Every finding on record at Mitchell-Hollingsworth Nursing & Rehabilitation

Based on record review, interviews, document review, and policy review, the facility failed to ensure that one of six residents (Resident (R) 137) reviewed for abuse, was free from abuse of 38 sample residents. This failure had the potential to affect resident safety. Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated [DATE], recorded It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.1.Review of R137's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R137 was initially admitted to the facility on [DATE], and readmitted [DATE] with diagnoses including Alzheimer's disease, dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and type two diabetes.Review of R137's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating R137 was severely cognitively impaired, and exhibited no behaviors.Review of R137's Care Plan, dated [DATE], with revision date of [DATE], located in the EMR under the Care Plan tab, revealed R137 is on Behavior Management Program monitored on Behavior Monitoring Record. Behaviors are: resident wanders into others resident room, laying in their beds, exit seeks, Resident believes that [he/she] talking to someone when talking to pictures on the wall, believes that it is someone else when looking into a mirror, thinks [he/she] is younger, Disrobing, voiding in inappropriate places, and will push other residents in their chairs and they don't want [his/her] to. Resident does not know personal space, invade the personal boundaries of others without permission. Interventions include: Call family to assist with redirection, Check code alert bracelet weekly for functioning status and daily for placement, Code alert bracelet applied to alert staff of unsafe wandering attempts, Decrease the frequency of behavioral episodes to once a month, If resident is wandering , take [his/her] to the bathroom, Resident receives services from [Name] Behavioral Health, Take resident for a walk off of unit around the building, Take resident on the screen in porch if weather permits, watch for resident if invading another resident's personal space. Approach in a calm manner and introduce yourself, explain tasks and importance of care, and reassure the resident that they are safe, and we are here to help [his/her].2. Review of R220's undated admission Record located in the EMR under the Profile tab, indicated R220 was initially admitted to the facility on [DATE], with a readmission on [DATE], and expired on [DATE]. Diagnoses included senile degeneration of brain, neurocognitive disorders with Lewy bodies, dementia with mood disorder, agitation, and anxiety, and psychotic disorder with delusions.Review of R220's quarterly MDS with an ARD of [DATE], located in the EMR under the MDS tab revealed a BIMS score of three out of 15, indicating the resident was severely cognitively impaired. R220 was assessed as experiencing hallucinations, delusions, and wanders one to three days out of the seven days look back period.Review of R220's Care Plan, dated [DATE], located in the EMR under the Care Plan tab, revealed R220 is on Behavior Management Program monitored on Behavior Monitoring Record-Behaviors are wander into others' room and exit seek; rejection of care; physical behaviors directed towards others, and verbal behaviors. Interventions included .Approach in a calm manner and introduce yourself, Explain tasks and importance of care, Reassure resident that they are safe and we are here to help them, Validate feelings and redirect thoughts if possible/appropriate, Praise efforts and cooperation, Give choices if possible, Assess for basic needs (comfort, pain, hunger, thirst, toileting, needs, etc.), Make sure resident is safe and return later to attempt tasks as needed, remove from excess stimulation and provide 1:1 attention asneeded, walk with resident if wandering and redirect thoughts to a different subject; return to station/room, contact resident rep, resident services director, mental health, therapist, family, or sponsor as needed, contact physician for as needed (PRN) medication if above interventions are not successful.Review of the facility's Resident Abuse, Neglect, and Unusual Occurrence Report, Detailed Investigation, dated [DATE], provided by the facility, revealed On [DATE] at approximately 11am [R220] and [R137] were standing in the hallway when [Certified Nurse Aide (CNA) 5] heard [R137] raise [his/her] voice which caused her to look around the corner from the nursing desk and witnessed [R220] hit [R137] in the face which resulted in [his/her] stumbling backwards into a resident's room without falling. CNA assisted [R137] while [R137] was holding [his/her] face oh it hurts. CNA noticed a red area above her lip. Resident Assistant who also responded to the residents walked with [R220] and did not leave [his/her] side assisted with [R137's] care. Intervention: Staff immediately intervened and removed both residents safely away from each other and attended to both simultaneously. [R137] was assessed and treated with a cold pack on [his/her] lip, physician and family notified. [R220] was assigned 1:1 care until [he/she] transferred to an acute care facility for continued assessment and treatment. [R220] was admitted to the [Name] for further assessment and treatment. Based on findings from the statements, eyewitnesses, interviews and resident's history, it was concluded that there was a resident-to-resident altercation of Abuse-Physical between said residents. During an interview on [DATE] at 2:48 PM, the Director of Nursing (DON) stated he recalled this incident, unsure what caused it, but resident had behaviors including wandering. DON added it was witnessed by the CNA. CNA5 and the Resident Assistant were unavailable for interview.

Based on record review, interview, and policy review, the facility failed to ensure one of five residents (Resident (R) 7) reviewed for unnecessary medications had an appropriate diagnosis for the use of an atypical antipsychotic medication with dementia of 38 sample residents. Findings include:Review of the facility's policy titled, Use of Psychotropic Medications, reviewed 04/22/25, revealed: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals.Review of the facility's policy titled, Addressing Medication Regime Review Irregularities, reviewed 10/24/24, revealed: Policy: The facility should provide timely responses to irregularities identified as a result of a resident's medication regimen review (MRR). Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy.Review of R7's admission Record from the electronic medical record (EMR) Profile tab revealed a facility admission date of 07/23/25 with medical diagnoses that included pelvic fracture, dementia without behavioral disturbance, delirium, somnolence, lack of coordination, altered mental status, and restlessness and agitation.Review of R7's Order Summary from the EMR Orders tab revealed orders for: -Quetiapine (an atypical antipsychotic medication, brand name Seroquel) 100 milligrams (mg) at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, ordered on 08/14/25 and -Seroquel 25mg (generic name Quetiapine) daily related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, ordered on 09/02/25. During an interview on 09/18/25 at 4:25 PM, the Quality Improvement Registered Nurse (QIRN) provided a physician signed document, dated 07/22/25, with an applicable diagnosis for atypical antipsychotics for residents with dementia. Review of the document, provided by the facility, revealed, [R7's name] is prescribed Seroquel for Dementia with behavioral disturbances.The Director of Nursing (DON) provided a list of Consultant Pharmacist medication reviews completed on 08/11/25 and 09/11/25 that revealed no recommendations were made regarding R7's use of an atypical antipsychotic medication.During an interview on 09/18/25 at 5:58 PM regarding the August 2025 and September 2025 Pharmacist medication reviews and the dementia without behavioral issues diagnosis in the EMR for the atypical antipsychotic prescription, the DON stated an expectation that the Pharmacist would identify the discrepancy and noted She (Consulting Pharmacist) normally does look at the diagnosis to be sure they are appropriate. The Pharmacist was unavailable for interview. Review of the National Institute of Health (NIH) article titled, Atypical Antipsychotic use in Patients with Dementia: Managing Safety Concerns located at https://pmc.ncbi.nlm.nih.gov/articles/PMC3516138/, published 09/12, revealed: In the elderly population, the largest number of prescriptions for atypical antipsychotics is written for the neuropsychiatric symptoms (NPS) of dementia (1). NPS (e.g., delusions, depression, agitation) affect up to 97% of people with dementia over the course of their illness (2). No atypical antipsychotic is FDA-approved for the treatment of any NPS in dementia.The 2012 American Geriatric Society (AGS) Beers consensus criteria for safe medication use in the elderly (7) recommend avoiding antipsychotics to treat NPS of dementia due to the increased mortality and CVAE [cardiovascular adverse events] risk unless nonpharmacological options have failed and patient is threat to self or others. Additional adverse effects include cardiovascular and metabolic effects, extrapyramidal symptoms, cognitive worsening, infections, and falls.Review of the NIH article titled, FDA [Food and Drug Administration] warns about using antipsychotic drugs for dementia located at https://pmc.ncbi.nlm.nih.gov/articles/PMC556368/#:~:text=The%20US%20Food%20and%20Drug,stroke%2C%20obesity%2C%20and%20diabetes, corrected on 05/28/05, revealed The FDA asked manufacturers to place a black box warning on drug labels-indicating an adverse reaction that may result in death or serious injury-noting the increased death rates and that these drugs are not approved for the treatment of behavioral symptoms in elderly patients with dementia. The drugs affected include aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), clozapine (Clozaril), and ziprasidone (Geodon). A drug used for depression associated with bipolar disorder, olanzapine (Symbyax), was included in the advisory warning.

Based on record review, interview, and facility policy review, the facility failed to ensure two of three residents (Resident (R) 3 and R12) Resident Representative (RR) or Family Member (FM) reviewed for facility initiated emergent transfer to the hospital received a written notice of transfer and/or a written bed hold notice from a sample of 38 residents. This failure had the potential to affect the resident and their Resident Representative by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include:Review of the facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), reviewed 09/22/22, revealed: Policy Explanation and Compliance Guidelines.4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing f. request. h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations. 1. Review of R3's admission Record from the electronic medical record (EMR) Profile tab revealed a facility admission date of 10/11/24, readmission on [DATE], with medical diagnoses that included intervertebral disc degeneration, back pain, tremors, fall history, weakness, history of poliomyelitis, generalized muscle weakness, difficulty in walking, altered mental status, and restlessness and agitation. A review of R3's EMR Progress Notes tab revealed: Effective Date: 07/19/2025 12:55 [PM] Type: FALL DOCUMENTATION Note Text: Called to patient's room by another LPN [Licensed Practical Nurse] ([name]). She states the patient fell. Upon entering the patient's room, the patient was in [sic] the floor just inside the door and laying slightly to the left side in a semi sitting position. [He/She] was assisted into wheelchair x 2 and complains of left hip and elbow pain. Charge nurse ordering x rays. [Practitioner name] notified. 07/19/2025 14:30 [2:30 PM] General Nurse's Note Text: Pt [Patient] left facility via EMS [Emergency Medical Services to [Hospital name]. A review of R3's EMR Miscellaneous tab revealed a transfer/discharge notice, dated 07/19/25, that showed the resident was unable to sign and the box for the form being mailed to the RR or FM was not checked. 2. Review of R12's admission Record from the EMR Profile tab revealed the latest facility admission date of 07/23/25 with medical diagnoses that included critical illness myopathy, recurrent pneumonia, type II diabetes, anxiety, venous embolisms, osteoarthritis, and fibromyalgia. A review of R12's EMR Progress Notes tab revealed R12 had been sent to the hospital on [DATE] for sepsis, 05/28/25 for purulent drainage around a feeding tube site, 06/03/25 for an unresponsive episode, and 07/18/25 for altered mental status with diaphoresis. Review of R12's EMR Miscellaneous tab revealed transfer notices for the above dates but no evidence that the notices had been provided to the RR or FM. During an interview on 09/17/25 at 3:51 PM, the Quality Improvement Registered Nurse (QIRN) stated nothing was provided in writing to the RR/FM, but the family was always called and was aware of the transfer. The QIRN reviewed the transfer notices for R3 and R12 and confirmed the box at the bottom of the forms, that the form had been mailed out, was not checked. During a telephone interview on 09/18/2025 at 2:42 PM regarding receipt of the written notice of transfer and/or discharge, R12's RR/FM (FM12) stated, I'm in communication with them [facility] on the phone or while I'm there. They contact me regularly. When clarified about a written notice for the dates of emergent transfer, FM12 stated Those were all emergent, so I wasn't there to receive anything in writing. FM12 clarified that nothing had been mailed, and she had not been provided with anything in writing. During an interview on 09/18/25 at 5:43 PM regarding the emergent transfer process, Registered Nurse (RN) 1 stated, I call the physician, then call 911, then call the family to let them know. Get our transfer paperwork, the bed hold agreement; prepare the transfer paperwork [clarified document for EMS and EMS signs the last page for our records as to who took the resident]. Print off three of them, one for EMS, one for the ER, and one for us to keep. Then I call report to hospital when EMS gets here, take down the information of who I reported to in ER. When asked if anything was given to the patient in writing, RN1 responded They take the bed hold agreement and it has transfer information on the back, it goes with the hospital documentation. When the patient family goes to see the patient or comes back here, we can give them a copy. RN1 was not aware of anything being provided to the family unless they came in to get it.

Based on record review, interviews, and facility policy review, facility failed to conduct a thorough falls root cause analysis for two of eight residents (Residents(R) 137 and R3) reviewed for falls of 38 sample residents. This failure could result in the facility's inability to discover the reason behind the resident's fall and put the appropriate interventions in place based on the reason for the fall.Findings include:Review of the facility's policy titled, Fall Prevention Program, dated 11/20/24, recorded When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the residents' care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. h. Initiate an intervention as appropriate to the cause of the fall to reduce the opportunity for a fall to recur.1.Review of R137's undated admission Record located in the EMR under the Profile tab, indicated R137 was initially admitted to the facility on [DATE], and readmitted [DATE] with diagnoses including Alzheimer's disease, dementia, and osteoarthritis.Review of R137's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/19/23, located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score three out of 15, indicating R137 was severely cognitively impaired, and exhibited no behaviors. R137 was independent with bed mobility, transfers, walking in room and in corridor. R137 required extensive assistance from two staff members for dressing, toilet use, and personal hygiene.Review of R137's Care Plan, dated 11/10/21, located in the EMR under Care Plan tab, revealed Potential for falls related to dementia, poor safety awareness, psychotropic medication, wandering, pain, anemia. Interventions included attempt to ensure resident wearing own appropriate footwear while ambulating (Resident often removes), attempt to keep as safe as possible, attempt to keep wheeled chairs out of day area when not in use, bring resident out to day area when restless, ensure resident has on non-skid shoes daily, mattress to be taken out of room, monitor resident gait and balance, monitor resident when ambulating and remind [his/her] to walk slower so [she/he] does not trip on [his/her] own feet, therapy evaluation initiated, administer medications as ordered and monitor for possible side effects that could contribute to falls (dizziness, drowsiness, weakness, hypotension, etc.), Ensure all fall precautions are in place, ensure resident has non-skid footwear that fits adequately, keep frequently used items within easy reach, keep gripper socks or non-skid shoes on as tolerated by resident, keep pathways well-lit and clutter free, keep resident's adjustable bed in the lowest position with the wheels locked, keep resident's call light accessible and answer calls in a timely manner, notify physician and resident's sponsor if resident has a fall and any injuries if they occur, assist with toileting as needed, monitor falls and safety issues, provide cueing and supervision as needed, and silent bed alarm placed to alert staff of unsafe transfers.Review of the facility's Fall Incident Report, provided by the facility and dated 08/29/25, recorded R137 observed lying on floor with head facing the door and feet facing the bed. [R137] noted to be dressed and dry. [R137] noted to have non-skid socks in place. [R137] alert with confusion. [R137] yells out when moved. [R137] roommate states that resident fell. Transferred to emergency room (ER) for evaluation and treatment. Right trochanter fracture.Review of the facility's Root Cause Analysis, dated 09/02/25, recorded Change in Care/Action: X-rays ordered by Medical Doctor (MD), x-ray obtained 08/29/25 at 12:20 PM, x-ray reveals acute non-displaced right femoral intertrochanteric fracture. MD and family notified of findings-order given to transfer to ER, resident admitted to hospital for management of fracture. Silent bed alarm added to be to alert staff of unsafe transfers. There was no investigation into the cause of R137's fall. During an interview on 09/18/25 at 4:57 PM, Licensed Practical Nurse (LPN) 3 was questioned if she had witnessed R137's fall. LPN3 stated that No, I got to work at 6:30 AM and [R137's] call light was on. I went to [his/her] room and saw [R137] on the floor, when I tried moving [his/her], [she/he] cried out ow, ow and gripped [his/her] hips. Notified physician and family, physician ordered transfer to hospital. Roommate said [R137] fell. LPN3 was asked if she thought that R137's roommate was cognitive enough to know R137 fell. LPN3 stated Yes, I believe [his/her] roommate was aware enough to know [she/he] fell and turned the call light on.2. Review of R3's admission Record from the EMR Profile tab revealed a facility admission date of 10/11/24, readmission on [DATE], with medical diagnoses that included intervertebral disc degeneration, back pain, tremors, fall history, weakness, history of poliomyelitis, generalized muscle weakness, difficulty in walking, altered mental status, and restlessness and agitation.Review of R3's EMR Progress Notes tab showed: 07/19/2025 12:55 [PM] Fall Documentation. Note Text: Called to patient's room by another LPN [Licensed Practical Nurse] (name in parentheses). She states the patient fell. Upon entering the patient's room, the patient was in the floor just inside the door and laying slightly to the left side in a semi sitting position. [He/She] was assisted into wheelchair x 2 and complains of left hip and elbow pain. Charge nurse ordering x rays. [Practitioner Name] notified. 07/19/2025 14:30 [2:30 PM] General Nurse's Note. Note Text: PT [patient] left facility via EMS [Emergency Medical Services] to [Hospital identified].A request for the fall investigation yielded a Witnessed Fall incident report that did not give a plausible explanation for the fall. A second request was made for the fall investigation, and the facility provided a Root Cause Analysis document.Review of the facility provided Root Cause Analysis Resident QI [Quality Improvement] Details, document regarding R3's fall, dated 08/19/25, revealed: Findings. [Staff member name] was called to residents room by LPN [Name]. She stated the patient fell. Upon entering the patients room, the patient was in [sic] the floor just inside the door and laying slightly to the left side of the door in a semi sitting position. Assist to wheelchair x2 assist. [He/She] is c/o [complaint of] left hip pain and elbow pain. Notified [his/her] charge nurse and xrays are being ordered. [Practitioner Name] notified. Change in Care/Action. Assisted to wheelchair x2 assist. Pt left facility via EMS and admitted with left hip fracture. After return from hospital resident relocated to room across from nurses desk, bed alarm added to bed. Intervention in place to have resident up in day area when out of bed and no sitter present. Expected Outcome. Patien [sic] to return to facility. Left hip to heal and care to continue.On 09/17/25 at 4:30 PM, the Director of Nursing (DON) reviewed the Root Cause Analysis [RCA] and confirmed there was no cause of the fall identified on the RCA and there were no witness statements included.During an interview on 09/18/25 at 5:51 PM regarding the Root Cause Analysis, the DON stated, It's very important how a fall occurred to set an intervention to keep it from happening again. We only do RCAs on falls with major injuries.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure alternatives were attempted prior to the use of side rails for two of two residents (Resident (R) 7 and R12) reviewed for side rails out of 38 sample residents. This failure had the potential to increase accidental entrapment or injury from bed rail usage when an alternate assistive device may have been effective.Findings include:Review of the facility's policy titled, Proper Use of Bed Rails, reviewed 07/07/25, revealed: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails.Resident Assessment: .2. The resident assessment may include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. Resident and family preference for the use of side rails, excluding full length rails, to assist with bed mobility or positioning will be honored. Appropriate Alternatives 9. The facility may attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include, but are not limited to: a. Roll guards b. Foam bumpers c. Lowering the bed d. Concave mattresses 10. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered. 11. If no appropriate alternatives are identified, the medical record should include evidence of the following: a. Purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful b. Assessment of the resident, the bed, the mattress, and rail for entrapment risk (which would include ensuring bed dimensions are appropriate for resident size/weight), and c. Risks and benefits were reviewed with the resident or resident representative, and informed consent was given before installation or use.1. Review of R7's admission Record from the electronic medical record (EMR) Profile tab revealed a facility admission date of 07/23/25 with medical diagnoses that included pelvic fracture, dementia, delirium, somnolence, lack of coordination, altered mental status, and restlessness and agitation.Review of R7's EMR admission Minimum Data Set (MDS) tab with an Assessment Reference Date (ARD) of 07/29/25 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, indicative of severe cognitive impairment.Observations on 09/16/25 at 3:03 PM revealed R7 had bilateral upper bed rails on his bed. On 09/17/25 at 8:50 AM and 09/18/25 at 2:30 PM, R7 was observed in bed with the bed rails up. Review of R7's EMR Assessments tab revealed a Bed Side-Rail Safety Assessment, dated 08/05/25, that had blank fill in areas for: 10a. List side rail alternatives considered but not attempted because they were considered inappropriate for resident. 10b. List any Side Rail alternatives attempted that failed to meet resident's needs. However, 10c was checked that both the resident and family requested the use of bedside rails. Review of R7's EMR Care Plan tab revealed a focus, initiated 07/22/25, of Potential for injury from bed side rails related to: impaired mobility with a goal of: Resident will benefit from the use of bed side rails AEB [As Evidenced By]: no documented injury from side rails through the next review period. with interventions of: (1/4) bed rails for (safety, mobility, and weakness), 1 and/or 2 rails PRN [as needed] -Annual side rail safety inspection completed by maintenance staff. -Observe for and report loose rails, sharp edges, or other possible problems with side rails.-Observe for and report safety concerns or entrapment risks. 2. Review of R12's admission Record from the EMR Profile tab revealed the latest facility admission date of 07/23/25 with medical diagnoses that included critical illness myopathy, recurrent pneumonia, type II diabetes, anxiety, venous embolisms, osteoarthritis, and fibromyalgia. Review of R12's EMR quarterly MDS tab with an ARD of 08/25/25 revealed a BIMS score of 15 out of 15, indicative of being cognitively intact.Observation on 09/16/25 at 1:50 PM revealed R12 in bed with bilateral upper bed rails, and at 3:31 PM, R12 was out of his/her room but the bilateral bed rails were in the up position on the bed.Review of R12's EMR Assessment tab showed Bed Side-Rail Safety Assessments, dated 02/21/25, 03/12/25, 05/20/25, 05/30/25, 06/12/25, 07/03/25, and 08/05/25. All assessments were blank for 10a. List side rail alternatives considered but not attempted because they were considered inappropriate for resident and 10b. List any Side Rail alternatives attempted that failed to meet resident's needs with the exception of the 07/03/25 assessment which had N/A [not applicable] for both 10a and 10b.Review of R12's EMR Care Plan tab showed a focus, initiated 07/23/25, of Potential for injury from bed side rails related to: impaired mobility with a goal of Resident will benefit from the use of bed side rails AEB: no documented injury from side rails through the next review period with interventions of: -Annual side rail safety inspection completed by maintenance staff. -Observe for and report loose rails, sharp edges, or other possible problems with side rails.-Observe for and report safety concerns or entrapment risks. -Resident has left and right 1/4 length side rails for bed mobility and transfers; 1 and/or 2 rails PRN. -Side rails provide a feeling of comfort and security for resident. -Side rails provide a hand-hold for getting in and out of bed and during transfers. During an interview on 09/17/25 at 3:51 PM, the Quality Improvement Registered Nurse (QIRN) stated the facility reviewed the risk/benefits with the family ensuring the family understands the government says there could be entrapment but if they request side rails they get them. The QIRN continued on to say it was a resident's rights issue to have side rails if requested. At 5:01 PM, the QIRN provided the facility policy and stated she was sure the facility would be updating things as she reviewed the regulations and resident rights don't trump the regulation.In an interview on 09/18/25 at 5:56 PM regarding bed rail use expectations, the Director of Nursing (DON) stated, A lot of patients and families prefer to have rails, a lot use for mobility and bed controls hang there. When asked to clarify about attempted alternatives prior to the use of rails, the DON responded, We really never have in the past, never heard them [family/ residents] expressed desire for alternate other than a bed rail.

Based on observation, interview, product review, and policy review, the facility failed to ensure expired medications were not available for resident use in the medication room refrigerator for one of three medication rooms (200-hall) reviewed for medications. This had the potential to affect any of the 37 people residing on the 200 hall. Findings include:Review of the facility's policy titled, Medication Storage, reviewed 04/22/25, revealed:Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Policy Explanation and Compliance Guidelines.8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.Observation of the 200 hall Medication Room on 09/18/25 at 11:00 AM with Licensed Practical Nurse (LPN) 4 revealed a tuberculin purified protein derivative (PPD) vial with an opened date on the box of 07/29/25 in the refrigerator. LPN4 verified the open date and then reviewed/ verified the side of the product box that stated after the vial had been entered it should be discarded after 30 days. At 11:04 AM, LPN4 then replaced the vial back in the refrigerator stated she would dispose of it properly later. During an interview on 09/18/25 at 5:50 PM, the Director of Nursing (DON) stated, [The PPD] Should have been moved to the dc'd [discontinued] meds. If not moved to dc meds, it may have been stored in the fridge, but it should not be available for resident use.

Based on observation, interviews, record review, and review of a facility policy titled, admission orders [REDACTED]. This affected RI #222, one of two residents for whom admission orders [REDACTED] Findings Include: A review of a facility policy titled, admission orders [REDACTED]. A physician . must provide orders for the residents' immediate care and needs .Policy . Compliance Guidelines: 1. The written orders should include at a minimum . c. Routine care orders . 2. The orders should . provide essential care to the resident . on admission. RI #222 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #222's Physician order [REDACTED].#222 upon admission to the facility on [DATE]. A review of RI #222's admission care plan revealed the following: . Potential for Altered Elimination . [MEDICAL CONDITION] . Bladder . Foley Catheter Use . Foley Cath will remain patent with the implementation of nursing interventions thru next 90 day review . A review of Admission assessment dated [DATE] for RI #222 revealed . Section 1. [MEDICAL CONDITION] .1. Catheter Present .Yes . A review of the Physician's Admission Progress Note, dated 8/29/2019, revealed . Admission note, records reviewed . male paraplegic x 2 years after [MEDICATION NAME] abscess, Chronic indwelling foley . A review of the STR (Short Term Rehab) Daily Evaluation forms dated 8/29/2019 and 9/03/2019 revealed . 2. Catheter . Foley Catheter care provided. Catheter patent, draining via gravity . On 9/04/19 at 8:38 a.m., the surveyor observed RI #222 sitting in a recliner in the resident's room with a privacy cover over a catheter bag attached to the left lower side of the resident's recliner. RI #222 stated that upon admission to the facility, she/he had been admitted with a foley catheter due to [DIAGNOSES REDACTED]. On 9/05/19 at 8:33 a.m., an interview was conducted with Employee Identifier (EI) #1, a Register Nurse. EI #1 was asked who had been the admitting nurse for RI #222 on admission to the facility on [DATE]. EI #1 stated she had been RI #222's nurse on admission. EI #1 was asked what physician orders [REDACTED]. EI #1 stated that the following should have been ordered for a resident on admission if they came in with with a urinary foley catheter: the type of catheter, the size of catheter, size of catheter bulb, when to change the catheter, the reason for the catheter, and care of the foley catheter. EI #1 was asked did RI #222 have a urinary foley catheter on admission to the facility on [DATE]. EI #1 stated yes, that EI #222 had a urinary foley catheter due to the [DIAGNOSES REDACTED]. EI #1 was asked why did RI #222 not have an order for [REDACTED].#1 stated that she forgot to write the order. WI #1 was asked why would it be important for RI #222 to have an order for [REDACTED].#1 stated that RI #222 needed an order on admission for an urinary foley catheter due to ensure the proper use and care for the foley catheter was provided for RI #222. On 9/05/19 at 8:42 a.m., an interview was conducted with EI #2, Director of Nursing/ Registered Nurse. EI #2 was asked who had been responsible for obtaining a physician order [REDACTED].#2 stated the the nurses on the unit were responsible for ensuring a resident had an order on admission for the use and care of a foley catheter. EI #2 was asked did EI #222 have a urinary foley catheter on admission on 8/28/2019. EI #2 stated that RI #222 had an urinary foley catheter on admission, but did not have a physician order. EI #2 further stated that EI #222 had an admitting [DIAGNOSES REDACTED]. EI #2 was asked why would it be important for EI #222 to have had an order for [REDACTED]. On 09/05/19 at 9:10 a.m., the surveyor conducted a telephone interview with EI #3, the Medical Director/Physician. EI #3 was asked should there have been an order for [REDACTED].#3 stated yes there should have been because the RI #222 was admitted with a [MEDICAL CONDITION] Bladder and a paraplegic. EI #3 was asked would there have been any harm for RI #222 having a foley catheter without an physician order [REDACTED].#3 stated no, because RI #222 needed the foley catheter upon admission.

Based on observation, interview and review of the (YEAR) U.S. Food & Drug Administration Food Code reference to When to Wash, Temperature and Time Control Frozen Food, Person In Charge and a facility Policy/Procedures , titled, Clean Dishes - Manual Dishwashing, the facility failed to: 1. prevent potential cross-contamination as evidenced by: a. staff not [MEDICATION NAME] appropriate hand hygiene and glove use when necessary after potential contamination by using the left gloved hand to push against a wall while leaning in to pull dish racks from the dishmachine and resting the right gloved hand on the ledge of the dish apron continuing to sort, stack, and store clean/sanitized dishes and utensil, b. the cook's failure to practice appropriate hand hygiene and glove use when necessary after potential glove contamination by touching the handle of a push cart, c. staff placing soiled pot holders on top of clean sauce dishes stored on the steamtable at the tray line. 2. assure a nourishment unit freezer was maintained at a level to keep (Ice Cream) frozen solid, 3. assure by monitoring/documenting cold food (Milk) was maintained at 41 degrees Fahrenheit (F.) or below when served from the tray line, as evidenced by: no data for 11 of 21 opportunities. 4. assure correct manual dishwashing procedures were followed regarding the correct water temperature, chemical concentration in 93 of 93 opportunities for the month of (MONTH) (YEAR). These deficient practices had the potential to affect all residents receiving meals from dietary. 1. a. The Food Code 2-301.14, page 49/50, addressed When to Wash . (F) During Food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (I) After engaging in other activities that contaminate the hands . On 07/31/18 at 10:20 AM, an observation was made of a food service worker using her left gloved hand to touch the wall while leaning in to pull a rack from the dish machine. The worker then placed her right gloved hand and rested it on the rail of the dish apron. On 7/31/18 at 11:45 AM, the food service worker, Employee Identifier (EI) #6, was interviewed. She was asked if she touched the wall with the her left gloved hand when leaning in to pull a rack from the machine and did she rest her right gloved hand on the apron railing. EI #6 acknowledged that she had. She was asked if she washed her hands & changed gloves. EI #6 said she did not and suggested it was potential cross contamination when asked about contamination. 1. b. On 7/31/18 at 10:28 AM, the cook was observed at the stove, wearing gloves and touching a push cart handle. She removed her gloves, placed them on a counter top, pulled 2 cleaned gloves from a box, threw the soiled gloves into the trash and then regloved. She did not wash her hands during this process. The cook EI #5, was then asked if she washed her hands after touching the cart. She replied no. She was asked if she changed gloves, she replied yes. 1. c. On 7/31/18 at 10:45 AM, an observation was made of the cook placing soiled hot pads on clean sauce dishes on trayline. 2. The Food Code 3-501.11 Temperature and Time Control, page 92, addressed frozen food. Stored frozen foods shall be maintained frozen. On 7/31/18 at 5:00 PM, an observation was made of the 300 Hall nourishment room. The ice cream in the freezer unit was noted to be soft to the touch. 3. On 8/01/18 at 3:15 PM, a review of the facility's daily Temp Log sheets used for documenting the temperatures of the food items for breakfast, lunch and supper meals was conducted. The days of (MONTH) 8, 9,10,11,13, 14 and one sheet with no date were reveiwed. On 7/8, there were 3 omissions of the milk temp being taken, breakfast, lunch and supper. For 7/9 there was one omission of the milk temp taken, lunch. On 7/10 there two omissions of the milk temp taken, lunch and supper. On 7/11/18 there were two omissions of the milk temp taken, lunch and supper. A Temp Log sheet provided, no date. indicated two omissions of the milk temp taken, lunch and supper. On 7/13 there was one omission of the milk temp taken, lunch. On 7/14 there was one omission of the milk temp taken, breakfast. The Certified Dietary Manager tabulated the data to reveal there was no recorded data for milk temps taken on 11 of 21 entries. When asked what she thought was the reason for no recorded data, EI #4 replied the probable cause was the scheduling of staff, a new person to record the temps. 4. A facility policy titled Cleaning Dishes - Manual Dishwashing date 2013, addressed the sanitizing of dishes. Procedure: . 6. Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate. Sanitize all dishes by immersion in one of the following: . Disinfectant Quaternary Ammonium . Strength 105 to 200 PPM 75 degree Fahrenheit Per manufactures. The Food Code addressed, Duties 2-103.11 The Person In Charge shall ensure that: . (K) Employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution temperatures and exposure time for hot water sanitizing and chemical concentration . A review of the (MONTH) (YEAR) Sanitizing Sink Chemical Level form was conducted. The form provided documentation of all 31 days and all three shifts for the chemical level. For each entry the number 300 was documented, except for two entries of 200 and one entry with an arrow pointing up. The CDM reported it was her fault for the staff's failure to monitor water temperature to assure accuracy of chemical test. EI #4 reported it was a potential for bacterial contamination.

Based on observation, interviews, medical record review and a review of facility's policies titled Administering Medications and Workstation Use and Security, the facility failed to ensure the MAR (Medication Administration Record) screen for Resident Identifier ( RI) #93 was not left up/unlocked and open for public view. This affected RI #93 one of 22 sampled residents. Findings Include: RI #93 was admitted to the facility on [DATE]. A review of a facility policy titled, Administering Medications, with a revised date of 5/19/2017 revealed: .Highlights . Safety of Medication Cart 11. During administration of medications, . Employees will log-off/lock screen of applications containing electronic record . A review of a facility policy titled, Workstation Use and Security, with a revised date of 6/15/17 revealed: Policy: It is the policy of this company for employees to protect resident's electronic protected health information (EPHI) .Such safeguards will be used to .keep resident information private and secure from unauthorized users . Policy Explanation and Compliance Guidelines: .6. Employees will log-off/lock screen of applications containing EPHI before leaving workstations in public view On 07/31/18 at 9:23 a.m., the surveyor observed a MAR indicated [REDACTED]. The screen contained RI #93' personal information, primary contact, primary physician, diagnoses, current medications and other information. Employee Identifier (EI) #7, Registered Nurse (RN), Director of Nurse (DON) was on the hallway and surveyor asked EI #7 to view the screen left up/unlocked and open for public view. On 7/31/18 at 9:24 a.m. an interview was conducted with (EI) #7. EI #7 was asked should the MAR indicated [REDACTED]. EI #7 said no, it should not be left up/unlocked with resident's information open for public view, the screen should be lock when not in use. EI #7 was asked who left the MAR indicated [REDACTED]. EI #7 said, EI #1. On 08/01/18 at 2:53 p.m., an interview was conducted with EI #1, a LPN (Licensed Practical Nurse). EI #1 was asked if she was giving medications on 7/31/18, on the 400 hall. EI #1 said yes, she was. EI #1 was asked if she left MAR indicated [REDACTED]. EI #1 said, Yes. EI #1 was asked what was the facility's policy regarding the MAR indicated [REDACTED]. EI #1 said, Privacy

Based on an observation, interview, medical record review, and review of a facility policy titled Smoking- (name of facility), the facility failed to ensure a care plan was revised for a resident that smoked. This deficient practice affected Resident Identifier (RI) #76, one of three residents sampled for smoking. Findings Include: RI #76 was admitted to the facility on [DATE]. A review of a facility policy titled Smoking- (name of facility) with a revision date of 9/21/2017 revealed: .5. All residents that smoke will have a smoking care plan in place that outlines any smoking-related privileges, restrictions, and concerns . A review of RI #76 s Smoking Assessments dated 9/28/2017 revealed: .F .2. Team Decision: 1. Safe to smoke without supervision . A review RI #76's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident used tobacco. A review of RI #76 s Smoking Assessments dated 12/27/2017 revealed: .F .2. Team Decision: 1. Safe to smoke without supervision . A review of RI #76's care plan with a revision date of 1/26/2018 revealed: . Resident will smoke in designated smoking areas with supervision over the next review . A review of RI #76 s Smoking Assessments dated 3/20/2018 revealed: .F .2. Team Decision: 1. Safe to smoke without supervision . On 7/31/2018 at 5:23 p.m., the surveyor observed RI #76, outside of the facility in a designated smoking area, without supervision while smoking. On 8/02/2018 at 9:12 a.m., an interview was conducted with Employee Identifier (EI) #3, a Restorative Registered Nurse. EI #3 was asked if RI #76 was a smoker. EI #3 stated yes. EI #3 was asked if a smoking assessment had been completed on the RI #76. EI #3 stated there were three smoking assessments completed on RI #76. EI #3 further stated that smoking assessments were completed on 9/28/2017, 12/27/2017, and 03/20/2018 for RI #76, and the team decision states the resident is safe to smoke without supervision. EI #3 was asked if RI #76 had a care plan for smoking. EI #3 stated yes. EI #3 was asked what #76's care plan goal stated. EI #3 replied that the care plan goal for RI #76 stated the resident will smoke in designated areas with supervision, but the care plan is incorrect. EI #3 was asked what should the care plan goal for RI # 76 state. EI #3 stated it should state that the resident will smoke in designated smoking areas without supervision. EI #3 further stated that a revision should have been done on RI #76's smoking care plan. EI #3 was asked what the purpose of revising a care plan. EI #3 stated a care plan should be revised to make sure it is updated accurately to meet the needs of the resident and it lets the staff know how to take care of the resident.

Based on observation, interviews, medical review, Potter and Perry, Fundamentals of Nursing, Ninth Edition, and a facility policy titled Administration of Eye Drops, the facility failed to ensure a licensed nurse did not put on gloves from the right pocket of the uniform top, prior to administering an eye drop medication. This deficient practice affected Resident Identifier (RI) #4, one of one resident observed receiving an eye drop medication and one of five licensed nurses observed during medication administration. Findings Include: RI #4 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of a facility policy titled, Administration of Eye Drops with an implemented date of 11/28/2016 and a revision date of 08/02/2018 revealed: .Wear clean gloves during administration . A review of of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 32, Medication Administration, with copyright of (YEAR), page 660-661, documented: .Skill 32-2 Administering Ophthalmic Medications .6 .apply clean gloves .reduces transmission of microorganisms . A review of RI # 4's physician's orders [REDACTED]. Artificial Tears Solution 1.4% ([MEDICATION NAME] Alcohol) Instill 1 drop in both eyes two times a day for dry eye syndrome . A review of the Minimum Data Set (MDS) Quarterly dated 07/17/2018 revealed: .Additional Active Diagnosis .Dry Eye Syndrome of Unspecified Lacrimal Gland . A review of RI # 4's Medication Administration Record [REDACTED] On 08/01/18 at 9:00 a.m., Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), was observed during medication pass observation for RI #4. The surveyor observed EI #1 remove gloves from the right pocket of the uniform top and put them on her hands, prior to administering an eye drop medication to RI #4's right and left eye. On 08/02/2018 at 10:15 a.m., an interview was conducted with EI #2, a Registered Nurse, Infection Control. EI #2 was asked where would you obtain gloves to wear prior to putting on before giving a resident an eye drop medication. EI #2 stated you should get gloves from the glove box in the hallway, medication cart or the resident's room. EI #2 was asked what would be the problem if you took a pair of gloves out of the pocket of the top of your uniform, put the gloves on your hands, prior to administering an eye drop medication to a resident. EI #2 stated the gloves could be contaminated from the pocket of the uniform and could cause an infection to the resident, or contaminate the eye drop container. EI #2 was asked does the facility have a policy on wearing gloves during administering an eye medication. EI #2 stated yes and you should wear clean gloves during administration of eye drops. On 08/02/2018 at 10:25 a.m., a telephone interview was conducted with EI #1 a Licensed Nurse. EI #1 was asked during the medication administration of eye drops to RI #4, after you washed your hands and prior to giving the eye drop medication, what did you do. EI # stated she took a pair of gloves out of the right pocked of the uniform top and put on her hands. EI #1 further stated that she should have got the gloves from the glove box in the resident's room, and not from the right pocket. EI #1 was asked what would be the problem of taking the gloves out of the right pocket of the uniform top, put on the gloves, and administer the eye drops to the resident. EI#1 stated that the gloves from the right pocket could be contaminated, and this could cause the resident to have an infection. EI #1 was asked what was the facility policy on using gloves during administering eye drop medication. EI #1 stated the policy states you should use clean gloves. EI #1 further states that when she put the gloves in her right uniform pocket, the gloves became contaminated and would not be clean. EI #1 was asked if the facility policy was followed when you took the gloves out of the right pocket of the uniform top. EI #1 stated no.

Based on review of Resident Identifier (RI) #1's medical record, the facility's policy titled Reporting Abuse to Facility Management and Other Agency's, ABUSE INSERVICE-REVIEW QUESTIONS and Abuse In-Service Review Answers, the facility's investigation file and interviews, the facility failed to protect RI #1, a cognitively impaired dependent resident, after the resident was sexually assaulted by Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA). EI #4, a CNA stated she observed her co-worker, EI #5, engaging in a sexual act with RI #1 on 11/02/17. EI #4 stated near the end of the evening shift, around 10:55 p.m., she went to look for EI #5 because she needed his assistance with another resident. EI #4 stated she remembered EI #5 had volunteered to provide care to RI #1, in an effort to help complete assignments before the oncoming shift (11:00 p.m. to 7:00 a.m.) came on duty. EI #4 stated when she opened RI #1's room door, she observed EI #5 straddled on top of RI #1 having sex with the resident. EI #4 stated both the resident and EI #5 were naked from the waist down and EI #5 was sitting on top of RI #1. EI #5's underwear and scrub pants were on the floor. EI #4, shocked by this observation, informed EI #5 that she was going to report what she had observed to the Charge Nurse, EI #6. According to EI #4, EI #5 asked her to please not tell. EI #4 admitted she did not implement the facility's established procedure of what to do when abuse was witnessed. EI #4 failed to ensure RI #1 was safe, when she left the resident unattended to report what she observed to EI #6, the Charge Nurse. EI #4 stated she wished she had drawn attention by screaming or alerting staff when she was in RI #1's room that night instead of closing the door, leaving RI #1 unsupervised and unprotected. Furthermore, after EI #6, the Licensed Practical Nurse (LPN) Charge Nurse and EI #7, the Registered Nurse (RN) Supervisor were made aware of what EI #4 had witnessed, they failed to protect RI #1 by not immediately going to the resident's room to ensure the resident's safety. This deficient practice placed RI #1, one of 13 sampled residents in immediate jeopardy of serious injury, harm or death. On 11/17/17 at 12:46 p.m., EI #1, the Administrator and EI #2, the Director of Nursing (DON) were notified of findings of substandard quality of care at the immediate jeopardy level in the area of Resident Behavior and Facility Practices, F 226. Findings include: On 11/03/17, the facility submitted an allegation of sexual abuse to the Alabama State Survey Agency. The report documented on 11/02/17 at 10:50 p.m., CNA, (EI #4) REPORTED THAT SHE WITNESSED CNA, (EI #5) ON TOP OF RESIDENT, (RI #1). CNA, (EI #4) STATED THAT CNA, (EI #5) WAS UNCLOTHED FROM THE WAIST DOWN . The facility's policy titled Reporting Abuse to Facility Management and Other Agency's with an implemented date of 11/28/16, documented: . Policy Interpretation and Implementation 1. Our facility does not condone resident abuse by anyone, including staff members . 2. c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident . An undated facility document titled ABUSE INSERVICE-REVIEW QUESTIONS and Abuse In-Service Review Answers, documented 3. What is the first thing you do if you witness Abuse happening or you suspect it has happened? . The answer was listed as Stay with the resident and make sure the resident is safe. The next question on the document was 4. Do you leave the resident unattended? The answer was listed as NO. Question #5 was listed as, How would you get someone's attention to help while you stay with the resident? The answer was listed as *YELL for help, *pull the call light/bathroom light, *make loud noise. RI #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #1's Admission Minimum Data Set with an assessment reference date of 09/14/17, assessed RI #1 as being severely impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) of 0. RI #1 was assessed as requiring limited assistance of one person for bed mobility and extensive assistance of one person for transfers, personal hygiene and bathing. RI #1 was also identified as being occasionally incontinent of bladder. Contained within the facility's investigative file was a CNA's, EI #4's, written statement dated 11/02/17 at 10:50 p.m., which documented: I entered resident's room and saw the other employee sitting on top of the resident. Both the employee and resident were undressed from the waist down. The employee jumped off of the resident and squated (squatted) in the floor. He picked his underwear and pants up out of the floor. I told the employee that I was going to tell our nurse and he asked me to please don't tell her. I shut the door and ran to the nurse and reported to her what I saw. On 11/14/17 at 3:11 p.m., the surveyor conducted an interview with EI #4, a CNA. According to EI #4, the last time she saw EI #5 was about 10:35 p.m., when he stated he was going to take care of RI #1. EI #4 stated around 10:40 p.m., she went into RI #1's room and asked EI #5 if he needed any help. According to EI #4, EI #5 stated he did not need any help but asked EI #4 for a sheet. EI #4 stated she retrieved a sheet from the cart and handed it through the door to EI #5. Then around 10:55 p.m., EI #4 stated she went to look for EI #5 and opened RI #1's room door. According to EI #4, she walked into RI #1's room and saw EI #5 having sex with RI #1. EI #4 stated they were both naked from the waist down and EI #5 was sitting on top of RI #1. When asked if she saw any penetration, EI #4 stated no but when EI #5 jumped off of RI #1, RI #1 did have an erection. EI #4 explained that EI #5 had on a scrub top but his scrub pants and underwear was on the floor, close to the bed. EI #4 stated, When (EI #5) saw me he asked me please not to tell. EI #4 stated she left the room to inform the nurse, after she had observed EI #5 to stand up and put his pants on. EI #4 stated she informed EI #6, a LPN, who was at the nurses' station counting medications for shift change. EI #4 stated she informed EI #6 that she had went into RI #1's room to get EI #5 and when she opened the door, she saw EI #5 on top of RI #1 having sex. When asked what EI #6 did, EI #4 stated she told me to come with her and we both went to the supervisor's office. When asked if EI #6 made an attempt to go into RI #1's room after being informed of what just occurred, EI #4 replied, not that I know of. EI #4 was asked, was there anyone in the room with RI #1 after the incident. EI #4 answered, No ma'am. EI #4 explained that RI #1 was left unattended when she went to report the incident to EI #6. The surveyor asked EI #4 what the facility's abuse policy said staff should do when a resident was found in a potentially abusive situation. EI #4 said the first thing staff were to do was to protect the resident, then draw attention and not leave the resident alone. When asked if she protected RI #1 during the incident, EI #4 said she wished she had drawn attention by screaming or alerting staff when she was in RI #1's room that night. Contained within the facility's investigative file was RI #1's written interview statement conducted by the local police investigator and witnessed by EI #2, the Director of Nursing, dated 11/03/17 at 3:00 p.m., which documented: . Q (question): Did the male CNA do anything inappropriate with you while he was taking care of you? A (answer): No, I don't think so, I don't remember. Q: You comfortable with him? A: Well, I don't want to lie anymore. Q: Lie about what? A: Sex, Sex with me. I (RI #1) told him No, and that I didn't want that. Q: What did he do? A: Place his penis in my rectum. Q: Did he do that? A: No, but he tried to. A nurse (CNA) came in and stopped it. I hope it doesn't ever happen again. Q: Was he on top of you? A: Yes. Q: Did he perform oral sex on you? A: No. Q: Did you do it to him? A: No, but he tried. I told him to stop. On 11/14/17 at 12:23 p.m., the local police investigator was interviewed. According to the investigator, a CNA walked in on EI #5 who was straddled on top of RI #1 nude from the waist down having sex. The local investigator stated when he spoke with RI #1, RI #1 said EI #5 tried to penetrate (him/her) but RI #1 told EI #5 no and resisted him. According to the local investigator, RI #1 stated EI #5 had RI #1 to perform oral sex on him. Afterwards, EI #5 got on top of RI #1, then the nurse (CNA) entered the room. The local investigator further explained that EI #5 was interviewed on 11/03/17 and denied all sexual allegations. EI #5 told the local investigator he was pulling RI #1 up in the bed. When asked where EI #5 is at now, the local investigator replied, He's in jail. He still denies having sex with (RI #1). One of the stipulations put on (EI #5) by the judge is that he cannot work in a nursing home facility. We had probable cause to make the arrest. That's why he's in jail. It is a criminal investigation now, in the hands of the DA (District Attorney). On 11/15/17 at 3:44 p.m., an interview was conducted with EI #9, a CNA who worked the 3:00 p.m. to 11:00 p.m. shift on 11/02/17. EI #9 said when she saw EI #5 exit RI #1's room she was standing at the Kiosk on the unit, which is by a bathroom and the nurses' station. EI #9 stated where she stood was about halfway down the hallway from RI #1's room. EI #9 stated she observed EI #5 walk to the soiled utility room holding either a towel or diaper (adult brief) in his hand. EI #9 stated she did not see EI #5 again until he was walking toward the supervisor's office. On 11/14/17 at 5:23 p.m., the surveyor conducted an interview with EI #6, the LPN Charge Nurse assigned to care for RI #1 during the 3:00 p.m. to 11:00 p.m. shift on 11/02/17. EI #6 was asked to give an account of the events that happened regarding RI #1. EI #6 stated when EI #4 approached her at the nurses' station, EI #4 was in a panic, terrified state. According to EI #6, EI #4 said she had seen EI #5 on top of RI #1. EI #6 said she took EI #4 to the supervisor's (EI #7's) office. EI #7, the RN Supervisor was then informed by EI #4 what she had witnessed. EI #6 said she left EI #4 in EI #7's office and went back to the nurses' station to finish counting medications and give report. When asked if she went to RI #1's room, EI #6 said not at that time. The surveyor asked EI #6 what staff was told to do when they see or suspect a resident is being abused. EI #6 replied, scream or holler to get anybody's attention and not leave the resident. The surveyor asked EI #6 if she heard EI #4 scream or holler for assistance that evening. EI #6 replied, No. On 11/14/17 at 6:04 p.m., the surveyor conducted an interview with EI #7, the evening shift RN Supervisor. EI #7 said it was almost change of shift when EI #6 and EI #4 came to her office. EI #7 said EI #4 was upset and could hardly talk. EI #7 said after EI #4 calmed down she informed them she had observed EI #5 on top of RI #1 and they were both undressed from the waist down. EI #7 said EI #4 said when she entered RI #1's room, EI #5 jumped off the bed, crouched down, and grabbed his clothes from off the floor. EI #7 said EI #4 told EI #5 that she was going to tell the nurse. According to EI #7, EI #5 told EI #4, please don't tell, then EI #4 ran out of the room to tell the LPN, EI #6. The surveyor asked EI #7 did anyone see where EI #5 went after the incident occurred. EI #7 said from what she understood, EI #5 had a brief in his hand and discarded it in the garbage. According to EI #7, after EI #4 had explained what had occurred, EI #5 walked into the supervisor's office. When asked how much time went by before EI #5 came to the supervisor's office, EI #7 replied, Maybe four or five minutes. EI #7 said as soon as EI #5 entered the office she told him she would have to suspend him because of an allegation of abuse; however, EI #5 accused EI #4 of lying. EI #7 explained how she informed EI #5 that he had to be suspended for his protection as well as for the resident's protection pending an investigation. The surveyor asked what the facility's abuse policy directed the staff to do when a resident is observed being abused or if abuse is suspected. EI #7 said staff should first make sure the resident is safe, then notify the supervisor. The surveyor asked EI #7 should the resident be left unattended. EI #7 replied, No, they should not be left alone. Contained within the facility's investigative file was a written statement by EI #5 dated 11/03/17, which documented: . I put the sheet on (RI #1) and then tried to pull (RI #1) up but couldn't so I got on the bed on my knees on each side of the resident and put both of my arms under (RI #1's) and began to pull (RI #1) up and then (EI #4) walked in and said oh my god (God) and I'm going to tell (EI #6). I said wait what? and (EI #4) slammed the door and left. Then I finished covering the resident up and pick (picked) up the diaper and wash rag and put them in the dirty bins and went to the supervisor's office . EI #5's EMPLOYEE ACTION FORM dated 11/02/17 documented: . Suspention (Suspension) due to alleged inappropriate interaction with a resident, suspended without pay pending investigation . On 11/15/17 at 7:59 a.m., the surveyor conducted an interview with EI #8, a RN Supervisor. According to EI #8, she was present in EI #7's office when EI #4 (CNA) and EI #6 (LPN) came to report the incident regarding RI #1. EI #8 said EI #4 looked upset and was about to hyperventilate. According to EI #8, after EI #4 explained what she had witnessed between RI #1 and EI #5, EI #5 approached the supervisor's office. It was at this time, EI #8 left the supervisor's office and went to the nurses' station to find the write-up (EMPLOYEE ACTION FORM) form. EI #8 said after she had shuffled through the forms and found one, she then went to check on RI #1. EI #8 said there was no one in RI #1's room and the resident was in the bed. During an interview on 11/15/17 at 5:39 p.m., EI #3, the Abuse Coordinator stated on 11/02/17 at 11:21 p.m., she received a call from EI #7 (RN Supervisor) that there was a report of possible sexual abuse. EI #3 stated she was told a CNA witnessed a male CNA on top of a resident (RI #1) in the bed straddled, and unclothed from the waist down. After asking, EI #3 stated the male CNA had been suspended. EI #3 stated she immediately got dressed and came to the nursing home. EI #3 stated she arrived at the facility around 11:45 p.m., and went to see RI #1. The resident was in the bed asleep. When asked was anyone in RI #1's room at that time, EI #3 replied, no. According to EI #3, when the resident was questioned by her and other staff, the resident stated that girl went running her mouth; the best thing to do was to let it go. EI #3 stated after the resident admitted to the local police investigator on 11/03/17 that something happened, the resident was sent to the crisis center for an examination. When asked what she expected the staff to do when they observe a resident in a potentially abusive situation, EI #3 stated to protect the resident and report. EI #3 was asked, how staff was taught to protect the resident. EI #3 replied, Don't leave the resident alone if the alleged perpetrator is still with the resident. EI #3 acknowledged that in the CNA's (EI #4) first statement, the CNA admitted to closing the door, leaving the perpetrator in RI #1's room. EI #3 further acknowledged that in the perpetrator's (EI #5's) statement, he also stated EI #4 (CNA) closed the door. EI #3 stated in her staff training she told the staff to draw attention to the room, by yelling, screaming, making loud noises, or press the bathroom call light to get attention to that room. When asked if EI #4 had done those things after she observed EI #5 on top of RI #1, EI #3 replied, No. In a follow-up interview with EI #3, the Abuse Coordinator on 11/17/17 at 9:23 a.m., EI #3 said the purpose for not leaving the resident alone when an abusive situation had been observed was because the staff could not totally ensure the resident's safety if they or someone else was not with the resident. When asked if RI #1 had the ability to consent, EI #3 replied, to simple things (he/she) can. EI #3 was then asked if RI #1 had the capacity to consent to sexual activity. EI #3 replied, yes because in RI #1's statement, the resident stated he/she told EI #5 (perpetrator) no. RI #1's Progress Note dated 11/03/17 at 17:30 (5:30 p.m.), documented . Decision was made by administration and family to have resident assessed at Crisis Services of (name of region). (RI #1) was transported by ambulance at apx (approximately) 5:30pm and accompanied by (name of facility staff). Resident and RN were met by . (RI #1's responsible party) . During a telephone interview with RI #1's responsible party on 11/16/17 at 9:21 a.m., he stated when the nurse at the Crisis Center asked RI #1 what happened, RI #1 said, he was trying to have sex with me. Contained within the facility's investigation was an undated typed document which read . The Abuse Committee reviewed this report and concluded that CNA (EI #5) sexually assaulted resident (RI #1) late in the evening of Thursday, 11-2-2017. Sexual abuse of a resident by CNA (EI #5) is substantiated . EI #5's EMPLOYEE ACTION FORM dated 11/06/17, indicated during a telephone call, EI #5 was notified his employment with the facility was terminated. ************************* On 11/16/17 at 6:00 p.m., the facility submitted an Allegation of Credible Compliance for F 226, which documented: This A(NAME) constitutes a written allegation of substantial compliance with federal Medicare and Medicaid requirements. F226 11/2/17 at 10:50 p.m. - Female CNA witnessed male CNA straddling RI #1 in bed with both being unclothed from the waist down. 11/2/17 at 10:52 p.m. - Female CNA reports incident to supervisor 11/2/17 at 11:05 p.m. - Male CNA was immediately suspended and left the building. Witness statements were obtained. 11/2/17 at 11:21 a.m. - Abuse Coordinator and abuse committee members were notified. 11/2/17 at 11:55 p.m. - The . Police Department were notified. 11/3/17 at 12:10 a.m. - Police Officer on site and interviewed RI #1. 11/3/17 at 1:00 a.m. - Police Officer interviews female CNA witness. 11/3/17 - CNA witness received one on one inservice by Nursing Supervisor on what to do to ensure resident safety if abuse is suspected, do not leave resident unattended. 11/3/17 at 12:46 a.m. - A skin assessment was completed on RI #1. Bruising was noted to outside of RI #1's left hand. 11/3/17 at 12:46 a.m. - Online incident report to state agency was entered. 11/3/17 at 1:50 a.m. - Medical Director notified 11/3/17 at 2:20 a.m. - Resident Representative notified. 11/3/17 at 2 a.m. - All staff on duty were In-serviced using the Abuse In-service- November 3rd 2017. 11/3/17 at 7 a.m. - Oncoming staff were in-serviced as they were clocking in on Abuse In-service November 3rd 2017. 11/3/17 at 9:30 a.m. - Medical director assessed resident and ordered X- ray of finger. 11/3/17 at 10:30 a.m. - Phone in-service provided to Abuse Committee and members of the administrative staff by legal consultant and Nurse Consultant, on Reporting Requirements under the Elder Justice Act. 11/3/17 - Follow up body audit completed on RI #1 by station nurse. 11/3/17 and 11/4/17 - The Ombudsman was notified of incident. 11/3/17 - Phone in-service began for all absent staff. All staff on payroll, including absent staff, staff on leave, and prn staff, were in-serviced using the Abuse In-Service November 3, 2017 by phone or in person by 8 p.m. on Friday, November 3, and those in-serviced by telephone only will be in-serviced in person before returning to work. 11/3/17 - Current residents on the station RI #1 resided, and ones able to participate in an interview were interviewed by the resident services staff. No other residents were noted to be affected. 11/3/17 - Skin assessments were performed on 6 residents that would not be able to participate in an interview. No other residents were noted to be affected. 11/3/17 - Staff interviews were conducted with 3/11 shift employees that have worked with Male CNA. 11/3/17 - Abuse Committee interviewed Male CNA. 11/3/17 - Police Detective interviews RI #1 at facility. 11/3/17 - Mini Mental Exam and Brief interview for mental status exam were completed on RI #1. 11/3/17 - RI #1 transported by ambulance to the Rape Crisis Center. 11/3/17 - RI #1 provided an alternate private room, and family remained with resident throughout shift. 11/4/17 - Administrator and Director of Nursing met with family to ensure resident safety. RI #1 requested to return to own room. Care plan updated to reflect that two staff members should enter the room at all times. 11/6/17 - Mental Health counselors were consulted and began seeing resident. 11/6/17-Interviewable residents throughout the facility were interviewed and asked if any staff member made them feel uncomfortable. All concerns were addressed. 11/9/17-Staff questionnaire done with staff on observing any unusual behavior of male C.N.A. No concerns were voiced. ************************* After review of the facility's investigation file, in-service/education records, staff interviews, and Quality Assurance plan, the facility implemented corrective actions from 11/02/17 to 11/06/17. The scope/severity of F 226 was lowered to a D level, to allow the facility to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiency was cited as a result of complaint/report number AL 416.

Based observations, interviews and a facility policy titled, Workstation Use and Security, the facility failed to ensure residents on the 200 hall were provided privacy as the licensed nurse did not close out the computer screen when she left the cart. This affected six of 40 residents on the 200 hall. Findings include: A facility policy titled, Workstation Use and Security with a revised date of 6/15/2017, revealed: Policy: It is the policy of this company for employees to protect resident's electronic protected health information (EPHI) when housed on company devices by implementing physical safeguards as necessary. Such safeguards will be used to prevent theft and keep resident information private and secure from unauthorized users. Policy Explanation and Compliance Guidelines: . 6. Computers in public areas will require . Employees will log-off/lock screen of applications containing EPHI before leaving workstations in public view. On 6/13/2017 from 5:29 PM through 5:50 PM, during the initial tour of the 200 hall, Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was observed leaving the medication cart and going to rooms to give medications. EI #2 was being called to the nurses station and asked for help with a resident by a family member. The medication cart screen was left open and unattended six times during this time period, exposing private medical information for six of the 40 residents on the 200 hall. On 6/15/2017 at 8:55 AM, an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked after medications were obtained from the medication cart, what should have been done with the computer prior to leaving the cart. EI #1 said, the lid should have been closed or the nurse should have logged off. EI #1 was asked was it an appropriate practice for resident health information to be visible to residents or visitors in the facility. EI #1 said, no. EI #1 was asked what was the potential harm when residents' personal health information was left in view of residents and visitors. EI #1 said, it was a violation of privacy. On 6/15/2017 at 12:51 PM, an interview was conducted with EI #2, LPN. EI #2 was asked after medications were retrieved from the medication cart, what should have been done with the computer prior to leaving the medication cart. EI #2 said, the screen should have been covered or the computer should have been closed. EI #2 was asked, was it an appropriate practice to have left the resident health information on the screen visible when the medication cart was left. EI #2 said, no. EI #2 was asked what was the potential harm to residents when personal health information was left in view of residents and visitors. EI #2 said, privacy.

Based on observation and interview the facility failed to ensure Resident Identifier (RI) #10's most recent Quarterly Minimum Data Set (MDS) documented the resident was receiving Hospice Services. This affected 1 of 9 residents sampled for Hospice Services. Findings Include: RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's most recent Physician order [REDACTED].Admit to .Hospice .Active .01/18/2016 . A review of RI #10's most recent Quarterly Minimum Data Set (MDS) was completed on 05/11/2016. Section O did not show RI #10 was receiving Hospice Services. An interview was completed with Employee Identifier (EI) # 6, MDS Nurse on 5/12/16 at 11:30 AM. EI # 6 indicated RI # 10 was currently on Hospice and he/she was admitted in January 2016. EI # 6 was asked if RI # 10's MDS dated [DATE] was marked to show he/she was receiving Hospice. EI # 6 replied no. EI # 6 was asked if it should be marked to show RI # 10 was receiving Hospice. EI # 6 replied yes that it was overlooked. EI # 6 was asked why it was important to show RI # 10 was receiving Hospice on the MDS. EI # 6 replied to show end of life and for accuracy.

Based on observation, interview and record review the facility failed to ensure RI (Resident Identifier) #12 received a pureed diet as ordered. This occurred on 5/11/16 at the the breakfast meal. This affected one of seventeen residents whom meals were observed. Findings include: A facility policy titled: Therapeutic Diets with a revised date of December 2008 documented: . 5. The Food Services Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.7. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet . RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's most recent Annual MDS (Minimum Data Set) with an Assessment Reference Date of 4/06/2016 revealed a BIMS (Brief Interview for Mental Status) of 10 which indicated moderately impaired cognition. The MDS also revealed RI #12 was independent for eating with no set up or help from staff. RI #12's Physician orders [REDACTED].Regular diet Pureed texture . RI #12's Annual Nutrition assessment dated [DATE] revealed the following: .Diet pureed r/t (related to) difficult chewing . On 5/11/16 at 8:15 AM, breakfast was served to RI #12 in his/her room. The tray card revealed .DIET: Pureed . RI #12 was served two pieces of bacon, one biscuit, one cheese danish, scrambled eggs and two bowls of oatmeal. RI #12 ate his/her two bowls of oatmeal and drank his/her fluids. RI #12 had only upper teeth. RI #12 said he/she could not eat the bacon, biscuit and cheese danish because he/she could not chew it. On 5/11/16 at 8:40 AM, EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse) was asked what type of diet is RI #12 prescribed. EI #4 said, RI #12 was prescribed a pureed diet. EI #4 was asked to look at RI #12's diet to determine if he/she was served the right diet. After EI #4 looked at RI #12's tray card, she stated, No. EI #4 was asked what should be on RI #12's diet. EI #4 replied, all the food should have been pureed. EI #4 was asked what was the potential harm with a resident not served their prescribed diet. EI #4 replied, RI #12 would not be able to consume as much food. On 05/12/16 at 1:40 PM, an interview was conducted with EI #5, the Dietary Manager. EI #5 was asked how does the dietary staff know what diet to serve a resident. EI #5 replied, the resident diet is on the tray card. EI #5 was asked who is responsible for ensuring the right diet is on the resident's tray. EI #5 replied the dietary staff check the trays, but the last checker who sees the tray before it goes to the station/unit. EI #5 was asked what is the potential harm for a resident served the wrong diet. EI #5 replied, the resident could get choked or not be able to eat their food because it is not the right consistency.

Based on observation, interview and record review the facility failed to (1) ensure a licensed staff did not touch the inside of Resident Identifier (RI) #18 and #19's medication cup with her bare finger during an observation of medication administration on 05/11/16. This affected two of 10 residents observed during the medication pass; and 2) the staff did not touch a clean brief with soiled gloves for RI #11. This was observed during incontinent care on 5/11/16. This affected one of three observations of incontinent care. Findings Include: A facility policy with a revised date of December 2012 titled: Administering Medications. documented: Highlights; Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed.22. Staff shall follow established facility infection control procedures .for the administration of medications, as applicable. On 05/11/16, at 07:40 AM Employee Identifier (EI) #1 Licensed Practical Nurse (LPN) was observed by the surveyor preparing RI #18's medication. She touched the inside of the medication cup with her bare finger. Immediately after administering RI #18's medication EI #1 continued to prepare medications for RI #19. She also touched the inside of this residents medication cup with her bare finger. On 05/12/16, at 1:58 PM EI #1 LPN was asked if she was aware she had touched the inside of RI #18 and 19's medication cups with her bare finger. EI #1 stated, Well I didn't realize it. EI #1 was asked why she should not touch the inside of the medication cup with her bare finger. She stated, Cross Contamination. EI #1 was asked what the potential for harm would be for touching the inside of the medication cup with her bare finger. She stated, Cross contamination, if my hands are not clean whatever I may have may get inside the resident's cup. She was then asked what the facility's policy was regarding giving residents medication related to picking up the cup. EI #1 stated, Never touch the rim or the inside. On 05/12/16, at 9:50 AM EI #2 Infection Control Registered Nurse was asked should a medication nurse touch the inside of a resident's medication cup with her bare finger while preparing their medications. EI #2 stated, No. EI #2 was asked what the facility's policy was related to the above question. She replied, Pop the medication in the cup. Hold the cup on the outside around the cup. EI #2 was asked what the potential for harm was if a nurse touches the inside of the resident's medication cup with her bare finger. She stated, Cross contamination. EI #2 was asked if she was aware EI #1 was observed touching the inside of RI #18 and #19's medication cups while preparing their medications on 05/11/16. EI #2 replied that she became aware after the administrator told her on 05/11/16. 2. A review of facility policy titled Perineal Care with a revised date of October 2010 revealed .Steps in the Procedure .11. Discard disposable items .12. Remove gloves . RI #11 was readmitted to the facility 11/23/15 with a [DIAGNOSES REDACTED]. On 5/11/16 at 10:30 AM, EI #3, Certified Nursing Assistant, was observed providing incontinent care for RI #11. EI #3 cleaned RI #11's front then reached for the clean brief and placed it on the bed. EI #3 then turned RI #11 to the right side and cleaned the bowel movement from the resident. EI #3 then placed the clean brief on RI #11 with the same soiled gloves. On 5/11/16 at 3:15 PM an interview was conducted with EI #3, she was asked when should she change gloves during incontinent care. EI #3 replied after touching something dirty. EI #3 was asked if she changed gloves before putting on the clean brief. EI #3 replied no. EI #3 was asked if she should touch a clean brief with soiled gloves. EI #3 replied no. EI #3 was asked what was the harm in touching the clean brief with soiled gloves. EI #3 replied cross contamination. On 5/12/16 at 9:50 AM an interview was conducted with EI #2, Infection Control Nurse, she was asked what types of infections was she currently monitoring. EI #2 replied Urinary Tract Infections. EI #2 was asked what was the policy for changing gloves during incontinent care. EI #2 replied never touch anything clean with a dirty glove, not to cross contaminate. EI#2 was asked if staff should touch a clean brief with soiled gloves. EI #2 replied no. EI #2 was asked what was the potential for harm in the staff touching a clean brief with soiled gloves. EI #2 replied cross contamination and spreading infections.

Based on observations from the facility's video surveillance footage, interviews, record review and review of a facility policy titled "Recognizing Signs and Symptoms of Abuse/Neglect", Employee Identifier (EI) #15, a dietary worker, and two CNA's (Certified Nursing Assistants), EI #16 and EI #17 watched Resident Identifier (RI ) #1, who was identified as having limited impairment to his/her left hand, roll uncontrollably in a wheelchair down the facility's employee and visitor parking lot without making an attempt to assist RI #1 in stopping or controlling the wheelchair. On 3/27/2015, the Alabama Department of Public Health received video surveillance footage of the 02/13/2015 incident. Review of the facility's video surveillance footage revealed on 02/13/2015 at 5:08 p.m., EI #15 pushed RI #1 into the smoking area. After removing his hand from RI #1's wheelchair, the chair continued to roll toward the parking lot adjacent to the smoking area. EI #15 watched as RI #1's wheelchair rolled without making an attempt to stop the wheelchair. Two additional staff members, EI #16 (a CNA) and EI #17 (a CNA) were also observed together in the smoking area. The facility's video surveillance footage revealed both CNAs watched RI #1 roll toward the employee and visitors parking lot making no attempt to help RI #1 stop or control the wheelchair. An interview with EI #16 confirmed that she observed RI #1's wheelchair hit the curb, causing RI #1 to go "airborne", landing on the ground face first. EI #16 also revealed it took her about a minute to a minute and a half before she responded to the incident. EI #17's statements, provided to the facility regarding this incident, revealed EI #17 observed RI #1 hit the concrete curb and fall on his/her head. Neither EI #16 nor EI #17 responded immediately to RI #1 after they witnessed the incident. As measured by the Maintenance Supervisor, EI #20, RI #1's wheelchair rolled 53 feet from the smoking area onto the uneven area of pavement in the parking lot, then turned and rolled an additional 147 feet into a concrete curb. After hitting the concrete curb, RI #1 was thrown out of the chair into the air, landing an additional 25 feet further, face down on the ground on a steep grassy slope. During an interview EI #18, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on the 3 PM to 11 PM shift on 02/13/2015, stated EI #17 informed her RI #1 went across the parking lot and fell out of a wheelchair. EI #18 responded to the accident and witnessed RI #1 lying face down in the grass. EI #18 acknowledged resident safety was number one and it was neglect if staff watched RI #1 roll in a wheelchair without making an attempt to stop the resident. RI #1 was assessed by EI #19, a RN (Registered Nurse) supervisor and noted to have a nose bleed, an abrasion to the bridge of the nose and a reddened area to the right forehead. RI #1 was sent to the emergency room (ER) for evaluation. This deficient practice affected RI #1, one of one resident sampled for neglect and posed an immediate threat to the safety of RI #1 because it was likely to cause serious harm, injury or death. On 04/02/2015, at 6:03 p.m., EI #1, the Administrator, EI #2, the (DON) Director of Nursing and EI #3, the Assistant Director of Nursing were notified of the findings of substandard quality of care at the Immediate Jeopardy level "J" in the area of Resident Behavior & Facility Practices, F 224. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOCC), observing the safety gate in the smoking area, observing the signs on the safety gate for staff and delivery personnel, conducting interviews with staff at the facility and reviewing the facility's in-service sheets to determine if the facility implemented their AOCC, the survey team abated the Immediate Jeopardy. The immediate jeopardy began on 02/13/2015 and was abated on 04/04/2015. Findings Include: Cross reference F 323. A facility policy titled "Recognizing Signs and Symptoms of Abuse/Neglect", with a revised date of November 2010, documented: "Policy Statement Our facility will not condone any form of resident abuse or neglect ... Policy Interpretation and Implementation ... 2. "Neglect" is defined as failure to provide goods and services as necessary to avoid physical harm mental anguish, or mental illness ... b. Signs of/Actual Physical Neglect: ... Caregiver indifference to resident's personal care and needs; ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2015, identified RI #1 to score a 15 on the Brief Interview for Mental Status (BIMS) indicating RI #1 was cognitively intact for decision making. The MDS also revealed RI #1 was totally dependent for transfers and required supervision for Locomotion off the unit. On the MDS, under "Functional Limitation in Range of Motion", RI #1 was noted to have impairment of both upper and lower extremities on one side. RI #1 was observed in the facility on 03/31/2015 at 5:15 p.m., seated in a wheelchair at the Nurses Station. RI #1's left hand was [MEDICAL CONDITION] (swollen) and contracted. The resident's left foot was resting on the left foot pedal of the wheel chair and the right foot was positioned on the floor. A review of the facility's initial report to Division of Health Care Facilities, dated 02/14/2015, documented: "... Incident Type 5) Select Category: Neglect ... 9) Date and time of occurrence: 02/13/2015 10) Time: 05:35 PM 11) Narrative summary of the incident: RESIDENT, (RI #1) WAS ATTEMPTING TO GO OUTSIDE TO SMOKE IN THE SMOKING AREA. (RI #1) REPORTED THAT (HE/SHE) WAS CAUGHT IN THE DOORWAY AND THEN A DIETARY WORKER, (EI #15) WAS ASSISTING (HIM/HER) THROUGH THE DOOR. RESIDENT, (RI #1) REPORTED THAT (HE/SHE) THOUGHT THAT (EI #15) WAS STILL PUSHING (HIM/HER) AND THAT (HE/SHE) TOLD HIM HE WAS ROLLING (HIM/HER) TOO FAST. CAMERA FOOTAGE SHOWS THAT (EI #15) HAD LET GO OF RESIDENT, (RI #1's) WHEELCHAIR. THE SLOPE OF THE PAYMENT CAUSED RESIDENT, (RI #1) TO ROLL OUT OF CONTROL DOWN TO THE CURB AND THE WHEELCHAIR FLIPPED (HIM/HER) OUT ONTO THE GRASS. RESIDENT DID HAVE MINOR INJURIES AND WAS SENT TO THE emergency room HOSPITAL FOR EVALUATION AND TREATMENT. RESIDENT RETURNED TO FACILITY ON 2-13-15. 12) Was there an adverse outcome to the resident (s)? Yes 13) Describe the adverse outcome to the resident (s): COMPLAINING OF PAIN TO LEFT RIB AND HIP. ABRASIONS TO NOSE, FOREHEAD AND LEFT LEG ..." A review of the Facility's Investigative Committee Findings, dated 02/19/2015, documented: "ABUSE COMMITTEE INVESTIGATED INCIDENT ... RESIDENT (RI #1) STATED THAT (RI #1) WAS ATTEMPTING TO GO OUTSIDE TO THE SMOKING AREA AND GOT CAUGHT IN THE DOORWAY. (RI #1) STATED THAT A DIETARY EMPLOYEE, (EI #15) ASSISTED (HIM/HER) THROUGH THE DOOR AND THAT (HE/SHE) THOUGHT THE EMPLOYEE (EI #15) WAS STILL PUSHING (HIM/HER). RESIDENT, (RI #1) STATED THAT (HE/SHE) WAS TELLING EMPLOYEE TO SLOW DOWN NOT REALIZING THAT THE EMPLOYEE HAD ALREADY RELEASED (HIS/HER) WHEELCHAIR. RESIDENT (RI #1's) WHEELCHAIR FOLLOWED THE SLOPE OF THE PAVEMENT OUT INTO THE PARKING AREA AND HIT A CURB. THE WHEELCHAIR FLIPPED THE RESIDENT (RI #1) OUT ONTO THE GRASS. WITNESSES WERE (EI #15), DIETARY; (EI #16), CNA, (EI #17), CNA; AND RESIDENT (name of another resident). CNA (EI #17) DID GO INTO FACILITY TO CALL FOR HELP. (EI #18), LPN, (EI #19), RN AND (name of another RN) WENT TO AIDE RESIDENT. RESIDENT, (RI #1) DID HAVE MINOR INJURIES VISIBLE WHICH INCLUDED ABRASIONS TO THE NOSE, FOREHEAD AND LEFT LEG. (RI #1) WAS ALSO COMPLAINING OF PAIN TO LEFT RIB AND HIP. RESIDENT WAS TRANSPORTED BY AMBULANCE TO THE HOSPITAL FOR EVALUATION AND TREATMENT ... NO OTHER INJURIES IDENTIFIED BY THE HOSPITAL, RESIDENT (RI #1) RETURNED TO THE FACILITY SAME EVENING. DIETARY EMPLOYEE (EI #15), (EI #16), CNA, AND (EI #17), CNA WERE SUSPENDED. ABUSE COMMITTEE CONCLUDED THAT NEGLECT ON THE PART OF THE THREE EMPLOYEES ..." A review of RI #1's "Narrative Notes" documented: "... Note Time: ... 02/13/15 07:37 PM ... Note: Nursing: resident sent to (name of local hospital) ER for evaluation ..." A review of the facility's "TRANSFER/DISCHARGE REPORT" with a date of February 13, 2015 documented: "... CHIEF COMPLAINT (reason for transfer) Around 5:30 pm had a spill from (RI #1's) wheelchair into a grassy area ... Landed face down c/o (complained of) (L) (left) Rib pain, (L) hip pain, abrasions to nose, forehead & (and) (L) leg..." A review of RI #1's hospital records revealed the following: "... Date: 02/13/15 ... ARRIVAL TIME: 1909 (7:09 p.m.) HPI (History Physical Information) General Questions Chief Complaint: fell Stated Complaint: fell , LEFT HIP AND RIB PAIN ... History of Present Illness When Fall Occurred: this evening ... Injuries/Pain Location: face, lower extremity, other (rib pain) Reason for Fall: lost balance Loss of Consciousness: Dazed Associated Symptoms: chest pain (Rib pain) ... HPI Comment: (Age of RI #1) year old (male/female) with history of stroke [MEDICAL CONDITION](Hypertension) presents to ED (emergency department) via (by way of ) EMS (Emergency Medical System) with injuries to (his/her) left ribs and hip sustained in a fall from (his/her) wheelchair ... (He/she) has abrasions on (his/her) forehead, nose, left thigh and left lower leg ... states (he/she) did "see stars" briefly ... Exam ... CVS (Cardiovascular System) exam comment: Left lateral chest is tender to palpation ... Skin problem comment Abrasions to forehead, nose, left hip and left lower extremity ... Extremities comment: Left lateral hip tender to palpation ..." Another review of RI #1's "Narrative Notes" documented: "02/14/15 01:30 AM ... Note: Nursing: late entry for 2/13/15 resident had a fall from wheelchair, c/0 (Complained of) pain in left ribcage, sent to (name of local hospital) ER (emergency room ) for eval. (evaluation) ..." A review of the facility's incident report titled, "Witnessed Fall" with a revised date of 02/13/2015 at 10:48 (10:48 p.m.), documented: "... Incident Location: Outside ... Incident Description Nursing Description: CNA came to floor & (and) said that resident had fallen out of (his/her) WC (Wheelchair). notified supervisor. staff observed resident lying in the grass out back of the facility. (He/she) was laying face down w (with)/legs straight out. WC (wheelchair) was pitched forward. RN assessed ROM (Range of Motion) & resident was assisted back into (RI #1's) WC. Resident was brought back inside & put on the bed. Resident c/o pain in (his/her) left hip area & left ribs ... Immediate Action Taken Description: sent to (name of local hospital) for evaluation ..." According to the above incident report, RI #1 received an abrasion to the face, a skin tear to the left knee and a skin tear to the front of his/her left lower leg. Also contained in the facility's investigative file were statements given by RI #1, EI #15, dietary worker, EI #16, CNA, and EI #17, CNA, regarding the incident. RI #1's typed statement, dated 2/14/2015, documented: "Post incident statement from (RI #1) Can you tell me what happened to you yesterday? I was trying to go outside to smoke and got caught in the metal doors. He (dietary worker) said "Here let me help you" and helped me get outside by pushing me with one hand. He asked me where I wanted to go and I told him anywhere close to an ash tray. He kept pushing me and I told him I did not think I could make the curb. I thought he was still pushing me when I kept talking to him and I thought he was answering. Later someone told me "they watched the camera and he was not pushing me. There were several people out there." This statement was signed by RI #1 and two staff members. On 04/01/2015 at 8:05 a.m., the surveyor conducted an interview with RI #1. The surveyor asked RI #1 what happened on the day of the incident. RI #1 said he/she was pushed in the wheelchair outside to smoke by a man from the kitchen and the wheelchair kept rolling. RI #1 said the facility informed him/her that he/she was not being pushed by a staff member and the incident was reviewed on camera. On 04/02/2015 at 12:38 p.m., the surveyor conducted a second interview with RI #1. The surveyor asked RI #1 what did he/she do when the wheelchair continued to roll. RI #1 said he/she tried to put his/her right foot down, but the wheelchair continued to roll. RI #1 said "(he/she) didn't want to break (his/her) foot." RI #1 said while the wheelchair was rolling he/she was headed toward a truck and thought he/her was about to hit the truck. RI #1 said the wheelchair then turned and started rolling toward the parking lot area. RI #1 said he/she hit something and went flying out the chair. The surveyor asked RI #1 did anyone see the wheelchair roll and hit the curb. RI #1 said there were people out there and he/she was sure they did. The surveyor asked RI #1 how did it make him/her feel when the wheelchair rolled out of control. RI #1 said he/she was concerned about his/her hip. RI #1 said he/she hit the ground pretty hard and fell flat on his/her face. RI #1 said he/she had a bad bruise to his/her right leg. The surveyor asked RI #1 how long was he/she lying on the ground before anyone came to help him/her. RI #1 said it was probably about a minute or two but seemed like forever because he/she couldn't move. A hand written statement given by EI #15, the dietary worker, dated 2/14/2015, documented: "Date of Incident: 02/13/15 ... Description of Incident: I was going to take a brake (break) when I saw a patince (patient) going out to smoke in a wheel chair. I pushed (him/her) outside and parked (him/her) and started to talk to (name of another resident) and was smoking. I heard the nurses say (he/she) was going down the hill and (he/she) hit the curb. I ran down the hill to help (him/her) but the nurses told me not to touch or move him/her) because they had to take pictures of how he/she) was laying about that time more people came out to help so I went back to the kitchen and started back to working." This statement was signed by EI #15 on 2/17/15. On 03/31/2015 at 11:22 a.m., a phone interview was conducted with EI #15. The surveyor asked EI #15, the dietary worker who pushed RI #1's wheelchair onto the smoking area, to explain what happened on the day of the incident involving RI #1. EI #15 said after he parked RI #1 he started smoking and was talking with another resident. EI #15 said when he looked back, RI #1 was going down the hill. EI #15 said RI #1 went across the parking lot and then went down. The surveyor asked EI #15 where did RI #1 go down. EI #15 said RI #1 went down on the left side of the parking lot. EI #15 said RI #1 hit the curb then flipped onto the grass. The surveyor asked EI #15 did he see RI #1 flip out of the wheelchair. EI #15 said he did and observed RI #1 laying face down on the ground. The surveyor asked EI #15 what did he do when RI #1 flipped out of the wheelchair. EI #15 said he ran down to help RI #1 and the nurses (EI #16 and EI #17) told him to not touch RI #1 because pictures had to be taken of RI #1. The surveyor asked EI #15 where were the nurses when the incident occurred. EI #15 said the nurses were right across from him in the smoking area. The surveyor asked EI #15 how far was the curb, that RI #1 hit, from the smoking area. EI #15 said about 30-40 yards. EI #15 stated when RI #1 flipped from the wheelchair it probably was a couple of minutes before anyone responded to RI #1. EI #15 said one of the nurses that was present in the smoking area went inside of the facility and the second nurse remained outside but did not respond immediately to RI#1. On 04/01/2015 at 4:15 p.m., the Maintenance Director, EI #20, the Administrator, EI #1 and the Abuse Coordinator, EI #4 were asked by the surveyor to observe the path RI #1 traveled during this incident, as well as the area in which RI #1 was found. EI #20 measured from the smoking area to an uneven area of pavement in the parking lot and stated it was "53 feet." EI #4 informed the surveyor the uneven spot in the payment caused RI #1's wheelchair to turn and travel toward a curb where visitors and employees parked their cars. EI #20 measured from the uneven payment in the parking lot to the curb and said it was "147 feet." EI #20 measured from the curb to the area RI #1 was found on the grass and stated it was an additional "25 feet." A hand written statement given by EI #16 (one of the CNAs) dated 2/17/2015, documented: "... Date of Incident: 2/13/15 Type of Incident: Resident Fall Description of Incident: I was on my 15 min (minute) break when I saw (RI #1) being wheeled out. (EI #17) (&) and I was talking and she ask where is that (gender of resident) going and I said what (gender of resident). I turned around and saw (gender of resident) going to the curb where hit (where RI #1 hit) and went airborne and hit the ground face first." This statement was signed by EI #16 on 2/17/15. On 04/01/2015 at 10:05 p.m., a phone interview was conducted with EI #16. The surveyor asked EI #16 when did she first observe RI #1 in the smoking area. EI #16 said she was on a 15 minute break and she and EI #17 were in conversation. EI #16 said EI #17 looked over her (EI #16's) shoulder and said where is that (man/woman) going. EI #16 said she turned and looked and saw RI #1 rolling down the hill. EI #16 said by then, RI #1 had hit the curb and was "airborne." EI #16 said when RI #1 hit the curb RI #1 came out of his/her wheelchair. The surveyor asked EI #16 what did she do after RI #1 hit the curb in the parking lot. EI #16 said she was startled at first. EI #16 said it took her maybe a minute to a minute and a half to go to where RI #1 was. EI #16 said she had hurt her back and couldn't run to RI #1. The survyor asked EI #16 was she smoking when the incident occurred. EI #16 said she was. The surveyor asked EI #16 why she waited the amount of time she did before she responded to RI #1 falling down the hill. EI #16 said she was shocked and startled. EI #16 said she was the first one to go down the hill. EI #16 said RI #1 was face down on his/her stomach and was grunting. EI #16 said she could not see RI #1's face. EI #16 said RI #1 had fallen down the hill away from his/her wheelchair. EI #16 said RI #1's body had landed several feet from the wheelchair. EI #16 said she asked RI #1 if he/she was OK and he/she grunted. A hand written statement given by EI #17, the other CNA, dated 2/17/2015, documented: "... Date of Incident: (Blank line) Type of Incident: (Blank Line) Description of Incident: I (EI #17's name) went on my break While I was outside talking to my co worker and on my phone i (I) looked up and notice (RI #1) hit the curb concrete and go head first into the grass hill ..." This statement signed by EI #17 and was dated 2/17/15. Attempts were made to contact EI #17 on 04/0120/15 at 5:12 p.m., 04/02/2015 at 8:00 a.m., and on 04/3/2015 at 12:25 p.m. All attempts were unsuccessful. On 04/01/2015 at 5:24 p.m., the surveyor conducted an interview with EI #18, the LPN assigned to care for RI #1 on 02/13/15 on the 3-11 shift. EI #18 said EI #17 came to the nurses station and said RI #1 went across the parking lot and fell out of his/her wheelchair. The surveyor asked EI #18 what did she observe when she saw RI #1. EI #18 said RI #1 was laying face down in the grass. EI #18 said from what she gathered, RI #1's footrest hit a chunk of concrete. EI #18 said RI #1 was face down in the grass with his/her head going down a hilly surface. EI #18 said RI #1 had an abrasion on the bridge of his/her nose and she believed a skin tear to his/her leg. EI #18 said if staff observed a wheelchair rolling in the parking lot they should do their best to grab hold of the wheelchair. EI #18 said knowing RI #1, he/her is paralyzed on one side and would not have been able to stop the wheelchair with the one leg if it was going very fast. EI #18 further said it was neglect if staff watched RI #1's wheelchair roll and not attempt to stop it. The surveyor asked EI #18 why she would call it neglect. EI #18 replied, "Because our number one thing is safety for the resident ..." On 04/02/2015 at 8:11 a.m., the surveyor conducted an interview with EI #4, the Abuse Coordinator. EI #4 said the Abuse Committee felt like there was a lack of response or very delayed lack of response from the employee who were in the smoking area. EI #4 said the committee felt there was no response after RI #1 was laying in the grass. EI #4 said that was the biggest issue. EI #4 said the committee felt EI #15 could have assisted RI #1 from stopping to roll and locked the brakes on the wheelchair. The surveyor asked EI #4 did the Abuse Committee determine how long it took the staff in the smoking area to respond to RI #1. EI #4 said from reviewing the video the committee felt it was too long. EI #4 said that was based on EI #16, the CNA, walking away from the direction where RI #1 was to sit her soda bottle down, then took her time walking back to the curb in the smoking area, hold on to a post in the area and then took more time to finish smoking a cigarette before putting it out. EI #4 said EI #16 looked in the area where EI #15 was standing before walking in the direction where RI #1 was. EI #4 said when EI #15 was noticed in the video, he was observed looking in the direction where RI #1 had rolled off then turned his back to the area and began to talk to another resident in the area. The surveyor asked EI #4 what should have been the appropriate response when RI #1 hit the curb in the parking lot. EI #4 replied, I think the appropriate response should have been at least one of them went to RI #1 immediately. On 04/02/2015 at 1:01 p.m., the surveyor conducted an interview with EI #19, the RN supervisor who responded when RI #1 was thrown from the wheelchair on 02/13/2015. The surveyor asked EI #19 when was she made aware RI #1 had rolled down a hill. EI #19 said EI #18 called the supervisors' station and reported that EI #17, the CNA, had just reported to her that RI #1 rolled down the hill. The surveyor asked EI #19 what she observed when she saw RI #1. EI #19 said RI #1 was laying face down with his/her arms straight down by his/her sides with his/her legs straight but crossed at the ankles. The surveyor asked EI #19 to describe the hill. EI #19 said the hill was semi-steep. EI #19 said RI #1 landed on the grass and was a good distance from the wheelchair. EI #19 said RI #1's forehead was red, his/her nose was very red and bleeding and it was believed RI #1's nose was broken. EI #19 said it was evident RI #1's face hit the ground. EI #19 said the Abuse Committee determined RI #1 was not given aide and assistance when danger was imminent. EI #19 said the incident was given the category of neglect because there was neglect to offer aide when there was imminent danger. EI #19 said that danger was imminent when RI #1 started rolling down the hill. EI #19 said looking at both of the facility's videos, it was apparent that staff in the area at that time were aware before RI #1 hit the bottom (curb) that RI #1 was going down the hill. EI #19 replied, "Their reaction once (RI #1) landed on the grass was very slow. They were slow to respond ..." On 04/02/15 at 2:32 p.m., the surveyor conducted an interview with EI #1, the Administrator. EI #1 said after observing the video footage he determined there was a lack of urgency to check on RI #1 by employees EI #15, EI #16 and EI #17. EI #1 said one of the CNA's did go get help but the other CNA continued to smoke her cigarette. This deficiency was cited as the result of the investigation of complaint/report #AL 874, AL 876 and AL 877. ******************************************************** On 04/04/15 at 10:30 a.m., the facility submitted an Allegation of Credible Compliance for F 224, which documented: Credible Allegation of Compliance (AOC) F224 1. · On 2/13/2015 a dietary worker and two CNAs were present when RI#1's wheelchair began to roll. All three employees failed to respond immediately as the wheelchair rolled and when the resident hit curb and fell out of the wheelchair. · On 2/13/2015 the dietary worker and two CNAs were suspended immediately. · On 2/13/2015 RI#1's attending physician and family were notified of incident. · On 2/13/2015 RI#1 was assessed by RN Supervisor and resident was noted to have abrasions to the nose, forehead and left leg and complained of pain to the left rib area and hip. · On 2/13/2015 RI#1 was sent to the Emergency Room for assessment. Resident returned to the facility with no major injuries noted. · On 2/14/2015 RI#1 was assisted/observed while smoking until a safety gate could be installed in the smoking area. · On 2/20/2015 the two CNAs were terminated. · On 2/23/2015 the dietary worker was terminated. 2. · During the week of 2/18/2015 all residents who smoked were assessed using the current Smoking Assessment. · On 3/01/2015 the Smoking Assessments were reviewed and revisions made. · On 3/02/2015 all residents who smoke were reassessed using an updated Smoking Assessment. All were deemed safe to smoke independently with the exception of resident RI#1. · There were no other residents assessed for smoking who used a manual wheelchair. All other residents that were deemed safe to smoke use motorized wheelchairs that cannot roll. 3. · On 3/10/2015 a safety gate was installed to prevent any resident in a manual wheelchair from accidentally rolling out of the designated smoking area. · On 4/02/2015 all staff currently at work were in serviced on manual wheelchair safety. If a resident needs assistance being wheeled out to the smoking area, that resident must be positioned in safe location to prevent rolling to an unsafe area. Lock brakes on wheelchair when appropriate. Failure to respond when a resident is in an unsafe situation is considered neglect. The definition of neglect is defined as failure to provide goods and service necessary to avoid physical harm, mental anguish, or mental illness. · On 4/03/2015 all staff currently working were in serviced on the importance of responding immediately when an unsafe incident is observed regarding a resident. · No employee may return to work until they complete both the in-services. · All newly hired employees will be in serviced during orientation. 4. · On 3/10/2015 Maintenance Director checked the gate for proper safety and documented compliance. This will be done daily and documented on the Safety Log. This is done by checking for closure of gate, proper latch closure and that the latch was securely placed in the concrete. · Gate is not to be used for staff entrance. · Gate is for emergency exit only, and will be opened only for deliveries. · If a delivery is being made the resident will be asked to return inside the facility or an employee will stay with the resident until the gate is secured. · On 3/31/2015 and 4/02/2015 the Corporate Nurse checked gate for proper closure and operation and found gate was latched properly. · On 4/03/2015 the Corporate Nurse checked gate for proper signage and the signs were observed to be in proper location. **************************************************************** On 03/31/2015, the surveyors observed the safety gate in the smoking area. On 04/02/2015, the facilty staff were inserviced on the following: "If a resident needs assistance being wheeled out to the smoking area, that resident must be positioned in safe location to prevent rolling to an unsafe area. Lock brakes on wheelchair when appropriate. Failure to respond when a resident is in an unsafe situation is considered neglect. The definition of neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness." On 04/03/2015, the facility staff were inserviced on the following: "All staff must respond immediately when an unsafe incident is observed regarding a resident." On 04/03/2015, the surveyors observed signs on the safety gate alerting staff that the gate was an "Emergency Exit Only" and alerting delivery personnel that "Delivery Personnel must check with staff before opening gate." On 04/04/2015, staff were interviewed to ensure they had received inservices on resident wheelchair safety, locking the resident's brakes on the wheelchair and responding immediately when an incident occurs. All staff interviewed had been inserviced.

Based on observations from the facility's video surveillance footage, interviews, record review and review of a facility policy titled "Safety and Supervision of Residents", the facility failed to ensure staff intervened to assist RI #1 in controlling this resident's wheelchair. RI #1's wheelchair rolled uncontrollably from the smoking area out into the parking area resulting in a fall with injury on 02/13/2015. On 3/27/2015, the Alabama Department of Public Health received video surveillance footage of the 02/13/2015 incident. Review of the facility's video surveillance footage revealed on 02/13/2015 at 5:08 p.m., EI #15 pushed RI #1 into the smoking area. After removing his hand from RI #1's wheelchair, the chair continued to roll uncontrollably toward the parking lot adjacent to the smoking area. EI #15 watched as RI #1's wheelchair rolled without making any attempt to stop the wheelchair. Two additional staff members, EI #16 (a CNA) and EI #17 (a CNA) were also observed together in the smoking area. Facility's video surveillance footage revealed both employees watched RI #1 roll toward the facility's employee and visitor parking lot making no attempt to help RI #1 stop or control the wheelchair. An interview with EI #16 confirmed that she observed RI #1's wheelchair hit the curb, causing RI #1 to go "airborne", landing on the ground face first. EI #16 also revealed it took her about a minute to a minute and a half before she responded to the incident. EI #17's statements, provided to the facility regarding this incident, revealed EI #17 observed RI #1 hit the concrete curb and fall on his/her head. Neither EI #16 nor EI #17 responded immediately to RI #1 after they witnessed the incident. In an interview with EI #19, the RN (Registered Nurse) supervisor on the 3-11 shift on 02/13/2015, EI #19 concluded the incident could have been prevented if EI #15 had brought RI #1's wheelchair to a complete stop. On 02/13/2015, RI #1 was assessed for injuries by EI #19 and sent to the emergency room (ER) for evaluation. The local ER assessed RI #1 for "abrasions to his/her forehead, nose, left hip and left lower extremity." Additionally, the facility failed to ensure RI #12 had non-skid socks on when out of bed. RI #12 sustained a fall on 03/29/2015, while not wearing non-skid socks. This deficient practice affected RI #1 and RI #12, two of eight residents sampled for falls and posed an immediate threat to the safety of residents because it was likely to cause serious harm, injury or death. On 04/02/2015, at 6:03 p.m., EI #1, the Administrator, EI #2, the DON (Director of Nursing) and EI #1, the Assistant Director of Nursing were notified of the findings of substandard quality of care at the Immediate Jeopardy level "J" in the area of Quality of Care Resident Behavior & Facility Practices, F 323. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOCC), observing the safety gate in the smoking area, observing the signs on the safety gate for staff and delivery personnel, conducting interviews with staff at the facility and reviewing the facility's in-service sheets to determine if the facility implemented their AOCC, the surveyor team abated the Immediate Jeopardy. The immediate jeopardy began on 02/13/2015 and was abated on 04/04/2015. Findings Include: Cross reference F 224. A facility policy titled "Safety and Supervision of Residents", with a revised date of December 2007, documented: "Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities ..." 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2015, identified RI #1 to score a 15 on the Brief Interview for Mental Status (BIMS) indicating RI #1 was cognitively intact for decision making. The MDS also revealed RI #1 was totally dependent for transfers and required supervision for Locomotion off the unit. On the MDS, under "Functional Limitation in Range of Motion", RI #1 was noted to have impairment of both upper and lower extremities on one side. RI #1 was observed in the facility on 03/31/2015 at 5:15 p.m., seated in a wheelchair at the Nurses Station. RI #1's left hand was edematous (swollen) and contracted. The resident's left foot was resting on the left foot pedal of the wheel chair and the right foot was positioned on the floor. A review of RI #1's "Narrative Notes" documented: "... Note Time: ... 02/13/15 07:37 PM ... Note: Nursing: resident sent to (name of local hospital) ER for evaluation ..." A review of RI #1's hospital records revealed the following: "... Date: 02/13/15 ... ARRIVAL TIME: 1909 (7:09 p.m.) HPI (History Physical Information) General Questions Chief Complaint: fell Stated Complaint: fell , LEFT HIP AND RIB PAIN ... History of Present Illness When Fall Occurred: this evening ... Injuries/Pain Location: face, lower extremity, other (rib pain) Reason for Fall: lost balance Loss of Consciousness: Dazed Associated Symptoms: chest pain (Rib pain) ... HPI Comment: (Age of RI #1) year old (male/female) with history of stroke and HTN (Hypertension) presents to ED (emergency department) via (by way of ) EMS (Emergency Medical System) with injuries to his left ribs and hip sustained in a fall from (his/her) wheelchair ... (He/She) has abrasions on (his/her) forehead, nose, left thigh and left lower leg ... states (he/she) did "see stars" briefly ... Exam ... CVS (Cardiovascular System) exam comment: Left lateral chest is tender to palpation ... Skin problem comment Abrasions to forehead, nose, left hip and left lower extremity ... Extremities comment: Left lateral hip tender to palpation ..." Another review of RI #1's "Narrative Notes" documented: "02/14/15 01:30 AM ... Note: Nursing: late entry for 2/13/15 resident had a fall from wheelchair, c/0 (Complained of) pain in left ribcage, sent to (name of local hospital) ER (emergency room ) for eval. (evaluation) ..." A review of the facility's incident report titled, "Witnessed Fall", with a revised date of 02/13/2015 at 10:48 (10:48 p.m.), documented: "... Incident Location: Outside ... Incident Description Nursing Description: CNA came to floor & (and) said that resident had fallen out of (RI #1's) WC (Wheelchair). notified supervisor. staff observed resident lying in the grass out back of the facility. (RI #1) was laying face down w (with)/legs straight out. WC was pitched forward. RN assessed ROM (Range of Motion) & resident was assisted back into (RI #1's) WC. Resident was brought back inside & put on the bed. Resident c/o pain in (RI #1's) left hip area & left ribs ... Immediate Action Taken Description: sent to (name of local hospital) for evaluation ..." According to the above incident report, RI #1 received an abrasion to the face, a skin tear to the left knee and a skin tear to the front of his/her left lower leg. On 03/31/2015 at 11:22 a.m., a phone interview was conducted with EI #15. The surveyor asked EI #15, the dietary worker who pushed RI #1's wheelchair on to the smoking area, to explain what happened after he helped RI #1 into the smoking area. EI #15 explained as he and RI #1 were going outside to smoke, he helped RI #1 through the door. EI #15 said after he parked RI #1 in the smoking area he started talking to another resident. EI #15 described when he looked back, RI #1 was going down the hill. EI #15 said RI #1 went across the parking lot and then went down. The surveyor asked EI #15 where did RI #1 go down. EI #15 said RI #1 hit a curb, then flipped onto the ground. The surveyor asked EI #15 when he said he parked RI #1, what did he mean. EI #15 said he pushed RI #1 to the smoking area where the resident smoked. The surveyor asked EI #15 did he lock the brakes on RI #1's wheelchair after he pushed RI #1 to the smoking area. EI #15 replied, "No." EI #15 said he had never locked the brakes on any residents wheelchair and that he worked in food services in the kitchen. On 04/01/2015 at 5:24 p.m., the surveyor conducted an interview with EI #18, the LPN assigned to care for RI #1 on 02/13/2015 on the 3-11 shift. EI #18 said if staff observed a wheelchair rolling in the parking lot they should do their best to grab hold of the wheelchair. EI #18 said knowing that RI #1 was paralyzed on one side he/she would not have been able to stop the wheelchair with the one leg if it was going very fast. On 04/02/2015 at 8:11 a.m., the surveyor conducted an interview with EI #4, the Abuse Coordinator. EI #4 stated the Abuse Committee determined the biggest issue with the incident was that EI #15 should have assisted RI #1 to stop the wheelchair from rolling and EI #15 could have locked the brakes on RI #1's wheelchair when he pushed the resident onto the smoking area. RI #1 was interviewed on 04/02/2015 at 12:38 p.m. The surveyor asked RI #1 where was his/her wheelchair normally parked when he/she went to the smoking area to smoke. RI #1 said he/she normally did not go out as far as EI #15 pushed him/her. RI #1 said he/she normally stayed under the shed. The surveyor asked RI #1 did anyone see his/her wheelchair when it began to roll. RI #1 was sure they did because there were four or five people in the smoking area at the time. The surveyor asked RI #1 if he/she felt the incident could have been prevented. RI #1 stated, "Yes. There were several people around the parking lot. They could have caught hold my handle on the back of the wheelchair." On 04/02/2015 at 1:01 p.m., the surveyor conducted an interview with EI #19, the RN supervisor who responded when RI #1 was flipped from the wheelchair on 02/13/2015. EI #19 said when EI #15 assisted RI #1 out to the smoking area, EI #15 failed to bring RI #1's wheelchair to a complete stop. EI #19 said the incident could have been prevented if EI #15 had brought the wheelchair to a complete stop. On 04/02/2015 at 1:59 p.m., the surveyor conducted an interview with the DON (Director of Nursing), EI #2. EI #2 said when she reviewed the facility's video surveillance footage, she saw EI #15 push RI #1 into the smoking area. EI #2 said EI #15 had his hand on the wheelchair, turned to talk to another resident and she saw RI #1's wheelchair continue to roll. EI #2 said RI #1's wheelchair rolled and hit a curb. EI #2 said if staff in the smoking had moved fast enough they could have stopped RI #1's wheelchair because they were not far from where RI #1 hit the curb. EI #2 said RI #1 just kept going and staff just stood there. EI #2 said the incident could have been avoidable if the CNA's had reacted like they should have. EI #2 said the CNA's could have stopped RI #1's wheelchair. On 04/02/2015 at 2:32 p.m., the surveyor conducted an interview with EI #1, the Administrator. EI #1 said when he reviewed the facility's video surveillance footage, he thought EI #15, #16 and #17 could have done more to stop RI #1 as the resident was rolling in the wheelchair. This deficiency was cited as the result of the investigation of complaint/report #AL 874, AL 876 and AL 877. ******************************************************** On 04/04/2015 at 10:30 a.m., the facility submitted an Allegation of Credible Compliance for F 323, which documented: Credible Allegation of Compliance (AOC) F323 1. · On 2/13/2015 a dietary worker and two CNAs were present when RI#1 ' s wheelchair began to roll. All three employees failed to respond immediately as the wheelchair rolled and when the resident hit the curb and fell out of the wheelchair. · On 2/13/2015 all three employees were suspended immediately. · On 2/16/2015 RI#1 ' s care plan was updated to reflect the resident ' s need for assistance while smoking. · On 2/20/2015 the two CNAs were terminated. · On 2/23/2015 the Dietary worker was terminated. · On 3/10/2015 after the gate was installed RI#1 was deemed safe to smoke independently 2. · On 2/13/2015 there were no other residents assessed for smoking that used a manual wheelchair. Other residents that smoke are in motorized wheelchairs that cannot roll · On 3/02/2015 All residents who smoke were reassessed using an updated Smoking Assessment and were deemed safe to smoke independently except for RI#1. · On 3/10/2015 a safety gate was constructed to prevent any resident in a manual wheelchair from accidentally rolling out of designated smoking area. 3. · On 4/02/2015 all staff currently working were in serviced on manual wheelchair safety. A return to work in-service is ongoing. · On 4/03/2015 all staff currently working were in serviced on responding immediately to any unsafe incident involving a resident. · On 4/03/2015 signs were posted to alert delivery persons to not open the gate without alerting staff member as well as to alert staff that gate is an emergency exit only. If delivery is being made the resident will be asked to return to the facility or an employee will stay with the resident until gate is secured. · On 4/03/2015 an in-service was conducted with all ancillary staff that were currently working including Resident Services, Medical Records, Maintenance, Business Office, Dietary, Housekeeping/Laundry, and Human Resources in the proper application of applying brakes on a wheelchair correctly with return demonstration. All employees were able to perform return demonstration · No employee will be allowed to return to work until in-service is completed and return demonstration has been performed. 4. · On 3/10/2015 safety gate was installed and inspected for proper functioning by Maintenance Director and the results were documented daily on Safety Log. The gate was found to be functioning properly. · On 3/10/2015 all Maintenance staff were in serviced on proper operation and securing of the gate with proper return demonstration of how to securely latch the gate. · On 3/31/2015, 4/2/2015 and 4/3/2015 the Corporate Nurse checked the gate for safety and found the gate to be latched securely. · On 4/03/2015 the Corporate Nurse checked the signage and interviewed three employees which included Dietary Manager and two CNAs about knowledge of resident safety. Signage was in place and staff interviewed were able to verbalize the need for wheelchair brakes being locked, and safe positioning of residents in the smoking area, the safety gate should be latched at all times and should only be used for deliveries. · On 4/03/2015 Maintenance Director trained the Nursing Supervisors on proper operation and securing of gate with proper return demonstration performed by Nursing Supervisors. **************************************************** On 03/31/2015, the surveyors observed the safety gate in the smoking area. On 04/03/2015, the surveyors observed signs on the safety gate alerting staff that the gate was an "Emergency Exit Only" and alerting delivery personnel that "Delivery Personnel must check with staff before opening gate." On 04/02/2015, the facilty staff were inserviced on the following: "If a resident needs assistance being wheeled out to the smoking area, that resident must be positioned in safe location to prevent rolling to an unsafe area. Lock brakes on wheelchair when appropriate. Failure to respond when a resident is in an unsafe situation is considered neglect. The definition of neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness." On 04/03/2015, the facility staff were inserviced on the following: "All staff must respond immediately when an unsafe incident is observed regarding a resident." On 04/04/2015, staff were interviewed to ensure they had received inservices on resident wheelchair safety, locking the resident's brakes on the wheelchair and responding immediately when an incident occurs. All staff interviewed had been inserviced. On 04/04/2015, the surveyor observed ancillary staff do return demonstrations on locking the brakes on a wheelchair. All ancillary staff observed were able to perform the return demonstration. 2) A review of the facility's policy titled, "Accidents and Incidents - Investigating and Reporting" with a revised date of April 2013, revealed the following: "... Policy Statement All accidents or incidents involving residents, ... occurring on our premises shall be investigated and reported to the Administrator. ... Policy Interpretation and Implementation ... 2. The following data as applicable shall be included on the "Report of Incident/Accident" form. ... c. The circumstances surrounding the accident or incident; ..." A review of the facility's policy titled, "Care Planning-Interdisciplinary Team" with a revised date of December 2008, revealed the following: "... Policy Interpretation and Implementation ... 7. When a new care plan intervention is required ... interventions are communication through electronic data ... 9. ... all information is used to promote quality resident care." RI #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Dementia with Behaviors, Personal History TIA (Transient Ischemic Attack). RI #12's Annual MDS (Minimum Data Set), dated 03/04/15, documented RI #12's BIMS (Brief Interview for Mental Status) score as seven, indicating moderate impairment in cognition. The MDS documented RI #12 required limited supervision with one person physical assist with walking in room, walking in corridor and was independent in locomotion on the unit. A review of RI #12's care plan with a problem onset date of 09/22/11 revealed the following: "... POTENTIAL FOR FALLS R/T (related to): LEFT FRONTAL CVA (Cerebral Vascular Accident); DEMENTIA WITH BEHAVIORS; DIABETES MELLITUS ... IMPAIRED BALANCE; GLAUCOMA ... Approaches ... 4/15/14 NON-SKID SOCKS OR SHOES TO BE WORN AT ALL TIMES." A review of RI # 12's incident report revealed on 03/29/15, RI #12 sustained a fall in the resident's room. RI #12 was observed sitting on the floor next to the bed, fully clothed and "sock footed" (socks on). When RI #12 was assisted from the floor the feet were noted to be sliding on the floor. The fall occurred at 10 AM and non-skid socks were placed on RI #12's feet. A note written by Employee Identifier (EI) #7 (Licensed Practical Nurse/LPN/Station Manager) stated ... PLEASE MAKE SURE RESIDENT HAS NON SKID SOCKS ON TO PREVENT FALL .... (EI #7's signature) 3/29/15" On 04/02/15 at 2:05 PM, the surveyor interviewed EI #7 and asked what happened regarding RI #12's fall on 03/29/15. EI #7 said a CNA told her RI #12 was on the floor next to the bed. EI #7 stated she went to check on the resident and RI #12 was on the side of bed sock footed. The surveyor asked what was sock footed. EI #7 said RI #12 had no shoes on just socks. The surveyor asked what type of socks. EI #7 said regular white socks. EI #7 was asked, according to RI #12's care plan, what type of socks should RI #12 have on. EI #7 said non-skid socks and it was an oversight on her part. The surveyor asked who was responsible for applying non-skid socks to RI #12. EI # 7 said the CNAs. The surveyor asked who reviewed the care plan and investigated the fall. EI #7 said EI #9 ( Registered Nurse/RN/Fall Nurse). EI #7 was asked what did she determine was the cause of the fall. EI #7 said RI #12 got up to put shoes on and slipped in the socks. EI #7 was asked what intervention was put in place to prevent further falls. EI #7 said non-skid socks. The surveyor asked should RI #12 have had non-skid socks on. EI #7 stated yes she (RI #12) should have. The surveyor asked was any other staff interviewed to see if non-skid socks were applied at any time the morning of the fall, 03/29/15, prior to the fall. EI #7 stated no. The surveyor asked EI #9 did she investigate or talk to staff related to the application of non-skid socks on the morning of the fall. EI #9 stated no. The surveyor asked EI #7 and EI #9 was the fall avoidable or unavoidable. EI #7 stated avoidable, because the non-skid socks were already on the care plan. EI #9 stated avoidable. On 04/02/15 at 4:55 PM, the surveyor conducted and interview with EI #8 (RN/MDS/Care Plan Coordinator). The surveyor provided a copy of RI #12's fall report and care plan for EI #8 to review. EI #8 was asked what intervention was put in place on 04/15/14 for potential for falls. EI #8 reviewed the care plan and stated potential for falls was nonskid socks or shoes to be worn at all times. The surveyor asked, based on the fall report and the care plan, was the care plan followed. EI #8 stated no, it was not because the resident should have had non-skid socks on. The surveyor asked why did the resident sustain the fall on 03/29/15. EI #8 stated the care plan had non-skid socks but, the care plan was not followed. EI #8 also stated the resident did not have non-skid socks on at the time of the fall. The surveyor asked was the fall on 03/29/15 avoidable or unavoidable. EI #8 stated avoidable.

Based on observations from the facility's video surveillance footage, interviews, record review and review of a facility policy titled "Safety and Supervision of Residents", the administrative staff, Employee Identifier (EI) #1, the Administrator, EI #2, the DON (Director of Nursing) and EI #4, the Abuse Coordinator failed to ensure facility staff were retrained and inserviced on patient safety including how to prevent and respond to accidents. On 02/13/2015 Resident Identifier (RI) #1 was observed on the facility's video surveillance footage rolling uncontrollably in his/her wheelchair across the facility's parking lot where employee's and visitor's cars were parked. RI #1 hit a curb and was thrown from the wheelchair resulting in a fall with injuries. On 03/27/2015, the Alabama Department of Public Health received video surveillance footage of the 02/13/2015 incident. Review of the facility's video surveillance footage revealed on 02/13/2015 at 5:08 p.m., EI #15 pushed RI #1 into the smoking area. After removing his hand from RI #1's wheelchair, the chair continued to roll uncontrollably toward the parking lot adjacent to the smoking area. EI #15 watched as RI #1's wheelchair rolled without making an attempt to stop the wheelchair. Two additional staff members, EI #16 (a CNA) and EI #17 (a CNA) were also observed together in the smoking area. The facility's video surveillance footage revealed both CNAs watched RI #1 roll toward the employee's and visitor's parking lot making no attempt to help RI #1 stop or control the wheelchair. An interview with EI #16 confirmed that she observed RI #1's wheelchair hit the curb, causing RI #1 to go "airborne", landing on the ground face first. EI #16 also revealed it took her about a minute to a minute and a half before she responded to the incident. EI #17's statements, provided to the facility regarding this incident, revealed EI #17 observed RI #1 hit the concrete curb and fall on his/her head. Neither EI #16 nor EI #17 responded immediately to RI #1 after they witnessed the incident. During interviews with Employee Identifier (EI) #1, the Administrator, EI #2, the DON (Director of Nursing) and EI #4, the Abuse Coordinator, it was confirmed that the Administrative staff failed to provide retraining/inservices to all staff on how to respond to an incident of this nature to prevent a reoccurrence. EI #4 admitted that the Abuse Committee did not come to the conclusion that staff should be inserviced. This deficient practice affected RI #1, one of one resident sampled for neglect and posed an immediate threat to the health and safety of RI #1, as it was likely to cause serious harm, injury, impairment, or death. On 04/02/15, at 6:03 p.m., EI #1, the facility's Administrator, EI #2, the DON and EI #3, the Assistant Director of Nursing were notified of the findings of substandard quality of care at the Immediate Jeopardy level "J" in the area of Administration, F 490. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOCC), observing the safety gate in the smoking area, observing the signs on the safety gate for staff and delivery personnel, conducting interviews with Administrative staff at the facility and reviewing the facility's in-service sheets to determine if the facility implemented their AOCC, the surveyor team abated the Immediate Jeopardy. The immediate jeopardy began on 02/13/2015 and was abated on 04/04/2015. Findings Include: Cross reference F 224 and F 323. A facility policy titled "Safety and Supervision of Residents", with a revised date of December 2007, documented: "... Policy Interpretation and Implementation Facility-Oriented Approach to Safety ... 4. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents ... Resident-Oriented Approach to Safety ... 4. Implementing interventions to reduce accidents risk and hazards shall include the following: ... a. communicating specific interventions to all relevant staff ... c. providing training, as necessary ... e. documenting interventions ..." 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2015, identified RI #1 to score a 15 on the Brief Interview for Mental Status (BIMS) indicating RI #1 was cognitively intact for decision making. The MDS also revealed RI #1 was totally dependent for transfers and required supervision for Locomotion off the unit. On the MDS, under "Functional Limitation in Range of Motion", RI #1 was noted to have impairment of both upper and lower extremities on one side. A review of the facility's incident report titled, "Witnessed Fall" with a revised date of 02/13/2015 at 10:48 (10:48 p.m.), documented: "... Incident Location: Outside ... Incident Description Nursing Description: CNA came to floor & (and) said that resident had fallen out of (RI #1's) WC (Wheelchair). notified supervisor. staff observed resident lying in the grass out back of the facility. (RI #1) was laying face down w (with)/legs straight out. WC was pitched forward. RN assessed ROM (Range of Motion) & resident was assisted back into (RI #1's) WC. Resident was brought back inside & put on the bed. Resident c/o pain in (RI #1's) left hip area & left ribs ... Immediate Action Taken Description: sent to (name of local hospital) for evaluation ..." According to the above incident report, RI #1 received an abrasion to the face, a skin tear to the left knee and a skin tear to the front of the left lower leg. This report was prepared by EI #18, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on 02/13/2015 on the 3-11 shift. On 04/01/2015 at 5:24 p.m., the surveyor conducted an interview with EI #18. EI #18 said on 02/13/2015 she was informed that RI #1 rolled across the parking lot and fell out of his/her wheelchair. EI #18 said when she arrived at the scene of the incident she observed RI #1 laying face down in the grass. EI #18 said RI #1 had an abrasion on the bridge of his/her nose and a skin tear on his/her right leg. The surveyor asked EI #18 had there been any inservices on resident safety after the incident. EI #18 replied, "No." A review of the Facility's Investigative Committee Findings, dated 02/19/2015, documented: "ABUSE COMMITTEE INVESTIGATED INCIDENT ... RESIDENT (RI #1) STATED THAT (RI #1) WAS ATTEMPTING TO GO OUTSIDE TO THE SMOKING AREA AND GOT CAUGHT IN THE DOORWAY. (RI #1) STATED THAT A DIETARY EMPLOYEE, (EI #15) ASSISTED (RI #1) THROUGH THE DOOR AND THAT (RI #1) THOUGHT THE EMPLOYEE (EI #15) WAS STILL PUSHING (RI #1). RESIDENT, (RI #1) STATED THAT (he/she) WAS TELLING EMPLOYEE TO SLOW DOWN NOT REALIZING THAT THE EMPLOYEE HAD ALREADY RELEASED (RI #1) WHEELCHAIR. RESIDENT (RI #1's) WHEELCHAIR FOLLOWED THE SLOPE OF THE PAVEMENT OUT INTO THE PARKING AREA AND HIT A CURB. THE WHEELCHAIR FLIPPED THE RESIDENT (RI #1) OUT ONTO THE GRASS. WITNESSES WERE (EI #15), DIETARY; (EI #16), CNA, (EI #17), CNA; AND RESIDENT (name of another resident). CNA (EI #17) DID GO INTO FACILITY TO CALL FOR HELP. (EI #18), LPN, (EI #19), RN AND (name of another RN) WENT TO AIDE RESIDENT. RESIDENT, (RI #1) DID HAVE MINOR INJURIES VISIBLE WHICH INCLUDED ABRASIONS TO THE NOSE, FOREHEAD AND LEFT LEG. (RI #1) WAS ALSO COMPLAINING OF PAIN TO LEFT RIB AND HIP. RESIDENT WAS TRANSPORTED BY AMBULANCE TO THE HOSPITAL FOR EVALUATION AND TREATMENT ... NO OTHER INJURIES IDENTIFIED BY THE HOSPITAL, RESIDENT (RI #1) RETURNED TO THE FACILITY SAME EVENING. DIETARY EMPLOYEE (EI #15), (EI #16), CNA, AND (EI #17), CNA WERE SUSPENDED. ABUSE COMMITTEE CONCLUDED THAT NEGLECT ON THE PART OF THE THREE EMPLOYEES ..." This document included signatures of EI #1, the Administrator, EI #2, the DON and EI #4, the Abuse Coordinator. On 04/02/2015 at 8:11 a.m., the surveyor conducted an interview with EI #4, the Abuse Coordinator. EI #4 said when the Abuse Committee reviewed the facility's video surveillance footage the committee felt there was a lack of response or very delayed response by the employees, EI #15, EI #16 and EI #17, in the smoking area. EI #4 said the committee felt there was also no response after RI #1 was observed laying on the grass. EI #4 said the biggest concern of the committee was that EI #15 could have locked the brakes on RI #1's wheelchair or stopped RI #1's wheelchair after the wheelchair began to roll. EI #4 said the appropriate response should have been for at least one of the employees in the smoking area to assist RI #1 immediately. The surveyor asked EI #4 were inservices done with staff (after EI #15 failed to lock the brakes on RI #1's wheel chair and staff failed to respond to RI #1 when the resident after he/she was thrown from the wheelchair). EI #4 replied, "No." The surveyor asked EI #4 why inservices had not been done. EI #4 said she could not answer that. EI #4 said the Abuse Committee just did not come up with that. EI #4 said she guessed inservices should have been done, but the Abuse Committee just did not come up with that. EI #4 said the facility had not had anything of that magnitude to happen before. The surveyor asked EI #4, with the incident being of the magnitude it was, did she think inservices should have been done. EI #4 replied, "Yes Ma'am, I do now." On 04/02/2015 at 1:01 p.m., the surveyor conducted an interview with EI #19, the RN supervisor who responded when RI #1 was thrown from the wheelchair on 02/13/2015. EI #19 said when she first observed RI #1 the resident was laying on the grass on a semi-steep hill. EI #19 said RI #1's right forehead was red, his/her nose was bleeding and she thought the resident's nose was broken. EI #19 said it was evident RI #1's face hit the ground. EI #19 said when she reviewed the facility's video surveillance footage, she could see that RI #1's wheelchair had not been brought to a complete stop. EI #19 said the incident could have been avoided if RI #1's wheel chair had been brought to a complete stop. When asked if staff were inserviced after the incident involving RI #1, EI #19 said she did not know. On 04/02/2015 at 1:59 p.m., the surveyor conducted an interview with EI #2, the DON. The surveyor asked EI #2 who was normally responsible for conducting inservices. EI #2 said she usually conducts inservices for the type of incident involving RI #1 that results in the State being notified. The surveyor asked EI #1, should an inservice have been conducted with staff (after EI #15 failed to lock the brakes on RI #1's wheelchair and the wheelchair rolled uncontrollably into the parking lot and hit a curb causing RI #1 to be thrown from the wheelchair onto his/her face on the grass). EI #2 replied, "Yea Ma'am." On 04/02/2015 at 2:32 p.m., the surveyor conducted an interview with EI #1, the Administrator. The surveyor asked EI #1 were inservices done (after EI #15 failed to lock the brakes on RI #1's wheelchair, the wheelchair rolled uncontrollably in the parking lot and hit a curb causing RI #1 to be thrown from the wheelchair onto his/her face on the grass). EI #1 replied, "No." The surveyor asked EI #1 what were the purposes of inservices. EI #1 replied, "To educate staff. Train or retrain in an area that needs improvement." The surveyor asked EI #1 should inservices have been done after the incident. EI #1 said he could see where inservices being done could have helped. The surveyor asked EI #1 when incidents/accidents happen at the facility, are inservices usually done. EI #1 replied, "Yes." ******************************************************************************** On 04/04/15 at 10:30 a.m., the facility submitted an Allegation of Credible Compliance for F 490, which documented: Credible Allegation of Compliance (AOC) F490 Administration 1. · On 2/13/2015 Administrative staff who is an RN Supervisor immediately suspended the Dietary worker and two CNAs for failing to respond to resident incident. · On 2/14/2015 the Administrator, Director of Nursing, Resident Services Director and Human Resources Director discussed the incident and reported to the Alabama Department of Public Health. · On 2/19/2015 Administrator, Director of Nursing in conjunction with the abuse committee which consists of Assistant Director of Nursing, Resident Services, Quality Improvement Nurse, Human Resources Director completed the investigation and the Alabama Department of Public Health was notified of incident investigation. · On 2/20/2015 the two CNAs were terminated. · On 2/23/2015 the Dietary worker was terminated. 2. · On 2/16/2015 the smoking incident regarding RI#1 was discussed in the Department Head Meeting and a time was set for further discussion to make possible changes in the smoking area to prevent reoccurrence. · On 2/16/2015 Administrator, Director of Nursing, Maintenance Director, Resident Services Director and QI Director inspected courtyards for possible alternate smoking areas. It was decided that a safety gate would be installed in the current smoking area to assure resident safety. · On 3/18/2015 the Quality Improvement Committee including the Administrator, Medical Director, Director of Nursing, Quality Improvement Coordinator, Human Resources Director, Medical Records Director, Maintenance Director, Education Nurse, Dietitian, CDM/Dietary Manager, Resident Services Director, Pharmacy Director, Therapy Director, Infection Control Nurse, Wound Care Nurse, Medication Management Nurse, Fall Nurse discussed changes made in smoking policies and smoking area. 3. · On 4/02/2015 Corporate Nurse in serviced Administrative staff including Administrator, Human Resources, Business office, Medical Records, Resident Services, MDS Coordinators, Admission Coordinator, Dietary, and Housekeeping/Laundry on wheelchair safety in the smoking area. · On 4/02/2015 Corporate Nurse inspected gate for proper security and reviewed Maintenance Safety Log and found all to be in compliance. · On 4/03/2015 Corporate Nurse in serviced Administrative staff on immediate response staff must make when resident is observed in an unsafe situation. 4. · On 3/31/2015, 4/2/2015 and 4/3/2015 the Corporate Nurse checked gate for safety and found to be latched securely. · On 4/03/2015 Corporate Nurse checked Maintenance Logs and found the security gate had been checked daily and latched properly. · On 4/03/2015 the Corporate Nurse checked the signage and interviewed three employees who included Dietary Manager and two CNAs about knowledge of resident safety. Signage was in place and staff interviewed were able to verbalize the need for wheelchair brakes being locked, and safe positioning of resident in the smoking area, the safety gate should be latched at all times and should only be used for deliveries. ******************************************************* On 04/02/2015, the following inservice was conducted by the facility's Corporate Nurse for the Administrative staff: "Inservices will be held by administrative staff when an incident occurs that has the potential to affect any additional residents. Failure to do so could result in disciplinary action." On 04/03/15, the surveyors reviewed Employment Action /Separation Forms where EI #15, EI #16 and EI #17 were terminated from the facility. On 04/04/15, Administrative staff interviewed were able to verbalize when staff should be inserviced.

Based on observations, interviews and record reviews, the facility failed to follow resident care plans by: 1) not providing incontinence care as needed to RI #15 on 04/02/2015, which resulted in the resident having to eat breakfast while wearing a soiled brief; 2) not applying non-skid socks to the feet of RI #12 on 03/29/15, which resulted in a fall; and 3) not placing oxygen tubing behind the ears of RI #7, which resulted in a reddened area behind the ear. This affected 3 of 27 sampled residents residing on 3 of 6 nursing stations whose plan of care was reviewed. Findings include: The facility policy titled, "Using the Care Plan," revised August 2006, documented: "..Policy Statement The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. 1) RI #15 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. RI #15's Annual Minimum Data Set (MDS) assessment, dated 02/18/2015, revealed the resident had short and long term memory deficits with moderate impairment for decision making in Activity of Daily Living tasks. The MDS also revealed RI#15 required extensive physical assistance with two plus person for toileting (cleanses self after elimination). The MDS identified RI #15 with always incontinent with bowel movement and bladder voiding. Review of RI #15's care plans revealed a focus of, "Potential /Actual Impaired Skin Integrity R/T (related to): Fragile Skin, Incontinent B/B (bowel and bladder), ... Date Initiated 12/05/2014 Revision on: 03/16/2015 ..." Interventions listed included: " ... Check For wetness/soiling q (every) 2 hours and prn (as needed), ... Date Initiated 12/05/2014." On 04/01/2015 the following observations were made on the hall where RI #15 resided: 8:45 AM, RI #15 was observed sitting up in the bed feeding herself. An odor was noticed coming from the resident; 09:06 AM, a restorative CNA (Certified Nursing Assistant) took RI #15's roommate into the room and straightened the roommates bed and left the room; 09:15 AM, the nurse unit manager entered the room and closed the door; 09:16 AM, the nurse opened the door and the resident could be seen positioned slightly on the right side. No odor could be detected at the time the nurse left the room. 09:17 AM, the nurse re-entered the room with the resident's stuffed animals. At this time a foul odor could be detected. 09:20 AM, staff entered the room to provide care. Staff did not provide incontinent care until 35 minutes after the foul odor was first detected by the surveyor. On 04/02/2015 at 12:50 PM, an interview was conducted with the Licensed Practical Nurse (LPN) Unit Manager, Employee Identifier (EI) #12. EI #12 was asked if she smelled anything in RI #15's room. She said she did not notice anything. The surveyor then explained to EI #12 what observations were made by the surveyor during breakfast, especially the observation of her entering RI #15's room and closing the door. EI #12 said that was her fault, she should have caught that (the odor) when she went in to repositioned the resident. EI #12 said the resident should have been cleaned up at that time. 2) A review of the facility's policy titled, "Care Planning-Interdisciplinary Team" with a revised date of December 2008, revealed the following: "... Policy Interpretation and Implementation ... 7. When a new care plan intervention is required ... interventions are communication through electronic data ... 9. ... all information is used to promote resident quality care." RI #12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Dementia with Behaviors, Personal History TIA ([MEDICAL CONDITION]). RI #12's Annual MDS (Minimum Data Set) dated 03/04/15 documented RI #12's BIMS (Brief Interview for Mental Status) score as seven indicating moderately impairment in cognition. The MDS documented RI #12 required limited supervision with one person physical assist with walking in room, walking in corridor and was independent in locomotion on the unit. A review of RI #12's care plan with a problem onset date of 09/22/11 revealed the following: "... POTENTIAL FOR FALLS R/T (related to): LEFT [MEDICAL CONDITION]; DEMENTIA WITH BEHAVIORS; DIABETES MELLITUS ... IMPAIRED BALANCE; [MEDICAL CONDITION] ... Approaches ... 4/15/14 NON-SKID SOCKS OR SHOES TO BE WORN AT ALL TIMES." A review of RI # 12's incident report revealed on 03/29/15, RI #12 sustained a fall in the resident's room. RI #12 was observed sitting on the floor next to her bed, fully clothed and "sock footed" (socks on). When RI #12 was assisted from the floor her feet was noted to be sliding on the floor. The fall occurred at 10 AM and non-skid socks were placed on RI #12's feet. A note written by Employee Identifier (EI) #7 (Licensed Practical Nurse/LPN/Station Manager) stated ... PLEASE MAKE SURE RESIDENT HAS NON SKID SOCKS ON TO PREVENT FALL .... (EI #7's signature) 3/29/15" On 04/02/15 at 2:05 PM, the surveyor interviewed EI #7. EI #7 was asked what happened regarding RI #12's fall on 03/29/15. EI #7 said that a CNA told her that RI #12 was on the floor next to the bed. EI #7 stated she went to check on the resident and said RI #12 was on the side of bed, sock footed. The surveyor asked what was sock footed. EI #7 said RI #12 had no shoes on just socks. The surveyor asked what type of socks. EI #7 said regular white socks. EI #7 was asked according to RI #12's care plan what type of socks should RI #12 have on. EI #7 said non-skid socks and it was an oversight on her part. The surveyor asked who was responsible for applying non-skid socks to RI #12. EI #7 said the CNAs. The surveyor asked who reviewed the care plan and investigated the fall. EI #7 said EI #9 ( Registered Nurse/RN/Fall Nurse). EI #7 was asked what did she determine was the cause of the fall. EI #7 said RI #12 got up to put shoes on and slipped in the socks. EI #7 was asked what intervention was put in place to prevent further falls. EI #7 said non-skid socks. The surveyor asked should RI #12 have had non-skid socks on. EI #7 stated yes the resident should have. On 04/02/15 at 4:55 PM, the surveyor conducted and interview with EI #8 (RN/MDS/Care Plan Coordinator). The surveyor provided EI #8 a copy of RI #12's fall report and care plan to review. EI #8 was asked what intervention was put in place on 04/15/14 for the potential for falls care plan. EI #8 reviewed the care plan and stated potential for falls was nonskid socks or shoes to be worn at all times. The surveyor asked based on the fall report and the care plan was the care plan followed. EI #8 stated no, it was not because the resident should have had non-skid socks on. 3) RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan for RI #7 with a Problem Onset date of 05/23/09 documented: "... POTENTIAL FOR IMPAIRED SKIN INTEGRITY R/T (relate /to) FRAGILE SKIN ... Approaches ... 11/03/10- Pad 02 (oxygen) tubing to protect area behind ears. Monitor area behind ears ..." RI #7's Significant Change MDS dated [DATE], documented a BIMS score of 15, which indicated RI #7 was cognitively intact. RI #7 was also documented for respiratory treatments to include the use of oxygen. During the initial tour on 03/31/15 at 12:20 PM, RI #7 was observed in the wheelchair with Oxygen via nasal cannula. There was no padding observed on the tubing behind both ears. On 04/01/15 at 8:46 AM, RI #7 was observed in the resident's room in bed with Oxygen via nasal cannula. There was no padding observed on the tubing behind both ears. On 04/02/15 at 1:25 PM, RI #7's Hospice Nurse was visiting. The Hospice Nurse was asked did she see any Oxygen tube padding behind RI #7's ears. The Hospice Nurse replied no. The Hospice Nurse was asked to look behind RI #7's ears and describe what she saw. The Hospice Nurse assessed the back area of RI #7's ears and commented there were redden areas behind both ears. On 04/02/15 at 1:35 PM, EI #23, CNA, was asked was she aware RI #7 was supposed to have the Oxygen tubing padded behind the ears. EI #23 replied she was not sure, but it would be on the care plan. EI #23 stated the padding was usually on but she had not seen it today. EI #23 was asked did she see the padding on 03/31/15. EI #23 replied she did not check. On 04/02/15 at 2:15 PM, EI #24, LPN, was asked was RI #7 suppose to have the Oxygen tubing padded behind the ears every day. EI #24 replied yes. EI #24 was asked who was responsible to make sure RI #7 had padding to the Oxygen tubing behind the ears. EI #24 replied Hospice Nurse and CNAs. EI #24 further commented that the CNA should be checking that at least every two hours when they check and change RI #7. EI #24 was asked what could be the potential harm if the Oxygen tubing was not padded behind RI #7's ears. EI #24 replied a pressure area could develop behind the ears. On 04/02/15 at 4:50 PM, EI #8, MDS/Care Plan Coordinator, was asked who was responsible to follow a resident's care plan. EI #8 replied everyone, the Nurses, CNAs, Dietary and all other staff that have an intervention on the care plan. EI #8 was asked who was responsible to monitor to make sure the Oxygen tubing was padded behind RI #7's ears. EI #8 replied the Change Nurse and the CNAs. EI #8 was informed by the surveyor there had not been any padding on the tubing behind RI #7's ears for the past three days. EI #8 was asked was RI #7's care plan followed if there was no padding to the tubing behind the ears for the past three days. EI #8 replied no it was not followed. EI #8 was asked what could be the potential harm as a result of the care plan not being followed. EI #8 replied there would be skin breakdown behind the ears.