 20, and temperature was 98.5. A record review of a statement written on [DATE] by Nurse #1 revealed in part: I was sitting at nurses station when a lady came to the desk and told me a male was outside in the road and he looked confused and she didn't know if he was a resident here and that she called 911. Nursing Assistant (NA) #1 heard this and immediately went outside to check. I left and went outside to help look for the male, at which time, the NA drove in the parking lot with Resident #2. We walked him in the building and I told NA #1 his wander guard did not go off. We walked him to the 200 Wing and told Nurse #2 what happened. NA #1 said I'm going to get a new wander guard and I told her to give it to me. I then activated the wander guard and checked the exits to make sure it was working. I then put it on the patient and cut the old one off. I looked at the old one and noticed is was not pushed in/activiated. An interview with NA #3 at 4:30 pm on [DATE], revealed the resident was always walking and talking. He did not try to exit but he was confused about his room. The NA noticed he didn ' t walk as much when they changed his room. He wore a wander guard. The NA reported the exit doors would only sound if the resident opened the door on Wing 100. She recalled a time on [DATE] that he did get out of the door on Wing 100. He was easily redirected back into the building. An observation on [DATE] at 4:45 pm revealed the facility had a total of seven exit doors. Two exit doors on the 100 Wing, two exit doors on the 200 Wing, the lobby exit door, an exit door which was called the back door that led to the smoking deck, and an exit door at the end of the service hall. The door in the lobby, the back door and the service door all had a monitor located to the side of the door. This monitor was set up to monitor resident wander guards. The two exit doors on Wing 100 and Wing 200 did not have this wander guard monitor. The exit doors were located at each end of each wing. Each of these exits had an alcove that led to the double doors. On the bilateral sides of this alcove, just as you enter, there were monitors on the wall about 1.5 feet up from the floor. The exit doors were noted to have a red fire alarm box on the side of the double exit doors. During this observation, both doors on the 100 Wing were able to be opened easily and no alarm sounded when the doors were opened. The 200 wing also had an exit door at each end of the wing and an alcove leading to the double doors to exit. Both exits on the 200 Wing also had the monitors just as you enter the alcove 1.5 feet up from the floor. A red fire alarm box was located on the side of the double doors. One of the two doors was able to be opened without an alarm sounding. The other door, the alarm sounded when opened. The doors were easily opened. An interview with the DON on [DATE] at 5:12 pm revealed the DON was responsible for checking the wanderguard system at each of the door exits with the wander guard monitor which included the lobby, the back door (smoke deck) and the service entrance. The DON reported she checked these every day with the tester. To check the system, she opened the door and used the tester designed for the model of these wander guards to ensure the wander guard monitor was working. The doors should alarm if working correctly. The DON reported that all of them were in working order. During the interview, the DON opened both exit doors on the 100 Wing. Both doors opened without the alarm sounding. She reported, I think they are suppose to sound. The Maintenance Director handles this. The DON proceeded to the exit doors on the 200 Wing and it was found that one of the doors did not sound when it was opened. There were monitor devices on the bilateral sides of each of the exit area walls. They were 1.5 feet above the floor and screwed to the walls. The DON believed these would alarm if a wanderguard walked through it, but she was not sure. An interview with the Maintenance Director (MD) on [DATE] at 6:15 pm was conducted. The MD revealed the exit doors on each wing should alarm when opened. On the 100 Wing, when he opened both doors, they did not alarm. He was curious as to why it did not alarm and realized the fire alarm box to the side of the door had a key lock which showed the position of the lock in the off position. This was noted on both doors on the 100 Wing. The MD opened one of the doors on the 200 Wing which opened without sounding an alarm. He noted that this fire box alarm also had the key position in the off position. On the way to the 200 Wing, the MD stopped in his office to get the key to the fire alarm boxes. The other exit door on Wing 2 did alarm when it was opened and the fire alarm box was noted to be in the on position. The on position showed the key lock going up and down. The off position showed the key lock going side to side. The MD locked all of these boxes at this time. The doors were tested again to confirm that they did alarm if opened when this fire alarm box was on. They all alarmed. The MD reported the monitors on the bilateral sides of each exit walls were not working, they were part of an old system. The MD was asked who held keys to the alarm boxes and he reported he had them but he did not know if anyone else did. He thought maybe the nurses kept one in their medication carts. The MD was asked who is responsible for ensuring that these doors are secured and he replied, I don ' t check the doors, I don ' t know who does. I know the DON checks the wander guard doors everyday. He then replied I had no idea those doors were not locked. The MD had no knowledge of any staff monitoring whether or not the exit doors were alarmed. An interview with Nurse #1 on [DATE] at 5:15 pm revealed she got a call from the Director of Nursing that day to transfer Resident #2 to the 200 Wing. The change was completed around 2:00 pm. Nurse #1 reported the resident kept coming back to the 100 Wing. The nurse stated The next thing I knew, he was out of the building. The nurse reported she realized it when a visitor came in and told her. At this time, NA #1 ran out to go and find him. The nurse went out to the front of the building to see if she could see him and saw him and the NA in a vehicle driving toward the facility. A person had picked them up and drove them back to the facility. The nurse and the NA walked him to the door of the 200 Wing. Nurse #1 reported she knew his wander guard was not working when he walked in through the back door (smoking deck) in the dining room. He had one on his ankle and it did not alarm when he walked through the door. She reported there is a device in the nursing medication carts to check the wander guard. If it turns green, it is working. The nurse said it was to be checked daily. She felt it was not activited due to the button not being pushed in. You need a pen or a key to push in the button to activate it. It ' s really hard. The nurse did not know who placed the wander guard on the resident and if that person activated it. She reported that it could have just popped back out. The nurse reported she thought Resident # 2 was gone from the facility for approximately 15 minutes. He was not far, but did not know how far he got. The nurse futher added that the exit doors with the wander guard monitor do not lock when a resident with a wander guard is near them. The doors with the wander guard monitors will sound if the resident is only 2 feet away from the door. The nurse reported there is no system in place to tell which door is alarming when an alarm sounds. The staff just follow the sounds and check all the doors. Nurse #1 told the 200 Wing Nurse #2, he had gotten out. The nurse reported that prior to his transfer to another room he was not exhibiting exit behaviors. He would walk around in circles on the unit, and he would have to be shown where his room was. At times, he would attempt to push the door on 100 Wing open. When you walk into the 100 Wing and go to the right, there is an exit door that he would try to push but he couldn ' t open it. She reported you need a key. The resident had some increased confusion on this day due to the room change. An interview with Nurse #4 at 9:00 am on [DATE] on the 200 Wing revealed she does not check the doors to see if the alarm is on or off. The nurse reported the MD checks them and she was never instructed to check them. She reported she has a key on the medication cart if it sounds so that she can stop it from alarming. Nurse #4 said that she has never turned the alarms off, but she did not check to see if they were turned on. An interview with Nurse #5 at 9:15 am on [DATE] revealed that the nurse ' s check the exit doors to be sure they are shut, not alarmed. She reported the MD checks the alarms, but she was not sure the last time they were checked. An observation of the Treatment Administration Record (TAR) at 9:15 am on [DATE], revealed that all four residents had a TAR in place for the wander guards. Each TAR was noted to have check placement of wander guard every shift and check operation of wander guard daily on the ,[DATE] shift. These were all signed off as being done by the nurses for each day for the month of February, 2016. Several attempts were made to contact the nurse who last checked the wander guard for Resident #2. These attempts were unsuccessful. An interview with Nurse #6 on [DATE] at 10:35 am revealed she was not aware of which residents had a wander guard. She also reported at this time she did not know how to check a wander guard for operation. She has never had to check one. She has only been working there for one week and she worked the day shift. She was not shown during orientation. The nurse reported that if a resident with wander guard tried to exit, the alarm would sound. She said she thought all the doors were suppose to alarm. An interview with NA #1 at 11:00 am at [DATE] revealed she arrived for work for the 2nd shift at 3:00 pm on [DATE]. The NA did her first round with her assigned residents. She recalled a lady came in (visitor) and wanted to know if we were missing a patient. The time was between 4:30 pm and 5:00 pm. She knew it was this time because it happened before the dinner trays come out. They were unaware of a patient missing at this time. The NA reported she immedietly went out toward the road in the front of building. An older couple pulled up in a car and asked if we were missing a resident. They told her to get in and took her further up the street to the left of building. The NA reported they just passed the facility driveway and she could see him from the car. He was standing on the left side of the street just before the street curved. At this time, he was not in the middle of the road. He was at the edge of the road. The road was a two lane paved road with a speed limt of 35 miles per hour. There were no sidewalks but each side had grassy areas. The area was primarily residential. The NA reported there were cars coming steadily in both directions at this time. The car she was in pulled off to the right. The gentleman driving the car got out of the car as did the NA. The NA reported she went towards the resident. The resident stated I am going home. The NA was able to convince the resident to get into the car and go back to the facility. While the resident was sitting in the car he stated again I want to go home. The resident was wearing blue jogging pants and hoodie made of nylon. He had no apparent injury. The sun was going down and it was getting colder. The temperature was 46 degrees. Once we got back to the facility, Nurse #1 and NA #1 walked him back into the facility toward the 200 Wing. The resident had his wander guard on his ankle. The wander guard did not alarm as he entered the door by the smoking area. Nurse #1 stated it ' s not working. The NA got another one. The Nurse tested the wander guard by using the tester in front of the monitored door they entered. The new wander guard was functioning and was placed on the resident. The NA reported the resident had never opened the exit doors, he just looked out the window. The NA explained that the wander guard worked by pushing a button in on the device to activate. There was a 90-day shelf life for the wander guard and an activate by date on the side of the unit. It is tested in front of the three doors that have the wander guard monitoring system. If it sounds when the door is opened, the wander guard is working. The fire exit doors on each wing do not alarm when the resident with a wanderguard goes near them. The alarm at the exit doors will only go off if you open the doors. The NA was not sure if the activating button could pop back out once it was pressed. She also did not know what the activate by date was on the wander guard that was not working. She stated she doesn ' t know if it went passed it ' s 90 days. She also reported there was no log maintained as to who got a wander guard and what the activate by date was when they applied the wander guard to a resident. The NA did not know which door Resident #2 exited. The NA did not recall hearing any alarms going off to alert that someone was exiting the building. The NA reported she did not call a Code 10 (an announcement made over the intercom system to inform the facility a resident had exited) because she just reacted quickly to get the resident to safety. During this interview, NA #1 was asked about the policy and procedure when a resident elopes. She replied that someone in the facility calls a Code Pink (which is now code 10), one NA checks the exit doors at each side of the hall, another NA checks the exit doors on the other side of the hall. Then they follow the sound of the alarms to try and figure out where it is coming from. They check all the exit doors and go outside. The NA does not recall if a code 10 was announced this evening because as soon as she heard the visitor ask if they were missing a patient, she left the building to go look for the resident. An observation was conducted on [DATE] at 12:50 pm. The front of the building faced a large grassed area with a smooth paved two lane road in front of the grassy area. The driveway to the facility had an entry and an exit The entrance of the driveway was on the right side of the building. The exit driveway was on the left side of the building. The lobby exit which was monitored with a wander guard system, went out to a parking lot for visitors on the right side of the building. The back door (smoking area) which was monitored with a wander guard system exited to the middle of the exit driveway on the left side. The service exit which was also monitored with a wander guard system exited in rear of building. There were a total of four fire exit doors. At this time, an observation confirmed the location where Resident #2 was found outside of the facility on [DATE] was 500 feet to the left of the facility on the two way paved road as reported by NA #1. An Interview was conducted with the DON at 9:15 am on [DATE]. The DON reported an incident report was not filled out for this elopement. She reported it was an over site that it was not done. She also reported no formal investigation was completed. She did not obtain statements from the staff regarding the incident. An interview with the MD at 11:30 am on [DATE] revealed there was no system in place for who checked the alarms at the exit doors. The keys to turn the alarm on and off were kept in the nurse ' s medication carts and the MD also had a key. An observation of a demonstration by the facility staff was done on [DATE] at 1:30 pm. A resident with an activated wander guard was taken to each wander guard monitored door. As the wander guard approached the lobby door, the system did not alarm. Once the door was opened, the alarm sounded. The wander guard was then taken to the service entrance doors. Again, the system did not alarm as the door was being approached. The alarm sounded once the door was opened. As the wander guard approached the back doors (smoking deck), the alarm sounded. The doors remained closed. An interview with the MD at 2:20 pm on [DATE] revealed the alarm should sound when a resident wearing a wander guard is approaching a door with the wander guard monitor system. It was explained that during the demonstration, the alarm did not sound in the lobby entrance and the service entrance until the resident opened the door. The alarm sounded at the back door (smoking deck) when the resident approached the door, but the doors remained closed. The MD was not sure why it was not alarming as you approach the doors. The MD was unclear as to when the wander guard monitors should alarm. He confirmed he did not know if it should alarm as you approach the door or if the door was opened. The manufacturers information was requested at this time from the MD and DON. An interview via phone with NA #6 at 2:48 pm on [DATE] revealed she worked on the 100 Wing on [DATE] 7am - 7pm on weekends. She did not take care of Resident #2 this day. She knows that he did have a room change from the 100 Wing to the 200 Wing. The NA reported she recalled a female visitor come into the facility (unknown time) and reported there was a patient in the middle of the road. She did not participate in the search for the resident as she was not aware until after he was brought back in. Additionally, she did not assist with moving the resident and his belongings from one wing to the other. She reported the last time she saw the resident was approximately 1:00 pm, but she could not say for certain what the time was. During the morning hours on the 100 Wing, Resident #2 was not walking around the wing. She believed he was in his room until he was moved to the other side. An interview with NA #7 at 3:07 pm on [DATE] via phone revealed she was working on the 2nd shift the night of [DATE] on the 200 Wing. She was not assigned to this resident, but did recall him walking around the 200 Wing at the start of the shift (approximately 3:00 pm). She was not aware the resident left the building until after he was returned. There was no announcement (code 10 or Code Pink) over the intercom. The NA reported that his room was on the 100 Wing until [DATE]. The NA reported she was aware he was on every 15 minute checks when they brought him back to the facility. She did not recall the time he came back, she thought it was about 5:30 pm. An interview with NA #8 at 3:30 pm on [DATE] via phone revealed Resident #2 had eloped and was returned back to the facility before her shift started on [DATE]. She worked 7pm - 7am on the weekends on the 200 Wing. He was very confused during this shift and kept asking to go home. He was being checked every 15 minutes and the NA walked him and watched him through out the shift. The NA reported the resident wanted to keep going back to the 100 Wing. The NA stated that this resident did have a wander guard on his ankle. She reported that if a resident eloped, a staff member would call Code Pink or Code 10, search the facility and the grounds. Once the resident was located and returned, have the nurse assess the resident. An interview with the Compliance Manager of the manufacturer of the wander guard was conducted at 4:46 pm on [DATE]. The manager reported there were two basic components of the wander guard. There was a rectangular piece mounted by each door the facility chose to protect. The range can detect approximately three feet to devices/bracelets that were worn by the resident. This was detected by a radio frequency. The system generates an alarm with two conditions. The first conditon was the equipment on the door and the bracelet/device need to be compatible. The second condition was if the door was opened. He reported it integrates with a magnetic lock. If the two conditions are met, it will sound the alarm. The facility had the option to get a lock mechanism. If this lock mechanism is in place it will activate the doors to lock when the resident is about three feet away. The Manager reported that if the magnetic switch is broken or misaligned it would cause malfunction. He also reported to activate a wander guard, there is a button on the side of the wander guard unit. It needs to be pressed in flush to the case. Once the button is pressed in, it should be tested by an open door. If it alarms and turns green, it is activated and can then be applied to the resident. The manager reported that it is possible for the button to pop back out, however it will not deactivate the device. He reported the causes of deactivation would be if the 90-day use period had expired or with impact such as going through a washer or dryer, misuse or abuse. An interview with the DON on [DATE] at 9:15 am revealed she did not keep a log of the wander guard devices or the activate by date when a new one was applied to a resident. She knew she applied all new devices to the wander guard residents on [DATE]. The activate by date was [DATE]. Nurse #1 applied a new wander guard to Resident #2 on [DATE]. The activate by date was [DATE]. Resident #2 ' s wander guard was discontinued on [DATE] when he was sent to the hospital. The DON reported she marked it on her desk calendar to replace the wander guards on [DATE]. She reported they would expire on [DATE] which was the 90th day since it was activated. The DON did not keep the wander guard that was on Resident #2 prior to [DATE] and also did not know what the activate by date on that wander guard was. During this interview, it was discussed that many staff members were interviewed and not everyone had the same understanding of how the wander guards worked or when the exit doors would alarm. There were many inconsistincies. The DON agreed that not all staff were aware of how the alarms were suppose to function. The DON further added that her expectation was that all staff know how each and every exit door alarmed and when they alarm. Additionally, her expectation was that staff have a full understanding of how the wander guard system worked. An interview with NA #9 via phone at 12:45 pm on [DATE] revealed that she was not assigned to the resident on [DATE] but she did remember that on this day he slept all morning and part of the early afternoon. She reported he had lunch in his room. The NA reported that he was moved to the other wing at approximately 2:00 pm. She recalled seeing him back on the 100 Wing around 3:00 pm. She said he seemed very confused and walked around the wing looking for his room. The NA reported she did not observe him trying to exit out of any doors. The NA reported she did not see the resident after NA #1 brought him back into the building and to the 200 Wing. The Administrator was notified of the immediate jeopardy on [DATE] at 8:50 am. The Facility provided an acceptable credible allegation on [DATE] at 7:40 pm. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On [DATE] at approximately 4:45 PM, the facility was notified by a visitor (female) are you missing a resident ? Nursing Assistant #1 exited the building and retrieved resident #2 and returned him to the facility. Nurse #1 exited the dining room and met nursing assistant #1 and escorted resident #2 into the dining room. Upon entering the dining room, resident #2 alarm did not sound. Resident #2 returned to 200 hall nurses station. 100 hall nurse #1 reported to 200 hall nurse #3 of the elopement. Nursing Assistant #1 retrieved a new wander guard bracelet from the facility ' s central supply closet. Nurse #1 tested the bracelet by taking the bracelet to the front door of the facility which was armed and functioning with a wander guard alarm system. The new wander guard bracelet was tested and placed on resident #2 right ankle. Nurse #1 stated that on [DATE], resident #2 had been returning to his previous room (room 103) on 100 hall, from 200 hall and that she, nurse #1, had not seen resident #2 for approximately 2 hours before the facility was notified that the resident was missing. The facility could not determine which door resident #2 exited. The facility cannot determine with 100% accuracy why the wander guard bracelet did not alarm. At approximately 6 PM, resident #2 was assessed for injury and vital signs were obtained by 200 hall nurse #3. No injuries were noted and vital signs were within normal ranges for resident #2. Nurse #3 documented resident #2 was pacing 200 hall looking for a way out to go home. Nurse #3 was unable to redirect. At approximately 7:20 PM, Nurse #3 called the facility ' s contract physician assistant and received an order for [REDACTED]. Nurse #3 administered one dose of Haldol 2 mg intramuscularly injection in the right upper buttocks and documented the resident tolerated it well. Resident #2 returned to the common area on hall 200, from room 213 bed A, sitting at table with 2 other facility residents. On [DATE], the facility staff initiated 15-minute checks on resident #2 for location/safety. On [DATE], the 15 minute checks on resident #2 for location/safety were discontinued due to hospitalization . On [DATE] at approximately 6:30 PM, the director of nursing (DON) reviewed and updated the care plan for resident #2 to reflect wandering, elopement and status of new wander guard bracelet placement/function. On [DATE], the DON and the Facility Services Director initiated weekly mock elopement drills for the next 4 weeks. On [DATE], the Facility Social Services Director contacted the Health Care Power of Attorney/Responsible Party to discuss alternate placement (memory care) per safety. On [DATE], Facility Social Services Director initiated communication with appropriate Long Term Care Centers, which provide care to residents living with Alzheimer and/or Dementia related diagnosis. On [DATE] the facility DON audited the February 2016 Treatment Administration Record (TAR) for resident #2. The TAR for resident #2 showed that the initial wander guard physician's order [REDACTED]. The TAR wander guard audit for placement, which was checked each shift, showed no holes or missed documentation. The TAR wander guard for function, which was checked on the 11PM-7AM shift every day, showed no holes or missed documentation. On [DATE], the facility administrator reviewed the February 2016 TAR for resident #2 to ensure accuracy. No holes or missed documentation for placement and function were observed. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice; On [DATE] at approximately 6:45 PM, the DON identified those residents having the potential to be affected by the same deficient practice. The DON identified four residents who had care plans for wandering behaviors. These residents were previously identified with wandering behaviors at the time of admission or once established as residents with wandering behaviors. At which time, the elopement-risk assessment was completed and the wander guard system/bracelet was tested and applied. Note: the elopement-risk assessment was deemed appropriate for residents with exit seeking behaviors and/or repetitive verbally expressing desire to leave the facility. The DON, Unit Manager, Social Services Director, Activity Director, and Therapy Program Director meet weekly for quality of care and change-in-conditions to include behaviors enabling a multi-disciplinary approach to each resident ' s continuum of care. On [DATE], Audit of Treatment Administration Record (TAR) by the DON showed physician orders [REDACTED]. On [DATE] at approximately 6:45PM, the DON assessed each resident with a wander guard bracelet and observed all of them with correct wander guards placement and functioning. The DON validated the functioning of the wander guard of all four residents by utilizing the bracelet wander guard universal tester housed in the 200 hall med cart. Additionally, the DON obtained from the central supply closet four new wander guard bracelets with 90 day expiration parameters. Each new wander guard bracelet was engaged, tested and applied to each of the four residents. The rationale to replace each bracelet is to ensure manufacturer ' s recommendations and compliance with 90 day expiration; [DATE] through [DATE]. On [DATE] at approximately 7 PM, the DON completed an audit of Treatment Administration Record (TAR) for 4 residents which showed physician orders [REDACTED]. The purpose for obtaining physician's order [REDACTED].

Based on record review and staff interviews, the facility failed to prevent injury to a demented resident by placing the resident's arm into her mouth causing the resident to bite her arm and lip for 1 (Resident #75) of 3 sampled residents reviewed for abuse. Findings included: Resident #75 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #75 had memory and decision making problems and had exhibited physical behavioral symptoms directed toward others and rejection of care. The care plans dated 11/18/14 (review date) were reviewed. One of care plan problems was "the resident was resistive to care at times related to dementia, she will sometime refuses her medications and meals." The goal was " the resident will cooperate with care through next review date." The approaches included "give clear explanation of all care activities prior to as they occur during each contact, if resident resists with activities of daily living (ADLs), reassure resident, leave and return 5-10 minutes later and try again, praise the resident when behavior was appropriate." Review of the nurse's notes dated 11/2/14 at 4:45 PM revealed "the certified nursing assistant (CNA) giving care to resident reported to writer that when she was giving care to resident, the resident attempted to bite the care giver's arm and she moved her arm away and then gave resident's arm to resident to bite and the resident bit her right arm around wrist area and also bit her left lower lip. A red dry bruise was noted to her right hand." The note indicated that the physician and the resident's responsible party were notified. The note further indicated the site of bite to right arm was cleansed with normal saline and antibiotic was applied. The site looked swollen and red. The 24 hour and 5 day reports were reviewed. The allegation was "resident abuse". The description of the incident was "employee brought resident to the desk and stated that resident was trying to bite her. So she put resident's arm in resident's mouth and resident bit self. Resident bit arm and had bite marks on her right arm as well as swollen cut on her lower lip and posterior right arm was swollen." The allegation was investigated and was substantiated. The alleged employee was terminated. On 12/3/14 at 2:50 PM, administrative staff #1 was interviewed. She stated that she was called by Nurse # 1 and was informed of the incident that happened to Resident #75 on 11/2/13. When she came to work the next day (11/3/14), she assessed Resident #75. The resident was found to have bite marks on her arm and her lip was swollen and broken. Administrative staff #1 further stated that the alleged nursing assistant (NA#1) was terminated. On 12/3/14 at 3:05 PM, Nurse #1 was interviewed. He stated that he was the weekend supervisor on 11/2/14 when the incident happened. Nurse #2 (nurse assigned to resident) had informed him of the incident happened to Resident #75. He went to assess the resident and he found the resident's lip was swollen and bleeding and her arm had bite/teeth marks. He added that he was informed of the incident late and NA # 1 had already left. He stated that he had counseled Nurse #2 for not informing him of the incident immediately. NA #1 continued to work after the incident until the end of her shift. Nurse #1 immediately called NA#1 to come back but she refused to come for an interview or write a statement. On 12/3/14 at 3:10 PM, NA #1 was not available for interview. On 12/3/14 at 4:15 PM, Nurse #2 was interviewed. She stated that she was assigned to Resident #75 the day of the incident (11/2/14). NA#1 came to the nurse's station with Resident #75 who was sitting on a wheelchair. NA #1 informed her that the resident was trying to bite her when she was doing care and she took the resident's arm and put it in her mouth and she bit herself. She observed the resident to have broken and swollen lip that was bleeding and teeth marks on her arm. She then informed her supervisor (Nurse #1). The incident happened around 4:45 PM. NA #1 left the facility when her shift ended and when she was called to come back she refused.

Based on observation, record review, resident and staff interviews, the facility failed to monitor fluid intake for one of one sampled residents on [MEDICAL TREATMENT] with fluid restriction (Resident #54) and failed to prevent infestation of maggots on resident #39. The findings included: 1. Resident #54 was admitted to the facility 8/5/14. Cumulative [DIAGNOSES REDACTED]. Resident #54 was on [MEDICAL TREATMENT]. A Quarterly MDS (Minimum Data Set) dated 10/31/14 indicated Resident #54 was cognitively intact. The resident was assessed as receiving [MEDICAL TREATMENT] as part of her medical treatment during the assessment period. A care plan dated 8/13/14 and last reviewed on 11/19/14 stated Resident #54 was on a therapeutic diet with 1200 cc. (cubic centimeters) fluid restriction. Interventions included, in part, monitor intake and record every meal. Physician orders [REDACTED]. Medication Administration Records for October, November and December 2014 were reviewed and revealed an entry that stated 1200 cc. fluid restriction. There was no documentation of the amount of fluid consumed by the resident recorded on any of the three MARs ' . A review of the nursing notes from October 1, 2014 through 12/3/2014 was conducted. There was no documentation of the amount of fluid consumed by Resident #54. On 12/4/14 at 10:30AM, an interview was conducted with Resident #54. She stated she was aware of her fluid restriction and tried to keep her fluid intake low. On 12/04/2014 at 1:38PM, Nurse #7 stated Resident #54 was not on a fluid restriction. On 12/4/14 at 1:56PM, Nurse #3 stated, if a resident was on a fluid restriction, there would be a physician's order [REDACTED]. She stated she was unaware that Resident #54 was on a fluid restriction. On 12/4/14 at 2:36PM, administrative staff #2 stated, if a resident was on a fluid restriction, the amount of fluid intake would be documented on an intake and output sheet. She reviewed Resident #54 ' s medical record and noted that the last intake and output record was in August 2014. Administrative staff #2 stated Resident #54 should have had an intake and output sheet and nursing staff should have recorded the intake on that sheet. On 12/4/14 at 2:48PM, administrative staff #1 stated she expected nursing staff to follow the facility policy and nursing staff should have documented the intake on the intake and output sheet. 2. Resident #39 was admitted to the facility 1/30/13. Cumulative [DIAGNOSES REDACTED]. Proper hygiene is important in controlling the [MEDICAL CONDITION].). A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #39 was cognitively intact. She was totally dependent for personal hygiene and bathing. A care plan dated 7/2/14 and last reviewed on 10/10/14 stated Resident #39 had an ADL (activity of daily living) self care performance deficit related to shortness of breath and [MEDICAL CONDITION]. Resident #39 refused a bath in bed/ showers at times. Interventions included: Resident is bedfast all or most of the time due to her preference. If a bath/ shower was refused, explain the importance of hygiene especially with the skin ailment on legs. Offer to return. Encourage her to set a time for care and return at that time. An addition to the care plan dated 10/17/14 indicated may use vinegar and water mix to spray on legs during bath/ shower. On 12/2/14 at 4:20PM, an interview was conducted with Resident #39. She stated that an incident happened in October when nursing staff were giving her incontinent care. Resident #39 stated she noticed a change in the nursing assistants ' faces during the incontinent care and became really upset when they would not tell her what they had seem. Resident #39 stated she told them she had a right to know and one of the nursing assistants pointed to a white object on her sheet. She stated the object was moving and she knew it was a maggot. Resident #39 stated she was only able to wash her face and hands. She said she had received showers every day after the nursing staff had observed the maggots and now received showers on Monday, Wednesday and Friday. Resident #39 stated nursing staff would sometimes not give her a shower on the day shift and day shift would tell her that the evening shift would administer the shower. Evening shift would not give her a shower and, therefore, she would not receive her bath or shower. Resident #39 stated she had never refused care, bathing or a shower. A review of shower schedule was conducted and revealed Resident #58 should receive her shower on first shift (day shift) every Monday, Wednesday and Friday. There was a note dated 12/1/14 on the front of the shower schedule that stated Resident #39 was to have her shower on first shift daily for the week of 12/1/14. On 12/3/14 at 6:31AM, NA (nursing assistant) #3 stated he was assisting staff with incontinent care on the day that the nursing staff observed the maggots on Resident #39. He said he did observe one to two maggots on resident #39 ' s lower leg at that time. On 12/3/14 at 9:20AM, Resident #39 was observed during her shower. Resident #39 had a large amount of blisters and nodules covering her body from her groin area to her ankles. No open areas were noted and no evidence of maggots was observed. On 12/3/14 at 10:40AM, administrative staff #1 stated she thought it was the first Sunday in October when she stopped by the facility and was told that Resident #39 had two " bugs " on her. She stated they cleaned her room and bed that day and gave her a shower. Administrative staff #1 stated they began daily showers at that time. She stated Resident #39 had been anxious about a shower because she had fallen from a Hoyer (mechanical lift) in another facility and consequently fractured a hip so she had a fear of falling. She said Resident #39 refused showers and baths and, if she refused her bath or shower, it would be documented on the NA (nursing assistant) flow sheets. Administrative staff #1 stated she thought Resident #39 got the maggots as a combination of her skin condition (Milroy ' s). Her legs would weep fluid and she also had food in the room which caused flies. Administrative staff stated she expected the nursing assistants to document on the flow sheet if Resident #39 refused baths/ showers and also expected licensed nursing staff to document the refusals in the nursing notes. NA flow sheets and nursing notes from September 1, 2014 through December 3, 2014 were reviewed with administrative staff #1 and no refusal had been documented during that time period. On 12/3/14 at 2:59PM, NA#4 stated she had provided care for Resident #39 on day shift for the past five months. She stated her assignment changed and she was not providing care for Resident #39 for about a month and resumed provision of care after Resident #39 was observed to have maggots. NA#4 indicated Resident #39 had never refused showers during the time that she had provided care for her.

Based on record review, staff interviews and resident interview, the facility failed to maintain standards of infection control as designated by the Centers for Disease Control (CDC) for 1 of 2 residents (Resident #2 and Resident #11) as evidenced by using the same needle on both residents, failure to discard sharps in the designated container, and contaminating syringes prior to injections. Immediate jeopardy began on November 3, 2011. The administrator was notified of the jeopardy on November 22, 2011 at 12:15 P.M. The immediate jeopardy was removed on November 22, 2011 at 3:15 PM. The deficiency was left out of compliance for continuing monitoring at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D). Findings include: Manufacturer's package insert for [MEDICATION NAME] (influenza virus vaccine) stated, "Dosage and Administration: A separate syringe and needle or a sterile disposable unit should be used for each injection to prevent transmission of infectious agents from one person to another. Needles should be disposed of properly and not recapped (after use)." In an interview with the Director Nursing on 11/21/11 at 2:50 PM revealed: Nurse #1 had not followed Policy and Procedure for intramuscular (IM) injections and the following errors and breaks in aseptic technique had occurred: 1. Used insulin syringes (manufacturers package states needle are 1/2 inch long); this type of needle is not suitable for intramuscular injections. 2. Nurse had drawn up multiple syringes at one time (nursing standards indicate only one injection is drawn up at a time, the injection is given, the needle sheathed (covered to prevent nurse from getting a finger stick) and then disposed of in the sharps container, 3. The needles were not recapped after drawing up the flu vaccine to prevent contamination while traveling to a resident's room; she had placed them in a metal clipboard which is not an aseptic environment, so all five syringes were contaminated, 4. The flu vaccine stock bottle was also placed in the clipboard so it was potentially contaminated, 5. Nurse had used the same needle on two different residents; the safety lock sheath was not pulled up and locked after the first injection (the safety sheath is to prevent the staff member from getting stuck with a contaminated needle; it is a plastic sheath which when pulled up locks and recesses the used needle, 6. Nurse had administered the flu injection in the thigh of Resident #2 rather than the deltoid muscle of the upper arm, 7. And she had not properly disposed of the used syringe and needle after giving Resident #11 his flu injection. In the same interview, the Director of Nursing stated that she had issued a personnel action to a nurse on 11/04/11 for "Failure to follow Policies and Procedures with regards to Medication Administration (IM) (intramuscular) Injections." She produced a document signed and dated by her stating the facts of the incident. "On Thursday, November 3/11 (Nurse #1) RN administered a Flu Vaccine to (Resident #2). Nurse #1 reported to the Unit Manager and DON (Director of Nursing) that she realized after administering injection to Resident #2 that the syringe was empty. The resident assumed this was a previously used needle and accused the staff member. The RN stated that there was a (possibility this was an unfilled syringe). The Medical Director was advised immediately and his directions were followed. STAT (at once) labs for blood transmitted diseases were ordered on Residents #2 and #11; (resident #11) who received his injection prior to Resident #2. Lab results were negative for blood transmitted diseases for both residents. Statements from Nurse #1 were obtained and she acknowledged her failure to follow policy and procedure surrounding Medication Administration (IM injections). As a precautionary measure STAT labs were drawn on three other residents. The lab results for these residents were also negative (for blood transmitted diseases). The staff member (Nurse #1) was terminated and the incident was reported to the NCBON (North Carolina Board of Nursing) secondary to the allegation. Inservices surrounding IM Injection Policy and Procedure was completed including demonstration of Safety Syringes." When asked for Nurse #1's statement, the DON produced a handwritten statement with Nurse #1' s signature dated 11/01/11 2:43 PM. The statement is quoted " At approximately 1:30-2:30 P, I went to med room (100 Hall) with (Nurse #2) and obtained flu vaccine out of refrigerator and grabbed a handful of insulin syringes. I took them to two hundred hall and sat at the nurse ' s station and filled syringes with vaccine that I had in front of me. I placed the syringes in my metal closed clipboard with vial (of flu vaccine) and alcohol sponges. I gave approx. 4-5 vaccines. My pattern has been when after I give a vaccine to put the syringe in the dirty needle box on the nurses carts. I gave (Resident #11) his flu vaccine and then (Resident #2). When I punctured (Resident #2) L (left) anterior thigh and pushed the plunger (on the syringe) - there was no injectable to go in. I withdrew needle. Resident #2 said ' there was nothing in there ...you shot me with a contaminated needle ' . I told him that it was probably one that I had not filled with vaccine." When asked for the investigation of the incident on 11/21/11 at 3:30 PM, the Director of Nursing produced the following notes she had taken on 11/03/11 at 3:50 PM. "Reported to me that Nurse #1 potentially injected a resident with (statement not finished). Q (from DON) (Question) Tell me what happened. A (Answer from Nurse 1) When I came on, I went to 100 Hall at 1:30 ish and Nurse #2 allowed me in narc (narcotics) room to get new bottle of flu vaccine and stock number is 110/201 and reached over and got some insulin or TB ([MEDICATION NAME]) syringes whatever I could get 0.5 ml (milliliters) out of and came to 200 hall. I asked DON to get some alcohol sponges out and I drew up syringes with vaccine. I did not count the number of syringes I had but just put them in my metal clipboard box. I gave approx 4-5 injections (I would need to see my paper to know who exactly I gave them to. My pattern has been to give injections then discard in needle box on cart. I gave (Resident #11) his injection-came out of his room- I saw Resident #2 in common areas- I do not know if I disposed of (Resident #11) needle- cause Resident #2 said "Am I next?" I took Resident #2 in a room and asked if he wanted in arm or leg and he said leg cause he couldn't feel anything. I picked up a syringe, injected into L (Left) anterior thigh, pushed plunger and it was at the end. Resident #2 said "Oh my God- you shot me with a needle already used-that's been used on someone else. I said "No I think that was one I had not pulled up vaccine in. He (Resident #2) came out of room and yelled " She shot me with a needle (that) was used." LPN (licensed practical nurse- unidentified) DON stated to resident that nurse would take care of it and get everything checked out. I went to ADON (assistant director of nursing who is also the SDC) office and spoke to ADON and said "Something bad has happened and I need to tell you what has happened "I gave Resident #11 a shot and after that I gave Resident #2 and there was no vaccine in syringe and he is saying I gave him a shot with contaminated needle." In an interview with the ADON and Unit Manager on 11/21/11 at 4:00 PM in the 200 Hall med room, the unit manager revealed the types of syringes stocked; needles for IM injections were longer than the insulin needles. She demonstrated that the syringe/needle is removed from the sterile packaging, the plunger is withdrawn to the proper dose as indicated by the calibrations on the syringe, the stock vial is swabbed with an alcohol pad, the needle is inserted into a stock vial, the air is expelled and the plunger is then withdrawn to the volumetric dose calibration. The safety sheath can be partially raised to prevent contamination. The (SDC) provided a copy of her investigation dated 11/03/11 at 4:45 PM. "Needle stick incident Was in DON office when Nurse #1 came in and said "I just (sic) stick Resident #2 with a used needle." DON spoke with her. (See interview with DON above). I left DON office and went to Resident #2, he propelled self into SW (Social Worker) office and stated that he had been stuck in the L (left) thigh and no med came out-then the nurse said "I stuck you with a bad needle." The Staff Development Coordinator (SDC) stated she had helped the DON to do the investigation of the incident and that she had conducted in-service for 100% of licensed staff by 11/04/11. Record review of the in-service training report titled: "Syringe disposal, after each use. 1. After drawing up medication- recap syringe until medication is administer. 2. After injection given-immediately engage safety cover (sheath) and deposit in red sharps containers, 3.Injectable medications should be prepared at medication cart, recapped-taken to resident room- after ID resident-administer medication with correct need size syringe, engage syringe safety-take back to med car and deposit in red sharps contain 4. Refer to policy." The Medical Director was onsite 11/03/11 at the time of the incident and the DON approached him for consultation. The Medical Director called the CDC in Atlanta for consultation. The M.D. was informed that the residents involved should immediately have laboratory evaluation of their blood for possible Human Immunodeficiency Virus (HIV) and Hepatitis. He was also instructed to follow up with the Board of Health for the County, which he did. The County Health Department stated that precautionary labs for HIV and Hepatitis should be done on all residents who had gotten the flu injection that day (11/03/11). When the SDC asked Nurse #1 which residents received the vaccine today, Nurse #1 stated, " The ones on the sheet of paper that are starred (*)." Nurse #1 then reversed her original statement saying that she gave Resident #2 influenza vaccine and Resident #11 got an empty syringe. The Medical Director gave instruction to the staff to summon the laboratory staff and get consents from the residents/or their responsible party. This was accomplished by the nursing staff and the required blood draws were done that afternoon 11/03/11. The Medical Director and DON spoke to Resident #2 explaining the necessary testing and he agreed to have the tests. In an interview with resident #2 on 11/21/11 at 3:45 PM, he stated Nurse #1 approached him in the day room and stated "(First Name) you're next" He stated Nurse #1 took him to a room, not his room, asked him if he wanted the shot in the arm or leg. Resident #2 said he would like it in the leg. He pulled up his left sweat pant leg and she stuck him above the knee in the thigh. The resident stated that the plunger didn't go down and there was no medicine in the syringe. He stated the nurse said "I stuck you with the wrong needle" . The resident stated she passed a red box (sharps container) on the way to get me. Why didn't she throw the used needle away before sticking me? He said he screamed at her and then lots of people came to talk to him and he agreed to get the lab drawn to screen for diseases. Resident #2 stated "I'm glad mine came back negative and I didn't get anything." Nurse #1 was terminated by phone on 11/04/11. The facility SDC submitted an incident report on Nurse #1 to the North Carolina Board of Nursing on 11/04/11 at 11:43 PM detailing the incident of 11/03/11. From the report; "Came into DON office and stated that she given a resident a flu vaccine-after sticking resident-realized syringe was empty and was a used syringe and needle she had used on another resident." "Did the Nurse acknowledge or accept responsibility?" Yes is checked. A 24 hour report was submitted to the Health Care Personnel Registry on 11/04/11 which stated "Nurse administering flu injection to residents. Nurse reported to Unit Manager she accidentally injected another resident with a syringe which had been used on another resident". A five day investigation report was submitted to the Health Care Registry Board on 11/08/11 which stated that "Resident #2 accused Nurse #1 of using Resident #11s needle (used) to give him a flu shot." Nurse #1 refused interview when called on 11/20/11 at 4:20 PM Interviews with four licensed staff for validation (nurses #2, #3, #4 and #5) on 11/22/11 at 11:00 AM revealed all of them had been in serviced on intramuscular injections and infection control. All four could identify proper syringe selection, proper intramuscular injection technique and proper discarding of contaminated material. The SDC was conducting return to demonstrations with all staff at 3:00 PM on 11/22/11. All nurses will be monitored for intramuscular injection competency on hire and yearly by the SDC. The Corrective Plan of Action submitted revealed: A Corrective action will be accomplished for those residents affected by the deficient practice as evidenced by the following: ? Upon becoming aware on 11 03 11 of the alleged injection with a used needle by reporting nurse; ALL Influenza injection administrations were suspended immediately. ? Nurse who reported incident was immediately removed from the floor and suspended from duties pending investigation on 11 03 11. Identified RN was terminated 11 04 11 for unsafe nursing practice. ? Medical Director was on site and was notified immediately 11 03 11. STAT lab orders were obtained and drawn immediately including Hepatitis panel, RPR, Liver Function, and HIV. List of five residents involved were identified immediately. Those five will have ongoing follow up lab work as per Medical Director ' s order and CDC recommendations every three months x one year. ? MD contacted CDC for guidance and was referred to Public Health for further instruction for all 5 identified residents. ? Responsible parties were notified of the incident and the need for STAT labs. ? Charts were audited on all identified residents for any [DIAGNOSES REDACTED]. B Corrective action will be accomplished for those residents having potential to be affected by the deficient practice as evidenced by the following: ? Influenza vaccine administration was suspended pending all licensed staff education regarding medication administration and safe use of syringes on 11 04 11. ? Audit of those who had not received the influenza vaccine as of 11 03 11, was conducted by Unit Managers, Infection Control Nurse and DON in order to identify the residents having the potential to be affected by the deficient practice 11 03 11. C Systemic measures will be put into place to ensure the deficient practice will not occur by way of: ? Staff education surrounding medication administration and injection technique initiated by SDC 11 04 11 and will be added to license nursing orientation and annually. ? Licensed staff will complete a Medication Administration check list as well as a demonstration of injection techniques initiated by SDC by 11 22 11. ? Pharmacy Consultant will assist with competency completion utilizing check list and skills lab with return demonstration upon orientation. ? Under the direction of the Medical Director, Staff Development Coordinator and Unit Managers (RN) will be solely responsible for Influenza Vaccine administration and program management as of 11 04 11. D The facility will monitor its performance to ensure solutions are sustained by way of: ? Staff Development will evaluate all licensed staff using competency checks regarding injections by 11 22 11. Competency checks will be addressed during monthly QA meetings X three months then monthly. ? A competency check list audit tool will be addressed during monthly QA meetings x 3 months then monthly and with annual return demonstrations of skills.