Every finding on record at NHC Healthcare, Moulton

Based on observation, interview, record review, and facility document and policy review, the facility failed to implement interventions to reduce the risk of fall related injuries for 1 (Resident #44) of 6 residents reviewed for accident hazards.Findings included: 1. An undated facility policy titled, Fall Prevention Program, revealed the Procedure included 3. Apply fall risk interventions as appropriate for the patient. A Resident Face Sheet revealed the facility admitted Resident #44 on 06/12/2026. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of nondisplaced intertrochanteric fracture of the left femur, muscle wasting and atrophy, difficulty in walking, dementia, hypertension, and history of falling. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2026, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with rolling left to right in bed, going from a sitting position to lying on the bed, and going from a lying position to sitting on the side of the bed. The MDS indicated the resident was dependent on staff for going from a sitting position to standing and with chair/bed-to-chair transfers. Resident #44's Care Plan, included a problem statement edited on 07/20/2026, that indicated the resident was at risk for falls related to a history of falls, cognitive impairments, being hard of hearing, having vision deficits, incontinence, psychotropic medication use, decreased mobility, and having multiple medical problems. Interventions directed staff to assist the resident to bed after lunch as they allowed (initiated 06/20/2026 and edited on 07/19/2026) and provide a low bed and fall mat to reduce the risk of injury (initiated 06/15/2026 and edited on 07/20/2026). Resident #44's untitled patient care tool (PCT), last updated on 06/15/2026, revealed the resident was on fall precautions and had fall interventions in place, which included a low bed and fall mats to reduce injury. During an observation on 07/19/2026 at 10:27 AM, Resident #44 was observed sleeping in bed. A fall mat was observed folded underneath a wheelchair at the foot of the resident's bed. A fall mat was not observed on the side of the resident's bed. During an observation on 07/20/2026 at 3:47 PM, Resident #44 was observed sleeping in bed. A fall mat was observed folded at the foot of the resident's bed. A fall mat was not observed on the side of the resident's bed. During an interview on 07/20/2026 at 3:50 PM, Certified Nurse Aide (CNA) #5 stated that information related to a resident's fall risk could be found on an information sheet in the resident's room and included interventions, such as non-skid footwear and fall mats. CNA #5 stated that fall mats were no longer used for Resident #44 because the resident had tripped over the fall mat before. CNA #5was not able to state why Resident #44 had a fall mat in their room. During an observation on 07/21/2026 at 4:09 AM, Resident #44 was observed resting in bed. A fall mat was observed on the side of the resident's bed. During an interview on 07/21/2026 at 5:05 AM, CNA #6 stated that Resident #44 was a high fall risk and attempted to get out of bed without assistance at times. CNA #6 stated that she conducted rounds every two hours to ensure residents' needs were met. CNA #6 stated that fall mats were still being used for Resident #44 due to their high fall risk and the resident's tendency to reach for things and roll out of the bed. CNA #6 stated that Resident #44 had never tripped over the fall mat. During an interview on 07/22/2026 at 3:20 PM, Registered Nurse (RN) #7 stated that Resident #44 had several falls in the facility and attempted to transfer themselves from the bed to the wheelchair and from the wheelchair to the bed without assistance. RN #7 stated that fall mats should have been in place for Resident #44 to prevent injuries from a fall. During an interview on 07/23/2026 at 11:07 AM, RN #8, who was a unit manager, stated that fall mats were implemented for residents who were at a high risk for falls. RN #8 stated that staff could find information related to a resident's fall risk in the resident's care plan, and CNA staff could refer to the PCT document that was posted in the resident's closet for information related to fall interventions. RN #8 stated that she expected Resident #44's fall mats to be in place when the resident was in bed. During an interview on 07/25/2026 at 10:17 AM, the Restorative Nurse stated that information related to resident fall interventions were located on the fall list located at the nurses' station and in the resident's PCT. The Restorative Nurse stated that she expected CNA staff to implement fall interventions as stated in the resident's care plan. During an interview on 07/25/2026 at 9:41 AM, the Assistant Director of Nursing (ADON) stated that CNA staff were able to find information related to a resident's fall risk by looking at the resident's PCT form or the resident's care plan. The ADON stated that she expected nursing staff to follow the resident's care plan interventions. During an interview on 07/25/2026 11:07 AM, the Administrator stated that he expected staff to follow resident care plan interventions and ensure they were implemented.

Based on facility policy review, record review, observation, and interview, the facility failed to maintain an effective infection control and prevention program related to the use of enhanced barrier precautions (EBP) for 1 (Resident #4) of 6 residents reviewed for infection control.Findings included: A facility policy titled, Enhanced Barrier Precautions, update March 2025, revealed, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact patient care activities that provide opportunities for transfer of MDRO to staff hands and clothing. The policy revealed, EBP are indicated for patients with any of the following, which included Wounds and/or indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO. The policy revealed, Providers and partners must wear gloves and a gown for the following High-Contact Patient Care Activities, which included Dressing; Transferring; Providing hygiene; and Changing briefs or assisting with toileting. A Resident Face Sheet revealed the facility admitted Resident #4 on 03/13/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of end stage renal disease, dependence on renal dialysis, and functional urinary incontinence. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with toileting hygiene, and the resident was frequently incontinent of urine and bowel. Resident #4's Care Plan, included a problem area edited on 05/19/2026, that indicated the resident was at risk for complications related to end stage renal failure and dialysis. Interventions instructed staff to implement EBP related to the presence of a vascular catheter (initiated 02/09/2026). Resident #4's Active Orders contained an order, dated 07/16/2026, for EBP every shift related to the presence of a vascular catheter. During an observation of incontinence care for Resident #4 on 07/20/2026 at 11:00 AM, Certified Nurse Aide (CNA) #9 and CNA #10 performed hand hygiene, gathered supplies for the procedure, and entered Resident #4's room. CNA #9 explained the procedure to Resident #4 and both staff members put on clean gloves. Signage was observed above Resident #4's bed that indicated the resident was on EBP. CNA #10 assisted with positioning Resident #4 during the procedure while CNA #9 performed the incontinence care. CNA #9 and CNA #10 did not put on a gown prior to the procedure. After completing the incontinence care for Resident #4, CNA #9 and CNA #10 repositioned Resident #4 for comfort, gathered the used supplies, doffed their gloves, and performed hand hygiene before exiting the room. During an interview on 07/20/2026 at 11:18 AM, CNA #9 stated that Resident #4 was on EBP due to having a dialysis port. CNA #9 stated that a gown, gloves, eye protection, and a mask would need to be worn if they were cleaning around the resident's dialysis site or if the resident was being given a full bed bath. CNA #9 stated she did not wear a gown for the incontinence care procedure because they were not around the resident's dialysis site. During an interview on 07/20/2026 at 11:23 AM, CNA #10 stated that Resident #4 had a dialysis port and was on EBP, which meant they would wear a gown if they were giving the resident a bed bath or if the nurse was accessing the resident's dialysis port. During an interview on 07/23/2026 at 11:03 AM, Registered Nurse (RN), who was a unit manager, stated that EBP was used to protect staff and residents. RN #8 stated that any resident with a port, a catheter, or any type of line would be on EBP. RN #8 stated that staff should wear a gown and gloves during any interactions with a resident on EBP, including incontinence care, toileting, or bathing. During an interview on 07/25/2026 at 9:28 AM, the Infection Preventionist (IP) stated that EBP was used to prevent residents from getting an infection from a staff member if they had a line going into their body. The IP stated that staff should wear a gown and gloves whenever they had direct contact with the resident on EBP, such as bathing, transferring, incontinence care, or caring for an indwelling device or wound. The IP stated that she educated CNA #9 and CNA #10 incorrectly before providing incontinence care to Resident #4. The IP stated that she expected staff to wear a gown and gloves when providing incontinence care to a resident on EBP. During an interview on 07/25/2026 at 9:35 AM, the Assistant Director of Nursing (ADON) stated that EBP was used to protect residents from getting infections from facility staff. The ADON stated that if a resident had a line or tube going into their body, it would be like a highway for bacteria going into their body and when staff wore a gown, it would protect the resident from getting an infection. The ADON stated that she expected staff to wear a gown and gloves when performing incontinence care for a resident on dialysis. During an interview on 07/25/2026 at 11:04 AM, the Administrator stated that he expected facility staff to follow infection control protocols related to EBP.

Based on interviews and review of the facility's Quality Assurance and Performance Improvement (QAPI) Manual, Subject: COMMITTEE MEMBERSHIP and Subject: GOVERNANCE AND LEADERSHIP, the governing body failed to provide oversight to the facility on the investigation and plans of action developed in QAPI, addressing Resident Identifier (RI) #1's accident on 9/26/2022 when RI #1's plans of care were not followed, and RI #1 was not provided assistance or supervision in accordance with his/her care plan. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. The RD told RI #1, a cognitively impaired resident with communication deficits and the need for assistance, to wait. The intent was to take the residents down a sloped sidewalk to a patio area. RI #1 wheeled him/her self out the door as the RN held the door open. RI #1 wheeled around the RD, who had another resident in a wheelchair, and down a sloped sidewalk unassisted. RI #1's wheelchair rolled down the slope, the left wheel of the wheelchair rolled off the sidewalk and overturned off the edge of the sidewalk, propelling RI #1 onto the ground face first on his/her left side on the ground. EI #6, the RD who initiated taking residents outside, did not know the level of supervision/assistance required for the residents before taking them outside an exit with a sloped sidewalk. EI #9, the RN who held open the door, said she was new, and she thought the RD was supervising the resident since she was wheeling another resident outside and asked the RN to hold the door open for them as she was returning from her lunch break. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. This deficient practice placed all 114 residents residing in the facility in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 11/3/2022 at 3:17 PM, the facility's Administrator (Employee Identifier (EI) #3); the Regional Administrator of the South Central Region for NHC Healthcare and member of the facility's Governing Body (EI #1); the facility's Director of Nursing (EI #4); and a Regional Nurse for NHC Healthcare (EI #2) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the immediate jeopardy findings in the area 483.70 Administration, at F837-Governing Body. Findings include: During the survey it was found that RI #1, a cognitively impaired resident with communication deficits and the need for staff assistance, sustained an accident on 09/26/2022 while going outside with facility staff unassisted. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. Cross Reference F656, F689, and F867. Review of the facility's QAPI Manual, Subject: COMMITTEE MEMBERSHIP, dated 01/01/2006, revealed the following: .COMMUNICATION TO GOVERNING BODY: The Administrator and Medical Director are to review and approve each month's committee minutes. In addition, copies of the Quality Assurance and Process Improvement Committee minutes are to be sent to the Regional QAPI Coordinator to review and discuss on a regional level . Regional QAPI Coordinators should forward to the NHC Quality Review Committee those reports which indicated the need for policy revision, practice change or other issues requiring attention . Further review of the facility's QAPI Manual, Subject: GOVERNANCE AND LEADERSHIP, revised 09/13/2022, revealed the following: . The QAPI Committee will report to the following groups as indicated: Regional staff monthly Corporate staff through established routes monthly . Copies of the QAPI Committee Minutes with all attachments are to be forwarded to the Regional Nurse . On 11/03/2022 at 10:54 AM an interview was conducted with EI #1, Regional Administrator of the South Central Region of NHC Healthcare and a member of the facility's governing body. EI #1 was asked when he was notified about the incident involving RI #1. EI #1 replied, he was notified per phone by EI #3, the Administrator, on 09/26/2022. EI #1 did not recall the exact time. EI #1 was asked what conversations he had and what feedback he provided to the facility regarding their investigation into the incident. EI #1 said they discussed it during the phone call on 09/26/2022, and he knew they had developed an action plan as a result of the incident. When asked where their conversation would be documented, EI #1 said he had not documented anything. EI #1 said the documentation would be up to EI #3, the Administrator, since she was the one responsible for the day-to-day operations of the facility. EI #1 went on to say that during the survey process, he became aware of a gap in the facility's investigation into the incident. EI #1 was asked, why following the care plan was not addressed in QAPI or in the action plan developed by the facility. EI #1 replied, he could not say. EI #1 was asked, why he did not identify not following the care plan as a causal factor during the facility's initial investigation into the incident. EI #1 replied, he could not say why it was not identified in the initial investigation. He was relying on the information provided to him. On 11/03/2022 at 11:43 AM an interview was conducted with EI #2, Regional Nurse. EI #2 was asked, what was her involvement with the investigation into the incident involving RI #1. EI #2 replied, she was notified by EI #4, the Director of Nursing (DON) on 9/26/2022, and EI #3 and EI #4 started the investigation. EI #2 stated EI #3 and EI #4 called her with the action plan developed by the facility and she reviewed it. EI #2 was unsure when EI #3 and EI #4 called her with the plan they developed. EI #2 stated she had not documented the conversations she had with EI #3 and EI #4 regarding RI #1's accident. EI #2 was asked what feedback she gave to EI #3 and EI #4 on the facility's investigation and subsequent action plan. EI #2 said she told EI #3 and EI #4 they needed to do an investigation for any gaps in the investigation, and she also told them to call the family, and they notified her of what EI #16 said that the cause of death was (a [CONDITION(S)]). EI #2 said based on what she knew at the time, there was no other feedback to give and she agreed with what they did. EI #2 was asked what her involvement was in the action plan. EI #2 replied, she reviewed it. EI #2 was asked what concerns she had with the facility's investigation and plan. EI #2 replied, she did not have any. EI #2 said she later found out that RI #1 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment) and was at the top of the stairs with no staff assistance. This deficient practice was cited as a result of the investigation of complaint/report number AL 123. ******************** On 11/04/2022 at 6:55 PM, the facility submitted the following acceptable Removal Plan addressing F837: .F837: Governing Body Effective 11/03/2022 @ 4:38pm, the Governing Body of NHC [NAME] consists of Regional Administrator (RA) and Regional Nurse (RN) hereafter referred to as Governing Body. Inservice completed 11/3/22 @ 4:38 pm by NHC AVP of Patient Services regarding responsibilities in oversight and guidance of the facility to ensure corrective actions are in place. AVP reviewed the requirements of F837 as well as the NHC QAPI Policy with both RA and RN. The requirements of F837 and the NHC QAPI Policy address the process of guidance and oversight to be provided by the Governing Body. The process for how the Governing Body will function was discussed and is as follows: The Governing Body will provide oversight and guidance to the center and the QAPI Committee by receiving copies of the QAPI meeting minutes monthly from the center's QAPI committee as well as through the review of other ongoing reports such as audits, budgets, staffing, investigations, complaints, etc. Feedback will be provided related to any identified causal factors for adverse events so the QAPI Committee can develop and implement effective plans to ensure any related problems are corrected . The Governing Body, Regional Administrator and Regional Nurse reviewed QAPI minutes on 11/03/2022 at 4:30 pm from the QAPI Committee meeting held on 10/20/22. Feedback on gaps was provided to Administrator regarding full completion of reports, fully implementing Root Cause Analysis and adequately documenting the actions of the committee as these areas were lacking in completion. Training was provided to the QAPI Committee (Administrator, DON, Medical Director, HIM, LE, DFNS, Environmental Services, Maintenance Director, DOR, BOM, Infection preventionist, Social services) by Regional QA Nurse related to the QAPI meeting process on 11/3/22 to ensure QAPI committee thoroughly reviews all factors r/t patient safety. To ensure QAPI committee determines and considers all causal factors for adverse events so QAPI can develop and implement effective plans to ensure any related problems are corrected. This training was conducted by use of NHC Quality Assurance Performance Improvement PowerPoint and NHC QAPI policy which includes steps and forms for use on root cause analysis (see attached) Exhibit # 3 QAPI training included: QAPI Training for above members covered CMS's five elements of QAPI: Design and Scope, Governance and Leadership, Feedback, Data Systems, & Monitoring, Performance Improvement Projects, and Systematic Analysis & Systemic Action. Quality Assurance Performance Improvement is the basis for all care delivered in this center. It is ongoing and comprehensive that includes all departments and services offered by the center to include clinical care, quality of life, and patient choice. The QAPI Committee is responsible for goal setting, monitoring of key indicators, determining PIPs to be instituted, and overall assuring the quality of all services rendered. The following key indicators of quality will be monitored on a monthly basis, In-house developed pressure ulcer rate, Rehospitalization rate, Unplanned weight loss, NPS scores, Falls rate, Antipsychotic usage rate, Census, Gift (complaint) trending, and the following will be reported as they occur Untoward Events and Survey Findings. All monitors reported will be prepared using NHC established protocols for determining center rates. All reports will contain comparison rates from the NHC Region, NHC Corporate, State averages, and national averages (if available). All reports submitted to the Committee will become attachments to the minutes for the month they were discussed along with any feedback provided by the Committee regarding reports submitted. Performance Improvement Projects will be determined by the QAPI Committee based on monitor results and/or survey findings. The number of PIPs per year should be based on monitoring results and will be prioritized based on the potential impact on patient care and the seriousness of the issue. PIPs will use rapid cycle methodology and reporting formats to accomplish goals. PIPs will include a representative from every department/job role which is impacted by the subject under improvement, including patients if appropriate. Systematic Analysis and Systemic Action will include utilizing root cause analysis that will be used to determine the underlying causes of issues. The 5 Why Method of root cause analysis will be used to determine root causes of problems. This root cause analysis will be reported to the Committee for feedback and become attachments to the minutes to ensure that submitted plans address the root cause. Minutes from meetings will be maintained by HIM and will contain at a minimum the following: Sign in sheet for those attending meeting, list of those members absent from the meeting, begin and end time of the meeting, all monitors reported and a brief synopsis of the discussion of each as well as any action to be taken from feedback from committee and the status of each PIP in progress. Copies of QAPI Committee Minutes with all attachments are to be forwarded to Governing Body by the 5th of month following the meeting for review of the center minutes, feedback will be provided as appropriate. Contents will be completed and immediacy will be removed on 11/3/22. After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F837 was lowered to an F level on 11/03/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, review of the facility's Quality Assurance and Performance Improvement (QAPI) Manual, Subject: GOVERNANCE AND LEADERSHIP and Subject: SAMPLE PLAN, and review of the facility's 10/20/2022 QUALITY IMPROVEMENT COMMITTEE MINUTES, the facility failed to ensure the QAPI committee thoroughly reviewed all causal factors related to Resident Identifier (RI) #1's fall from a wheelchair outdoors at the facility in order to develop an effective action plan to prevent any further resident safety concerns. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. The RD told RI #1, a cognitively impaired resident with communication deficits and the need for assistance, to wait. The intent was to take the residents down a sloped sidewalk to a patio area. RI #1 wheeled him/her self out the door as the RN held the door open. RI #1 wheeled around the RD, who had another resident in a wheelchair, and down a sloped sidewalk unassisted. RI #1's wheelchair rolled down the slope, the left wheel of the wheelchair rolled off the sidewalk and overturned off the edge of the sidewalk, propelling RI #1 onto the ground face first on his/her left side on the ground. EI #6, the RD who initiated taking residents outside, did not know the level of supervision/assistance required for the residents before taking them outside an exit with a sloped sidewalk. EI #9, the RN who held open the door, said she was new, and she thought the RD was supervising the resident since she was wheeling another resident outside and asked the RN to hold the door open for them as she was returning from her lunch break. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. This deficient practice placed all 114 residents residing in the facility in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 11/3/2022 at 3:17 PM, the facility's Administrator (Employee Identifier (EI) #3); the Regional Administrator of the South Central Region for NHC Healthcare and member of the facility's Governing Body (EI #1); the facility's Director of Nursing (EI #4); and a Regional Nurse for NHC Healthcare (EI #2) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the immediate jeopardy findings in the area Quality Assurance and Performance Improvement, F867. Findings include: During the survey it was found that RI #1, a cognitively impaired resident with communication deficits and the need for staff assistance, sustained an accident on 09/26/2022 while going outside with facility staff unassisted. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. Cross Reference F656, F689, and F837. Review of the facility's QAPI Manual, Subject: GOVERNANCE AND LEADERSHIP, with a revised date of 09/13/2022, revealed the following: The administration of the center will develop a culture that seeks input from center partners, residents, and families. .The QAPI Committee is responsible for goal setting, monitoring of key indicators, determining PIPs (Performance Improvement Projects) to be instituted, and overall assuring the quality of all services provided. . QAPI Committee Minutes: Minutes will be maintained . and will contain at a minimum the following: . All monitors reported and a brief synopsis of what the discussion of each was as well as any action to be taken . Further review of the facility's QAPI Manual, Subject: SAMPLE PLAN, with a revised date of 09/13/2022, revealed the following: . II. Scope: . f. The main focus of QAPI will be safety and high quality in all clinical interventions . g. The QAPI program will utilize regional, corporate, state, and national benchmarks as well as published best practices and clinical guidelines to determine appropriate care and to define and measure goals. . f. Systematic Analysis and Systematic Action i. Root Cause Analysis will be used to determine the underlying causes of issues. ii. The 5 (five) Why Method of root cause analysis will be used to determine root cause of problems . Review of the facility's QUALITY IMPROVEMENT COMMITTEE MINUTES, dated 10/20/2022, revealed the QAPI committee discussed a total of six untoward events during the meeting, including one fall with significant injury. These minutes also included multiple PIPs addressing various issues, but there was no information related to a root cause analysis or action plan addressing RI #1's 09/26/2022 incident. On 11/01/2022 at 12:00 PM an interview was conducted with EI #7, the Director of Health Information (HI). EI #7 was asked what was discussed regarding RI #1's 09/26/2022 incident during the 10/20/2022 QAPI meeting. EI #7 said they discussed an untoward fall with significant injuries and one investigation by an outside agency. EI #7 was asked, what was specifically discussed about the fall with significant injury during the QAPI meeting. EI #7 said they discussed what happened, what education had been provided and said it was an ongoing action plan. EI #7 was asked, what should have been included in the QAPI meeting minutes. EI #7 replied, there should a have been a brief report written about the discussion of monitors, a brief synopsis, and each action that should have been taken, if there was an action plan that was reported. EI #7 was asked when the facility implemented an action plan addressing the incident on 09/26/2022. EI #7 replied, it started that day on 09/26/2022; however, she indicated the Director of Nursing (DON), EI #4, was still working on the action plan. EI #7 said EI #4 developed the action plan. When asked what part the QAPI committee had in the development of the action plan, EI #7 replied, the plan was already written on 09/26/2022. EI #7 said that EI #4 reported she had a plan and had in-serviced the staff and was going to continue to monitor the plan to make sure that the staff were implementing the plan. On 11/02/2022 at 9:25 AM an interview was conducted with EI #4, the DON. EI #4 was asked, where in the action plan and staff training for the 09/26/2022 incident, did it address the specific type of assistance and supervision that was required when taking residents outside. EI #4 replied, it did not. EI #4 was asked why the action plan did not address that. EI #4 said she implemented her plan immediately, but it was still ongoing. When asked why all causal factors, such as providing supervision and assistance for resident safety, were not addressed in the QAPI meeting on 10/20/2022. EI #4 replied, because it was ongoing. When asked how the facility had identified what actions needed to be taken to address RI #1's 09/26/2022 incident, EI #4 again stated it was ongoing. When asked about the facility's process for root cause analysis, EI #4 explained it should involve asking who, when, why, what, and where, as all were factors that come into play when investigating an incident to prevent it from happening again. On 11/02/2022 at 12:08 PM an interview was conducted with EI #3, the Administrator. EI #3 was asked if the 10/20/2022 QAPI meeting minutes included a synopsis of the 09/26/2022 incident involving RI #1 and the actions needing to be taken to address the incident. EI #3 replied, they were not documented, only as an untoward event. On 11/02/2022 at 4:26 PM, EI #3 was asked what might have gone differently if staff had followed the care plan to assist RI #1 with locomotion. EI #3 said, RI #1's wheelchair might not have tipped over. When asked why the facility's root cause analysis of this incident had not identified that the resident's plan of care was not followed, EI #3 said it was a gap in their investigation process. This deficient practice was cited as a result of the investigation of complaint/report number AL 123. ******************** On 11/04/2022 at 6:55 PM, the facility submitted the following acceptable Removal Plan addressing F867: .F867-QAPI Effective 11/03/2022 @ 4:38pm, the Governing Body of NHC [NAME] consists of Regional Administrator and Regional Nurse hereafter referred to as Governing Body. Inservice completed 11/3/22 @ 4:38 pm by NHC AVP of Patient Services regarding responsibilities in oversight and guidance of the facility to ensure corrective actions are in place. AVP reviewed the requirements of F837 as well as the NHC QAPI Policy with both RA and RN. The requirements of F837 and the NHC QAPI Policy address the process of guidance and oversight to be provided by the Governing Body. The process for how the Governing Body will function was discussed and is as follows: The Governing Body will provide oversight and guidance to the center and the QAPI Committee by receiving copies of the QAPI meeting minutes monthly from the center's QAPI committee as well as through the review of other ongoing reports such as audits, budgets, staffing, investigations, complaints, etc. Feedback will be provided related to any identified causal factors for adverse events so the QAPI Committee can develop and implement effective plans to ensure any related problems are corrected . The Governing Body, Regional Administrator and Regional Nurse reviewed QAPI minutes on 11/03/2022 at 4:30 pm from the QAPI Committee meeting held on 10/20/22. Feedback on gaps was provided to Administrator regarding full completion of reports, fully implementing Root Cause Analysis and adequately documenting the actions of the committee as these areas were lacking in completion. Training was provided to the QAPI Committee by Regional QA Nurse related to the QAPI meeting process on 11/3/22 to ensure QAPI committee thoroughly reviews all factors r/t patient safety. To ensure QAPI committee determines and considers all causal factors for adverse events so QAPI can develop and implement effective plans to ensure any related problems are corrected . QAPI training included: QAPI Training for above members covered CMS's five elements of QAPI: Design and Scope, Governance and Leadership, Feedback, Data Systems, & Monitoring, Performance Improvement Projects, and Systematic Analysis & Systemic Action. The QAPI --Committee is responsible for goal setting, monitoring of key indicators, determining PIPs to be instituted, and overall assuring the quality of all services rendered. The following key indicators of quality will be monitored on a monthly basis, In-house developed pressure ulcer rate, Rehospitalization rate, Unplanned weight loss, NPS scores, Falls rate, Antipsychotic usage rate, Census, Gift (complaint) trending, and the following will be reported as they occur Untoward Events and Survey Findings. Performance Improvement Projects will be determined by the QAPI Committee based on monitor results and/or survey findings. PIPs will use rapid cycle methodology and reporting formats to accomplish goals. Systematic Analysis and Systemic Action will include utilizing root cause analysis that will be used to determine the underlying causes of issues. The 5 Why Method of root cause analysis will be used to determine root causes of problems. This root cause analysis will be reported to the Committee for feedback and become attachments to the minutes to ensure that submitted plans address the root cause. Contents will be completed and immediacy will be removed on 11/3/22 After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F867 was lowered to an F level on 11/03/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on record review, interviews, review of the facility's Fall Prevention Program, and review of the facility's Nursing Care Policies, the facility failed to ensure Resident Identifier (RI) #1's comprehensive care plans were implemented on 09/26/2022. RI #1's plan of care for falls had an approach that guided staff to assist with transfer and locomotion. RI #1 also had a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for communication problems and cognition deficits. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. The RD told RI #1, a cognitively impaired resident with communication deficits and the need for assistance, to wait. The intent was to take the residents down a sloped sidewalk to a patio area. RI #1 wheeled him/her self out the door as the RN held the door open. RI #1 wheeled around the RD, who had another resident in a wheelchair, and down a sloped sidewalk unassisted. RI #1's wheelchair rolled down the slope, the left wheel of the wheelchair rolled off the sidewalk and overturned off the edge of the sidewalk, propelling RI #1 onto the ground face first on his/her left side on the ground. EI #6, the RD who initiated taking residents outside, did not know the level of supervision/assistance required for the residents before taking them outside an exit with a sloped sidewalk. EI #9, the RN who held open the door, said she was new, and she thought the RD was supervising the resident since she was wheeling another resident outside and asked the RN to hold the door open for them as she was returning from her lunch break. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. This deficient practice placed RI #1, one of six sampled residents for whom care plans were reviewed, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 11/3/2022 at 3:17 PM, the facility's Administrator (Employee Identifier (EI) #3); the Regional Administrator of the South Central Region for NHC Healthcare and member of the Governing Body (EI #1); the facility's Director of Nursing (DON, EI #4); and a Regional Nurse for NHC Healthcare (EI #2) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the immediate jeopardy findings in the area of Develop/Implement Comprehensive Care Plans, F656. Findings include: Cross reference F689, F837, and F867. The State Agency received a complaint on 10/21/2022 that alleged the complainant was a witness to an accident that caused the death of a resident of the facility, RI #1. RI #1 was witnessed on 9/26/2022, outside, rolling down an incline in a wheelchair. The complainant alleged hearing someone calling out RI #1's name over and over and that was what caught the complainant's attention. The complainant reported that RI #1's wheelchair, while rolling down the incline, went off the edge of the concrete, and RI #1's wheelchair flipped over, throwing RI #1 onto concrete, face down, about three feet from the sidewalk. Review of an undated facility document titled Fall Prevention Program revealed the following: . PURPOSE: To reduce patient's risk of falling. 3. Apply fall risk interventions as appropriate for the patient . The facility provided for review, Patient Care Policies, page 13, which documented . 4.0 NURSING POLICIES . B. The care plan serves as a guide for care decisions and is made available for use by all patient care personnel. RI #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Care Plan for being at risk for falls related to balance problems, fall history, visual and hearing impairment, incontinence, weakness, and multiple medical problems, with a start date of 03/15/2021, documented approaches to assist with transfers and locomotion and to observe for unsafe actions and intervene. RI #1's Care Plan for cognitive deficits documented an approach dated 04/02/2021, to allow adequate time to answer and respond. RI #1's Care Plan for being at risk for having difficulty communicating related to a hearing and visual impairment, with a problem start date of 10/25/2021, documented approaches to observe for signs and symptoms of difficulty communicating and anticipate any unmet needs and to speak slowly, clearly, and to face RI #1 when talking, changing the tone of voice or repeating information as needed. Review of RI #1's most recent quarterly Minimum Data Set (MDS) assessment, dated 7/25/2022, revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. RI #1's MDS also documented the resident required extensive, two-person assistance with bed mobility and transfer, one-person physical assistance with locomotion on the unit (his/her room and adjacent corridor on the same floor). Per this assessment, locomotion off the unit did not occur. This assessment also indicated RI #1 used a wheelchair for mobility. Review of a Patient Care Report for RI #1 from Emergency Medical Services (EMS), dated 09/26/2022, revealed EMS arrived on the scene at 1:00 PM. This report documented [CONDITION(S)] prior to EMS arrival, patient dead at the scene. The report also indicated a witness at the scene said the resident fell from his/her wheelchair and lost consciousness. Per the EMS report, RI #1 had a formal DNR (Do Not Resuscitate order) and EI #16, the Medical Director, was present. RI #1's progress note dated 9/26/2022 documented . This nurse was notified at 12:55 pm that patient had fallen out of wheelchair in back sitting area. Upon arrival and assessing patient (he/she) was found to be absent of vital signs, . Dr. (EI #16) present . A typed facility statement from EI #6, the RD, dated 9/26/2022 at 4:21 PM documented the following: On 9-26-22, . (RI #6 and another resident) told me, . (EI #6's name), that they wanted to go sit outside. I asked .(EI #4, DON), if I was allowed to take patients outside by myself. She confirmed that I could take patients outside. after lunch. I took . (RI #6 and the other resident) downstairs via the elevator. I asked a CNA to help me take one of them outside. (RI #1) was sitting inside at the doorway to the exit where the patio is located. (He/She) told me that .(he/she) wanted to go outside as well. I told . (him/her) yes . but we have to wait on someone to help you. I looked back for additional help. A nurse came to the door and offered to help us. The nurse held the door open while I exited the building with .( RI #6). As I rounded the corner about to take .(RI #6) to the patio, .(RI #1) rolled up beside me at a continual roll. I asked . (him/her) to stop and to wait just a second and that I would take . (him/her).(He/She) did not respond to me.(He/She) kept rolling forward. I could not let go of . (RI #6), because .(he/she) would have rolled forward down the hill. I again told . (RI #1) to stop . (He/She) did not respond to me. I told the CNA in front of me that . (he/she) was rolling . She was in the process of moving . (the other resident) and could not reach . (RI #1) . (RI #1) kept rolling forward down the sidewalk. The left side wheel on . (his/her) wheel chair went off the side of the side walk tipping the wheel chair over . (RI #1) fell out of the wheelchair onto . (his/her) knees and then onto . (his/her) front side of . (his/her) body. Nursing immediately came to . (his/her) side at that time. A handwritten statement dated 9/26/2022, signed by EI #9, Registered Nurse (RN), documented the following: Upon arrival back from lunch . (at approximately 12:48 PM, EI #6, RD) . was taking several pts (patients) outside to sit . (RI #1) exited door . (with EI #6) . behind . pushing a . resident . (RI #1) using . (his/her) feet began self propelling down Ramp . (EI #6) instructed pt to stop but at that time pt had fallen. I didn't witness the actual fall. Upon arrival to pt, lying face down angled on .(left) shoulder. Shallow Respirations, Non Responsive. Multiple staff arrived . A handwritten statement dated 9/26/2022, signed by EI #15, CNA, documented the following: I was rolling a patient down to the pavilion outside, and as we got to the pavilion I heard someone scream at me catch .(him/her)! Stop .(him/her)! When I turned around I saw . (RI #1) rolling rapidly down the ramp. I ran as fast as I could . by the time I got to . (him/her) . (his/her) wheelchair had already went off the side walk and lunged . (him/her) forward causing . (him/her) to land hard face first on the ground, and cause . (him/her) to fall on . (his/her) side . A typed facility statement, signed by EI #4, DON, dated 9/26/2022, documented the following: I received a phone call on my cell phone at 12:55pm from downstairs CNA . she stated I needed to hurry and come to back parking lot area . (RI #1) had fallen out of . (his/her) chair and seemed to be unresponsive. I made it downstairs at 12:58 pm, patient was laying on . (his/her) back, Paramedic on scene. I stated patient was DNR. Patient had no pulse or respirations noted . A facility statement, signed by EI #16, the Medical Director, dated 9/26/2022, documented the following: On 9/26/22, I was notified by DON of . (RI #1) being unresponsive and apneic after falling out of wheelchair near back patio . On arrival . (RI #1) was unresponsive no respirations/pulse . patient was noted to be DNR . rhythm checked. Rhythm was PEA . (Pulseless Electrical Activity), no spontaneous respirations, no palpable pulse, and no reflexes elicited. Patient pronounced by me at 1:02pm . A facility POST INVESTIGATION OF INCIDENTS form, with an incident date of 09/26/2022, documented RI #1 was sitting in a wheelchair at the back door leading up to the incident. The document indicated staff were inserviced to use an alternate exit when taking patients to the gazebo/pavilion area. EI #4, the DON, signed the form as complete. RI #1's care plan and approaches not being followed was not identified as a contributing factor in the incident. On 10/25/2022 at 10:29 AM, EI #6, the RD, was asked to explain the incident on 9/26/2022 involving RI #1. EI #6 stated EI #9, RN, was holding the door open while EI #15, CNA, took a resident out the door and EI #6 took RI #6. EI #6 said RI #1 was sitting inside the door looking outside. According to EI #6, the CNA and the other resident went down first and she was pushing RI #6 in a wheelchair. EI #6 said when she got to the area just at the top where it sloped down, RI #1 rolled up beside her and at that point she realized RI #1 was rolling on his/her own. EI #6 said she asked RI #1 to wait until they got the others down to the patio, and continued to call out to RI #1, but RI #1 did not acknowledge her and kept rolling down the sidewalk toward the patio. EI #6 said, she could not let go of RI #6 because RI #6 would have rolled down too. EI #6 said, EI #9 was behind her somewhere, as she was looking forward and did not exactly know where EI #9 was. EI #6 said RI #1 moved the wheelchair with his/her feet. EI #6 said, she called out to EI #15, the CNA ahead of her, but she could not get to RI #1 before the left wheel went off the side of the sidewalk and tipped the wheelchair over to the left and RI #1 fell forward onto the sidewalk, knees hitting first and RI #1 fell forward. A phone interview was conducted on 10/25/2022 at 2:22 PM with EI #9, RN. EI #9 was asked about the incident with RI #1 on 9/26/2022. EI #9 said that she was coming back from her lunch break and opened the door for EI #6 and the residents she was taking to the gazebo. She stated that EI #1 rolled himself/herself out of the door while she held the door open. She stated that she turned and went into the facility and heard EI #6 say RI #1's name and stop and she stated that was when he/she fell out of the wheelchair. RI #9 was asked, when did EI #6 ask her to assist with the residents. EI #9 stated, EI #6 did not ask her to help, EI #6 just asked her to hold the door. EI #9 was asked, who assisted RI #1 out the door. EI #9 replied, no one. EI #9 was asked, what should have happened. EI #9 replied, RI #1 should have been assisted. EI #9 was asked, what was the risk of a resident wheeling themselves down an inclined sidewalk. EI #9 replied, the risk of falls. A follow-up interview was conducted with EI #6, the RD, on 10/25/2022 at 5:35 PM. EI #6 was asked, when she was taking the residents outside did she know she would need assistance. EI #6 replied, yes that is why she asked for assistance. EI #6 was asked, why would she need assistance. EI #6 replied, to get the residents to the patio because she would not want to leave one resident on the patio by themselves and go back and get another resident. EI #6 was asked, how would other staff assist her. EI #6 replied, to help safely push them down to the patio area until she could get down there to them. EI #6 was asked, what was the risk of someone wheeling themselves down a sidewalk slope. EI #6 replied, losing control of their wheelchair. EI #6 was asked, should RI #1 have been wheeling himself/herself down the sidewalk slope by himself/herself. EI #6 replied, she did not know RI #1's abilities. On 10/25/2022 at 6:28 PM EI #15, CNA, was asked about the incident on 9/26/2022 with RI #1. EI #15 said, EI #6 was pushing a resident and juggling her laptop in her other hand, and she offered to help. EI #15 said EI #6 told her they were going to the patio. EI #15 said, RI #1 was sitting at the door when she went through the door outside with another resident. EI #15 said EI #9 opened the door, and she went down to the patio. EI #15 said she then heard catch him/her, catch him/her, stop him/her, stop him/her, and she looked around toward the door and saw RI #1 coming down the ramp rapidly. EI #15 said, she ran as fast as she could, but the left wheel went off of the sidewalk, and RI #1 fell face first on his/her side. On 10/27/2022 at 9:41 AM, EI #6, RD, was interviewed with follow-up questions. EI #6 was asked how she determined the risk factors for each of the residents she was taking outside. EI #6 said she did not determine individual risk factors, but more overall risk factors and she needed three staff members to get all three of them to the patio. EI #6 said she did not know the supervision requirement for RI #1 but knew the three residents she was taking outside would need supervision to go outside. EI #6 was asked when she asked EI #9 to assist RI #1 down the sloped sidewalk. EI #6 said, she never directly asked EI #9 to assist RI #1 down the slope. EI #6 also said she did not ask anyone if she could take RI #1 outside, but the nurse manager, EI #9, assisted with the door, and she knew RI #1 was going outside. When asked who she communicated with about the level of supervision required for them to go outside, EI #6 said, no one really told her a level of supervision that they needed. On 10/30/2022 at 1:12 PM, EI #16, the attending physician for RI #1, was interviewed. When asked what his understanding was of what RI #1 was doing in that area on 9/26/2022 just prior to the incident, EI #16 said, something out on the patio because it was a really nice day. EI #16 did not know who was responsible for the resident in that area at that time. EI #16 said, what could have been done differently to prevent the accident was to not use that particular exit door and to have a better way of identifying residents' assistance needs. On 11/01/2022 at 12:58 PM, a follow-up interview was conducted with EI #16. EI #16 said if RI #1 was not left unattended the fall could have been avoided. EI #16 also stated if someone was controlling the wheelchair or if someone had locked RI #1's wheelchair wheels, RI #1 would not have rolled down the sidewalk alone. When asked what should have been done differently for RI #1 in this incident, EI #16 said, clarity of communication, better organization, and dietary should be clear on the status of assistance the residents need before taking them outside. On 11/03/2022 at 8:10 AM, EI #6, the RD, was asked how she knew what assistance RI #1 needed for locomotion. EI #6 said, from general daily observations that she had observed throughout the facility. EI #6 reviewed RI #1's care plan and said, RI #1 was limited to extensive assistance with Activities of Daily Living (ADLs) related to balance problems. EI #6 said, RI #1 was assist with transfers and locomotion with assistance of one person and that meant RI #1 would need someone to assist with locomotion. EI #6 said the risk of not following the care plan to assist with locomotion was the lack of maintaining RI #1's safety at all times. On 10/31/2022 at 10:15 AM, EI #4, DON, was asked what should have been done differently when taking residents out the east exit door. EI #4 said, they should have ensured that they had the proper number of staff needed to ensure resident safety. EI #4 said, before going out the door, they should have had a staff member assisting each resident when exiting the building. EI #4 clarified that each resident should have had someone holding onto their wheelchairs. When asked what she thought caused the incident, EI #4 said, the level of assistance RI #1 required was not provided. A follow up interview was conducted with EI #4 on 11/02/2022 at 5:41 PM. EI #4 was asked, what was the assistance level on the care plan for RI #1. EI #4 replied, limited to extensive assist. EI #4 was asked, what did limited to extensive assistance mean. EI #4 replied, assistance times one at the minimum. EI #4 was asked, why was the care plan not followed that stated to assist RI #1 with locomotion on 09/26/2022. EI #4 replied, miscommunication between two staff members. EI #4 was asked, how staff should have assisted RI #1 with locomotion on 09/26/2022. EI #4 replied, assist times one. When asked what would have assisting RI #1 with the wheelchair prevented, EI #4 said, possibly going off the sidewalk and the tipping of his/her wheelchair. EI #4 was asked, what was the risk of not following the care plan to assist with locomotion. EI #4 replied, falling. On 11/02/2022 at 4:26 PM, EI #3, the Administrator, was asked what might have gone differently if staff had followed RI #1's care plan. EI #3 said, RI #1's wheelchair might not have tipped over. EI #3 said, RI #1's care plan was not followed and there was a miscommunication between two staff members on 09/26/2022. This deficient practice was cited as a result of the investigation of complaint/report number AL 123. **************************************************************** On 11/04/2022 at 6:55 PM, the facility submitted the following acceptable Removal Plan addressing F656: F656-Care plan 10/30/22 MDS Coordinator began in-servicing all nursing partners on how to access the care plan and to utilize it for level of assistance required for patients. 11/3/22 RN trained MDS coordinator to ensure she was competent to train partners on how to access the care plan and to utilize it for level of assistance required for patients comprehensive care plan. 11/3/22 MDS Coordinator/designee all nursing partners in-service on how to access the care plan and to utilize it for level of assistance required for patients. This in-service was provided by the MDS Coordinator . 11/3/22 Regional Nurse in-serviced DON on Patient communication tool process and identified this system to communicate individualized patient requirements related to comprehensive plan of care to ensure staff provides needed assistance/supervision to patients. 11/3/22 4pm DON trained the following designees ( DHIM, WCC, UM, ADON, RN) on Patient communication tool process this is a system to communicate individualized patient requirements related to comprehensive plan of care to ensure staff provides needed assistance/supervision to patients. The DON and designees (DHIM WCC, UM, ADON, RN) immediately began in-servicing all partners on utilizing PCT/Care plan to provide care based on patients' requirements - person centered care. This training will be provided by the next worked shift for all partners prior to the next shift worked. Inservice included: The PCT should contain the following information ACL, developmental age comparison, BATF, preferred name, interests, care approaches, and abilities considering activities from all disciplines i.e. feeding, dressing, ambulation, transfers, communication. All partners have access to the patient communication tool. This tool provides all partners with the ability to know what type of assistance, cognitive abilities, and equipment the patient requires. Be sure to utilize this tool to assist patients or to notify the nurse should you notice a change in the patient. If you have questions, please see the nurse. If you do not know or have questions about the needs of a patient, ask the nurse prior to assisting any patient. 11/3/22 Reviewed/revised all patient care plans to ensure patients locomotion and transfer assistance was reflected in care plan. This was completed by Regional Nurse and Assistant Regional nurse by 10pm (11/3/22). 11/3/22 Administrator designated nursing leadership to review/update all patients' PCTs according to the PCT process . completed 11/3/22 10pm Contents will be completed and immediacy will be removed on 11/3/22 After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 11/03/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observation, record review, interviews, review of the facility's investigative file related to a fall involving Resident Identifier (RI) #1, review of Patient Care Policies and review of the facility's policy titled SUBJECT: Incident and Accident Process, the facility failed to provide needed assistance and/or supervision to RI #1, a resident in a wheelchair, to prevent an accident outdoors at the facility on 09/26/2022. RI #1's plan of care for falls had an approach that guided staff to assist with transfer and locomotion. RI #1 also had a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for communication problems and cognition deficits. On 9/26/2022 at approximately 1:00 PM, Employee Identifier (EI) #6, the Dietitian (RD), and EI #15, a Certified Nursing Assistant (CNA), took residents outdoors in wheelchairs while EI #9, a Registered Nurse (RN), held the door open. RI #1 self-propelled out the exit door with them. The RD told RI #1, a cognitively impaired resident with communication deficits and the need for assistance, to wait. The intent was to take the residents down a sloped sidewalk to a patio area. RI #1 wheeled him/her self out the door as the RN held the door open. RI #1 wheeled around the RD, who had another resident in a wheelchair, and down a sloped sidewalk unassisted. RI #1's wheelchair rolled down the slope, the left wheel of the wheelchair rolled off the sidewalk and overturned off the edge of the sidewalk, propelling RI #1 onto the ground face first on his/her left side on the ground. EI #6, the RD who initiated taking residents outside, did not know the level of supervision/assistance required for the residents before taking them outside an exit with a sloped sidewalk. EI #9, the RN who held open the door, said she was new, and she thought the RD was supervising the resident since she was wheeling another resident outside and asked the RN to hold the door open for them as she was returning from her lunch break. RI #1 was pronounced dead on the scene on 09/26/2022 at 1:02 PM, after being assessed by EI #16, the Medical Director, who was present at the facility when the incident occurred. This deficient practice placed RI #1, one of three sampled residents reviewed for accidents, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 11/3/2022 at 3:17 PM, the facility's Administrator (Employee Identifier (EI) #3); the Regional Administrator of the South Central Region for NHC Healthcare and member of the Governing Body (EI #1); the facility's Director of Nursing (DON, EI #4); and a Regional Nurse for NHC Healthcare (EI #2) were given a copy of the Immediate Jeopardy (IJ) template and were notified of the findings of substandard quality of care at the IJ level in the area of Accident Hazards/Supervision/Devices, F689. Findings include: Cross reference F656, F837, and F867. The State Agency received a complaint on 10/21/2022 that alleged the complainant was a witness to an accident that caused the death of a resident of the facility, RI #1. RI #1 was witnessed on 9/26/2022, outside, rolling down an incline in a wheelchair. The complainant alleged hearing someone calling out RI #1's name over and over and that was what caught the complainant's attention. The complainant reported that RI #1's wheelchair, while rolling down the incline, went off the edge of the concrete, and RI #1's wheelchair flipped over, throwing RI #1 onto concrete, face down, about three feet from the sidewalk. Review of an undated facility document titled Fall Prevention Program revealed the following: . PURPOSE: To reduce patient's risk of falling. 3. Apply fall risk interventions as appropriate for the patient . The facility provided for review, Patient Care Policies, page 13, which documented . 4.0 NURSING POLICIES . B. The care plan serves as a guide for care decisions and is made available for use by all patient care personnel. RI #1 was admitted to the facility on [DATE] and had diagnoses to include: [CONDITION(S)], Dementia, [CONDITION(S)], Kyphosis, Contracture of the Right Hand/Second Finger, Hallux Valgus of the Left and Right foot, Presence of Artificial Eye, and History of Falling. RI #1's Care Plan for being at risk for falls related to balance problems, fall history, visual and hearing impairment, incontinence, weakness, and multiple medical problems, with a start date of 03/15/2021, documented approaches to assist with transfers and locomotion and to observe for unsafe actions and intervene. RI #1's Care Plan for cognitive deficits documented an approach dated 04/02/2021, to allow adequate time to answer and respond. RI #1's Care Plan for being at risk for having difficulty communicating related to a hearing and visual impairment, with a problem start date of 10/25/2021, documented approaches to observe for signs and symptoms of difficulty communicating and anticipate any unmet needs and to speak slowly, clearly, and to face RI #1 when talking, changing the tone of voice or repeating information as needed. Review of RI #1's most recent quarterly Minimum Data Set (MDS) assessment, dated 7/25/2022, revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. RI #1's MDS also documented the resident required extensive, two-person assistance with bed mobility and transfer, one-person physical assistance with locomotion on the unit (his/her room and adjacent corridor on the same floor). Per this assessment, locomotion off the unit did not occur. This assessment also indicated RI #1 used a wheelchair for mobility. Review of a Patient Care Report for RI #1 from Emergency Medical Services (EMS), dated 09/26/2022, revealed EMS arrived on the scene at 1:00 PM. This report documented [CONDITION(S)] prior to EMS arrival, patient dead at the scene. The report also indicated a witness at the scene said the resident fell from his/her wheelchair and lost consciousness. Per the EMS report, RI #1 had a formal DNR (Do Not Resuscitate order) and EI #16, the Medical Director, was present. RI #1's progress note dated 9/26/2022 documented . This nurse was notified at 12:55 pm that patient had fallen out of wheelchair in back sitting area. Upon arrival and assessing patient (he/she) was found to be absent of vital signs, . Dr. (EI #16) present . A typed facility statement from EI #6, the RD, dated 9/26/2022 at 4:21 PM documented the following: On 9-26-22, . (RI #6 and another resident) told me, . (EI #6's name), that they wanted to go sit outside. I asked .(EI #4, DON), if I was allowed to take patients outside by myself. She confirmed that I could take patients outside. after lunch. I took . (RI #6 and the other resident) downstairs via the elevator. I asked a CNA to help me take one of them outside. (RI #1) was sitting inside at the doorway to the exit where the patio is located. (He/She) told me that .(he/she) wanted to go outside as well. I told . (him/her) yes . but we have to wait on someone to help you. I looked back for additional help. A nurse came to the door and offered to help us. The nurse held the door open while I exited the building with .( RI #6). As I rounded the corner about to take .(RI #6) to the patio, .(RI #1) rolled up beside me at a continual roll. I asked . (him/her) to stop and to wait just a second and that I would take . (him/her).(He/She) did not respond to me.(He/She) kept rolling forward. I could not let go of . (RI #6), because .(he/she) would have rolled forward down the hill. I again told . (RI #1) to stop . (He/She) did not respond to me. I told the CNA in front of me that . (he/she) was rolling . She was in the process of moving . (the other resident) and could not reach . (RI #1) . (RI #1) kept rolling forward down the sidewalk. The left side wheel on . (his/her) wheel chair went off the side of the side walk tipping the wheel chair over . (RI #1) fell out of the wheelchair onto . (his/her) knees and then onto . (his/her) front side of . (his/her) body. Nursing immediately came to . (his/her) side at that time. A handwritten statement dated 9/26/2022, signed by EI #9, Registered Nurse (RN), documented the following: Upon arrival back from lunch . (at approximately 12:48 PM, EI #6, RD) . was taking several pts (patients) outside to sit . (RI #1) exited door . (with EI #6) . behind . pushing a . resident . (RI #1) using . (his/her) feet began self propelling down Ramp . (EI #6) instructed pt to stop but at that time pt had fallen. I didn't witness the actual fall. Upon arrival to pt, lying face down angled on .(left) shoulder. Shallow Respirations, Non Responsive. Multiple staff arrived . A handwritten statement dated 9/26/2022, signed by EI #15, CNA, documented the following: I was rolling a patient down to the pavilion outside, and as we got to the pavilion I heard someone scream at me catch .(him/her)! Stop .(him/her)! When I turned around I saw . (RI #1) rolling rapidly down the ramp. I ran as fast as I could . by the time I got to . (him/her) . (his/her) wheelchair had already went off the side walk and lunged . (him/her) forward causing . (him/her) to land hard face first on the ground, and cause . (him/her) to fall on . (his/her) side . A typed facility statement, signed by EI #4, DON, dated 9/26/2022, documented the following: I received a phone call on my cell phone at 12:55pm from downstairs CNA . she stated I needed to hurry and come to back parking lot area . (RI #1) had fallen out of . (his/her) chair and seemed to be unresponsive. I made it downstairs at 12:58 pm, patient was laying on . (his/her) back, Paramedic on scene. I stated patient was DNR. Patient had no pulse or respirations noted . A facility statement, signed by EI #16, the Medical Director, dated 9/26/2022, documented the following: On 9/26/22, I was notified by DON of . (RI #1) being unresponsive and apneic after falling out of wheelchair near back patio . On arrival . (RI #1) was unresponsive no respirations/pulse . patient was noted to be DNR . rhythm checked. Rhythm was PEA . (Pulseless Electrical Activity), no spontaneous respirations, no palpable pulse, and no reflexes elicited. Patient pronounced by me at 1:02pm . A facility POST INVESTIGATION OF INCIDENTS form, with an incident date of 09/26/2022, documented RI #1 was sitting in a wheelchair at the back door leading up to the incident. The document indicated staff were inserviced to use an alternate exit when taking patients to the gazebo/pavillion area. EI #4, the DON, signed the form as complete. RI #1's care plan and approaches not being followed was not identified as a contributing factor in the incident. On 10/25/2022 at 10:29 AM, EI #6, the RD, was asked to explain the incident on 9/26/2022 involving RI #1. EI #6 stated EI #9, RN, was holding the door open while EI #15, CNA, took a resident out the door and EI #6 took RI #6. EI #6 said RI #1 was sitting inside the door looking outside. According to EI #6, the CNA and the other resident went down first and she was pushing RI #6 in a wheelchair. EI #6 said when she got to the area just at the top where it sloped down, RI #1 rolled up beside her and at that point she realized RI #1 was rolling on his/her own. EI #6 said she asked RI #1 to wait until they got the others down to the patio, and continued to call out to RI #1, but RI #1 did not acknowledge her and kept rolling down the sidewalk toward the patio. EI #6 said, she could not let go of RI #6 because RI #6 would have rolled down too. EI #6 said, EI #9 was behind her somewhere, as she was looking forward and did not exactly know where EI #9 was. EI #6 said RI #1 moved the wheelchair with his/her feet. EI #6 said, she called out to EI #15, the CNA ahead of her, but she could not get to RI #1 before the left wheel went off the side of the sidewalk and tipped the wheelchair over to the left and RI #1 fell forward onto the sidewalk, knees hitting first and RI #1 fell forward. A phone interview was conducted on 10/25/2022 at 2:22 PM with EI #9, RN. EI #9 was asked about the incident with RI #1 on 9/26/2022. EI #9 said that she was coming back from her lunch break and opened the door for EI #6 and the residents she was taking to the gazebo. She stated that EI #1 rolled himself/herself out of the door while she held the door open. She stated that she turned and went into the facility and heard EI #6 say RI #1's name and stop and she stated that was when he/she fell out of the wheelchair. RI #9 was asked, when did EI #6 ask her to assist with the residents. EI #9 stated, EI #6 did not ask her to help, EI #6 just asked her to hold the door. EI #9 was asked, who assisted RI #1 out the door. EI #9 replied, no one. EI #9 was asked, what should have happened. EI #9 replied, RI #1 should have been assisted. EI #9 was asked, what was the risk of a resident wheeling themselves down an inclined sidewalk. EI #9 replied, the risk of falls. A follow-up interview was conducted with EI #6, the RD, on 10/25/2022 at 5:35 PM. EI #6 was asked, when she was taking the residents outside did she know she would need assistance. EI #6 replied, yes that is why she asked for assistance. EI #6 was asked, why would she need assistance. EI #6 replied, to get the residents to the patio because she would not want to leave one resident on the patio by themselves and go back and get another resident. EI #6 was asked, how would other staff assist her. EI #6 replied, to help safely push them down to the patio area until she could get down there to them. EI #6 was asked, what was the risk of someone wheeling themselves down a sidewalk slope. EI #6 replied, losing control of their wheelchair. EI #6 was asked, should RI #1 have been wheeling himself/herself down the sidewalk slope by himself/herself. EI #6 replied, she did not know RI #1's abilities. On 10/25/2022 at 6:28 PM EI #15, CNA, was asked about the incident on 9/26/2022 with RI #1. EI #15 said, EI #6 was pushing a resident and juggling her laptop in her other hand, and she offered to help. EI #15 said EI #6 told her they were going to the patio. EI #15 said, RI #1 was sitting at the door when she went through the door outside with another resident. EI #15 said EI #9 opened the door, and she went down to the patio. EI #15 said she then heard catch him/her, catch him/her, stop him/her, stop him/her, and she looked around toward the door and saw RI #1 coming down the ramp rapidly. EI #15 said, she ran as fast as she could, but the left wheel went off of the sidewalk, and RI #1 fell face first on his/her side. On 10/27/2022 at 9:41 AM, EI #6, RD, was interviewed with follow-up questions. EI #6 was asked how she determined the risk factors for each of the residents she was taking outside. EI #6 said she did not determine individual risk factors, but more overall risk factors and she needed three staff members to get all three of them to the patio. EI #6 said she did not know the supervision requirement for RI #1 but knew the three residents she was taking outside would need supervision to go outside. When asked why she chose to use that particular exit, EI #6 said, it was the only exit she had used to get to the patio. EI #6 was asked when she asked EI #9 to assist RI #1 down the sloped sidewalk. EI #6 said, she never directly asked EI #9 to assist RI #1 down the slope. EI #6 also said she did not ask anyone if she could take RI #1 outside, but the nurse manager, EI #9, assisted with the door, and she knew RI #1 was going outside. When asked who she communicated with about the level of supervision required for them to go outside, EI #6 said, no one really told her a level of supervision that they needed. On 10/28/2022 at 3:00 PM, observations and measurements were made outside of the East exit door that was used at the time of the incident. From the exit door to the right side, where the sidewalk began to slope was measured to be nine feet. The sloped section of the sidewalk was measured to be 288 inches long, with a drop in elevation of 10.5 inches over that distance. On 10/30/2022 at 1:12 PM, EI #16, the attending physician for RI #1, was interviewed. When asked what his understanding was of what RI #1 was doing in that area on 9/26/2022 just prior to the incident, EI #16 said, something out on the patio because it was a really nice day. EI #16 did not know who was responsible for the resident in that area at that time. EI #16 said, what could have been done differently to prevent the accident was to not use that particular exit door and to have a better way of identifying residents' assistance needs. On 11/01/2022 at 12:58 PM, a follow-up interview was conducted with EI #16. EI #16 said if RI #1 was not left unattended the fall could have been avoided. EI #16 also stated if someone was controlling the wheelchair or if someone had locked RI #1's wheelchair wheels, RI #1 would not have rolled down the sidewalk alone. When asked what should have been done differently for RI #1 in this incident, EI #16 said, clarity of communication, better organization, and dietary should be clear on the status of assistance the residents need before taking them outside. On 11/03/2022 at 8:10 AM, EI #6, the RD, was asked how she knew what assistance RI #1 needed for locomotion. EI #6 said, from general daily observations that she had observed throughout the facility. EI #6 reviewed RI #1's care plan and said, RI #1 was limited to extensive assistance with Activities of Daily Living (ADLs) related to balance problems. EI #6 said, RI #1 was assist with transfers and locomotion with assistance of one person and that meant RI #1 would need someone to assist with locomotion. EI #6 said the risk of not following the care plan to assist with locomotion was the lack of maintaining RI #1's safety at all times. On 10/31/2022 at 10:15 AM, EI #4, DON, was asked what should have been done differently when taking residents out the east exit door, EI #4 said, they should have ensured that they had the proper number of staff needed to ensure resident safety. EI #4 said, before going out the door, they should have had a staff member assisting each resident when exiting the building. EI #4 clarified that each resident should have had someone holding onto their wheelchairs. EI #4 said, the difference in East and South exits was that the East exit had an incline in the sidewalk and South did not have an incline. When asked what should have been done to keep RI #1 from rolling down the sidewalk, EI #4 said, someone holding the wheelchair. When asked what she thought caused the incident, EI #4 said, the level of assistance RI #1 required was not provided. A follow up interview was conducted with EI #4 on 11/02/2022 at 5:41 PM. EI #4 was asked, what was the assistance level on the care plan for RI #1. EI #4 replied, limited to extensive assist. EI #4 was asked, what did limited to extensive assistance mean. EI #4 replied, assistance times one at the minimum. EI #4 was asked, why was the care plan not followed that stated to assist RI #1 with locomotion on 09/26/2022. EI #4 replied, miscommunication between two staff members. EI #4 was asked, how staff should have assisted RI #1 with locomotion on 09/26/2022. EI #4 replied, assist times one. When asked what would have assisting RI #1 with the wheelchair prevented, EI #4 said, possibly going off the sidewalk and the tipping of his/her wheelchair. EI #4 was asked, what was the risk of not following the care plan to assist with locomotion. EI #4 replied, falling. On 11/02/2022 at 5:59 PM, EI #4 was asked to clarify what she meant by miscommunication between two staff members. EI #4 said, EI #9 thought EI #6 was assisting RI #1, and EI #6 assumed RI #9 was assisting RI #1 on 9/26/2022 at the time they went outside. On 11/02/2022 at 4:26 PM, EI #3, the Administrator, was asked what might have gone differently if staff had followed the care plan to assist RI #1 with locomotion. EI #3 said, RI #1's wheelchair might not have tipped over. EI #3 said, RI #1's care plan was not followed and there was a miscommunication between two staff members on 09/26/2022. This deficient practice was cited as a result of the investigation of complaint/report number AL 123. **************************************************************** On 11/04/2022 at 6:55 PM, the facility submitted the following acceptable Removal Plan addressing F689: F689 9/26/22 Incident occurred at 12:55pm 9/26/22 Administrator assessed the East Hall exit to begin the investigation into what happened. Administrator immediately stopped use of east hall exit for patient use. Administrator notified all partners in building at the time not to use door on east hall downstairs. 9/26/22, RN- RD, CNA sent home at 2:18pm pending an investigation by the Administrator after discussion with the Regional Administrator and Regional Nurse. 9/26/22 POC was written by DON to include supervision of patients with cognitive impairments with a BIMS below 12. As DON/administrators immediate investigation indicated that this patient's BIMS was a risk. Identified patient had not been supervised and implemented immediate action to prevent patients requiring supervision to be left unattended. DON began inservicing all partners regarding patients with cognitive impairments are to be supervised when taken outside. 9/26/22 4pm DON (director of nursing) completed in-servicing with partners regarding patients with cognitive impairments are to be supervised when taken outside. 100% of partners in-serviced regarding cognitive impaired patients being supervised while outdoors and not utilizing East Hall exit door by 10/3/22. 9/27/22 Untoward event completed by DON to initiate the QAPI process for root cause analysis related to the incident. 9/27/22- RN-, RD, & CNA from incident, were individually in-serviced before start of next shift by the DON regarding supervising patients with cognitive impairments when assisting them outside. 9/28/22 DON initiated QA monitors on partners that had completed the training since 9/26/22 to ensure they knew what patients needed assistance to go outside. This began weekly starting 9/28/22 to 10/18/2022 this QA monitor was completed to ensure training on 9/26 (ended 10/3) was effective and was part of the POC to monitor 2 partners per week for 4 weeks. 10/18/22 100% of partners monitored were able to verbalize correct procedure regarding cognitively impaired patients being supervised outside and not using the east hall door. 10/20/22 QAPI meeting held. Discussion included incident and presented plan of correction. 10/30/22 began to 11/3/22 (completed) MDS Coordinator began an in-service for all nursing partners on how to access the care plan and to utilize it to provide the level of assistance required. 11/3/22 MDS Coordinator & DON completed all nursing partners in-services on how to access the care plan and to utilize it to provide the level of assistance required . 11/3/22 Regional Nurse in-serviced DON on Patient communication tool process and identified this system to communicate individualized patient requirements related to comprehensive plan of care to ensure facility staff provides needed assistance/supervision to residents. 11/3/22 All patients will be reviewed by DON or designee to ensure they have a PCT that accurately states level of assistance/supervision and locomotion including but not limited to when in hazardous areas of the facility premises 11/3/22. 11/3/22 4pm DON/designee(DHIM, WCC, UM, ADON, RN) began in-servicing all partners/all disciplines on utilizing PCT/care plan to provide care based on patient requirements - person centered care. This training will be provided for all facility staff before the start of the next scheduled shift. The inservice provides the partners information to provide patient centered care including what level of cognition and assistance the patient requires to prevent incidents of this nature from occurring again. This included training on regarding ensuring needs are communicated properly and thoroughly to other staff when working together to provide care for patients. Ensure that every patient has adequate supervision to accomplish needs tasks through thorough communication. Patient needs and supervision levels can be found on the care plan, PCT or by asking their nurse. This was completed 11/3/22 100% of all disciplines received this training. Inservice included: The PCT should contain the following information ACL, developmental age comparison, BATF, preferred name, interests, care approaches, and abilities considering activities from all disciplines i.e. feeding, dressing, ambulation, transfers, communication. All partners have access to the patient communication tool. This tool provides all partners with the ability to know what type of assistance, cognitive abilities, and equipment the patient requires. Be sure to utilize this tool to assist patients or to notify the nurse should you notice a change in the patient. If you have questions, please see the nurse. If you do not know or have questions about the needs of a patient, ask the nurse prior to assisting any patient. 11/3/22 RD was inserviced by administrator regarding ensuring needs are communicated properly and thoroughly to other staff when working together to provide care for patients. Ensure that every patient has adequate supervision to accomplish needs tasks through thorough communication. Patient needs and supervision levels can be found on the care plan, PCT or by asking their nurse. 11/4/22 10am bright yellow sign posted on East Hall exit door at standing eye level as well as seated eye level by Administrator that patients do not use this door. 11/4/22 2:30pm Administrator or designee (ADON, RD, ICP, UM) providing education to all patients regarding not using East Hall downstairs exit. 11/4/22 ADON, RD, UM, ICP called all family members of patients who are not cognitively intact to notify them that the East hall door should not be used for patients and to use the south hall entrance. A copy of the sign and map showing what door not to use and what door to use to enter downstairs was placed in all patient rooms. Ongoing purposes this will be placed in admission packet starting 11/4/22 Contents will be completed and immediacy will be removed on 11/4/2022 After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 11/04/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on record review, interviews, and review of a facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, the facility failed to ensure two allegations of resident-on-resident abuse were reported to the State Agency within two hours: 1) On 07/06/2022 Resident Identifier (RI) #4 was witnessed by staff slapping his/her roommate, RI #3, on the face and arm. The altercation was reported to the Director of Nursing (DON) and Abuse Coordinator/Administrator, but was not reported to the State Agency; and 2) On 07/24/2022 staff witnessed a resident-on-resident altercation between RI #4 and RI #5. This incident was also reported to the DON and Administrator/Abuse Coordinator, but was not reported to the State Agency. This deficient practice was noted with two of two abuse allegations identified while reviewing Progress Notes for three of six sampled residents reviewed for reporting requirements. Findings include: Review of a facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/2017, revealed the following: . 5. IDENTIFICATION POLICY Policy Any patient event that is reported to any partner by patient, family, other partner, or any other person will be considered an allegation of . abuse . if it meets any of the following criteria: 1. Any allegation (or) indication of possible willful infliction of injury . 3. Any patient or family complaint of physical or verbal harm . resulting from the actions of others . . 6. REPORTING POLICY Policy Any partner having either direct or indirect knowledge of any event that might constitute abuse . must report the event immediately, but no later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse . It is the policy of this facility that abuse allegations . are reported per Federal and State law not later than 2 hours after the allegation is made . 1) RI #3 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #3's Progress Notes revealed the following documentation about a resident-on-resident altercation involving RI #3 and RI #4: .07/06/2022 4:28 PM cna (Certified Nursing Assistant) reported that pt (patient) and room mate (RI #3 and RI #4) . started arguing and then pt (RI #4) . slapped pt (RI #3) in the face and on the arm. DON/ ADM (Administrator) notified immediately . This entry was made by Employee Identifier (EI) #5, Registered Nurse (RN)/Charge Nurse. During an interview on 10/31/2022 at 2:52 PM, EI #5, RN/Charge Nurse, was asked if she recalled the incident on 07/06/2022 when RI #4 slapped his/her roommate, RI #3, on the face and arm. EI #5 said yes, she did recall that day, that EI #20, a Certified Nursing Assistant (CNA) told her about the altercation. EI #5 said the incident was reported to the DON (EI #4) and the Administrator/Abuse Coordinator (EI #3). EI #4, the DON, was interviewed on 10/31/2022 at 4:37 PM. When asked if she recalled the resident-on resident altercation on 07/06/2022 involving RI #3 and RI #4, EI #4 said yes, she did. EI #4 confirmed the nurse had reported the incident to her, and indicated the two residents were arguing and RI #4 hit RI #3. EI #4 stated this incident would be considered an allegation of physical abuse. When asked if the allegation of physical abuse was reported to the State Agency, EI #4 said no, but after discussing it with the surveyors, she agreed it should have been reported within two hours. EI #4 reported that EI #3, the Administrator/Abuse Coordinator, was also aware of the resident-on-resident altercation involving RI #3 and RI #4. EI #3, the Administrator/Abuse Coordinator, was interviewed on 10/31/2022 at 5:06 PM. EI #3 stated EI #5, the RN/Unit Manager, had reported the 07/06/2022 resident-on-resident altercation involving RI #3 and RI #4. EI #3 said it was reported to her that one of the residents slapped the other one on the face and arm. When asked what type of abuse this allegation would be considered, EI #3 said physical abuse. EI #3 said the allegation had not been reported to the State Agency. When asked what the facility policy said regarding the reporting of alleged abuse, EI #3 said the policy indicated allegations of abuse should be reported within no later than two hours. 2) RI #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Event Report for RI #5 revealed the following note: 7/24/2022 . 3:15 PM I was in room next door to pt's (patient's) (RI #5's) and heard a loud noise of screaming coming from next door . Entered room . and witnessed (RI #5) slamming (his/her) rollator into (RI #4's side of w/c (wheelchair). Both were screaming at each other making verbal threats . EI #3, the Administrator/Abuse Coordinator, was interviewed on 10/31/2022 at 5:06 PM. When asked about RI #5's note dated 07/24/2022, EI #3 stated that this would be considered an allegation of abuse; however, EI #3 said they had not reported it to the State Agency. EI #3 said according to their policy, allegations of abuse should be reported within no later than two hours.

Based on observation, interviews and review of a facility policy titled, REFRIGERATOR AND FREEZER STORAGE, the facility failed to ensure three of seven honey thickened liquids in the walk-in cooler of the kitchen were labeled with a use by date. This failure had the potential to affect two residents who received honey thickened liquids out of 115 total residents who received meal trays from the kitchen. Findings Include: The facility policy titled, REFRIGERATOR AND FREEZER STORAGE, with a revised date of (MONTH) (YEAR), included . OUTCOME: Refrigerated and frozen foods will be stored properly . items must be labeled with the use by date before properly storing . On 11/03/19 at 10:58 a.m., the surveyor observed food items in the walk-in cooler. There was one container with honey-thickened milk, with no prepared date or use by date, and two containers with honey-thickened tea, with no prepared date or use by date. On 11/03/19 at 11:24 a.m., the surveyor conducted an interview with EI (Employee Identifier) #3, the Batch Cook. EI #3 was asked, how many out of the thirteen prepared thickened liquid containers were not labeled with a use by date. EI #3 stated a total of 3 items had no prepared or use by date. On 11/04/19 at 11:38 a.m., the surveyor conducted another interview with EI #3, the Batch Cook. EI #3 was asked, who was responsible for labeling the food items before placing them in the refrigerator/cooler/freezer. EI #3 stated any kitchen staff that prepared the food item was responsible for labeling the food items placed in the walk-in-cooler. EI #3 was asked, what labeling information should be placed on food items prior to placing in the walk-in-cooler. EI #3 stated the food item should be labeled with the name of the food, the date the food was prepared, and a use by date. EI #3 was asked, what was the potential concern to the resident when food items are not labeled and placed into the refrigerator/cooler/freezer. EI #3 stated there was a potential for food borne illnesses. On 11/05/19 at 11:50 a.m., the surveyor conducted an interview with EI #4, the Director of Food and Nutrition Services. The surveyor asked EI #4, who was responsible for labeling food items before placing them in the refrigerator/cooler/freezer. EI #4 stated the person that prepared the food item was responsible for labeling food items. EI #4 was asked, when should food items be labeled. EI #4 stated the day of preparation. The surveyor asked EI #4, what was the facility policy on labeling food items before placed in the refrigerator/cooler/freezer. EI #4 stated food items should be labeled with a use by date. EI #4 was asked, what was the potential concern to the resident when food items were not labeled and placed into the refrigerator/cooler/freezer. EI #4 stated it could cause a potential for food borne illness.

Based on observation, interviews, record review, and review of facility policies titled HANDWASHING, and Hand Washing and Hand Sanitizer, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), washed her hands after after she attempted to give Resident Identifier (RI) #63's eye drop medication, prior to placing RI #63's eye drop medication in the drawer of the medication cart. This affected RI #63, one of five residents observed during the medication administration pass, and EI #1, one of five nurses, observed during medication pass. Findings Include: RI #63 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. A review of a facility policy titled HANDWASHING, with a revised date of 10/01/2008, revealed . PR[NAME]EDURE wash your hands before and after contact with each patient . and . after removal of gloves . A review of a facility policy titled Hand Washing and Hand Sanitizer, with no date, revealed PURPOSE: Hand hygiene is the primary means to prevent the spread of infection . On 11/05/2019 at 8:50 a.m., the surveyor observed EI #1 during the medication administration pass. The surveyor observed EI #1 attempt to give RI #63's eye drop medication in the right and left eye, using gloved hands. She then removed her gloves, but did not wash her hands or use hand sanitizer. EI #1 opened the second drawer of the medication cart with both hands, and placed the eye drop medication in the medication cart. On 11/05/2019 at 11:30 a.m., the surveyor conducted an interview with EI #1, a LPN. EI #1 was asked what she should have done after she attempted to give RI #63's eye drop medication in the right and left eye, using gloved hands, removed her gloves, and prior to placing RI #63's eye drop medication in the medication cart. EI #1 stated she should have washed her hands. EI #1 was asked what was the facility policy on hand hygiene after a licensed nurse removed their gloves after contact with a resident. EI #1 stated you should wash and dry your hands after you remove your gloves, and after contact with a resident. EI #1 was asked if the facility policy was followed. EI #1 stated no. EI #1 was asked what would be the concern if a licensed nurse did not wash or sanitize her hands after she attempted to give eye drop medication, prior to placing the eye drops in the drawer of the medication cart. EI #1 stated the licensed nurse could cause cross contamination of infections to other patients. On 11/05/2019 at 11:49 a.m., the surveyor conducted an interview with EI #2, Infection Control Preventionist/Registered Nurse. EI #2 was asked what was the facility policy on hand hygiene after a licensed nurse came in contact with a resident and removed her gloves. EI #2 stated you should wash or sanitize your hands to prevent the spread of infection. EI #2 was asked what would be the concern if a licensed nurse did not wash or sanitize her hands after she attempted to give eye drop medication, in the right and left eye using gloved hands, removed her gloves, and prior to placing the eye drop medication in the medication cart. EI #2 stated it could cause a potential cross contamination to other patients.

Based on observation, interview and a facility policy titled, Security of PHI (Protected Health Information) During Day To Day Operations, the facility failed to ensure RI (Resident Identifier) #34's Electronic Medication Administration Record [REDACTED]. This deficient practice affected RI #34, one of twenty-three sampled residents. Findings Include: A review of a facility policy titled, Security of PHI During Day to Day Operations, with a revised date of 09/01/2013, revealed: .personal health information is used in a manner which promotes the confidentiality of the information . MAR . should not be left on carts open . RI #34 was admitted to the facility on [DATE]. On 09/18/18 at 08:37 a.m., the surveyor observed Employee Identifier (EI) #, Registered Nurse, walk away from the computer on a medication cart in the hallway with RI #34's Medication Administration Record [REDACTED]. On 09/18/2018 at 02:30 p.m., an interview was conducted with EI #1, a Registered Nurse. EI #1 was asked if she left RI #34's Medication Administration Record [REDACTED]. EI #1 stated yes. EI #1 was asked what should she have done prior to leaving the computer screen up/unlocked. EI #1 stated that she should have covered the screen up. EI #1 was asked what the facility policy was on confidentiality of a resident's record. EI #1 stated that you should close the computer screen or cover the resident's information up. EI #1 was asked what would be the potential harm with leaving a resident's Medication Administration Record [REDACTED]. EI# 1 replied that a resident's private information could be accessed by the public.

Based on observations, review of the (YEAR) Food Code, review of the facility policy/procedure titled Safety & Sanitation Best Practice Guidelines and staff interviews, the facility failed to ensure staff air dried five plates and ten bowls. This had the potential to affect up to 15 out of the 110 residents who received meal trays from dining services. Findings include: A review of the Food Code, U.S. (United States) Public Health Service and FDA (Food and Drug Administration) (YEAR) revealed the following: .4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT AND UTENSILS: (A) Shall be air-dried . A review of the dietary policy/procedure titled Safety & Sanitation Best Practice Guidelines, revised 11/2017, revealed the following: .11. Air-dry all items (Food Code 4-901.11). On 9/17/18 at 2:58 PM during the initial kitchen tour, Employee Identifier (EI) #5, Dietary Manager, was asked to take apart a stack of plates. Surveyor observed five plates to be wet. Surveyor asked EI #5 what was the substance on the surface of the plates. EI #5 stated water. Surveyor asked EI #5 what the potential harm was in being wet with water. EI #5 stated bacterial growth. EI #5 was asked how should you dry plates. EI #5 stated they should be air dried before they come off the line. On 9/18/18 at 11:20 AM during a follow up kitchen tour, EI #5 was asked to take apart a stack of bowls. Surveyor observed 10 bowls to be wet. Surveyor asked EI #5 what was the substance on the surface of the plates. EI #5 stated water. Surveyor then asked EI #5 what was that considered. EI #5 stated wet nesting. Surveyor asked what was the potential harm in wet nesting or water on the surface of the bowls. EI #5 stated bacterial growth. EI #5 was asked again how should you dry dishes and bowls. EI #5 stated they should be air dried.

Based on observations, staff interview and record reviews of the 2013 Food Code, facility policy and Department of Food & Nutrition dishmachine documentation for September 2017, the facility failed to prevent: I. Poor Cleaning and Sanitizing of Equipment by a failure to assure the Robo Coupe was air dried prior to storing on the stand. II. The facility failed to assure staff did use a hot water sanitizing rinse that was greater than 194 degrees Fahrenheit (F). According to the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), . The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 113 residents receiving meal trays from dining services as evidenced by a review of the facility Diet list. Findings include: I. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), . An observation of the operation of the dishmachine on 9/13/2017, at 9:05 AM, the temperature gauge read 196 degrees F. The Certified Dietary Manager (CDM) Employee Identifier (EI) #9 validated the reading. Record Review of the facility monitoring log titled DISHROOM TEMPERATURE AND PRODUCT RECORD for September 2017, revealed that documented temperatures exceeded 194 degrees F. for eight of 36 opportunities or 22 % of the of the time. The documented designated a rinse temperature of 180 degrees F. but failed to indicate an upper limit for staff monitoring . a. Facility document titled Safety & Sanitation Best Practice Guidelines Revised 1/20/11. Guidelines of High-Temperature Machines: .3. The temperature of the final sanitizing rinse must be a least 180 degrees F. b. A chemical company regular service call dated 9/13/2017, documented the observed final rinse temperature to be 190 degrees F. c. On 9/14/2017 at 2:30 PM, the facility Administrator submitted a document from CMS (Centers for Medicare & Medicaid Services S&C: 14-34-NH and dated May 20, 2014. The document addressed chemical sanitation but there was no reference to high temperature machines. During an interview on 9/14/2017 at 8:40 AM with the EI #9, the CDM was asked how one could assure effective sanitizing (when the machine registered 196 degree F.) and the response was that we cannot. II. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: Drying 4-901.11 Equipment and Utensils, Air-Dying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining . An observation on 9/13/2017 at 12:00 Noon revealed the Robo Coupe blender was stored on the stand atop the counter with the lid cover on, water was inside. EI #9 turned the blender over and water pooled on the counter top and at that time EI #9 said: Not air dried. During an interview with the CDM on 9/14/2017 at 8:40 AM, EI #9 was asked what the requirements were for manual dishwashing. EI #9 responded: Should be air dry and stated the potential risk was for bacterial growth.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #2 received meals from the kitchen at the same time her roommate did. This was observed on 9/13/2017 during lunch and supper meals. This affected RI #2, one of fourteen sampled residents observed during meals. Findings Include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/13/2017 at 11:40 a.m., the surveyor observed RI #2's meal tray arrived thirty minutes after his/her roommate received his/her meal. On 9/13/2017 at 5:32 p.m., the surveyor observed RI #2's meal arrived forty minutes after his/her roommate received his/her meal. An interview was conducted on 9/13/2017 at 5:40 p.m. with RI #2. RI #2 was asked if it bothered him/her that his/her roommate received his/her meal before he/she did. RI #2 stated, Yes, it does. RI #2 was asked how long did he/she usually have to wait for his/her meal after his/her roommate's meal arrived. RI #2 replied, Twenty to thirty minutes. RI #2 was asked if he/she knew why his/her roommate received his/her meals before he/she did. RI #2 stated that his/her roommate use to take his/her meals in the dining room but he/she quit. He/She also stated the dining room meals were served first. An interview was conducted on 9/14/2017 at 8:30 a.m. with Employee Identifier (EI) #1, the Charge Nurse. EI #1 was asked why RI #2's meal arrived thirty minutes after his/her roommates' meal arrived. EI #1 stated the roommate usually ate in the dining room and that the dining room trays arrive first. EI #1 was asked if she saw a problem with this. EI #1 stated yes, if they don't receive meals at the same time, or if they don't pull the curtain. She also stated residents in the same room should be served at the same time.

Based on observations, resident interview, staff interviews, medical record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a pain care plan was developed for RI (Resident Identifier) #13, who has a [DIAGNOSES REDACTED]. This deficient practice affected one of fourteen sampled residents whose care plans were reviewed. Findings include: RI #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #13's physician's orders [REDACTED]. [MEDICATION NAME] 100 MG (milligrams) . GIVE TWO CAPSULES BY MOUTH THREE TIMES A DAY FOR [MEDICAL CONDITION] PAIN . [MEDICATION NAME]-APAP 7.5-325 TAB . GIVE ONE BY MOUTH THREE TIMES DAILY . Diagnosis : pain . [MEDICATION NAME] 325 MG TABLET (TYLENOL) .TWO (2) BY MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN . [MEDICATION NAME]-APAP 7.5-325 TAB . ONE (1) BY MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN . A review of Potter and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, Chapter 18, Planning Nursing Care, page 240, states .After making a medical diagnosis, a health care provider will choose interventions and communicate the plan to the health care team. After identifying a patient's nursing [DIAGNOSES REDACTED]. During the survey initial tour on 09/13/2017 at 8:42 a.m., RI #13 was observed wearing a neck support pillow. During an interview with RI #13 on 09/14/2017 at 2:05 p.m., RI #13 was again observed wearing a neck support pillow. RI #13 was asked why he/she wore the neck support pillow. RI #13's response was, It keeps my neck from hurting. RI #13 was asked if he/she was hurting. RI #13's response was, No, not now. But sometimes I be hurting though. My foot, my neck, all over. But mostly, my foot. During an interview with EI (Employee Identifier) #6, Licensed Practical Nurse (LPN), Unit Manager, on 09/14/2017 at 3:00 p.m., EI #6 was asked if RI #13 had a pain care plan. Her response was, He/She does not have a pain care plan. During an interview with EI #7, Registered Nurse (RN), Minimum Data Set (MDS)/Care Plan Coordinator, on 09/14/2017 at 3:25 p.m., EI #7 was asked if RI #13 had a pain care plan. Her response was, No. I do not see one specifically for pain. EI #7 was asked if [DIAGNOSES REDACTED]. Her response was, Yes.

Based on review of the non-controlled drug destruction records, the CODE OF ALABAMA 1975, TITLE 34 CHAPTER 23 PRACTICE OF PHARMACY ACT 205. LEGISLATURE 1966 ALABAMA STATE BOARD OF PHARMACY and interview, the facility failed to have a method of destruction and the required two signatures for non-controlled drugs. Findings include: The CODE OF ALABAMA 1975, TITLE 34 CHAPTER 23 PRACTICE OF PHARMACY ACT 205. LEGISLATURE 1966 ALABAMA STATE BOARD OF PHARMACY, revealed . 2. Drugs may only be returned for the sole purpose of destruction .c.1. The Pharmacy shall maintain a separate log of all returned drugs .1. General description of returned drugs. 2. Date of return. 3. Date and method of destruction 6. Records must be completed and maintained by the facility and include: (iii)Method used for destruction .7. The pharmacist will verify that the list of drugs to be destroyed is accurate and with a Registered Nurse, will carry out destruction. Both will sign the destruction form indicating amounts listed are correct and have been destroyed. The facility Procedure for Controlled and Non Controlled substance disposal revealed: . E. all non controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: 10 In the facility director of nursing or designee and the pharmacist or designee and recorded by the pharmacist. A review of the Narcotic and Non-Narcotic Drug Destruction Record (June 2017- August 2017), revealed there was no method identified of how drugs were destroyed each month. On 9/14/17 at 4:00 PM , Employee Identifier (EI) #8, the Director of Nursing stated the drugs were destroyed with the pharmacist and a nurse; however there were no signatures nor method of destruction.

Based on observations, interviews with facility staff, review of a facility policy titled, INFECTION CONTROL MANUAL Subject: HANDWASHING, review of a facility policy titled, Personal Protective Equipment - Using Gloves and review of POTTER and PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure: 1. Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN), washed her hands after removing gloves and prior to donning gloves to administer an insulin injection to Resident Identifier (RI) #12. 2. EI #3, a Registered Nurse (RN), changed gloves after touching objects on the medication cart and before obtaining a finger stick blood sugar on unsampled resident #1. 3. EI #4, an LPN, did not use gloves from her pocket during administration of an eye drop for unsampled resident #2. This affected three of five nurses observed during medication administration on 09/13/17. Findings include: Review of POTTER and PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V, CHAPTER 32, SKILL 32-5 ADMINISTERING INJECTIONS, p. 671, revealed: STEP . 7. Apply cleans gloves . RATIONALE . Reduces transfer of microorganisms . Review of a facility policy titled, INFECTION CONTROL MANUAL Subject: HANDWASHING with a Revised Date 10-1-08 documented: B. HANDWASHING . PR(NAME)EDURE Wash hands before and after contact with each patient, . and before and after removal of gloves . Review of a facility policy titled, Personal Protective Equipment - Using Gloves, with no date, documented: . Miscellaneous . 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . 1. On 09/13/17 at 11:12 a.m., the surveyor observed EI #2 remove her gloves and don a clean pair of gloves without washing her hands prior to administration of an insulin injection for RI #12. 2. On 09/13/17 at 11:35 a.m., the surveyor observed EI #3 don gloves then obtain a lancet, test strip and alcohol wipe out of med cart and place on paper plate along with a glucometer. EI #3 then entered unsampled resident #1's room wearing the same gloves and obtained a finger stick blood sugar. 3. On 09/13/17 at 5:06 p.m., the surveyor observed EI #4 don gloves from her pocket before administering an eye drop in unsampled resident #2's right eye. On 09/14/17 at 1:40 p.m. in an interview with EI #3, the surveyor asked, did you obtain a finger stick blood sugar for unsampled resident #1 wearing the same gloves that you wore setting up the supplies. EI #3 said, yes, I did. EI #3 was asked, is that an infection control issue. EI #3 answered, yes, it is. On 09/14/17 at 1:58 p.m. in an interview with EI #5, RN, Assistant Director of Nursing/Infection Control, the surveyor asked, should employees wash their hands after removing gloves. EI #5 said, yes. EI #5 was asked, should gloves be put in an employee's pocket to use to administer eye drops. EI #5 answered, no. EI #5 was asked, should an employee use the same gloves that have been worn to pull medications and retrieve items from the medication cart to administer an injection or do a fingerstick. EI #5 said, no. On 09/14/17 at 3:45 p.m. in a telephone interview with EI #2, the surveyor asked, did you wash your hands after removing your gloves and before applying another pair to give RI #12's insulin injection. EI #2 said, I did not. I changed my gloves, but I did not use sanitizer or wash my hands. EI #2 was asked, is that an infection control issue. EI #2 replied, yes ma'am. On 09/14/17 at 4:15 p.m. in a telephone interview with EI #4, the surveyor asked, did you use gloves from your pocket to administer unsampled resident #2's Refresh eye drops. EI #4 said, yes.

Based on observation, interviews and record review, the facility failed to ensure RI (Resident Identifier) #2's fall care plan was revised to reflect the discontinuation of the fall mat. The facility further failed to ensure RI #11's care plan was revised to reflect the resident's ability to apply and remove the splint. This affected 2 of 20 sampled residents whose care plans were reviewed. Findings include: Review of the facility document titled, Care Plan Development, revised on 7/3/08 revealed: .13. Updating and Revising Care Plans Routine Reviews and Updates: Care plans are updated as needed . 1) RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Significant Change Minimum (MDS) data set [DATE] documented RI #2 required assistance of one person for ambulation in room. RI #2's Care Plans dated 7/8/2016 documented the following: .Patient has a history of falls .APPROACHES . Fall mat beside bed . On 08/23/2016 at 4:00 p.m., the surveyor noted RI #2 sitting on the bed. No fall mat was on the floor beside the bed. On 08/24/2016 at 11:24 a.m., the surveyor observed RI #2's room and noted a fall alarm to the bed but no fall mat. On 08/24/2016 at 3:47 p.m., the surveyor interviewed Employee Identifier (EI) #5, Registered Nurse (RN)/Unit Manager. EI #5 was asked what was the purpose of RI #2's care plan. She stated it was an individualized care plan which documents how staff is to take care of the resident. EI #5 was was asked to review RI #2's fall care plan. When asked what interventions should be in place, EI #5 listed several interventions to include a fall mat. EI #5 was asked why it was important to have the interventions in place. She stated the interventions were very important and had been put in place because of a fall. EI #5 was taken to RI #2's room and asked if the interventions were in place. She stated that she did not see the fall mat. When asked if the intervention should be in place, EI #5 stated yes, because it is a part of RI #2's care plan. When asked if RI #2's care plan was being followed she stated no. On 08/24/2016 at 5:05 p.m., the surveyor interviewed EI #6, the Restorative Nurse. EI #6 stated that RI #2's fall mat intervention had been removed at the end of July due to an improvement in RI #2's cognition and improvement in ability to transfer. EI #6 further stated that there was no documentation and that she should have documented the change in the care plan so that other staff members would know the fall mat had been removed. 2) The Restorative/Therapy Manual (undated) explains splint or brace assistance as of two types: 1. Where staff provides verbal and physical guidance and direction that teaches the patient how to apply, manipulate, and care for a brace or splint. 2. Where staff have a scheduled program of applying and removing a splint or brace, assess the patient's skin and circulation under the device, and reposition the limb in correct alignment. These sessions are planned, scheduled, and documented in the clinical record. RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent (annual) MDS assessment with an Assessment Reference Date of 06/22/16, identified RI #11 as cognitively intact (with a Brief Interview for Mental Status of 15 of 15) and no impairment in ability to understand or be understood. Upper and lower impairments in range of motion were documented on one side of RI #11. Physicians' orders dated 04/07/16, included the use of a splint to the resident's left hand: Apply splint at 9:00 A.M. (on) Remove at 1:00 P.M. (off) . Care plan interventions (last reviewed 06/27/16) related to the resident's need of extensive-dependent assistance with activities of daily living (except self feeding) included the use of: L (left) arm/hand splint assist (him/her) with Donning/Doffing L wrist/Arm splint as needed--(he/she) has been educated on its use; observe complicance (compliance) and provide education if needed. Splint to be put on after breakfast and taken off after lunch; splint is to the left wrist/arm. may wear protective sleeve to protect skin; observe for c/o (complaints of) tingling, pain, or numbness, and intervene (he/she) has been educated on donning/doffing splint, attatching (attaching)/loosening straps, and how to clean/store splint. observe for compliance (compliance) & s/x (symptoms of) breakdown such as redness, pain, etc and intervene . A copy of Splint Program . was located in RI #11's medical record signed by the Occupational Therapist and dated 05/29/15. .pt (patient has been taught how to put splint on/off, attatch (attach)/loosen straps, and how to clean/storage recommendation . Observations were made throughout the survey of RI #11. At no time was the hand/arm splint in place, despite care plan directives for use between 9:00 a.m. and 1:00 p.m.: a) 08/23/16 at 11:05 a.m. the resident was up in wheel chair with left arm/hand in special arm rest (padded trough) attached to wheelchair. b) 08/24/16 at 9:05 a.m. RI #11 was tending to potted plants outside on the patio, seated in the wheel chair. The left arm was positioned on the padded trough, with no arm/hand splint in place. When questioned, RI #11 stated it was the rehabilitation staff who applied the splint. 10:12 a.m.: The resident was seated in the wheel chair, in room. RI #11 retrieved two different splints from the dresser and explained the use of each (one for use in bed, applied by evening staff) and one used during the day time to the surveyor. RI #11's left arm was positioned in the padded arm trough without either splint in place. 12:07 p.m.: The resident was seated in the dining room, with no splint in place. RI #11 stated the splint had not been put on today. c) 08/25/16 at 9:20 a.m.: The resident was seated in the wheel chair, with left arm in the trough, no splint in place. RI #11 explained the staff applied the splint, and he/she could take it off during the day but it was too complicated to apply him/herself. 9:45 a.m.: The resident was seated in the wheel chair in his/her bedroom, with the left arm in the padded trough and no splint. RI #11 explained he/she could take the splint off, but could not put it on. RI #11 stated no one had applied the splint this day. On 08/25/16 at 9:34 a.m., the Restorative Nurse (EI #6) was interviewed regarding the purpose of the splint and application. EI #6 explained the splint was ordered to prevent further contractures to the (left) arm and hand, applied and removed by the resident; and the use verified by another nursing staff member (on the Medication Administration Record). When asked where in the care plan, was the resident's responsibility in applying and removing the splint, EI #6 found no documentation. On 08/25/16 at 10:25 a.m. EI #6 affirmed a change to the care plan had been made of the resident's responsibility in donning and doffing the splint.

Based on observation, interviews and record review, the facility failed to ensure that Employee Identifier (EI) #4, a Registered Nurse (RN), flushed RI (Resident Identifier) #1's PEG (Percutaneous Endoscopic Gastrostomy) tube prior to the administration of medications on 08/24/2016. This affected RI #1 one of one residents observed for PEG tube medication administration. Findings include: A facility policy titled GENERAL GUIDELINES FOR ADMINISTERING MEDICATION VIA (by way of) ENTERAL TUBE, dated 6/2016 documented: Policy The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Procedures . D. Enteral tubes are flushed with at least 30 mL (milliliter) of water before administering medications . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/23/2016 at 4:27 p.m. during the med (medication) pass observation. The surveyor observed EI #4, preparing and administering the following medications to RI #1: Juven one packet, [MEDICATION NAME] one tablet, [MEDICATION NAME] one tablet and [MEDICATION NAME] liquid 15 mLs. EI #4 checked the placement of RI #1's PEG Tube by aspiration and auscultation as required. EI #4 then administered the medications via the PEG tube. EI #4 did not flush the PEG tube prior to the administration of the medications. On 08/23/2016 at 5:07 p.m., the surveyor interviewed EI #4, the RN administering medications to RI #1. EI #4 stated she was uncertain of the facility policy regarding flushing PEG tubes prior to medication administration. She stated the tube should be flushed prior to administering medications but did not know how much. EI #4 further stated she had not flushed RI #1's PEG tube prior to the administration of medications. When asked why it was important to flush the PEG tube prior to medication administration, EI #4 stated you want a clear tube, so there would be no interactions. On 08/25/2016 at 8:45 a.m., the surveyor interviewed EI #2, the RN/Infection Control Nurse. (EI #1, the Director of Nursing was also in the room.) EI #2 was asked what should be done prior to administering medications via a PEG tube. She stated, flush with 30 mLs of water. When asked why this should be done, EI #2 stated it helps medications go through the tube easier. At the end of EI #2's interview, the surveyor asked EI #1, the Director of Nursing what should be done prior to administering medications via a PEG tube. EI #1 confirmed that the tube should be flushed with 30 mLs of water.

Based on observations and interviews the facility failed to ensure: 1) Employee Identifier (EI) #4, a Registered Nurse (RN), did not place her fingers inside the medication cups used to administer medications to RI #1 on 08/24/2016. 2) EI #3, a Certified Nursing Assistant (CNA) changed her gloves and washed her hands after completing incontinence care and prior to touching RI #8's brief. This affected RI #1, one of five residents observed during medication administration and RI #8, one of two residents observed during incontinent care. Findings include: 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/23/2016 at 4:27 p.m., the surveyor observed EI #4 preparing RI #1's medications for administration. EI #4 was observed to touch the inside of the medication cups prior to placing medications in them. On 08/23/2016 at 5:07 p.m., the surveyor interviewed EI #4. When asked what part of the medication cup should be touched, EI #4 stated the bottom and further stated, I touched the rim, didn't I? EI #4 further stated when touching the rim of the medication cup, she had touched the inside of the cup. When asked if her fingers should touch the inside of the medication cups, EI #4 stated, never due to infection control. On 08/25/2016 at 8:45 a.m., the surveyor interviewed EI #2, the RN/Infection Control Nurse. EI #2 was asked which part of the medication cup should be touched during medication administration. She stated, the bottom. EI #2 further stated that a nurse should not place her fingers in the medication cup for any reason because it could cause cross contamination. 2) A review of an undated facility policy titled Perineal Care revealed PURPOSE: To provide cleanliness and comfort to the patient, prevent infections .PROCEDURE: .5) Put on gloves .6 .b) Wash perineal area .e) Wash the rectal area .8) Remove gloves .9) Reposition bed covers . RI #8 was admitted to the facility 10/21/14 with [DIAGNOSES REDACTED]. A review of Laboratory form dated 7/7/16 for Urinalysis with Microscopic revealed BACTERIA LARGE. Further review of Laboratory form dated 7/8/16 revealed CULTURE URINE Identity Escherichia coli. On 8/24/16 at 9:00 a.m. Employee Identifier (EI) #3, CNA was observed cleaning RI #8. EI #3 cleaned the front then turned the resident to the side and cleaned the buttocks. EI #3 rolled the soiled pad toward the resident and placed the clean pad under RI #8 with the same soiled gloves. On 8/24/16 at 9:30 a.m. an interview was conducted with EI #3. EI #3 was asked how was she trained to do pericare. EI #3 replied wipe the front, then the buttocks area then change gloves after washing your hands and place the clean pad. EI #3 was asked when should she change gloves; she replied after each task. EI #3 was asked if she changed gloves before placing the clean pad. EI #3 replied no. EI #3 was asked what the harm was in not changing gloves before touching the clean pad. EI #3 replied infection. On 8/25/16 at 8:45 a.m. an interview was conducted with EI #2, Registered Nurse Infection Control. EI #2 was asked what type of infections was she currently monitoring. EI #2 replied UTIs. EI #2 was asked what should staff do after performing incontinent care and prior to touching clean items. EI #2 replied they should wash their hands. EI #2 was asked why should staff wash their hands. EI #2 replied cross contamination.

Based on observations, record review and interviews the facility failed to ensure a licensed staff provided privacy to Resident Identifier (RI) #15 when performing a blood glucose finger stick on 8/4/15. This was observed during medication pass observation and affected 1 of 8 residents observed during medication pass. Findings include: A facility policy titled: Specific medication administration procedures, with an effective date of 5/07 revealed, Procedures. B. Provide privacy for a resident if appropriate. RI #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #14's Physician order [REDACTED]. On 8/4/15 at 3:53 PM, during medication pass observation ,Employee Identifier (EI) #4, Licensed Practical Nurse, performed a blood glucose finger stick on RI #15 without closing the door and providing privacy. On 8/4/15 at 4:00 PM, an interview was conducted with EI #4. EI #4 was asked when entering RI #15's room and before performing a blood sugar check do recall what you did not do. EI #4 replied she forgot to close the door. EI #4 was asked what was the facility policy when administering medications. EI #4 replied close the door. EI #4 was asked what was the potential harm in not closing the door. EI #4 replied privacy. On 8/6/2015 at 10:00 AM, an interview was conducted with EI #3, Director of Nursing. EI #3 was asked what was the facility's policy regarding resident privacy during medication pass. EI #3 replied the resident's door should have been closed or the curtain should have been pulled to allow for privacy. EI #3 stated, it was a dignity issue for the resident when this is not done.

This deficiency was written as a result of complaint #AL 530. Based on interviews and record reviews, the facility failed to ensure EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse), EI #4, a CNA (Certified Nursing Assistant), EI #5, a CNA, and EI #6, a CNA, safely transported RI (Resident Identifier) #1, a dependent, confused, non-ambulatory resident, in a manner to prevent a fall with injuries. On [DATE] at 8:12 PM, a fire was discovered in the shower room next to RI #1's room. EI #6 transported the resident away from the fire without incident. After the fire department gave clearance, residents were transported back to their rooms. RI #1 was placed on a backboard, used by facility staff to perform CPR (Cardio Pulmonary Resuscitation). RI #1 was not secured to the backboard. Upon entering the resident's room, EI #s 3, 4, 5, and 6 held the backboard suspended approximately two and one half feet above the floor for approximately five to ten minutes, while EI #12, another CNA, made RI # 1's bed. RI #1 fell facedown off the suspended board onto the floor, hitting their head on a dresser/night stand. As a result of the fall, the resident was rendered unconscious and sustained two hematomas to the head. RI #1 was transported to a local emergency roiagnom on [DATE] and treated for [REDACTED]. According to the staff who transferred the resident, EI #s 3, 4, 5, and 6, they used the backboard to transfer RI #1 even though they had no prior training on using this device to transport residents. This affected RI #1, one of two residents transported by a backboard on [DATE]. This deficient practice posed an immediate threat to the health and safety of residents, as it is likely to cause serious harm, injury, impairment, or death. On [DATE] at 7:32 PM, the Administrator, DON (Director of Nursing), Senior Vice President, and two Regional Nurses were made aware that the surveyors identified an Immediate Jeopardy level "J" at F 323. The Immediate Jeopardy began on [DATE] and was relieved on [DATE] at 9:30 PM, when it was verified the facility implemented immediate corrective actions to remove the immediacy. The scope and severity of F 323 was lowered to a "D" level to allow the facility time to monitor and if necessary, revise their corrective actions to achieve substantial compliance with F 323. Findings include: On [DATE] at 3:52 PM, the Alabama Department of Public Health, Division of Health Care Facilities received a complaint alleging RI #1 had been dropped by facility staff while being transported on an unsecured backboard causing injury to the resident. A review of facility's undated policy titled, "TRANSFER, ONE MAN CRADLE DROP CARRY FOR USE IN EMERGENCY AND DISASTER SITUATIONS," revealed the following: "PURPOSE: Designated partner will use a one person cradle drop carry in emergency situation only. OBJECTIVE: Rapid evacuation of non-ambulatory patients using available partners. PROCEDURE: 1. Position blanket on floor so there is plenty of room above patient's head. 2. Remove legs from bed. 3. Hold patient at shoulder. 4. Get to your knees. 5. Slide patient from bed. 6. Wrap blanket around patient if overactive. 7. Two assistants maybe required on carpet. CRADLE DROP: * Grip under shoulders and hips. Put blanket on floor. * Slide to edge of bed. * On one knee or both knees slide patient down your chest. * Pull him out headfirst on blanket. NHC South Central Region Procedures Manual" RI #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) dated [DATE], revealed RI #1 identified as cognitively impaired for daily decision making as evidenced by inability of the resident to complete a Brief Memory Assessment. RI #1 was identified as having short and long term memory impairment and was as totally dependent on staff for all activities of daily living, including transfers. RI #1 did not ambulate. A review of the care plan dated [DATE] revealed RI #1 was "... at risk for falls related to weakness, decreased physical functioning, history of falls, incontinence, cognitive impairment and use of psychotropic medications and diuretics. ...Approaches Extensive-dependent assistance with transfers and mobility. ..." A review of the EMS (Emergency Medical Service) report dated [DATE] revealed RI #1 was identified as a Fall Victim. EMS staff were present with RI #1 at 9:11 PM. The "Chief Complaint: POSS (Possible) HEAD INJURY UNSP (Unspecified), Primary Symptom: Change in Responsiveness, Location: Head, Primary Impression: 959.90- Traumatic Injury, Secondary Impression: 959.90- Traumatic Injury Mechanisms: Blunt; Injury: Yes;... Cause: Falls ... Narrative "EMS ON SCENE ... EMS WERE CALLED TO A ROOM WHERE ... PATIENT HAD BEEN DROPPED FROM APPROXIMATELY 3 FEET TO THE FLOOR LANDING HEAD FIRST ON THE FLOOR POSITIVE LOSS OF CONSCIOUSNESS ..." A review of the facility's investigation regarding RI #1 revealed, "...Date of fall: [DATE] Time of fall: 9:30 PM FALLS TEAM MEETING NOTES Summary of meeting: Systemic or operational conditions that may contribute to falls? Any patterns or trends to the patient's falls? Pt (Patient) was being transferred by staff to bed via backboard after hall was evacuated. Pt became agitated and combative + (and) rolled off backboard to the floor. She landed on her abdomen, side and head. Had hematoma + (and) bruise noted to the forehead. Conclusion: MD (Medical Doctor) + (and) family notified. Pt sent for evaluation and treatment related to unresponsiveness with stable vital signs and hematoma to head. Results: No abuse or neglect suspected." This section was signed by EI #15 an LPN (Licensed Practical Nurse) A review of the "FSI- FALL SCENE INVESTIGATION REPORT," page 1 of 3, revealed, "Patient Name: (RI #1's name) Date of Fall: [DATE] Time of Fall: 9:30 PM Staff/Witness present at/or finding patient after fall: (EI #3's name) Draw a picture of area and position in which patient was found..." The drawing indicated a six-sided backboard with a narrow opening at the head (wide end) and a narrow opening at the foot (narrow end) of the backboard. EI #3 (LPN) was positioned at the head of the backboard, EI #6 (CNA) was located on the left side at the foot of the backboard, EI #5 (CNA) was located at the direct end (foot) of the backboard, and EI #4 (CNA) was located on the right side at the foot of the backboard. Three arrows were drawn indicating the resident rolled off towards the right side of the backboard. "Fall Summary Fall to floor (witnessed) (box checked) What was resident doing during or just prior to fall? Transfer assisted by staff (box checked) Fall location Patients room (box checked)...Describe patient's mental status prior to fall: Awake with confusion... ROOT CAUSE OF THIS FALL Review of contributing factors: Mood or mental status (checked) What appears to be the initial root cause(s) of the fall? Resident's restlessness and sudden movement on transfer backboard Describe initial interventions to prevent future falls: If using a transfer backboard, use one with straps NURSE COMPLETING FORM: (EI #3's name) Date and Time: [DATE] 12:30" Included in the investigation were the following handwritten statements: EI #6's (CNA) statement, dated [DATE], revealed RI #1 was placed on a carrying board. The resident began to panic as staff members were carrying the resident to the bed. The staff paused in the resident's room while they waited for RI #1's bed to be made. RI #1 panicked because the resident was frightened about the fire earlier and for being carried. RI #1 began to struggle to get free and then rolled to the resident's right and rolled off the carrying board. RI #1's head was struck on the night stand. EI #6 indicated he did not see any straps securing RI #1 to the backboard. EI #4's (CNA) statement, dated [DATE], revealed she assisted EI #s 3, 5, and 6 to return RI #1 to the resident's room on a backboard. After entering the resident's room, staff had to wait for the bed to be made. EI #4 indicated the resident fell to the right off the backboard and onto the floor. EI #5's (CNA)undated statement, indicated four (EI #s 3, 4, and 6) people were holding the board as they were waiting for RI #1's bed to be made. RI #1 became agitated and was trying to roll. The resident rolled off toward the dresser and hit their head. A review of RI #1's the local hospital history and physical dated [DATE] revealed, RI #1 presented to the emergency department "CHIEF COMPLAINT: Fall, Closed head trauma." The resident presented with a complaint of fall and injury. The report indicated, "There was a fire at the nursing home and the patient was moved due to her room being next door to where the fire started. The patient was being put back in (RI #1's) room and (RI #1) was dropped off the backboard, face first, and (RI #1) was noted to have a hematoma on (RI #1's) forehead, skin tear to the left hand. ... The patient admitted to the hospital for observation due to closed head trauma." An interview was conducted with a member of the fire department on [DATE] at 3:56 PM. The fireman stated he was across the hall from RI #1's room at the time of the fall and responded to a thud and screams. The fireman stepped into the resident's room and saw RI #1 on the floor. On [DATE] at 4:39 PM an interview was conducted with the Paramedic who was onsite and responded to RI #1's fall. The Paramedic observed RI #1 dazed, with a hematoma on the head and semi-responsive. Staff reported to the Paramedic that the backboard tilted and RI #1 fell face first on the floor. During a subsequent interview on [DATE] at 7:37 AM the Paramedic stated he was informed by staff that RI #1 was unconscious for 2 to 3 minutes following the fall. An interview was conducted with EI #4 on [DATE] at 5:26 PM. EI #4 (CNA) assisted with returning RI #1 to the room using a backboard. EI #4 did not know where the backboard came from and stated she had never seen it before. EI #4 recalled waiting in the room with the other staff members (EI #3, 5, and 6) for RI #1's bed to be made ready and stated, "...the next thing I know she tilted and flipped over." When asked what was in place to keep RI #1 from falling, EI #4 responded, "Nothing." When the surveyor inquired what training had EI #4 received regarding use of the backboard, EI #4 reported none and that was the first time EI #4 had ever used a backboard. An interview was conducted on [DATE] at 7:37 AM with EI #5 (CNA), who assisted with RI #1's transfer using the backboard. EI #5 stated she had never seen the backboard before. EI #5 explained that while waiting for RI #1's mattress to be put on the bed, "...the resident was wiggling and kind of fighting us, before we knew it she was in the floor." When asked what was in place to keep RI #1 from falling, EI #5 replied, "I don't remember anything..." EI #5 reported she had no training on use of the backboard until after the incident. When asked if the backboard was a safe choice for transporting RI #1 back to her room, EI #5 responded that initially it was thought to be. However, EI #5 indicated that was no longer her opinion. When EI #5 was asked why the backboard would not be considered the safe choice for transporting RI #1, EI #5 answered, "Because (RI #1) got hurt and it could have been prevented." On [DATE] at 8:17 AM, a telephone interview was conducted with EI #6, CNA who participated in transporting RI #1 back to the room using the backboard. When asked where the board came from, EI #6 reported, "I have no idea, I had never seen that board before." EI #6 recalled that the staff members were walking in the room and the bed was not ready. "The person on the side of the board moved it. (RI #1) was panicky and rolled." EI #6 reported receiving no training on use of the backboard prior to [DATE]. EI #6 further explained staff figured with 4 people it would be safe, but it was a poor choice because RI #1 was panicking and could fall. On [DATE] at 12:57 PM, an interview was conducted with EI #12, the CNA who prepared RI #1's bed at the time of the fall. EI #12 reported that before RI #1 could be put in the bed, she had to put the air mattress back in place and make up the bed. EI #12 estimated this task took no more than 5 to 10 minutes. On [DATE] at 1:20 PM, an interview was conducted with EI #3 (the LPN in charge nurse on the date of the incident). EI #3 reported assisting with transporting RI #1 back to the room on a "yellow strapless backboard." When asked why, EI #3 responded, "That was all we had..." EI #3 did not know who made the decision to transport RI #1 using the backboard. When EI #3 was asked who was in charge at the time of the code for EI #3's area, EI #3 answered, "Me." EI #3 did not know where the backboard came from or had ever seen the backboard before. EI #3 recalled the events of the incident as follows, "...We are holding (RI #1), a CNA is fixing the bed, ... we were waiting, standing at attention, everybody still." EI #3 further explained he thought RI #1 became confused and restless. EI #3 described how the resident was suspended two and half feet off the floor. When asked what was in place to keep the resident from falling off the side, EI #3 responded, "Nothing really." EI #3 admitted RI #1 had a history of [REDACTED]. EI #3 was asked if the backboard was a safe choice for transporting the resident back to the room EI #3 answered, "No Ma'am." When asked why, EI #3 answered, "The straps are needed." EI #3 denied having received any training regarding the use of the backboard. In a subsequent interview on [DATE] at 10:02 AM, , EI #3 was asked how long had RI #1 had been unconscious after the fall. EI #3 estimated RI #1 had been unconscious for about a minute. On [DATE] at 10:23 AM, the surveyor requested the policy for the backboard. EI #2, the DON (Director of Nursing), reported, "We don't have a policy on the backboard. The board is what we use for CPR." An interview was conducted with EI #11, an RN (Registered Nurse), on [DATE] at 2:28 PM. EI #11 reported if the resident can't get up, staff were trained to cradle scoop. When asked what would have been the safest mode per policy to transfer RI #1 back to the room, EI #11 answered, "The scoop slide with sheet." An interview was conducted with EI #9, RN, on [DATE] at 1:34 PM. EI #9 reported seeing the backboard after the fall in RI #1's room. EI #9 reported that EI #7, a CNA, had suggested the backboard be used for another resident and had retrieved it from downstairs in Central Supply. EI #9 indicated she had not received any training regarding the backboard. EI #9 was asked if the backboard was a safe choice for transporting the resident back to the room. EI #9 responded, "I don't think so, we could have just put (RI #1) in the room by ourselves." EI #9 did not know why RI #1 was transported on the backboard, and stated, "It wasn't called for." An interview was conducted on [DATE] at 2:15 PM with EI #10, LPN. EI #10 reported being across the hall, hearing a commotion, then stepping into RI #1's room. When asked what was observed, EI #10 said RI #1 was in the floor and EI #3, LPN, was assessing the resident. EI #10 went in to help and observed RI #1 unconscious with a knot forming on the forehead. EI #10 reported observing RI #1 unconscious for one and one-half minutes before leaving the resident's room. EI #10 did not recall receiving any training on use of a backboard. EI #10 reported she thought the chair to be a safer choice for transporting RI #1. An interview was conducted with EI #2, DON on [DATE] at 3:49 PM. EI #2 reported that according to the investigation, RI #1 was transported back to the room using the backboard, but did not know why. EI #2 stated that at times, RI #1 did have restlessness and combative behaviors. EI #2 did not know who made the decision to place RI #1 on the backboard. EI #2 was asked what precautions were taken to keep the resident safe while being transported back to the room. EI #2 responded, "There was adequate staff assisting with the transfer. There was no rush. I actually saw them transporting (RI #1) down the hall and never once thought that it was an unsafe action." When asked what did the facility policy say regarding transferring the resident during an emergency, EI #2 answered, "If we can't use wheelchair, we use the slide." EI #2 was asked if transferring the residents on backboards without securing them, was a safe use of equipment and EI #2 answered, "No." EI #2 reported staff had not received training regarding using backboards prior to [DATE]. EI #2 was asked if a resident should be suspended on a backboard, unsecured. EI #2 responded, "I feel like if the persons felt like they were in control, it should be safe." When asked why wasn't a board with straps used for RI #1 on [DATE], EI #2 answered, "I don't know." EI #2 reported there was no policy in place regarding backboards. An interview was conducted with EI #1, the Administrator on [DATE] at 4:58 PM. EI #1 reported that RI #1 was transported back to the room utilizing a backboard. When asked what precautions should have been taken, EI #1 answered, "Straps could have been a precautionary." EI #1 reported that transferring residents on backboards without using straps was not considered to be safe use of equipment. EI #1 stated staff had not received training regarding the use of backboards prior to [DATE]. EI #1 was asked if a resident should be suspended on a backboard, unstrapped. EI #1 answered, "Probably not." EI #1 confirmed that the facility did not have a policy in place regarding the backboards and stated the policy regarding transferring RI #1 back to the room was not followed. EI #1 reported the staff members were trained on safe modes of transport during an emergency situation, but none of the methods included a backboard. During a subsequent interview with EI #1 on [DATE] at 6:04 PM, EI #1 stated prior to the incident, staff should have secured RI #1 to the backboard to prevent the resident from falling. EI #1 stated there had not been about monitoring or follow-up after the incident. *************************************** Allegation of Compliance (AOC) F323 On [DATE] at 9:01 PM, the facility provided the surveyors with an acceptable AOC, which documented: F323 Incidents/Accidents 1. Corrected Actions Accomplished For the Patient Found To Have Been Affected By The Allegedly Deficient Practice -On [DATE] transfer backboard was removed from use in the center -Patient #4181 care plan was updated to remove emergency use of transfer board 2. How We Have Identified Other Residents Having The Potential To Be Affected By The Same Practice And What Corrective Action Has Been Taken -Overseen by (name of Regional Nurse) and completed on [DATE] a review of all patient care plans to ensure back board was not listed as a transfer device and appropriate transfer devices were care planned -(Name of Regional Nurse) in-serviced the DON and ADON on the centers non-use of transfer backboards and the requirement to receive training prior to the use of any new transfer devices on [DATE] 3. The Measures We Have Put In Place And Systematic Changes We Have Made To Ensure That The Practice Does Not Recur. -Overseen by (name of Regional Nurse) in-service training was conducted with the nursing staff on [DATE] of the center's policies related to back boards for transfers. Specific training was given regarding the requirement to receive training prior to use of any new transfer devices. -Overseen by (name of Regional Nurse), any partners that are on leave or otherwise unavailable will be in-serviced prior to their next shift worked. -(Name of Regional Nurse) will in-service Administrator and DON regarding the centers policy of the non-use of transfer back boards and the requirement that all partners must receive training prior to use of any new transfer devices completed on [DATE] 4. The Corrective Actions Will Be Monitored To Ensure The Practice Will Not Recur. -Beginning the week of [DATE] an interview QA (Quality Assurance) will be conducted by the ADON assessing partner knowledge regarding use of new transfer equipment and devices used to transfer patients. 3 nursing partners will be questioned each week times 4 weeks ensuring understanding of receiving training prior to using any new transfer devices and the center's policies related to the non-use of back boards for transfers. -All Quality Assurance studies and monitors will be reported to the center's Quality Assurance Committee which consists of Administrator, DON, Medical Director, Registered Dietician, Social Worker, and Health Information Manager. Each study and monitor will continue as directed by the Quality Assurance Committee. ************************************** After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on [DATE] at 9:30 PM. The scope and severity was lowered to "D" level to allow the facility time to monitor/revise their corrective actions.

This deficiency was written as a result of complaint #AL 530. Based on interviews and record reviews, the facility administration failed to develop and implement a policy and/or procedure for the use of a backboard. On [DATE], staff placed RI #1 on a backboard for transport to the resident's room. According to facility staff, the backboard was used to perform CPR, (Cardio [MEDICAL CONDITION] Resuscitation). RI #1 was not secured to the backboard and fell facedown onto the floor, hitting their head on a dresser/night stand. As a result of the fall, the resident was rendered unconscious and sustained two hematomas to the head and a skin tear. RI #1 was transferred to a local emergency room and treated for [REDACTED]. This affected RI #1, one of two residents transported by a backboard on [DATE]. This deficient practice posed an immediate threat to the health and safety of residents, as it is likely to cause serious harm, injury, impairment, or death. On [DATE] at 7:32 PM, the Administrator, DON (Director of Nursing), Senior Vice President, and two Regional Nurses were made aware that the surveyors identified an Immediate Jeopardy level "J" at F 490. The Immediate Jeopardy began on [DATE] and was relieved on [DATE] at 9:30 PM, when it was verified the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F 490 was lowered to a "D" level to allow the facility time to monitor and if necessary, revise their corrective actions to achieve substantial compliance with F 490. Findings include: Refer to F323. On [DATE] at 3:52 PM, the Alabama Department of Public Health, Division of Health Care Facilities received a complaint alleging RI #1 had been dropped by facility staff while being transported on an unsecured backboard causing injury to the resident. A review of the Administrator's job description, dated [DATE] revealed: "The Administrator has complete administrative and managerial responsibilities within the health care center, ..., coordinator, and support person for Department Directors, other partners, . ...DUTIES AND RESPONSIBILITIES: ...9. Ability to interpret and implement regulations (state and federal). 10. Ability to organize and implement systems. 16. Promote safety awareness through center activities, safety committee and incentive programs ...." A review of the Director of Nursing's job description, dated [DATE], revealed: "The DON has administrative and managerial authority, responsibility, and accountability for the function, activities, and training of the Nursing Services' Staff. The DON is under the direction of the Administrator. PERFORMANCE REQUIREMENTS: Special Demands: ...5. Ability to interpret and implement regulations (state and federal). 6. Ability to organize and implement systems. 10. Working knowledge of center's fire, safety, and disaster procedures. DUTIES AND RESPONSIBILITIES: I. PATIENT CARE MANAGEMENT A. GENERAL DESCRIPTION: ...2. Implements federal, state, and local regulations pertaining to nursing services. 3. Assesses the implementation of effective strategies and methods of delivery of nursing services. ... II. OPERATIONAL MANAGEMENT A. GENERAL DESCRIPTION: ...2. Participates in development of institutional policies. 5. Administers policies and formulates procedures for the nursing department. 9. Manages ...training, ... of all nursing staff. B. SPECIFIC ITEMS: 1. Participates in development and maintenance of nursing services' philosophy and objectives, standards of practice, policy and procedure..." A review of the EMS (Emergency Medical Service) report dated [DATE] identified RI #1 as a Fall Victim. EMS staff were present with RI #1 at 9:11 PM. The report documented RI #1's chief complaint as a possible head injury. The report further documented RI #1 had been dropped approximately 3 feet from a back board landing head first on the floor and losing consciousness. A review of the facility's investigation regarding RI #1 revealed, "...Date of fall: [DATE] Time of fall: 9:30 PM, ... ROOT CAUSE OF THIS FALL ... Resident's restlessness and sudden movement on transfer backboard Describe initial interventions to prevent future falls: If using a transfer backboard, use one with straps NURSE COMPLETING FORM: (EI #3's name) Date and Time: [DATE] 12:30" RI #1's hospital history and physical dated [DATE] revealed, RI #1 presented to the emergency department "CHIEF COMPLAINT: Fall, Closed head trauma. ..." On [DATE] at 10:23 AM, the surveyor requested the policy for the backboard. EI #2, the DON (Director of Nursing), reported, "We don't have a policy on the backboard. The board is what we use for CPR." An interview was conducted with EI #2, DON, on [DATE] at 3:49 PM. EI #2 reported that according to the investigation, RI #1 was transported back to the room via backboard, but did not know why. EI #2 reported that at times, RI #1 did have restlessness and combative behaviors. EI #2 was asked what precautions were taken to keep the resident safe while being transported back to the room. EI #2 responded, "There was adequate staff assisting with the transfer. There was no rush. I actually saw them transporting (RI #1) down the hall and never once thought that it was an unsafe action." When asked what did the facility policy say regarding transferring the resident during an emergency, EI #2 answered, "If we can't use wheelchair, we use the slide." EI #2 was asked if transferring the residents on backboards without securing them, was a safe use of equipment and EI #2 answered, "No." EI #2 reported staff had not received training regarding using backboards prior to [DATE]. EI #2 was asked what could be the potential negative outcome if a resident was transported on a backboard without being secured to the board. EI #2 responded, "It depends on the resident and their status, it could be anything from skin tear, to fracture, to no injury." EI #2 reported there was no facility policy in place regarding backboards. EI #2 further added that the purpose of implementing policies was to keep residents safe. An interview was conducted with EI #1, the Administrator on [DATE] at 4:58 PM. EI #1 reported that RI #1 was transported back to the room utilizing a backboard. When asked what precautions should have been taken, EI #1 answered, "Straps could have been a precautionary." EI #1 reported that transferring residents on backboards without using straps was not considered to be safe use of equipment. EI #1 stated staff had not received training regarding the use of backboards prior to [DATE]. EI #1 was asked if a resident should be suspended on a backboard, unstrapped. EI #1 answered, "Probably not." EI #1 confirmed that the facility did not have a policy in place regarding the backboards and stated the policy regarding transferring RI #1 back to the room was not followed. EI #1 reported the staff members were trained on safe modes of transport during an emergency situation, but none of the methods included a backboard. *************************************** Allegation of Compliance (AOC) F490 On [DATE] at 9:01 PM, the facility provided the surveyors with an acceptable AOC, which documented: F490 Administration 1. Corrected Actions Accomplished For The Patient Found To Have Been Affected By The Allegedly Deficient Practice -On [DATE] transfer backboard was removed from use in the center -Patient # 4181 care plan was updated to remove emergency use of transfer board 2. How We Have Identified Other Residents Having The Potential To Be Affected By The Same Practice And What Corrective Action Has Been Taken -Overseen by (name of Regional Nurse) and completed on [DATE] a review of all patient care plans to ensure back board was not listed as a transfer device and appropriate transfer devices were care planned (Name of Regional Nurse) in-serviced the DON and ADON on the centers non-use of transfer backboards and the requirement to receive training prior to the use of any new transfer devices on [DATE] 3. The Measures We Have Put In Place And Systematic Changes We Have Made To Ensure That The Practice Does Not Recur. -Overseen by (name of Regional Nurse), in-service training was conducted with the nursing staff on [DATE] of the center's policies related to back boards for transfers. Specific training was given regarding the requirement to receive training prior to use of any new transfer devices. -Overseen by (name of Regional Nurse), any partners that are on leave or otherwise unavailable will be in-serviced prior to their next shift worked. -(Name of Regional Nurse) will in-service Administrator and DON regarding the centers policy of the non-use of transfer back boards and the requirement that all partners must receive training prior to use of any new transfer devices completed on [DATE] 4. The Corrective Actions Will Be Monitored To Ensure The Practice Will Not Recur -Beginning the week of [DATE] an interview QA (Quality Assurance) will be conducted by the ADON assessing partner knowledge regarding use of new transfer equipment and devices used to transfer patients. 3 nursing partners will be questioned each week times 4 weeks ensuring understanding of receiving training prior to using any new transfer devices and the center's policies related to the non-use of back boards for transfers. -All Quality Assurance studies and monitors will be reported to the center's Quality Assurance Committee which consists of Administrator, DON, Medical Director, Registered Dietician, Social Worker, and Health Information Manager. Each study and monitor will continue as directed by the Quality Assurance Committee. ********************************* After reviewing and verifying the implementation of the facility's acceptable Allegation Of Credible Compliance, the immediate jeopardy was relieved on [DATE] at 9:30 PM. The scope and severity was lowered to "D" level to allow the facility time to monitor/revise their corrective actions.