Every finding on record at Okeena Health and Rehabilitation Center LLC

Based on policy review, record review, job description review, and interview, the facility failed to ensure comprehensive nutritional assessments were completed timely by a dietitian for 2 of 3 (Resident #256 and Resident #259) residents reviewed for new admissions. The findings include: 1. Review of the facility's policy titled, Nutritional Management, dated 12/1/2024, revealed .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall conditions .A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission . Review of a Registered Dietitian job description undated and unsigned revealed .Major Duties and Responsibilities .Provides registered dietitian services in one or more sites according to policies and procedures, and federal and state requirements. Plans, organizes, develops, and directs the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines, and regulations. Assesses/Monitors the residents' nutritional status and provides recommendations to clinical/medical staff. Completes nutritional assessments on residents . 2. Review of the medical record revealed Resident #256 was admitted on [DATE], with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #256 was severely cognitively impaired. Review of the medical record revealed the facility failed to complete a comprehensive nutritional assessment within 72 hours of admission for Resident #256 until 1/16/2025, 6 days after admission. 3. Review of the medical record revealed Resident #259 was readmitted to the facility on [DATE], with diagnoses including Protein-Calorie Malnutrition, Toxic Encephalopathy, and Respiratory Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #259 was cognitively intact. Review of the medical record revealed the facility failed to complete a comprehensive nutritional assessment within 72 hours of admission for Resident #259 until 1/16/2025, the 8th day after admission. During an interview on 1/13/2025 at 8:52 AM, the uncertified Director of Dietary (DD) confirmed the former Registered Dietitian quit after Christmas. The DD was asked who supervises her since she was not certified. The DD stated, No one, I am on my own. During an interview on 1/15/2025 at 3:40 PM, the Director of Nursing (DON) confirmed that the former Registered Dietitian's last day of employment was 12/27/2024 and that the new Dietitian (working remotely) started on 1/13/2025. The DON confirmed that Resident #256 and Resident #259 did not have a comprehensive nutritional assessment completed within 72 hours of admission or readmission. 49311

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty ice machine. The facility had a census of 88 residents. The findings include: 1. Review of the facility policy titled, Ice Machines and Portable Ice Carts, dated 12/1/2024, revealed .It is the policy of this facility to ensure that ice machines/carts are working and in proper order, cleaned, and maintained .Ice machines/carts can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning .Proper cleaning, maintenance, and infection control in relation to the ice machines is important to decrease the risk of illness to residents .The ice machines will be cleaned at any time contamination may have occurred or when visibly soiled . 2. During an interview on 1/14/2025 at 11:07 AM, the Dietary Director (DD) stated the cleaning/maintenance of the ice machine was contracted with an outside company. The DD was asked who in the facility was responsible for the ice machine. She stated, I am. Observation of the ice machine located in the Activity Room on 1/14/2025 at 1:18 PM and 2:35 PM, revealed a white chalky substance dripping down the left and right sides of the machine, and down the cart the ice machine was sitting on. During an interview on 1/14/2025 at 2:39 PM, the Administrator confirmed the ice machine should be clean and should not have white chalky substance anywhere on the machine or the cart.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infections when 1 of 14 staff (Certified Nursing Assistants (CNA) G) failed to properly remove their personal protective equipment (PPE) during dining services, when 2 of 15 staff (CNA F and Certified Occupational Therapist Assistant (COTA) BB) failed to properly disinfect reusable resident equipment before exiting an isolation room, and when 2 of 14 staff (CNA H and CNA I) failed to perform hand hygiene during dining. The findings include: 1. Review of the facility's policy titled, Routine Cleaning and Disinfection, dated 12/2024, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Resident chairs .Standard precautions will be adhered to when cleaning any blood or body fluid spills, or soiled material that have the potential to contain these or other potentially contaminated substances .Use of gloves, gown, mask, eye protection or face shield . Review of the facility's undated policy titled, Resident Rights, revealed .Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . Review of the facility's policy titled, Infection Prevention and Control Program, dated 12/1/2024, revealed .Equipment Protocol .Single use devises must be discarded after use and are never used for more than one resident .Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as CONTAMINATED and place in the soiled utility room for pickup and processing . Review of the facility policy titled, Transmission-Based (Isolation) Precautions, dated 12/1/2024, revealed .It is our policy to take appropriate precautions to prevent transmission of pathogen, based on the pathogens' mode of transmission .Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . Review of the facility policy titled, Hand Hygiene, dated 12/2024, .All staff will perform proper hand hygiene procedures to prevent the spread of infection .After handling items potentially contaminated with blood, body, fluids, secretions, or excretions .Before applying and after removing personal, protective (PPE), including gloves . 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Acute Kidney Failure, Chronic Obstructive Pulmonary Disease, and Muscle Weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status Score (BIMS) of 14, which indicated the resident was cognitively intact. Review of a Nurses Note dated 1/9/2025, revealed Resident tested positive for covid .isolation . Review of a Physicians Order dated 1/16/2025, revealed .Infection .COVID 19 .Precautions Type .contact, droplet .Covid Isolation starting 1/9/2025 . Review of the Care Plan dated 1/16/2025, revealed .The resident has a Respiratory Infection [COVID19] .Isolation-droplet precautions .Date Initiated .1/16/2025 .Revision on .1/16/2025 . Observation and interview on the 200 hall on 1/15/25 at 8:13 AM, revealed COTA BB, was standing outside of the resident's room and was given a wheelchair from inside Resident #38's room, swiped the arms of the wheelchair and the seat of the wheelchair, walked down the hall with her gloves on, entered the therapy gym, and sprayed the wheelchair with a disinfectant spray and let it stand to dry. The COTA BB was asked should you have cleaned the contaminated chair outside in the hallway. The COTA stated, I wiped a little of it down with the cloth . The COTA confirmed the chair should have been cleaned inside of the resident's room thoroughly prior to pushing the chair down the hallway to the therapy gym. During an interview on 1/16/2025 at 11:10 AM, the Director of Nursing (DON) and the Infection Control Preventionist (ICP) confirmed that Resident #38 was positive for COVIID on 1/9/2025 and has been in Transmission Based Precautions since 1/9/025. During an interview on 1/16/2025 at 7:30 PM, the DON confirmed that reusable resident equipment should be cleaned with an approved disinfectant prior to bringing the equipment out of the resident's room who is in transmission-based precautions. The DON confirmed the wheelchair should have been cleaned in the Resident #38's room prior to being transported down the hallway to the therapy gym. 3. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Cellulitis of bilateral lower limbs, Pressure Ulcer of Left Buttock, Diabetes, Influenza, Dementia, Cardiomegaly, and Pneumonia. Review of the admission Minimum Data Set (MDS) dated [DATE], Resident #80 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. Review of the Physician's Orders dated 1/9/2025, revealed .Droplet isolation for THE FLU .every shift . Observations on the 400 hall on 1/13/2025 at 9:54 AM and 4:59 PM, on 1/14/2025 at 8:20 AM and 4:57 PM, confirmed Resident #80 was in Enhanced Barrier Precautions and should have been in Transmission Based Precautions for influenza. Observation on 400 Hall on 1/13/2025 at 12:12 PM, revealed CNA G applied an isolation gown and gloves prior to entering Resident #80's room with meal tray, exited the isolation room and removed her gown and gloves in the hallway. CNA G rolled up the gown and gloves in her hand and walked down the hall to the shower room to discard of the used isolation gown and gloves. During an interview on 1/13/2025 at 12:26 PM, CNA G was asked where she should have removed her PPE. CNA G stated. In the resident's room. 4. Review of medical record revealed Resident #92 was admitted on [DATE], with diagnoses including Anxiety and COVID-19. Review of the admission MDS dated [DATE], revealed Resident #92 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of the Physician's orders dated 1/11/2025, revealed .Infection: COVID-19 . Precaution Type: droplet . Observation during dining on 1/13/2025 at 12:29 PM, revealed CNA F exited Resident #92's room with goggles on top of her head, and attempted to enter another resident's room, before cleaning her goggles. During an interview on 1/13/2025 at 12:31 PM, CNA F confirmed that she should have removed the goggles before exiting the room. 5. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Diabetes and Acquired Absence of Right Leg Above the Knee. Review of the admission MDS dated [DATE], revealed Resident #49 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Observation on 1/14/2025 at 7:48 AM, revealed CNA H entered Resident #49's room, picked up the bed remote to raise the bed, repositioned the resident, picked up a breakfast sandwich with her bare hands, and handed it to Resident #49. CNA H failed to perform hand hygiene after touching a potentially contaminated items and failed to apply gloves before picking up the resident's food and serving it to a resident. 6. Review of the medical record revealed Resident #5 was admitted to the facility 7/30/2021, with diagnoses including Diabetes and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #5 had a BIMS score of 3, which indicated the resident was severely cognitively impaired. Observation on 1/14/2025 at 8:03 AM, revealed CNA I entered Resident #5's room, picked up and moved a floor mat to the other side of the room, and failed to perform hand hygiene. CNA I then removed Resident #5's lid from the plate, put sugar in the resident's coffee and cut up the resident's food. CNA I failed to perform hand hygiene after touching potentially a contaminated item and before setting up the resident's meal tray. During an interview on 1/16/2025 at 7:52 PM, the DON stated .Reusable equipment should be cleaned thoroughly before exiting a resident's room [isolation], then allowed to dry before transporting to a clean area . During an interview on 1/16/2025 at 5:43 PM, the DON confirmed staff should not use their bare hands to pick up the resident's food, should use gloved hands to pick up the resident's food, and perform hand hygiene before and after applying gloves. 38439 46047 49311

Based on policy review, medical record review, observation, and interview, the facility failed to treat residents with respect and dignity when 1 of 13 (Certified Nursing Assistant (CNA) G) staff members stood over a resident (Resident #66) to assist with the meal, and when 2 of 13 (CNA M, CNA H) staff members observed during dining failed to use courtesy titles when addressing two residents (Resident #22, #26, and #83). The findings include: 1. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated August 2024, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Heart Disease, Dementia, and Depression. Observation in Resident's #66 room on 1/13/2025 at 12:14 PM, revealed CNA G stood over Resident #66, put food on the utensil, and put it to the resident's mouth to encourage and assist with her lunch meal. During an interview on 400 Hall on 1/13/2025 at 12:27 PM, CNA G was asked, should you have stood over the resident to assist her with her meal. CNA G stated, No, ma'am. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Diabetes, Heart Failure, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #26 had a BIMS score of 3, which indicated the resident was severely impaired cognition, and required set-up assistance from staff for eating. Observation in Resident #26's room on 1/14/2025 at 7:48 AM, revealed CNA H entered the resident's room set up the resident's meal tray and stated to Resident #26, .You are being sweet today, girl . 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Central Cord Syndrome Spinal Cord, Quadriplegia, and Atrial Fibrillation. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact, and required set up for meals. 4. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension, Alcoholic Cirrhosis of the Liver, Hepatic Encephalopathy, and Epilepsy. Review of the admission MDS dated [DATE], revealed Resident #83 did not have a BIMs score, had short-and-long term memory loss, was severely cognitively impaired, and required supervision for eating. 5. Observation during dining on the 300 Hall on 1/13/2025 at 11:48 AM, revealed CNA M removed a tray from the meal cart and pointed to 2 trays left on the meal cart and stated out loud in the hallway, These two are feeders. CNA M was asked who the trays belong to. CNA M stated, [Named Resident #22 and Named Resident #83]. During an interview on 1/16/25 at 5:08 PM, the Director of Nursing (DON) confirmed that staff should use courtesy titles when addressing residents and residents should not be referred to as feeders. 38439 46047

Based on medical record review, observation, and interview, the facility failed to ensure a clean, safe, and sanitary environment in 7 of 64 (Resident #2, #12, #13, #30, #36, #51, #53, #54, #57, #62, #72, #73, #78, and #79) resident shared bathrooms when personal hygiene items were found unlabeled and uncontained. The findings include: 1. Resident #2 and Resident #72 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Malignant Neoplasm of Nasal Cavity, and Pneumonia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental status (BIMS) score of 9, indicating the resident was moderately cognitively impaired, required assistance with Activities of Daily Living Skills (ADLS), required supervision with toileting hygiene, and was incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Ulcerative Colitis, Dementia, and Gastroparesis. Review of the annual MDS dated [DATE], revealed Resident #72 had a BIMS score of 11, indicating the resident was moderately cognitively impaired, required moderate assistance with ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #2 and Resident #72's shared bathroom on 1/13/2025 at 9:19 AM, 10:00 AM, and 11:15 AM, revealed the following: A gray wash basin on the back of the toilet unlabeled and uncontained. Four (4) gray wash basins stacked inside of each other on the floor beside the toilet unlabeled and uncontained. A gray bedpan on the floor beside the toilet unlabeled and uncontained. A peach colored toothbrush holder on the sink unlabeled and uncontained. A plunger resting on the floor beside the toilet uncontained. 2. Resident #12 and Resident #30 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Chronic Obstructive Pulmonary Disease, Depression, and Malignant Neoplasm of the Large Intestine. Review of the admission MDS dated [DATE], revealed Resident #12 had a BIMS score of 3, indicating the resident was severely cognitively impaired, required maximal assistance with toileting, and incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Myocardial Infarction, Atrial Fibrillation, Need for Assistance with Personal Care, and Muscle Weakness. Review of the quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 15, indicating the resident was cognitively intact, required moderate assistance with ADLs, and maximal assistance with toileting. c. Observation in Resident #12 and #30's shared bathroom on 1/13/2024 at 9:29 AM, 10:00 AM, 11:20 AM, and on 1/14/2024 at 8:10 AM, revealed a gray wash basin on the back of the toilet unlabeled and uncontained 3. Resident #54 and Resident #57 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident # 54 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Osteomyelitis, and Atherosclerosis. Review of the annual MDS dated [DATE], revealed Resident #54 had a BIMS score of 3, indicating the resident was severely cognitive impaired, and dependent on staff for ADLS and toileting. b. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis, Respiratory Failure, Obesity, Muscle Weakness, and Need for Assistance with Personal Care. Review of the quarterly MDS dated [DATE], revealed Resident #57 had a BIMS score of 10, indicating the resident was moderately cognitively impaired, dependent on staff for ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #54 and #57's shared bathroom on 1/13/2025 at 9:34 AM, 10:14 AM, and 11:55 AM, revealed the following: A gray wash basin on the back of toilet unlabeled and uncontained. A urinal sitting on the assist bar unlabeled and uncontained. 4. Resident #13 and Resident #53 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Obesity, Pneumonia, Bradycardia, and Atrioventricular Block. Review of the quarterly MDS dated [DATE], revealed Resident #13 had a BIMS score of 12, indicating the resident was cognitively intact, dependent on staff for ADLS, and incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE], with diagnoses including Hypothyroidism, Hypertension, Anxiety, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #53 had a BIMS score of 15, indicating the resident was cognitively intact, independent with ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #13 and Resident #53's shared bathroom on 1/13/2025 at 9:38 AM and 11:55 AM, revealed the following: A gray bedpan on the floor underneath the sink unlabeled and uncontained. Two gray wash basins on the back of the toilet unlabeled and uncontained. 5. Resident #78 and Resident #79 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Compression Fracture of Vertebra, Osteomyelitis, Delirium, Muscle Weakness, Overactive Bladder, and Cognitive Communication Deficit. Review of the quarterly MDS dated [DATE], revealed Resident #78 had a BIMS score of 9, indicating the resident was moderately cognitively intact, required maximal assistance with toileting, set up for personal hygiene, and continent of both bowel and bladder. b. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, Macular Degeneration, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #79 had a BIMS score of 13, indicating the resident was cognitively intact, required set up for personal hygiene, moderate assistance for toileting, and incontinent of both bowel and bladder. c. Observation in Resident #78 and Resident #79's shared bathroom on 1/13/2024 at 9:43 AM and 11:15 AM, revealed a gray bed pan stacked inside of a gray wash basin on the back of the toilet unlabeled and uncontained. 6. Resident #36 and Resident #62 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Anxiety, Congestive Heart Failure, and Insomnia Review of the annual MDS dated [DATE], revealed Resident #36 had a BIMS score of 3, indicating the resident was severely cognitively impaired, dependent on staff for ADLS, and incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Hypertension, Osteoporosis, Shortness of Breath, Hearing Loss, and Pneumonia. Review of the quarterly MDS dated [DATE], revealed Resident #62 had a BIMS score of 3, indicating the resident was severely cognitively impaired, dependent on staff for all ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #36 and Resident #62's shared bathroom on 1/13/2025 at 9:44 AM and 11:35 AM, revealed the following: A gray wash basin on the back of the toilet unlabeled and uncontained. A green denture cup on top of the sink unlabeled and uncontained. 7. Resident #51 and Resident #73 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Quadriplegia, and Neuromuscular Dysfunction of Bladder. Review of the quarterly MDS dated [DATE], revealed Resident #51 had a BIMS score of 15, indicating the resident was cognitively intact, and dependent on staff for all ADLS. b. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses including Alcoholic Cirrhosis of the Liver, Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Depression. Review of the annual MDS dated [DATE], revealed Resident #73 had a BIMS score of 14, indicating the resident was cognitively intact, required supervision with ADLS, and continent of both bowel and bladder. c. Observation in Resident #51's and Resident #73's shared bathroom on 1/13/2025 at 9:50 AM, 11:45 AM, and on 1/14/2025 at 8:03 AM, revealed the following: A gray wash basin on back of the toilet unlabeled and uncontained. A graduate dispenser on back of the toilet unlabeled and uncontained. A large dark gray bowl sitting on top of the sink unlabeled and uncontained. A clear plastic storage container sitting on top of the sink unlabeled and uncontained. 8. During an interview on 1/16/2025 at 5:08 PM, the Director of Nursing confirmed that all personal hygiene items should be placed in plastic bags and stored in the bottom drawer of the residents' bedside table or on the top shelf of the residents' wardrobe and should not be left in the bathroom unlabeled and uncontained. The DON confirmed that all denture cups should be labeled with the resident's name and placed in the top drawer of the bedside table.

Based on policy review, medical record review, and interview, the facility failed to revise care plans for 4 of 18 (Resident #12, #38, #80, and #92) resident care plans reviewed for Pressure Ulcers, COVID, Transmission Based Precautions (TBP), and Influenza. The findings include: 1. Review of the facility's policy titled, Care Plan Revisions Upon Status Change, dated 12/1/2024, revealed .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change .The comprehensive care plan will be reviewed, and revised .when a resident experiences a status change . Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 12/1/2024, revealed .The staging of pressure injuries will be clearly identified .the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .Assessments of pressure injuries will be .documented on the Initial and / or Weekly Wound Assessment .the staging of pressure injuries will be clearly identified .interventions will be documented in the care plan . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Anxiety, Peripheral Vascular Disease, and Malignant Neoplasm of the Intestine. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #12 had a Brief Interview for Mental Status score (BIMS) of 3, which indicated the resident was severely cognitively impaired, dependent on staff for Activities of Daily Living skills, and incontinent of both bowel and bladder. Review of the Care Plan dated 9/30/2024, revealed no care plan for being at risk, the development, prevention, and treatment of pressure ulcers. Review of a Weekly Wound assessment dated [DATE], confirmed Resident #12 had pressure ulcers to both her left and right heel. Review of the facility's undated Pressure Ulcer list revealed .[Resident #12] .DTPI [deep tissue pressure injury] .L [left] heel .DTPI .R [right] heel .FA [facility acquired] .12/27/2024 . Review of a [Named Wound Care Company] INITIAL WOUND EVALUATION & MANAGMENT SUMMARY, dated 1/14/2025, revealed .Patient presents with wounds on her left heel .right heel .UNSTAGEABLE [DUE TO NECROSIS (dead tissue] OF THE RIGHT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .Duration .> [greater than] 14 days .UNSTAGEABLE .OF THE LEFT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .duration .> 14 days . Observation in Resident #12's room on 1/15/2025 at 3:30 PM, revealed the Wound Nurse, entered the room, donned PPE (personal protective equipment), removed the dressings to both the right and left heel, and exposed the pressure wounds to the resident's right and left heel. The wounds to the right and left heel were dark brown in color and hard to touch with characteristics of a DTI. The facility failed to revise Resident #12's care plan to prevent or address unstageable pressure ulcers/injuries to the left and right heel. During an interview on 1/16/2025 at 6:20 PM, the Director of Nursing (DON) confirmed the care plan should have been revised to show Resident #12 was at risk, developed, and being treated for pressure ulcers. 3. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Acute Kidney Failure, Chronic Obstructive Pulmonary Disease, and Muscle Weakness. Review of the admission MDS dated [DATE], revealed Resident #38 had a BIMS score of 14, which indicated the resident was cognitively intact. Review of a Nurses Note dated 1/9/2025, revealed Resident tested positive for covid .isolation . Review of the Care Plan dated 1/16/2025, revealed .The resident has a Respiratory Infection (COVID 19) .Isolation-droplet precautions .Date Initiated .1/16/2025 .Revision on .1/16/2025 . The facility failed to revise the care plan for COVID 19 and Transmission Based Precautions until 1/16/2025, 7 days after Resident #38 tested positive for COVID 19. Review of a Physicians Order dated 1/16/2025, revealed .Infection .COVID 19 .Precautions Type .contact, droplet .Covid Isolation starting 1/9/2025 . Observation during dining on the 200 hall on 1/13/2025 at 12:15 PM, revealed Certified Nursing Assistant (CNA CC) donned PPE (Personal Protective Equipment) and delivered a meal tray to Resident #38. CNA CC confirmed Resident #38 was in isolation due to COVID 19. Observations on the 200 Hall on 1/14/2025 at 7:48 AM and at 5:00 PM, revealed Resident #38 remained in contact / droplet isolation precautions for COVID. During an interview on 1/16/25 at 11:10 AM, the DON and the Infection Control Preventionist (ICP) confirmed that Resident #38 was positive for COVID on 1/9/2025 and has been in Transmission Based Precautions since 1/9/025. The DON confirmed that Resident #38 should have had a care plan developed and revised for infections related to COVID and Transmission Based Precautions. 4. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Cellulitis of bilateral lower limbs, Pressure Ulcer of Left Buttock, Diabetes, Influenza, Dementia, Cardiomegaly, and Pneumonia. Review of the admission MDS dated [DATE], Resident #80 had a BIMS score of 6, which indicated severe cognitive impairment. Review of the Care Plan dated 10/24/2024, revealed no documentation for Resident #80 being in TBP due to being positive for Influenza. Review of the Nurses' Progress Note dated 1/9/2025, revealed RESIDENT MOVED TO 419A DUE TO POSITIVE FOR THE FLU WILL BE IN DROPLET ISOLATION Resident#80's care plan was not revised to reflect positive for the Flu and droplet isolation. During an interview on 1/16/2025 at 4:05 PM, the DON was asked should Resident #80's care plan have TBP for flu documented. The DON stated, Yes .I don't see it . 5. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE], with diagnoses including COVID 19, Neuromuscular Dysfunction of the Bladder, and Abnormal Gait. Review of the admission MDS dated [DATE], revealed Resident #92 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of a Physician's Order dated 1/7/2025, revealed .contact droplet precautions .in room alone. Observation during dining on the 200 hall on 1/13/2025 at 12:25 PM, revealed Certified Nursing Assistant (CNA CC) donned PPE and delivered a meal tray to Resident #38. CNA CC confirmed Resident #92 was in isolation due to COVID 19. Observation on the 200 hall on 1/14/2025 at 7:48 AM and at 5:00 PM, revealed Resident #92 remained in TBP for COVID. During an interview on 1/16/25 at 11:10 AM, the DON and the Infection Control Preventionist (ICP) confirmed that Resident #92 was positive for COVID on 1/5/2025 and has been in TBP since 1/5/2025 and remains in TBP. The DON confirmed that Resident #92's care plan should be revised to reflect infections related to COVID and TBP. 38439

Based on policy review, medical record review, observation, and interview the facility failed to stage pressure wounds correctly for 1 of 2 (Resident #12) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility's policy titled Pressure Injury Prevention and Management, dated 12/1/2024, revealed .The staging of pressure injuries will be clearly identified .the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .Assessments of pressure injuries will be .documented on the Initial and / or Weekly Wound Assessment .the staging of pressure injuries will be clearly identified .interventions will be documented in the care plan . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Anxiety, Peripheral Vascular Disease, and Malignant Neoplasm of the Intestine. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired, dependent on staff for ADLs, incontinent of both bowel and bladder. Review of the Care Plan dated 9/30/2024, revealed no care plan for pressure injuries. Review of an Initial Wound assessment dated [DATE], revealed .Non Pressure .Date Wound was Identified .12/27/2024 .Acquired after admission to facility .Non Pressure .Left heel .Type .Vascular .Length .4.5 x Width 4.5 x Depth .utd [unable to determine] .dark purple .Pain Management Plan .off-loading boots . Review of an Initial Wound assessment dated [DATE], revealed .Date wound was identified .12/27/2024 .Type .Non pressure .Right heel .Type .Vascular .Length .5.0 x Width 5.0 x Depth .utd .dark purple .Pain Management Plan .off-loading boots . Review of a Weekly Wound assessment dated [DATE], revealed .Type of Wound .Non Pressure .Vascular . for the Left and Right Heels. Review of a Weekly Wound assessment dated [DATE], revealed .Type of wound .Non-Pressure .Vascular . for the Left and Right Hells. Review of the facility's undated Pressure Ulcer list revealed .DTPI [deep tissue pressure injury] .L [left] heel .DTPI .R [right] heel .FA [facility acquired] .12/27/2025 . Review of a (Named Wound Care Company) INITIAL WOUND EVALUATOIN & MANAGMENT SUMMARY, dated 1/14/2025, revealed .Patient presents with wounds on her left heel .right heel .UNSTAGEABLE (DUE TO NECROSIS) OF THE RIGHT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .Duration .> (greater than) 14 days .UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .duration .> 14 days . Observation in Resident #12's room on 1/15/25 at 3:30 PM, revealed the Wound Nurse, entered the room and removed the dressings to Resident #12's left and right heels. The right and left heel were both dark brown in color and hardened areas. During an interview on 1/16/25 at 2:51 PM, the Wound Nurse confirmed the wounds on Resident #12's left and right heels were deep tissue injuries and were not vascular. During an interview on 1/16/25 at 5:08 PM, the Director of Nursing (DON) confirmed that in order to classify a wound as vascular that a physician would have to make that diagnosis from a doppler assessment. The DON confirmed that she expects the wound nurse to stage wounds correctly to ensure proper care and treatment of all wounds.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure an environment free of accident hazards when sharps and hazardous personal items were found in 2 of 66 (Resident #2 and Resident #71) resident occupied rooms. The findings include: 1. Review of the facility's undated policy titled, Resident Rights, revealed .Safe Environment .The resident has a right to a safe .environment . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hypertensive Heart Disease, Malignant Neoplasm of the Nasal Cavity, and Pneumonia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately cognitively impaired, and required assistance with activities of daily living skills (ADLs). Observation in Resident #2's room on 1/13/2025 at 9:19 AM, at 10:00 AM, and 11:15 AM, revealed the following items sitting on a wooden bookshelf uncontained and easily accessible: An 8.8 oz (ounce) can of air fresher. An 8 oz can of body spray. An 8 oz bottle of cherry lemonade scented body spray. During observation and interview in Resident #2's room on 1/13/2025 at 11:44 AM, revealed Licensed Practical Nurse (LPN) O was shown the air fresher, the body sprays and was asked how these items should be stored. LPN O confirmed they should be stored in plastic bags, in the resident's drawer and out of reach of residents. LPN O confirmed the items could be hazardous to residents' safety. During an interview on 1/16/2025 at 5:08 PM, the Director of Nursing (DON) confirmed that air freshers and body sprays should not be stored on a shelf and easily accessible to residents, they should be stored in a plastic bag out of reach of residents in the bedside table. The DON confirmed these items are hazards to residents' safety. 3. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Left Shoulder Effusion, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. Review of the admission MDS assessment dated [DATE], revealed Resident #71 had a BIMS score of 12, indicating the resident was moderately cognitively impaired and required supervision from staff for ADLs. Resident #71 was mobile via wheelchair. Observation in Resident #71's bathroom on 1/13/2025 at 10:11 AM, 1/13/2025 at 3:54 PM, and 1/16/2025 at 11:08 AM, revealed an unattended and unsecure disposable razor on the bathroom vanity. During an interview and observation in Resident #71's on 1/16/2025 at 11:18 AM, the Director of Nursing (DON) was asked if the razor should be left in the resident's bathroom unsecured and unattended. The DON confirmed that the razor should not be left in resident's bathroom and should be in the sharp container.

Based on document review and interview, the facility failed to post the scheduled total number of full-time employees (FTEs) scheduled to work a shift, and their total FTEs hours for 31 of 31 sampled days and failed to post the total actual hours worked by the licensed and unlicensed staff responsible for resident care on the facility's Today's Staffing form for 31 of 31 sampled days. The findings include: Review of the facility's Today's Staffing documents dated 12/9/2024 thru 1/10/2025, revealed the facility failed to complete the number of FTEs scheduled to work and failed to total the number of actual hours worked for licensed and non-licensed staff. During an interview on 1/16/2025 at 8:28 AM, the Scheduler was asked to review the daily staff postings for 12/9/2024 to 1/10/2025 and was asked if they were completed. The Scheduler confirmed they were incomplete and should have included the number of FTEs scheduled, the total hours worked every shift for both licensed and non-licensed staff, and they should reflect any changes due to call-ins. During an interview on 1/16/2025 at 9:55 AM, the Director of Nursing confirmed the daily staff postings were incomplete, should be completed daily to reflect the total FTEs, the total hours worked by both licensed and non-licensed staff members, and should reflect any changes due to call-ins.

Based on policy review, review of the Pharmacy Products and Services Agreement, medical record review, review of facility drug destruction documentation, and interview, the facility failed to properly document narcotic medications signed in error or wasted, failed to document administration of narcotics on the Medication Administration Record (MAR), failed to identify and report discrepancies for the narcotic count, and failed to ensure drug destruction sheets were signed by a licensed pharmacist for 3 of 4 months ([DATE], [DATE], and [DATE]) of drug destruction documentation reviewed. The findings include: 1. Review of the facility's policy titled, Medication Administration: Controlled Medications, dated ,d+[DATE], revealed .Provide guidance on promoting safe, high quality resident care, compliant with state and federal regulations regarding monitoring the use of controlled substances .The facility shall have safeguards in place to prevent loss, diversion, or accidental exposure .Controlled substances dispensed from Pharmacy and placed on a non-automated medication cart/refrigerator are sent with a Controlled Drug Receipt/Record Disposition form and once received and place in the cart or cabinet recorded on the Narcotic Control record. Written documentation must be clearly legible with all applicable information provided .The dose noted on the medication record must match the dose recorded on the Medication Administration Record, the controlled Drug receipt/Record/Disposition form and order .The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances .Obtaining/Removing/destroying Medications .The entire amount of controlled substances obtained or dispensed is accounted for .When the dosage form dispensed is larger than the dose, the total dose administered, and that portion destroyed is documented to show the total disposition of the drug on the Controlled Drug Receipt/Record/Disposition form Each removal of medication is documented on the Controlled Drug Receipt/Record/Disposition form .Two licensed staff must witness and disposal or destruction of a controlled substance due to waste or refusal and document same on the Controlled drug Receipt/Record/Disposition form .Disposition of Discontinued/Expired Controlled Medications .Controlled substances are destroyed by a consultant pharmacist and the Director of Nursing (DON) or designee .Discrepancy resolution .Any discrepancies which cannot be resolved must be reported immediately as follows .Notify the DON immediately and the pharmacy .Compete an investigation detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted .DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy .Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies . 2. Review of the facility's policy titled, Pharmacy Products and Services Agreement, dated ,d+[DATE], revealed .Supervision of the records and disposition of a controlled drugs and the maintenance of such records in sufficient detail so as to allow an accurate reconciliation of such controlled drugs .Consulting Services .Monthly narcotic destruction . 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Low Back Pain and Chronic Kidney Disease. Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# [prescription number] 18857027 Date Dispensed [DATE] .[Resident #57] .Drug/Name/Strength Hydrocodone/APAP [Acetaminophen] [a medication used for pain] ,d+[DATE] MG [Milligram] .Directions TAKE ONE TAB [tablet] BY MOUTH THREE TIMES DAILY .Quantity Dispensed 8 .[Licensed Practical Nurse (LPN) R] .nurse receiving medication .9 Quantity Received [DATE] .Every dose must be accounted for and requires charting on the Medication Administration Record. Disposition of Remaining Doses Quantity Destroyed: 4 . Review of the Physicians Order dated [DATE], revealed Lortab [Hydrocodone/APAP] 5 mg [milligram]-325 mg tablet PRN [as needed] Every 8 Hours for 30 Days . Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# 18857027 Date Dispensed [DATE] .[Resident #57] .Drug/Name/Strength Hydrocodone/APAP ,d+[DATE] MG .Directions TAKE ONE TAB [tablet] BY MOUTH THREE TIMES DAILY . Quantity Destroyed: 4 .Date: [DATE] RN [Registered Nurse] Signature [RN A] . Review of the form's administration documentation revealed the following: The medication was signed as being administered on [DATE] and [DATE], with 6 tablets left after the administration on [DATE]. On [DATE] at 8:00 PM, one tablet was signed as being administered by RN A, with 5 tablets left. On [DATE] at 8:00 PM, one tablet was signed as being administered by LPN T, with 4 tablets left. The entry was crossed through with 1 line stating, Pulled in error not given, written beside LPN T's entry and marked through with several lines. The number 4 was written below LPN T's entry. Review of the Medication Administration Record (MAR) dated [DATE] revealed 1 dose of Lortab 5 mg -325 mg was administered daily on [DATE] and [DATE]. Review of the MAR dated [DATE] revealed no orders for Lortab 5mg-325 mg and no documentation that the medication was administered or attempted to be administered. Review of the Discontinued Narcotic Control Record dated [DATE], revealed ,d+[DATE] [[DATE]] [2:10 PM] .[Resident #57] Hydrocodone/APAP ,d+[DATE] MG TAB .Qty: 4 .RX: 18857027 .Nurse: [LPN R] Nurse: [LPN Z]. 4 Hydrocodone/APAP ,d+[DATE] mg tabs were documented as wasted by a pharmacist and RN A on [DATE]. The medication removed from the cart on [DATE] was not documented as given on the MAR, was not documented as wasted and the administration and note that it was pulled in error were both marked out, resulting in improper documentation of whether it was given or wasted. The discrepancy was not identified by the staff who placed the card in the drop box or by the nurse or pharmacy during drug destruction. 4. Review of the medical record revealed Resident #258 was admitted to the facility on [DATE], with diagnoses including Open Wound, Left Lower Leg, Peripheral Vascular Disease, and Polyneuropathy. Review of the Physician's order dated [DATE] revealed Gabapentin [a medication used to treat seizures and nerve pain] Capsule 300 MG Give 1 capsule by mouth three times a day . Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# 19660408 Date Dispensed [DATE] .[Resident #258] .Drug/Name/Strength Gabapentin Capsule 300 MG .Directions TAKE ONE CAPSULE THREE TIMES DAILY .Quantity Dispensed 60 .[LPN N] .nurse receiving medication 60 Quantity Received [DATE] Date .Every dose must be accounted for and requires charting on the Medication Administration Record. Disposition of Remaining Doses Quantity Destroyed: 36 Date: [DATE] RN Signature [RN A] . Review of the forms administration documentation revealed the following: 3 tablets daily are signed out as being administer on [DATE]-[DATE]. On [DATE], 2 doses were signed as being administered, with 37 tablets left to count after the second dose. No other doses were signed out as being administered. Review of the MAR dated [DATE] revealed Gabapentin 300 mg was administered 3 times daily on [DATE]-[DATE] and 2 times at 9 AM and 2 PM on [DATE]. The medication was discontinued after the 2:00 PM dose on [DATE]. Review of the Discontinued Narcotic Control Record dated [DATE], revealed, XXX[DATE] [2025] 6A [6:00 AM] .[Resident #258] Gabapentin CAP (capsule) 300 MG .Qty: 36 .RX: 19660408 .Nurse: [LPN N] Nurse [RN T] . 36 Gabapentin 300 mg tablets were documented as wasted by a pharmacist and RN A on [DATE]. The Controlled Drug Receipt/Record/Disposition Form showed 37 tablets left but 36 tablets were documented as being placed in the drop box and as being disposed of. The discrepancy was not identified by the nurses who placed the medication in the drop box or by the nurse or pharmacist who disposed of the medication. 5. Review of the medical record revealed Resident #353 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Restlessness, Agitation, and Dementia. Review of the Physician's Order, dated [DATE], revealed Lorazepam [a medication used to treat anxiety and agitation] .2 mg/mL (milliliters) oral concentrate PRN Every 4 Hours for 30 Days .Take one quarter (0.25) milliliters by mouth every 4 hours, as needed . Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# 19232201 Date Dispensed [DATE] .[Resident 353] .Drug/Name/Strength Lorazepam 2MG/ML LIQ [Liquid] CONC [Concentrate] Directions TAKE .(0.25) Milliliters .EVERY FOUR HOURS AS NEEDED .Quantity Dispensed 30.00 ML .[LPN N] .nurse receiving medication 30 ml Quantity Received [DATE] Date .Every dose must be accounted for and requires charting on the Medication Administration Record. Disposition of Remaining Doses Quantity Destroyed: 29 [ML] Date: [DATE] RN Signature [RN A] . Review of the forms administration documentation revealed the following: The medication was documented as being administered on [DATE], [DATE] and [DATE], with 29.25 ml being left after the dose on [DATE]. On [DATE] at 8:00 AM, LPN O signed out 0.25 ml with 29 ml left, then drew lines through the entry. On [DATE] at 11:00 AM, LPN O signed out 0.25 ml with 28.75 ml left, then drew lines through the entry. On [DATE] at 4:00 PM, LPN O signed out 0.25 ml with 28.75 ml left, then drew one line through the entry. The word Error and LPN O's initials were written 1 time in large letters beside the 3 entries, instead of beside each entry, on [DATE]. The number 29 was written below the third entry made by LPN O, indicating 29 ml was left. There was no documentation of medication being wasted. LPN N documented 29 ml left to count on the right side of the form. Review of the Medication Administration Record, dated [DATE], revealed Resident #353 received 0.25 ml of Lorazepam concentrate 1 time daily on [DATE], [DATE] and [DATE]. There was no other documentation of administration or attempted administration on [DATE]. Review of the Discontinued Narcotic Control Record dated [DATE], revealed XXX,d+[DATE] [[DATE]] 7A [7:00 AM][Resident #353] Lorazepam 2MG/ML LIQ CONC Qty: [12 crossed through and 29 ML written below] .RX: 19232201 .Nurse [LPN N] Nurse [RN Q] . 29 ML of Lorazepam was documented as wasted by a pharmacist and RN A on [DATE]. The medication removed from the bottle on [DATE] was not documented on the MAR as being offered to the resident or on the Controlled Drug Receipt/Record/Disposition Form as having been wasted. The discrepancy was not identified by the staff who placed the medication in the drop box or by the nurse or pharmacy during drug destruction on [DATE]. 6. Review of the facility's Discontinued Narcotic Control Record form revealed the Pharmacist and the Nurse should sign and date the bottom of the form. Review of the drug destruction records for [DATE], revealed 1 undated Discontinued Narcotic Control Record form was not signed by the Pharmacist. During an interview on [DATE] at 3:35 PM, Assistant Director of Nursing (ADON) B confirmed she destroyed medications with the pharmacist on [DATE] and did not notice that 1 of the 4 sheets was not signed by the Pharmacist. ADON B confirmed both the Pharmacist and the nurse destroying the medications should sign the Discontinued Narcotic Control Record. During an interview on [DATE] at 9:40 AM, the Director of Nursing (DON) confirmed the Pharmacist and the nurse destroying the medications should sign the Discontinued Narcotic Control Record. 7. During an interview on [DATE] at 2:23 PM, LPN AA confirmed that 2 nurses count narcotics at the beginning and end of each shift, the off going nurse looks at the Controlled Drug Receipt/Record/Disposition Form and calls out the number of pills that should be left on the card or the amount that should be left in the bottle, the oncoming nurse verifies the correct amount of medication is present. LPN AA confirmed if the narcotic count is not correct, the on call (Nurse Manager) should be notified immediately. LPN AA confirmed errors in documentation on the Controlled Drug Receipt/Record/Disposition Form should be crossed out with 1 line and initialed. LPN AA confirmed narcotic medications that are removed from the medication cart but not given are to be wasted, and a second nurse should witness the disposal of the medication and both nurses should document that it was wasted on the Controlled Drug Receipt/Record/Disposition Form. LPN AA confirmed when medications are placed in the narcotic disposal locked box, in the medication room, 2 nurses verify the count on the Discontinued Narcotic Control Record, only nurses have a key to the medication room and to the top portion of the locked box where meds are placed, only ADON B has a key to the bottom portion of the locked box where medications are removed from. During an interview on [DATE] at 2:55 PM, RN A confirmed she assisted the pharmacist with drug destruction on [DATE] and on [DATE]. RN A confirmed she had never assisted with drug destruction prior to [DATE] and was instructed by the pharmacist to look at the Discontinued Narcotic Control Record and verified the count was correct when they called it out for each Resident's medication. RN A confirmed the pharmacist wrote the quantity of the medication destroyed on the Controlled Drug Receipt/Record/Disposition Form after she signed the sheets. RN A confirmed she was not aware of any discrepancies during the drug destruction process. RN A was shown Resident #353's Lorazepam 2MG Controlled Drug Receipt/Record/Disposition Form and confirmed that LPN O had made the 3 entries with lines through them and LPN N had written 29 ml left to count (with 29 ml circled) on the right side of the form. RN A was asked, if the 3 entries made by LPN O were errored out correctly. RN A stated No. RN A confirmed the medication was not documented correctly as having been wasted. RN A was asked, what was the amount left in the bottle after the last dose that was correctly documented was given. RN A stated, 29.25 ml. RN A was asked what amount was documented as destroyed. RN A stated, 29 [milliliters]. RN A was asked, according to the amount of medication signed as being administered on the Controlled Drug Receipt/Record/Disposition Form, was the correct amount of medication destroyed. RN A stated, I don't think so. RN A was shown Resident #258's Gabapentin 300 MG Controlled Drug Receipt/Record/Disposition Form and confirmed the quantity left after the last capsule was signed as given was 37 but the quantity destroyed of was 36. RN A confirmed there was a discrepancy in the count of Resident #258's Gabapentin 300 mg. RN A was shown Resident #57's Hydrocodone/APAP ,d+[DATE] MG Controlled Drug Receipt/Record/Disposition Form and confirmed she signed as administering the medication on [DATE] and that the documentation on [DATE] was by LPN T. RN A confirmed there were 5 tablets left after she administered the medication on [DATE]. RN A confirmed the documentation by LPN T on [DATE] showing one tablet was signed as being administered, then crossed through with one line, with Pulled in error not given written to the side and crossed through was not correct documentation. RN A confirmed she was unable to tell from looking at the Controlled Drug Receipt/Record/Disposition Form if the medication on [DATE] had been given or wasted. RN A was shown the MAR dated [DATE] and confirmed there was no documentation Hydrocodone APAP ,d+[DATE] mg was signed out on [DATE] or on [DATE]. RN A was asked should medication be signed out on the MAR when it is given. RN A stated Yes. RN A confirmed there was a discrepancy with Resident # 57's Hydrocodone/APAP ,d+[DATE] mg due to the medication not being signed as given or wasted. During an interview with ADON B on [DATE] at 3:35 PM, ADON B was shown Resident #353's Lorazepam 2MG Controlled Drug Receipt/Record/Disposition Form and confirmed that the entries made by LPN O on [DATE] were not errored out correctly and the medication was not signed out as being wasted. ADON B confirmed there was a discrepancy in the quantity documented as remaining after the last dose signed out correctly and the quantity being destroyed. ADON B was shown Resident #258's Gabapentin 300 MG Controlled Drug Receipt/Record/Disposition Form and confirmed the quantity left after the last capsule was signed as given was 37 but the quantity destroyed of was 36. ADON B confirmed there was a discrepancy in the count of Resident #258's Gabapentin 300 mg. ADON B was shown Resident #57's Hydrocodone/APAP ,d+[DATE] MG Controlled Drug Receipt/Record/Disposition Form and confirmed she was unable to tell from looking at the form if the medication removed from the cart had been given or wasted on [DATE]. ADON B was shown the MAR dated [DATE] and confirmed there was no documentation Hydrocodone APAP ,d+[DATE] mg was signed out on [DATE] or on [DATE]. ADON B confirmed medications should be signed out on the MAR after they are administered. ADON B confirmed there was a discrepancy in the count of Resident #57's Hydrocodone/APAP ,d+[DATE] mg. ADON B confirmed she usually wastes medications with the pharmacy but did not assist on [DATE] and [DATE]. ADON B confirmed the pharmacist looks at the actual medication and the Controlled Drug Receipt/Record/Disposition Form, she looks at the Discontinued Narcotic Control Record and confirms the quantity the pharmacist calls out. ADON B confirmed the discrepancies with the medications should have been identified by staff placing medications in the locked box or during drug destruction. ADON B confirmed if medication discrepancies are identified an investigation should be initiated. ADON B was asked if an investigation was initiated to determine the cause of any of these discrepancies. ADON B stated, It doesn't look like it. During an interview on [DATE] at 9:40 AM, the DON confirmed she was not notified until [DATE] about the discrepancies with drug destruction on [DATE] and [DATE]. The DON confirmed 2 nurses count narcotics each shift and 2 nurses verify the count when placing them in the drug destruction lock box for disposal. The DON confirmed the quantity documented as being left and the quantity documented as being destroyed did not match on Resident #258's Gabapentin 300 mg. The DON confirmed medication was errored out incorrectly or not documented correctly as being wasted on Resident #57's Hydrocodone/APAP ,d+[DATE] MG Controlled Drug Receipt/Record/Disposition Form and Resident #353's Lorazepam 2MG Controlled Drug Receipt/Record/Disposition Form. The DON confirmed Hydrocodone /APAP ,d+[DATE] mg was not documented as administered or wasted on Resident #57's [DATE] MAR. The DON confirmed Gabapentin 300 mg was not documented as given after 2:00 PM on [DATE] on Resident #258's [DATE] MAR. The DON confirmed Lorazepam 2mg was not documented as being wasted or administered on [DATE] on Resident #353's [DATE] MAR. The DON was asked should staff have identified these discrepancies during narcotic count, when placing them in the drug destruction box, or during the drug destruction process. The DON stated, Yes. The DON was asked, should you be notified as soon as discrepancies are identified. The DON stated, Yes .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 1 staff member (Wound Nurse) left the treatment cart unlocked, unattended, and out of sight. The findings include: Review of the facility's policy Medication Storage, dated 12/1/2024, revealed .All drugs and biologicals will be stored in locked compartments .medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .Only authorized personnel will have access to the keys to locked compartments. A random observation and interview on the 300 hall on 1/16/2025 at 2:50 PM, revealed an unlocked, and unattended treatment cart. The Director of Nursing (DON) was coming up the hall and was asked, are there medications on this treatment cart. The DON stated, Yes. The DON was asked should the cart be left unlocked and unattended. The DON stated, No. Observation and an interview on the 300/400 hall, at the treatment cart on 1/16/2025 at 5:50 PM, revealed a 0.50 ounce (oz) tube of Medihoney (medication to debride pressure wounds), a 56.7 oz tube of B & C wound dressing (medication used to treat wounds), one pair of nail clippers, a 4oz tube of hydrogel (medication to treat pressure wounds), a 0.22 gram tube of Mipircron ointment (medication used to treat hard to heal wounds), and a 15 gram bottle of Nyamyc topical powder (used to treat wounds with fungus and yeast). The Wound Nurse was asked are these medications used for wounds and skin issues. The Wound Nurse stated, Yes, they are .

Based on policy review, video camera footage review, weather website review, medical record review, observation, and interview, the facility neglected to provide a safe environment and ensure supervision to prevent neglect for 1 of 6 sampled residents (Resident #1) reviewed for elopement risk and neglect. The facility's failure to provide adequate supervision to prevent neglect resulted in Immediate Jeopardy (IJ) when Resident #1, a severely impaired vulnerable resident, wearing an ankle wanderguard monitor (a monitoring device to alert staff of a resident attempting to exit the facility unattended) was left unsupervised in the facility's lobby, and exited the facility through an unsecured entrance door that was alarming. The facility did not respond to a door alarm that had been activated and were unaware Resident #1 was missing from the facility until a staff member was notified by a former neighbor that the resident was at the neighbor's home, which was approximately 1 mile from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Regional Director of Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 6/16/2022 at 2:55 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed on 4/24/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on 6/13/2022 through 6/16/2022. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction. The findings include: Review of the facility's policy titled, Abuse Prohibition Plan, dated 6/10/2021, revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm . Review of the facility's policy titled, Elopements and Wandering Patients, revised 6/21/2021, revealed .This facility ensures that residents who exhibit wandering behavior .receive adequate supervision .Elopement occurs when a resident leaves the premise or a safe area without authorization .and/or necessary supervision to do so . Review of a closed medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission/Readmission assessment dated [DATE], revealed Resident #1 was an elopement risk and Resident #1 stated she's not going to stay. A wander guard monitor was initiated. Review of the Elopement Risk assessment dated [DATE], revealed Resident #1 was assessed at risk for elopement with the potential risk factors of Dementia, Anxiety, Depression, experienced periods of cognitive impairment and/or poor decision-making skills and ambulated independently. The definitive risk factors documented the resident made comments about leaving the facility and wandered about the facility without purpose. Resident #1 was assessed as a high risk for elopement and a wanderguard monitor was initiated. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was unsteady but able to stabilize without staff assistance during transition and walking. Resident #1 was always continent of bowel and bladder and was assessed as using a wander/elopement alarm daily. Review of the Care Plan revised on 3/24/2022, revealed Resident #1 was at risk for elopement and had short-term memory impairment. The interventions to address this concern included encourage activities, redirect when wandering, monitor resident's location to ensure safety, and use a wanderguard/location monitor daily. The facility provided a copy of the video camera footage of the incident to the State Agency. The video camera footage contained footage from 2 cameras in the facility. The video titled, ae29 was footage from the camera located in the 2nd Entrance Lobby. The video titled, e29 was footage from the camera located in the 300/400 Nurses' Station. The video footage had a date of 4/24/2022 and the time was visible on the footage but there was no audio. Review of the video camera footage revealed the following on 4/24/2022: a. At 2:20 PM, Resident #1 was seated in the lobby near the 2nd Entrance Door. b. At 2:22 PM, the staff member screening the door, left the lobby area, which left the entrance unattended. c. At 2:24 PM, Licensed Practical Nurse (LPN) #1 exited the entrance door using a remote-control door opener. LPN #1 was going on a break. c. At 2:25 PM, Visitor #1 approached the entrance door and pulled the door handle. d. At 2:26 PM, Visitor #1 entered the facility, checked his temperature, and walked from the lobby area toward the 200 Hall. e. At 2:27 PM, Resident #1 exited the entrance door. f. At 2:29 PM, the door screener returned to the lobby, walked to the door, and entered the code for the door alarm system. g. At 3:00 PM, 33 minutes later, a telephone call to the facility alerted staff that Resident #1 was at her former neighbor's home which was approximately 1 mile from the facility. Resident #1 was returned to the facility by LPN #1. i. Staff were unaware Resident #1 was not in the facility for approximately 33 minutes. The facility did not provide supervision for an elopement risk resident, wearing a wander guard monitor, and did not respond to the door alarm that had been activated. Resident #1 was left unsupervised in the lobby and exited the facility through an unsecured entrance door. Observations of the surrounding area on 6/15/2022 at 12:26 PM, revealed the facility is located on a two-lane busy street, the entrance/exit from the facility is located on a 2 lane highly traveled road, 0.3 miles from the hospital, with a posted speed limit of 25 miles per hour. There were no sidewalks along this two-lane street in front of the facility until one gets closer to the hospital area. Resident #1 had to cross this two-lane busy road to get to her former neighbor's home. Review of Local Weather.com, revealed the high temperature on 4/24/2022 was 82 degrees. During an interview on 6/14/2022 at 12:15 PM, the Maintenance Director confirmed the door alarm was activated when the visitor pulled the door and entered the facility, the door alarm was audible to staff, and the door panel located in the Nurses' Station showed the location of the alarming door on the door panel. The Maintenance Director confirmed the door alarm would activate if the door was not closed completely and the wanderguard would not function with the door alarm activated and this this would allow Resident #1 to exit though the door. During an interview on 6/14/2022 at 2:43 PM, Screener #1 stated, .when I returned the door alarm was going off .I turned the alarm off .they [nurses] were at the Nurses' Station .I did not know a resident was missing .I did not notice her [Resident #1] being gone . During an interview on 6/14/2022 at 3:02 PM, Certified Nursing Assistant (CNA) #1 stated, .she [Resident #1] was my resident that day .she was upset when her family who visited that day left .she was a wanderer and did not stay in her room .she was always walking or sitting in the lobby area I was not aware a resident was missing until [Named LPN #1] asked about her [Resident #1] after she received the anonymous phone call . During a telephone interview on 6/15/2022 at 3:06 PM, Visitor #1 confirmed the alarm was sounding when he entered the facility. Visitor #1 confirmed there were no staff in the lobby area when he entered the facility. During a telephone interview on 6/16/2022 at 7:28 AM, Resident #1's former neighbor stated, .I heard someone knock on the door .she [Resident #1] was standing on my porch .[the neighbor asked] do they [nursing home staff] know you are here .she [Resident #1] said ' .no they don't know I'm here' .I immediately called the facility to let them know she was here .they came and got her . During an interview on 6/16/2022 at 1:04 PM, the DON confirmed staff did not respond to the door alarm timely or check the doors. The DON confirmed Resident #1 was not safe outside the facility unsupervised and facility staff were not aware Resident #1 was missing from the facility. During an interview on 6/16/2022 at 1:48 PM, the Administrator confirmed the facility staff did not respond to the door alarm when sounding, facility staff are responsible for ensuring a resident's safety, and it was unsafe for Resident #1 to be out of the facility unsupervised. The facility's corrective action plan included the following: A. On 4/24/2022, a Nurses' Event Note was completed upon return to the facility. The surveyors verified this through review of the Nurses' Event Note and interview with LPN #1. B. On 4/24/2022, Resident #1 was placed on 1 on 1 supervision until 9:00 PM and then placed on every 15-minute checks. The surveyors verified this through review of the signature sheets, interview with facility staff, and medical record review. C. On 4/24/2022, the facility accounted for 100 percent (%) of the residents in the facility. The surveyors verified this through review of the resident count sheets and interview with Administration and facility staff. D. On 4/24/2022, all residents with wanderguards were verified for placement and functionality. The surveyors reviewed the audit sheets for wanderguard placement and testing. E. On 4/24/2022, all residents with wanderguards were placed on 15-minute checks for 24 hours. The surveyors reviewed the signature sheet for every 15-minute checks. F. On 4/24/2022, Elopement Risk Assessments were reviewed and updated on 100 % of the residents. Care plans were reviewed and revised as needed between 4/24/2022-4/25/2022. The surveyors verified this through review of the audit sheets and medical record review of sampled residents. G. On 4/24/2022, visual signs were placed on the front doors alerting visitors, families, and friends to not pull on the door but to ring the doorbell and await staff assistance to enter and exit the facility. The surveyors verified this through observation of the signage on the facility doors. H. On 4/24/2022, a message was sent to resident representatives via the secured messaging system, notifying them the second entrance to the facility would no longer be used to enter the facility. Visitors should use the first entrance only. The surveyors verified this through review of the email documentation and interview with the Administrator. I. On 4/24/2022, the Administrator called the family member that was seen on the video holding the door on the exterior side until the door opened and the alarm sounded. The family member was informed of the procedure to visit at the facility. The surveyors verified this through interview with the Administrator and the family member. J. On 4/24/2022, in-services related to elopement procedure, exit-seeking behavior, responding to alarms, and conducting a head count when alarm sounds was conducted for on duty facility staff. All staff were in-serviced prior to working and were in-serviced by 4/25/2022. The surveyors verified this through review of the in-service documentation and interviews with facility staff on all shifts. K. On 4/24/2022, the admission packet was updated to include a letter indicating the procedure for entering the building and instructions to refrain from pulling on the exterior doors to gain entrance for visitation. The surveyors verified this through review of the admission packet. L. On 4/24/2022, an elopement drill was completed. The surveyors verified this through review of the elopement drill signature sheet and interviews with staff on all shifts. M. On 4/24/2022, a 100% door audit was completed. The surveyors verified this through review of the door audits and interview with the Maintenance Director. N. On 4/24/2022, audits of the exit doors and alarms, proper response to door alarms and quarterly Elopement Risk Assessments with plans of care were initiated on 4/24/2022. Audits continue daily on business days. Quality Assurance (QA) audits for compliance to be conducted daily for 7 days, weekly for 3 weeks, monthly for 2 months, and quarterly ongoing with any adverse finding reported to the Quality Assurance Performance Improvement (QAPI) committee. The surveyors verified this through review of audits, observation of staff response to door alarms, and interviews with facility staff and Administration. O. On 4/24/2022, the Medical Director, Administrator, DON and ADON were notified of the incident. The surveyors verified this through interview with the Medical Director, Administrator, DON and ADON. P. On 4/25/2022, the door screeners were educated to not leave the door post unless there was a relief person to assume the duties. The surveyors verified this through review of in-service sign sheets and interviews with the door screeners. Q. On 4/25/2022, all newly hired personnel will be educated during orientation on identifying residents assessed to be high risk for elopement and the elopement/wandering patient policy and procedure, procedure for responding to alarms which includes checking the physical environment after responding to alarms and performing a head count of the physical location of patients. The surveyors verified this through interviews with newly hired staff and with Administration. R. On 4/25/2022, a policy review was conducted, with no changes recommended. The surveyors verified this through interview with the Administrator, DON, and the Medical Director. S. On 4/25/2022, a doorbell was installed on the South Front Entrance Door for visitors to gain access to the facility. The surveyors verified this through observation of the doorbell. T. On 4/25/2022, the egress bar was undocked on the 2nd Entrance Door (so visitors cannot pull on the door for 15 seconds to enter the building). The surveyors verified this through observation of the 2nd Entrance Door and interviews with the Maintenance Director and Administrator. U. On 4/25/2022, an AdHoc (impromptu) QAPI meeting was held to discuss the incident, the interventions, and the preventative measures going forward. The surveyors verified this through review of the QAPI sign-in sheet and interviews with Administration and the Medical Director. V. On 4/25/2022, 100% of the facility staff in-services related to elopement procedure, responding to alarms and exit-seeking behaviors were completed. The surveyors verified this through review of the in-service sign in sheets and interviews with staff on all shifts.

Based on policy review, facility video footage review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for 1 of 6 sampled residents (Resident #1) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy when Resident #1, a vulnerable severely impaired resident, wearing a wanderguard bracelet (a monitoring device to alert staff of a resident attempting to exit the facility unattended) exited the facility unsupervised through an unsecured door. Resident #1 was found approximately 1 mile from the facility approximately 33 minutes later. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm and impairment or death to a resident. The Administrator, Director of Nursing (DON), Regional Director of Nurse Consultant, and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 6/16/2022 at 2:55 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed on 4/24/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyors on 6/13/2022 through 6/16/2022. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopements and Wandering Patients, revised 6/21/2021, revealed .This facility ensures that residents who exhibit wandering behavior .receive adequate supervision .Elopement occurs when a resident leaves the premise or a safe area without authorization .and/or necessary supervision to do so . Review of the facility's policy titled, Resident Rights and Resident Responsibilities, revised 1/2022, revealed .the resident has a right to a safe .environment . Review of the facility's policy titled, Accidents and Supervision, revised 10/21/2021, revealed .resident environment remains as free of accidents as is possible; and each resident receives adequate supervision .to prevent accidents .identify hazard (s) and risk (s) .definition .any unexpected or unintentional incident .risk .characteristic of an individual resident that influences the likelihood of an accident .adequate supervision refers to interventions and means of mitigating risk of an accident .the facility will provide adequate supervision to prevent accidents . Review of a closed medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, Depressive Episodes, Abnormal Weight Loss, and Dementia. Review of the Nursing Admission/Readmission assessment dated [DATE], revealed Resident #1 was alert and oriented to person and place and was assessed an elopement risk. Resident #1 stated she was not going to stay. Review of the admission Elopement Risk assessment dated [DATE], revealed Resident #1 was assessed as high risk for elopement. The intervention of a wanderguard bracelet was initiated. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3, which indicated severe cognitive impairment for daily decision making. Resident #1 was independent with supervision for Activities of Daily Living (ADL) and required one person assistance with dressing and bathing. Resident #1 was assessed as using a wander/elopement alarm daily. Review of the Care Plan revised 3/24/2022, revealed Resident #1 was at risk for elopement and had short-term memory impairment. The interventions included to encourage activities, redirect when wandering, monitor the resident's location to ensure safety, and use wanderguard/location monitor daily. Review of the Nurses' Event Note dated 4/24/2022 at 3:30 PM, revealed Resident #1 left the building without an escort. The facility provided a copy of the video camera footage of the incident to the State Agency. The video copy contained footage from 2 cameras in the facility. The video titled, ae29 was footage from the camera located in the 2nd Entrance Lobby. The video titled, e29 was footage from the camera located in the 300/400 Nurses' Station. The video did not have audio. The video had the date of 4/24/2022 and the times were visible on the footage. Review of the video footage revealed the following on 4/24/2022: a. At 2:20 PM, Resident #1 was seated in a recliner located in the lobby of the facility. A facility employee, Screener #1, was seated at a table near the exit door of the facility. b. At 2:22 PM, Screener #1 walked out of the 2nd Entrance Lobby. c. At 2:24 PM, Licensed Practical Nurse (LPN) #1 exited through the 2nd Entrance Door. LPN #1 was going on a break. d. At 2:26 PM, Visitor #1 entered the facility through the door. No staff were observed entering the code to allow the visitor to enter the facility, no staff checked the door, and no staff looked outside the door. e. At 2:27 PM, Resident #1 exited the facility through the same exit door. f. At 2:28 PM, LPN #2 was observed standing at the medication cart which was located at the 300/400 Nurses' Station. Screener #1 was in the 2nd Entrance Lobby. The door alarm was activated at this point. No staff were observed checking the door that was alarming and no staff were observed looking outside. g. At 2:29 PM, Screener #1 went to the keypad located by the door and entered the code for the door alarm system. Observations of the surrounding area on 6/15/2022 at 12:26 PM, revealed the facility is located on a two-lane busy street, the entrance/exit from the facility is located on a 2 lane highly traveled road, 0.3 miles from the hospital, with a posted speed limit of 25 miles per hour. There were no sidewalks along this two-lane street in front of the facility until one gets closer to the hospital area. Resident #1 had to cross this two-lane busy road to get to her former neighbor's home. Review of Local Weather.com, revealed the high temperature on 4/24/2022 was 82 degrees. During an interview on 6/14/2022 at 12:15 PM, the Maintenance Director stated, .the day of the incident [elopement] the door was in the docked position, which means someone could pull on the door handle from the outside, after 15 seconds the door would open allowing them to enter . During an interview on 6/14/2022 at 2:43 PM, Screener #1 stated, .when I left for break the alarm was not sounding .when I returned alarm was going off .I turned the alarm off .I thought the nurses knew what was going on with the alarm because they were at the Nurses' Station .I did not know a resident was missing . During an interview on 6/14/2022 at 3:02 PM, Certified Nursing Assistant (CNA) #1 stated, .I was not aware a resident was missing until [Named LPN #1] asked about her [Resident #1] after she [LPN #1] received the anonymous phone call . During an interview on 6/15/2022 at 11:50 AM, the Administrator stated .staff did not respond to the door alarm in a timely manner .staff are responsible for residents' safety . During a telephone interview on 6/15/2022 at 3:06 PM, Visitor #1 confirmed the alarm was sounding when he entered the facility. Visitor #1 confirmed there were no staff in the lobby when he entered the facility. During an interview on 6/15/2022 at 3:17 PM, Screener #2 stated, .sometimes the door [1st Entrance Door] will not completely close and I have to get up and pull it closed because it will alarm . During a telephone interview on 6/16/2022 at 7:28 AM, Resident #1's former neighbor stated, .I heard someone knock on the door .she [Resident #1] was standing on my porch .I asked her how did you get here .do they [nursing home staff] know you are here .she said ' .I'm tired right now, I walked here .no they don't know I'm here' .she had a bottle of water in her hand .I immediately called the facility to let them know she was here .it scared me .they came and got her . During an interview on 6/16/2022 at 1:04 PM, the DON confirmed staff did not respond to the door alarm timely, Resident #1 was not safe outside the facility unsupervised, and the facility staff were not aware Resident #1 was missing from the facility. During an interview on 6/16/2022 at 1:48 PM, the Administrator confirmed staff did not know Resident #1 was missing until the telephone call was received at 3:00 PM and it was unsafe for Resident #1 to be out of the facility unsupervised. The facility's corrective action plan included the following: A. On 4/24/2022, a Nurses' Event Note was completed upon return to the facility. The surveyors verified this through review of the Nurses' Event Note and interview with LPN #1. B. On 4/24/2022, Resident #1 was placed on 1 on 1 supervision until 9:00 PM and then placed on every 15-minute checks. The surveyors verified this through review of the signature sheets, interview with facility staff, and medical record review. C. On 4/24/2022, a 100 percent (%) resident count was completed. The surveyors verified this through review of the count sheet and interviews with Administration and facility staff. D. On 4/24/2022, all residents with wanderguards were verified for placement and functionality. The surveyors reviewed the audit sheet for wanderguard placement and testing. E. On 4/24/2022, all residents with wanderguards were placed on 15-minute checks for 24 hours. The surveyors reviewed the signature sheet for every 15-minute checks. F. On 4/24/2022, Elopement Risk Assessments were reviewed and updated on 100% of residents. Care plans were reviewed and revised as needed between 4/24/2022-4/25/2022. The surveyors verified this through review of the audit sheets and medical record review of sampled residents. G. On 4/24/2022, visual signs were placed on the front doors alerting visitors, families, and friends to not pull on the door but to ring the doorbell and await staff assistance to enter and exit the building. The surveyors verified this through observation of the signage on the facility doors. H. On 4/24/2022, a message was sent to resident representatives via the secured messaging system notifying them the second entrance to the facility will no longer be used to enter the facility. Visitors should use the first entrance only. The surveyors verified this through review of the email documentation and interview with the Administrator. I. On 4/24/2022, the Administrator called the family member that was seen on the video holding the door on the exterior side until the door opened and the alarm sounded. The family member was informed of the procedure to visit the facility. The surveyors verified this through interviews with the Administrator and the family member. J. On 4/24/2022, in-services for on duty facility staff were conducted. The in-services were related to the elopement procedure, exit-seeking behavior, responding to alarms, and conducting the head count when the alarm sounds. All staff were in-serviced prior to working and all were in-serviced by 4/25/2022. The surveyors verified this through a review of the in-service documentation and interviews with facility staff on all shifts. K. On 4/24/2022, the admission packet was updated to include a letter indicating the procedure for entering the building and instructions to refrain from pulling on exterior doors to gain entrance for visitation. The surveyors verified this through review of the admission packet. L. On 4/24/2022, an elopement drill was completed. The surveyors verified this through review of the elopement drill signature sheet and interviews with staff on all shifts. M. On 4/24/2022, a 100% door audit was completed. The surveyors verified this through review of the door audits and interview with the Maintenance Director. N. On 4/24/2022, audits of the exit doors and alarms, proper response to door alarms, quarterly Elopement Risk Assessments, and plans of care were initiated. Audits continue daily on business days. Quality Assurance (QA) audits for compliance will be conducted daily for 7 days, weekly for 3 weeks, monthly for 2 months and quarterly ongoing with any adverse finding to be reported to the Quality Assurance Performance Improvement (QAPI) committee. The surveyors verified this through review of the audits, observation of staff response to door alarms, and interviews with facility staff and Administration. O. On 4/24/2022, the Medical Director, Administrator, DON and ADON were notified of the incident. The surveyors verified this through interview with the Medical Director, Administrator, DON, and ADON. P. On 4/25/2022, the door screeners were educated to not leave the door post unless there was a relief person to assume the duties. The surveyors verified this through review of the in-service sign sheet and interviews with the door screeners. Q. On 4/25/2022, all newly hired personnel will be educated during orientation on identifying residents assessed to be high risk for elopement, the elopement/wandering patient policy and procedure, procedure for responding to alarms which includes checking the physical environment after responding to alarms and performing a head count and the physical location of the residents. The surveyors verified this through interviews with newly hired staff and with Administration. R. On 4/25/2022, a policy review was conducted with no changes recommended. The surveyors verified this through interviews with the Administrator, DON, and the Medical Director. S. On 4/25/2022, a doorbell was installed on the South Front entrance door for visitors to gain access to the facility. The surveyors verified this through observation of the doorbell. T. On 4/25/2022, the egress bar was undocked on the 2nd Entrance Door (so visitors cannot pull on the door for 15 seconds to enter the building). The surveyors verified this through observation of the 2nd Entrance Door and interviews with the Maintenance Director and Administrator. U. On 4/25/2022, an AdHoc (impromptu) QAPI meeting was held to discuss the incident, the interventions and preventative measures going forward. The surveyors verified this through review of the QAPI sign in sheet and interviews with Administration and the Medical Director. V. On 4/25/2022, 100% of the facility staff in-services related to elopement procedure, responding to alarms and exit-seeking behaviors were completed. The surveyors verified this through review of the in-service sign in sheets and interviews with staff on all shifts.

Based on policy review, United States Drug Administration (USDA) Refrigeration & Food Safety Chart review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dust particles on the wall near the steam table and over a tray of dietary bowls, rust and dust particles on the vents over the steam table, when food items were stored opened and undated in the walk-in cooler, walk-in freezer and the reach-in refrigerator, when food was stored past the open dates in the walk-in refrigerator, when 1 of 3 dietary staff (Dietary Staff #1) touched food with her bare hands, and when 1 of 18 staff members (Certified Nursing Assistants (CNA) #1) were observed touching a resident's food. The facility had a census of 87, with 83 of those residents receiving a meal tray from the kitchen. The findings include: Review of the facility's policy titled, Food Service, dated 7/12/2021, revealed .All stored items should have an expiration date or a purchase/delivery date . Review of the USDA Refrigeration & Food Safety Chart guidelines titled, USDA Food Purchased Refrigerated, dated 1/28/2021, revealed .Ham (Pre-Cooked) Fully Cooked Slices .Refrigerator 3-4 days .hot dogs after opening .Refrigerator .1 week . Observation during the initial tour of the Kitchen on 7/18/2021 beginning at 9:05 AM, revealed the following: a. dark dust particles on the wall next to the steam table b. 43 bowls sitting on a tray on top of a stainless-steel meal cart with dark dust particles noted on top of the meal cart and dark dust particles on the ceiling tile above the cart and the bowls. c. Dietary Aide #1 used her bare hands to transfer cake slices from the aluminum package to the serving bowls. d. 15 slices of bread in a clear package stored on a metal rack near the handwashing station, opened and undated, without an expiration date or received date. e. 13 bread halves and 3 hamburger buns stored on top of a box on a metal cart near the entrance of the walk-in freezer undated. f. 6 hot dog buns on the shelf in the walk-in cooler, opened and undated. g. 3 Bratwurst Sausage on the shelf in the walk-in freezer, opened and undated. h. 4 breaded fish fillets on the shelf in the walk-in freezer, opened and undated. i. a large stainless-steel stock pot on the bottom shelf of a metal table outside of the Dietary Manager's office uncovered and with a green film on the top. j. 1/2 of a tomato in a bowl on the top of the steam table uncovered. k. 5 slices of bacon on a plate on the top of the steam table uncovered l. 1 bowel of corn flakes sitting on a metal cart near the steam table uncovered. m. 5 slices of yellow cake in bowls on top of the work-station at the end of the steam table uncovered. Observation in the Kitchen in the dry food storage room on 7/19/2021 beginning at 8:00 AM, revealed the following: a. 1 bag of graham cracker crumbs opened and undated. b. 1 bag of elbow macaroni opened and undated. c. 1 bag of linguine noodles opened and undated. d. 1-21 oz (ounce) plastic container of garlic powder opened and undated. e. 1-16 oz plastic container of whole celery seed opened and undated. f. 1-14 oz plastic container of ground cayenne pepper opened and undated. g. 1-12 oz plastic container of poultry seasoning opened and undated. h. 1-15 oz plastic container of ground cinnamon opened and undated. i. 1-13 oz plastic container of Mediterranean style ground oregano opened and undated. j. 1-12 oz plastic container of ginger powder opened and undated. k. 1- 28 oz plastic container of lemon pepper seasoning salt opened and undated. l. 1-16 oz plastic container of chili powder opened and undated. m. 1-6 oz plastic container of thyme opened and undated. n. 1-16 oz plastic container of ground cinnamon opened and undated. o. 1-64 oz container of Unsweetened Almond Milk opened and undated in the reach in refrigerator. p. 1 Pimento cheese sandwich in a plastic storage bag undated in the reach in refrigerator. n. 1 plastic storage bag with ham slices dated 7/14/2021, stored past the refrigerated storage date in the reach in refrigerator. o. 1-5 lb [pound] plastic container of chicken salad with the seal broken and the lid lifted with no open date in the reach in refrigerator. During an interview on 7/19/2021 at 8:45 AM, the Dietary Manager was asked should dry foods and spices be stored without an open date. The Dietary Manager stated, No, they should have dates [open dates]. The Dietary Manager confirmed that the walls, ceiling tiles and vents should be free of dust and rust. During an interview on 7/20/2021 at 3:45 PM, the Registered Dietician (RD) confirmed that the pimento cheese sandwich should have had a date put on it when it was put into the reach-in refrigerator. The RD confirmed that any food left out should be covered and dated. The RD confirmed that the vents and ceiling tiles should be free of dust and debris. The RD confirmed that food which has been opened should be stored with an open date when placed in the walk-in cooler or the reach in refrigerator. The RD was asked if staff should touch food with their bare hands. The RD stated, No, they shouldn't. Observation in the Dining Room on 7/20/2021 at 7:55 AM, revealed CNA #1 spread jelly on Resident #20's biscuit with her bare hands, without performing hand hygiene. During an interview on 7/21/2021 at 8:25 AM, the Director of Nursing (DON) was asked if staff should handle resident's food with their bare hands. The DON stated, Absolutely not.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 17 staff members (Certified Nursing Assistant (CNA) #3, #4, #5, and #6 and Licensed Practical Nurse (LPN) #1) did not use courtesy titles to address Resident #38, #50, #61, #70, #71, and #339 during dining, and 1 of 4 nurses (LPN #2) failed to provide dignity for Resident #33 during medication administration. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity Policy, with a revision date of 11/30/2017, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Maintain resident privacy . Observation in the resident's room during dining on 7/19/2021 at 7:36 AM, revealed CNA #3 stated, .she's a feeder, within hearing distance of Resident #61. Observation in the resident's room during dining on 7/19/2021 at 7:43 AM, revealed LPN #1 stated, .he's not a feeder, within hearing distance of Resident #70. Observation in the resident's room during dining on 7/19/2021 at 7:51 AM, revealed CNA #4 stated, .she's a feeder, within hearing distance of Resident #50. Observation in the resident's room during dining on 7/19/2021 at 7:59 AM, revealed CNA #4 stated, .she's not a feeder, within hearing distance of Resident #71. Observation in the resident's room during dining on 7/19/2021 at 8:16 AM, revealed CNA #5 stated, .she's not a feeder, within hearing distance of Resident #38. Observation in the resident's room during dining on 7/19/2021 at 8:35 AM, revealed CNA #6 stated, .she's a feeder, within hearing distance of Resident #339. Observations in the resident's room on 7/20/2021 at 8:41 AM, during medication administration, revealed LPN #2 unzipped Resident #33's gown, exposing her chest and bra, as she looked for an old medication patch to remove before applying a new one. The door to the room was open, and Resident #33 could be seen from the hallway. During an interview on 7/21/2021 at 7:45 PM, The Director of Nursing (DON) confirmed residents should not be called feeders. The DON was asked if a resident's room door should be closed when staff exposed a resident's chest and bra. The DON stated, .yes .

Based on policy review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner resulting in delayed mealtimes on the 400 Hall. This had the potential to affect 37 of the 89 residents who had received a meal tray. The findings include: Review of the facility's policy titled, Dietary-Dining Services, dated 10/2020, revealed .Cart Delivery Times Meals must be delivered to the residents in a timely fashion . Observation of the 400 Hall meal cart revealed the cart was delivered to the 400 Hall on 7/19/2021 at 7:26 AM. Observation of the 400 Hall meal cart on 7/19/2021, revealed the last meal tray served to a resident was at 8:40 AM. One hour and 14 minutes elapsed between the time the meal cart arrived on the hall and the last tray was served. During an interview on 7/21/2021 at 7:45 PM, the Director of Nursing confirmed meal cart delivery on the hall should be 30 minutes.

Based on review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance, medical record review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed when an indwelling urinary catheter bag was on the floor for 1 of 1 sampled resident (Resident #27) reviewed with an indwelling urinary catheter, and the Activity Director and Certified Nursing Assistant (CNA) #8 entered the front door of the facility and walked throughout the facility prior to being screened. The finding include: Review of the CMS Long-Term Care Facility Guidance dated 4/2/2020, revealed .Long-term care facilities should immediately implement symptom screening for all .In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors .) should be asked about COVID-19 symptoms and they must also have their temperature checked. An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately .Facilities should limit access points and ensure that all accessible entrances have a screening station . Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .two times monthly .Change foley catheter .as needed . Observations in the resident's room on 7/18/2021 at 8:45 AM and 12:36 PM, 7/19/2021 at 7:31 AM, and on 7/20/2021 at 8:20 AM, revealed Resident #27's bedside drainage bag was hanging on the side of the bed and the bag and tubing were touching the floor. During an interview on 7/21/2021 at 8:20 AM, the Director of Nursing (DON) was asked if a bedside drainage bag should be on the floor. The DON stated, .No, it should never be on the floor. Observation at the front door of the facility on 7/18/2021 at 12:00 PM, the Activity Director was observed entering the front door of the facility, wearing a mask, sanitized her hands, then walked down a short hallway to the main Dining Room, she walked in between the tables of residents that were waiting for lunch, into a hallway next to the Kitchen (where the time clock and screening station was located), prior to being screened for COVID-19 symptoms. During an interview on 7/18/2021 at 12:05 PM, the Activity Director was asked if she screens for symptoms when she enters the building. The Activity Director stated that she screens at the time clock. During an interview on 7/19/2021 at 3:43 PM, Certified Nursing Assistant (CNA) #8 confirmed she comes into the front door of the facility and stated, . I go to the clock, take my temp [temperature] and answer [screening] questions .

Based on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of resident medical records for 3 of 5 sampled residents (Resident #33, #70, and #339) observed during medication administration. The findings include: Review of the facility's policy titled, Patient Confidentiality with a revision date of 2/2021, revealed .All efforts will be made to protect the confidentiality/privacy of the resident and their health information. This includes privacy in relation to care, medical records protection . Review of the medical record, revealed Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the 400 Hall on 7/20/2021 at 8:20 AM, revealed Resident #70's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's name and medications were visible on the computer monitor screen. Review of the medical record, revealed Resident #339 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the 400 Hall on 7/20/2021 at 8:30 AM, revealed Resident #339's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's name and medications were visible on the computer monitor screen. Review of the medical record, revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the 400 Hall on 7/20/2021 at 8:51 AM, revealed Resident #33's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's name and medications were visible on the computer monitor screen. During an interview on 7/21/2021 at 7:51 PM, the Director of Nursing (DON) was asked if a resident's personal health information should be visible on the computer monitor screen when the medication cart was unattended. The DON stated, No.

Based on review of Nursing Home Transfers and Discharges Frequently Asked Questions (FAQ), medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 2 of 4 sampled residents (Resident #59 and #61) reviewed for hospitalization s. The findings include: Review of undated document titled Nursing Home Transfers and Discharges FAQ, revealed .This monthly report should include all residents who are transferred out of the facility for care. This includes all emergency room visits, geri-psych [Geriatric-Psychiatric] stays or hospital stays . Review of the medical record, revealed Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurses 'Note dated 3/25/2021, revealed, .NP [Nurse Practitioner] evaluated resident due to BP [blood pressure] 80/40, pulse 105, temp [temperature] 100.4. Noted a very foul odor to wound vac. NP gave order to send to ER [emergency room ] for further evaluation . Review of a Nurses' Note dated 3/25/2021, revealed .Called [Named Hospital] for an update on Resident [Resident #59] .RN [Registered Nurse] stated that she was admitted to ICU [Intensive Care Unit] for [CONDITION(S)] and [CONDITION(S)] . Review of the medical record, revealed Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation that the Ombudsman had been notified of these transfers to the hospital for Resident #59 and #61. During an interview on 7/21/2021 at 8:15 AM, the Administrator stated, .She [Business Office Manager] was not using the correct form and she wasn't sending the hospital discharges to the Ombudsman .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Care Plan interventions were implemented and followed for 2 of 6 sampled residents (Resident #26 and #65) reviewed for activities of daily living (ADLs). The findings include: Review of the facility's policy titled, .Comprehensive Careplan [Care Plan] ., revised 3/25/2021, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be prepared by an interdisciplinary team .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Review of the facility's policy titled, .Range of Motion - Prevention of Decline Policy, revised 5/31/2020, revealed .Range of Motion .means the full movement potential of a joint .The facility in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care .Licensed nurses will assess resident's range of motion (such as current extent of movement of his/her joints and the identification of limitations) on admission/readmission, quarterly, and upon a significant change .Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion .This includes .Appropriate equipment .Care plan interventions will be developed and delivered through the facility's restorative Program .A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quality Assurance (QA) Contract for Resident #65 dated 4/14/2020, revealed .Please complete hand hygiene of washing and thoroughly drying of bilateral hands daily .After hygiene .place BLUE THERAPY CARROTS in both hands. The larger end of the Therapy Carrot should be placed in thumb with remaining fingers wrapped around rest of Therapy Carrot. The right hand is typically less resistive, however the left hand is more resistive requiring more extensive PROM [Passive Range of Motion] to placing the Therapy Carrot. Pt. [Patient] can wear these at all times with exception of hygiene which should be completely [completed] daily . Review of an Occupational Therapy (OT) Screen dated 3/1/2021, revealed .Patient was d/c'd [discontinued] from OT services in April 2020 with QA written for patient to have Blue Therapy Carrots in bilateral hand [hands], and hands to be thoroughly cleaned daily. Patient did not have carrots in bilateral hands upon writer's assessment . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #65 had severe cognitive impairment, was totally dependent on staff for Activities of Daily Living (ADL), and had impaired range of motion to both upper and lower extremities. Review of the Care Plan dated 9/30/2021 revealed, .[CONDITION(S)] to R [Right] side related to CVA Blue therapy carrots (hand rolls) to hands bilaterally daily . The Care Plan did not describe how to place the carrots in both hands and did not specify that the carrots were to be always worn, except for (hand) hygiene. Review of the Resident Care Summary Assessment (a form provided to the Certified Nursing Assistants (CNAs) so they will know how to care for the resident), revealed .carrots/handrolls to hands bilaterally as tolerated . The Resident Care Summary Assessment did not describe how to place the carrots in both hands and did not specify that the carrots were to be always worn, except for (hand) hygiene. Review of an Occupational Therapy Screen dated 6/14/2021 revealed when the therapist entered Resident #65's room, she noted the bilateral hand carrots were in the bedside table. Observation in the resident's room on 7/19/2021 at 2:12 PM, and 7/20/2021 at 10:15 AM, revealed Resident #65 lying in bed. There were no blue carrots in her hands. During an interview on 7/20/2021 at 10:17 AM, CNA #2 confirmed she was the CNA for Resident #65. She was asked if she placed the blue therapy carrots in Resident #65's hands when she performed her ADL care. She stated, .I didn't know we were supposed to . During observation and interview in the resident's room on 7/20/2021 at 11:00 AM, CNA #1 and Restorative CNA #7 confirmed there were no blue therapy carrots or handrolls in Resident #65's hands. Restorative CNA #1 stated she was supposed to have handrolls placed in her hands daily. CNA #1 stated, .I don't know why they forget to put the handrolls on . Restorative CNA #7 was able to open Resident #65's left hand slightly, and a foul odor came from the hand. Both CNAs confirmed the foul odor and CNA #1 stated, .that [left hand] needs to be cleaned . During an interview on 7/21/2021 at 9:05 AM, the MDS/Restorative Coordinator was asked why the application of handrolls instead of carrots was written in the Care Plan for Resident #65. She stated, .I didn't know what a carrot was . During an interview on 7/21/2021 at 9:37 AM, the OT was asked if therapy carrots and handrolls are the same thing. She said they were two different things and stated, .When I discharged her, I recommended the blue therapy carrots in both hands . She confirmed Resident #65 was to always have the blue therapy carrots, except during hand hygiene. She confirmed she made the recommendation during the Interdisciplinary Team Meeting which included the MDS/Restorative Coordinator. She confirmed the recommendations go on the Care Plan and the nurses should carry out the Care Plan. During an interview on 7/21/2021 at 1:19 PM, the MDS/Restorative Coordinator was asked if the facility could provide documentation that CNAs placed the devices in Resident #65's hands daily for the entire day. She stated there was no charting system for that. Review of the facility's policy titled, Hearing and Vision Policy, dated 10/2020, revealed .It is the policy of this facility to ensure that residents receive proper treatment and assistive devices to maintain vision .Employees should refer any identified need for hearing or vision services/appliances to the social worker .Employees will assist the resident with the use of any devices .needed to maintain vision .Assistive devices to maintain vision include glasses . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 12/1/2020, revealed .ability to see in adequate light is impaired .Assist [Resident #26] to clean and put on glasses each morning . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #26 had impaired vision and required extensive to total assistance from staff for all Activities of Daily Living (ADLs). Observation on 7/18/2021 at 9:03 AM, 12:16 PM, and 3:33 PM, on 7/19/2021 at 7:42 AM and 2:10 PM, on 7/20/2021 at 10:28 AM and 4:10 PM, and on 7/21/2021 at 8:40 AM, revealed Resident #26 was not wearing glasses. During an interview on 7/19/2021 at 9:16 AM, Resident #26's family member was asked if there were any concerns about Resident #26. The family member confirmed Resident #26's glasses were missing. During an interview on 7/19/2021 at 5:14 PM, the Social Worker stated she was not aware that Resident #26's glasses were missing. During an interview on 7/21/2021 at 8:40 AM, CNA #6 was asked where Resident #26's glasses were. CNA #6 stated, .thank you for telling me .she does wear glasses .she had them at one time .I know I haven't seen them .we get so busy, we don't think about it . During an interview on 7/21/2021 at 8:45 AM, Licensed Practical Nurse (LPN) #3 was asked about Resident #26's glasses. LPN #3 confirmed she didn't know Resident #26 had glasses and stated, .When she gets a card, we read it to her . During an interview on 7/21/2021 at 3:47 PM, the MDS/Restorative Coordinator was asked if the CNAs who care for Resident #26 should know she had glasses and should assist her with them. She confirmed the CNAs knew she had glasses because it's on the Care Plan and on the Resident Care Summary Assessment. She confirmed the CNAs should have reported the missing glasses to the charge nurse. During an interview on 7/21/2021 at 8:00 PM, the Director of Nursing (DON) confirmed the purpose of the resident's Care Plan was for the facility staff to know how to care for the resident. She confirmed that if the Care Plan included an intervention for staff to clean and apply a resident's glasses, staff should make sure the resident has their glasses.

Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, review of Snell, M. A. (1999). Guidelines For Safely Transporting Wheelchair Users. OT Practice. 4(5) ,[DATE], policy review, observation, and interview, the facility failed to ensure the implementation of professional standards of practice for 4 of 4 (Resident #58, #1, #240, and #242) sampled residents reviewed who were being transported to and from [MEDICAL TREATMENT] by a transportation wheelchair van service. The facility failed to ensure residents' safety by conducting resident safety risk assessments in order to determine the residents' abilities to independently travel in a transportation van service to and return from [MEDICAL TREATMENT] treatments; and ensure a safety plan was developed and implemented for residents' safe transportation to and return from [MEDICAL TREATMENT] treatments. The failure of the facility to develop and implement a safety plan for residents using a transportation van service resulted in Immediate Jeopardy (IJ) for Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility was cited an Immediate Jeopardy at F281-K. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F281-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits (a defect in the function of one or more of the senses, such as [MEDICAL CONDITION]) . The Guidelines For Safely Transporting Wheelchair Users. OT Practice article documented, .Each person's wheelchair and seating system is a specialized unit designed to fit and provide unique postural control to him or her. When someone is to be transported in his or her wheelchair, the therapist, in conjunction with the client, family and rehabilitation supply dealer, needs to recommend and provide equipment that takes the transportation information into consideration. Additional equipment recommendations may be necessary to establish the highest possible safety level during transportation . The [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#58's status to a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], and the quarterly MDS dated [DATE], revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x (of) 2 for transfers and extensive staff assist x 1 for locomotion, walking did not occur, was not steady for surface to surface transfers, and was only able to stabilize with human assistance. No use of mobility device was documented. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday continuous (name of [MEDICAL TREATMENT] clinic) . The current care plan dated [DATE] documented, .[MEDICAL TREATMENT] on 3 days/week .is still Tu (Tuesday) /Th (Thursday) /Sa (Saturday) at .(Name of [MEDICAL TREATMENT] Clinic); transported by w/c (wheelchair) van . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, which indicated Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer to [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheel chair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide any documentation that an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to independently and safely transport via wheelchair van without an escort to [MEDICAL TREATMENT] after the recent significant change of condition of a left above the knee amputation on [DATE]. The Clinical Notes Report dated [DATE] at 1:51 PM documented, .resident (Resident #58) returned from access center (outpatient surgery center) .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he did slide out of wheelchair . The facility was unable to provide documentation a fall investigation or a Post Fall risk assessment was performed after the fall during transport on [DATE]. Review of the current care plan dated [DATE] revealed no revisions to Resident #58's care plan with safety interventions being developed and implemented to ensure the patient's safety while being transported by the transportation van services for medical purposes. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . The physician's office History and Physical dated [DATE] documented, .Pt (patient) was scheduled for an ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that enables the physician to examine the pancreatic and bile ducts using a bendable lighted tube inserted through the mouth into the stomach and the small intestine) .Tues [DATE] .After pt has [MEDICAL TREATMENT] . The facility's clinical notes dated [DATE] at 5:49 AM, documented, .res (resident) is LOA to [MEDICAL TREATMENT] via wheelchair van . On [DATE] at 10:05 PM the facility's clinical notes documented, .nurse from (name of hospital) called this evening giving report on resident stating that O2 (oxygen) levels were low coming out of surgery but as soon as they were stable resident would be on way with new orders for ABT (antibiotic) and clear liquids . On [DATE] at 1:55 PM the facility's clinical notes documented, .resident returned from hospital . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 14, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted and a transportation safety plan was implemented for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION], to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required a surgical procedure with an overnight hospital stay, with return to the facility on [DATE]. The facility's clinical notes dated [DATE] at 10:35 PM documented, .received new order from md (medical doctor) office to send (Patient #58) to ER (emergency room ) to tx (treatment) and evaluation due to recent episodes of confusion .prior to transfer resident's O2 % (percent) was 83 (normal range ,[DATE]%). Oxygen .was applied by this nurse. ems (emergency medical services) came and (Resident #58) was taken by ems to hospital around 4pm . The Hospital History and Physical dated [DATE] documented, .was transferred from nursing home with confusion and [MEDICAL CONDITION] to the 80s on room air .also .right upper extremity swelling .Impression Metabolic [MEDICAL CONDITION] (Temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired) .Acute hypoxemic [MEDICAL CONDITION] (Fluid build-up in the air sacs in the lungs) .[MEDICAL CONDITION] disorder (A low number of platelets in the blood) .End stage [MEDICAL CONDITION] . The facility's clinical notes dated [DATE] at 5:42 PM, documented, .Resident returned to facility after [MEDICAL TREATMENT], pt discharged from hospital this am . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 16, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment and safety plan for transportation was implemented for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required an overnight hospital stay, with return to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's clinical notes dated [DATE] at 5:41 AM, documented, .Res (resident) LOA (Leave of Absence) to [MEDICAL TREATMENT] via w/c van . On [DATE] at 11:06 AM the facility's clinical notes documented, .received call from (name of clinic) [MEDICAL TREATMENT] that resident was in the process of being picked up by (name of company) transportation and w/c tipped backwards (off the lift gate of the van) with resident (#58) in it; this nurse was informed that resident hit head (on concrete) during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval (evaluation) and tx (treatment) . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient states: was getting in van the driver was lifting his wheelchair and (Resident #58) fell out of wheelchair backward (off the lift gate of the van) and hit .head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient sustained injury to the head, patient was at [MEDICAL TREATMENT] and they were getting him into there (their) van and there chir (their chair) flipped (off the lift gate of the van) and hit .head (on concrete) .Differential Diagnoses: [REDACTED].Fairly extensive bilateral temporal Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for higher level of care). [DIAGNOSES REDACTED]. Interview with the DON on [DATE] at 10:25 AM, in the conference room, the DON was asked if the facility had a transport safety assessment and plan for residents to travel without an escort via wheelchair van to [MEDICAL TREATMENT]. The DON stated, .It does not specifically ask that question . The DON verified there was no specific policy related to completion of assessment for safety for residents traveling in the wheelchair van without an escort. The facility was unable to provide documentation that Resident #58, a vulnerable resident with [MEDICAL CONDITION] and bilateral lower extremity amputations, received a safety assessment to determine his ability to safely participate in travel without an escort to [MEDICAL TREATMENT] after the changes in status as follows: a. after a significant change in status when Resident #58 returned to the facility [DATE] after a Left above the Knee Amputation, changing his status to a bilateral [MEDICAL CONDITION]; b. after Resident #58 sustained a fall out of the wheelchair while traveling in the transportation van on [DATE]; c. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after a surgical procedure and [MEDICAL CONDITION] (low oxygen levels); d. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after episodes of confusion and [MEDICAL CONDITION]. The failure of the facility to ensure a safety plan was developed or implemented for residents who used a transportation van service for medical reasons resulted in an IJ for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment, and received [MEDICAL TREATMENT] while a resident at the facility. The facility's Care Plan Report dated [DATE] documented, .[MEDICAL TREATMENT] on Tues, Thurs, Sat .goes by community van in her w/c . The facility's Physician order [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . The facility was unable to provide documentation that Resident #1 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Medical record review revealed Resident #240 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #240 had a BIMS score of 5, indicating severe cognitive impairment, and received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the nurses' notes dated [DATE], [DATE], and [DATE] revealed Resident #240 went to [MEDICAL TREATMENT] via wheelchair van. Observations of Resident #240 on [DATE] at 8:51 AM, in Resident #240's room, revealed he was alert, hard of hearing, and lying in bed with the head of bed up. The breakfast meal was on the overbed table, and Resident #240 was leaning to the left side in bed. Resident #240 was asked whether he needed assistance with positioning, and he nodded his head to confirm that he did. The facility was unable to provide documentation that Resident #240 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Medical record review revealed Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #242 had a BIMS score of 13, indicating no cognitive impairment, and received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] and [DATE] revealed Resident #242 was transported to [MEDICAL TREATMENT] via wheelchair van. The facility was unable to provide documentation that Resident #242 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The facility was cited an Immediate Jeopardy at F281-K. The noncompliance continues at F281-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, policy review, observation, and interview, the facility failed to ensure a comprehensive approach to all care and services provided to facility residents and ensure communication between the [MEDICAL TREATMENT] center and the facility for 3 of 5 (Resident #58, #1, and #93) sampled residents reviewed receiving outpatient [MEDICAL TREATMENT]. The facility failed to ensure safety assessments and plans were completed and implemented prior to residents being transported by a transportation van service for medical services for 4 of 4 (Resident #58, #1, #240, and #242) sampled residents reviewed who were receiving outpatient [MEDICAL TREATMENT] and using a transportation van service. The failure of the facility to provide the appropriate safety assessment/reassessment and plans resulted in Immediate Jeopardy for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F309-K which is Substandard Quality of Care. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the IJ, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE], and continued until an allegation of compliance (A(NAME)) was received on [DATE] at 6:57 PM, and validated on [DATE] and [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F309-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits (a defect in the function of one or more of the senses, such as [MEDICAL CONDITION]) . Review of the [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic and any costs related to such transportation. If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . Review of the facility's [MEDICAL TREATMENT] Patient Services policy dated [DATE], documented, At times, we will have patients with [MEDICAL TREATMENT] orders. There are several special interventions to be implemented with a patient receiving [MEDICAL TREATMENT] .Nursing documentation required: Pre and Post [MEDICAL TREATMENT] weights . The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .After a fall .Significant change in medical status .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#58 being a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x 2 staff for transfers and extensive staff assist x 1 for locomotion, walking did not occur, and was not steady for surface to surface transfers, was only able to stabilize with human assistance. No use of mobility device was documented. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday continuous (name of [MEDICAL TREATMENT] clinic) . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, indicating Resident #58 was moderate risk (score of ,[DATE]) for falls. Review of the Transfer to [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheel chair van to the [MEDICAL TREATMENT] clinic. The current care plan dated [DATE] documented, .[MEDICAL TREATMENT] on 3 days/week (verify schedule) is still Tu (Tuesday) /Th (Thursday) /Sa (Saturday) at .(Name of [MEDICAL TREATMENT] Clinic); transported by w/c (wheel chair) van . The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the recent significant change of condition of a left above the knee amputation (surgical removal of the left leg above the knee) on [DATE]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The Physical Therapy (PT) progress notes dated [DATE] at 8:44 AM documented, .Pt (patient) presents with increased swelling with RUE (right upper extremity) which is limiting use and support required . The Physical Therapy (PT) progress notes dated [DATE] at 2:23 PM documented, .Comments: Pt demonstrates fair participation with poor to fair tolerance to therapy sessions. Pt has [MEDICAL TREATMENT] Tue (Tuesday), Thurs (Thursday), and Sat (Saturday) in the am. Treatment on those days cont (continue) to be performed post treatment in the pm in which pt demonstrates increased fatigue/weakness post [MEDICAL TREATMENT] treatments and tolerance/participation is limited. Pt presents with increased swelling with RUE (right upper extremity) which is limiting use and support required . The Clinical Notes Report dated [DATE] at 1:51 PM, documented, .resident returned from access center .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he did slide out of wheelchair . The facility was unable to provide documentation a fall investigation was completed after the fall during transport on [DATE]. The facility was unable to provide documentation a post-fall risk assessment was conducted after the fall from the wheelchair during transport on [DATE] per the facility's Fall Risk/Fall Prevention Guidelines policy. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . Review of the care plan dated [DATE] revealed no revisions to Resident #58's care plan with interventions(s) associated with the cause of the fall on [DATE] while riding in the wheelchair van. The physician's orders [REDACTED].PT service at this time to restorative care. Interview with PT #1, on [DATE] at 1:15 PM, in the conference room, PT #1 was asked when Resident #58 was discharged from therapy. PT #1 stated on [DATE] Resident #58 was reaching a plateau, and was more fatigued. PT #1 stated Resident #58 was discharged to restorative nursing for that week. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs) resident, to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the fall from the wheelchair during transport on [DATE]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The physician's office history and physical dated [DATE] documented, .Assessment .Common bile duct stone .Discussion/Summary .Pt (patient) was scheduled for an ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that enables your physician to examine the pancreatic and bile ducts using a bendable lighted tube inserted through the mouth into the stomach and the small intestine) .Tues [DATE] .After pt has [MEDICAL TREATMENT] . The facility's Clinical Notes dated [DATE] at 5:49 AM, documented, .res (resident) is LOA (leave of absence) to [MEDICAL TREATMENT] via wheelchair van . The facility's Clinical Notes dated [DATE] at 10:05 PM, documented, .nurse from (name of hospital) called this evening giving report on resident stating that O2 (oxygen) levels were low coming out of surgery but as soon as they were stable resident would be on way with new orders for ABT (antibiotic) and clear liquids . The facility's Clinical Notes dated [DATE] at 1:55 PM, documented, .resident returned from hospital . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 14, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. The physician's orders [REDACTED].PT clarification order for 5 to 7 x a week include there (therapeutic) ex (exercise), there act (activity) . Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required a surgical procedure with an overnight hospital stay, with return to the facility on [DATE]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The PT DC (Discharge) Summary dated [DATE] documented, .Pt (patient) currently with max (maximum) potential established with mod (moderate) A (assist) for bed mobility with use of handrails, transfer with use of Hoyer lift with max A x ,[DATE]. PT services have been DC (discontinued) to restorative care (Therapies provided by nursing staff) . The Clinical Notes dated [DATE] at 10:35 PM documented, received new order from md (medical doctor) office to send to ER (emergency room ) to tx (treatment) and evaluation due to recent episodes of confusion .prior to transfer resident's O2 % (percent) was 83 (normal range ,[DATE]%). Oxygen .was applied by this nurse. ems (emergency medical services) came and was taken by ems to hospital (Hospital #1) around 4pm . Hospital #1's History and Physical dated [DATE] documented, .was transferred from nursing home with confusion and [MEDICAL CONDITION] (low oxygen levels) to the 80s (normal range ,[DATE]%) on room air .also .right upper extremity swelling .Impression Metabolic [MEDICAL CONDITION] (Temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired) .Acute hypoxemic [MEDICAL CONDITION] (Fluid build-up in the air sacs in the lungs) .[MEDICAL CONDITION] disorder (A low number of platelets in the blood) .End stage [MEDICAL CONDITION] . The facility's Clinical Notes dated [DATE] at 5:42 PM, documented, Resident returned to facility after [MEDICAL TREATMENT], pt discharged from hospital this am . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 16, indicating Resident #58 was at moderate risk (score ,[DATE]) for falls. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required an overnight hospital stay, with return to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The facility's Clinical Notes Report dated [DATE] at 5:41 AM, documented, .Res (resident) LOA to [MEDICAL TREATMENT] via w/c van . The facility's Clinical Notes Report dated [DATE] at 11:06 AM, documented, .received call from (name of clinic) [MEDICAL TREATMENT] that resident was in the process of being picked up by (name of company) transportation and w/c tipped backwards (off of the lift gate) with resident in it; this nurse was informed that resident hit head (on concrete) during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval and tx . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient states: was getting in van the driver was lifting his wheelchair (on the lift gate) and (Resident #58) fell out of wheelchair backward and hit his head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient sustained injury to the head, patient was at [MEDICAL TREATMENT] and they were getting him into there (their) van and there chir (their chair) flipped (off the lift gate on the van) and (Resident #58) hit .head .Differential Diagnoses: [REDACTED].Fairly extensive bilateral temporal subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for a higher level of care). [DIAGNOSES REDACTED]. Review of the PT DC Summary dated [DATE] revealed Resident #58 was not receiving PT services at the time of the last fall on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 10:31 AM, in the conference room, the DON was asked how it was determined the resident could safely travel in the transport van without an escort. The DON stated, You're going to have to read the PT (Physical Therapy) note .There's no assessment to see if he was safe to go in the van . The DON was asked how the facility assessed Resident #58 for safety to travel in the wheelchair van without an escort after he was readmitted from having the second lower extremity amputation [DATE], after he fell during transport on [DATE], and after his changes in condition and return from hospitalization s [DATE] and [DATE]. The DON stated, We don't do an assessment to say he can travel .when therapy picked him up, if he wasn't safe to be up in the chair, they would have told us. There was one little period he got weak .Restorative (Restorative Nursing Services, therapies provided by nursing staff) picked him up at that time . The DON was asked how was it determined whether residents need an escort to ride with them during transport in the wheelchair van. The DON stated, .people just don't go with them .you're not going to see that documented . The DON was asked whether she would expect the residents to be assessed/reassessed for traveling to appointments or treatments alone or without escorts after a change is status, hospitalization s or falls. The DON stated, .I would expect therapy to re-evaluate him. When we call to make the transportation and all of that, they would not go out there and assess him to put him on the van. If they felt like he was not safe to ride the van, they would let us know . The DON was asked to explain the process to determine what type of transportation the residents need for transport. The DON stated, .It goes more by the certification and necessity . Interview with the Rehab Manager on [DATE] at 11:36 AM, in the conference room, the Rehab Manager was asked how residents were assessed to safely travel without an escort in the wheelchair van. The Rehab Manager stated, .We don't assess them getting on the van because it is a lift. They don't transfer them. He never leaves that wheelchair. He gets on the lift, and they strap him in . The facility was unable to provide documentation that Resident #58 received a safety assessment to travel without an escort to [MEDICAL TREATMENT] after the following: a. after a significant change in status when Resident #58 returned to the facility [DATE] after a Left above the Knee Amputation (surgical removal of the left leg above the knee), changing his status to a bilateral [MEDICAL CONDITION] (surgical removal of both legs); b. after Resident #58 sustained a fall while traveling in the transportation van on [DATE]; c. after a change in condition when Resident #58 returned from the hospital on [DATE] after a surgical procedure and [MEDICAL CONDITION] (low levels of oxygen); d. after a change in condition when Resident #58 returned from the hospital on [DATE] after episodes of confusion and [MEDICAL CONDITION]. The failure of the facility to ensure safe conditions were provided for transport, failure to assess a resident for ability to participate in transport, and failure to provide a plan for safe transport to and return from [MEDICAL TREATMENT] treatments for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), resulted in IJ for Resident #58 when the resident sustained [REDACTED]. Review of the [MEDICAL TREATMENT] communication sheets revealed there was no [MEDICAL TREATMENT] communication between facility and [MEDICAL TREATMENT] for Resident #58 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment, and received [MEDICAL TREATMENT] while a resident at the facility. The Care Plan Report dated [DATE] documented, .[MEDICAL TREATMENT] on Tues, Thurs, Sat .goes by community van in her w/c: BE AWARE she occasionally needs extra day of [MEDICAL TREATMENT] . The Physician order [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . The facility was unable to provide documentation that Resident #1 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication sheets revealed no [MEDICAL TREATMENT] communication documented between the facility and [MEDICAL TREATMENT] for Resident #1 for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated severe cognitive impairment, and [MEDICAL TREATMENT] treatments. The care plan dated [DATE] documented, .risk for complications of [MEDICAL CONDITION] .[MEDICAL CONDITION] requiring [MEDICAL TREATMENT] . A physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the [MEDICAL TREATMENT] communication sheets revealed there was no [MEDICAL TREATMENT] communication documented between the facility and [MEDICAL TREATMENT] for Resident #93 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with Assistant Director of Nursing (ADON) #2 on [DATE] at 2:53 PM, in the conference room, ADON #2 was asked about the missing transfer forms. ADON #2 stated, .sometimes the sheet doesn't come back with them ADON #2 was asked what the nurses do if the [MEDICAL TREATMENT] sheet does not come back with the resident. ADON #2 stated, .They would call and they'd say they'd fax it and we didn't get it and that shift nurse would go off . Medical record review revealed Resident #240 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 5, which indicated severe cognitive impairment and received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . The nurses' notes dated [DATE], [DATE], and [DATE] documented Resident #240 went to [MEDICAL TREATMENT] via wheelchair van. Observations of Resident #240 on [DATE] at 8:51 AM, revealed him to bed alert, hard of hearing, and lying in bed with the head of bed up. The breakfast meal was on the overbed table in front of the resident, and Resident #240 was leaning to the left side in bed. Resident #240 was asked whether he needed assistance with positioning, and he nodded his head to confirm that he did. The facility was unable to provide documentation that Resident #240 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Medical record review revealed Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment, and Resident #242 received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the TRANSFER TO [MEDICAL TREATMENT] forms dated [DATE] and [DATE], revealed Resident #242 was transported to [MEDICAL TREATMENT] via wheelchair van. The facility was unable to provide documentation that Resident #242 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. The facility's failure to ensure a comprehensive approach to all care and services provided to facility residents and ensure communication between the [MEDICAL TREATMENT] center and the facility for Resident #58, #1, and #93; and the facility's failure to ensure safety assessments and plans were completed and implemented prior to residents being transported by a transportation van service for Resident #58, #1, #240, and #242 resulted in Immediate Jeopardy for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F309-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, policy review, dialysis agreement review, medical record review, observation and interview, the facility failed to ensure residents at risk for falls were completely and accurately assessed for fall risk for 6 of 7 (Resident #58, #14, #41, #127, #142, and #167) sampled residents reviewed for falls; failed to ensure falls were thoroughly investigated with the implementation of new interventions to prevent further falls for 1 of 7 (Resident #58) sampled residents; and failed to ensure safety assessments were completed for 4 of 4 (Resident #58, #1, #240, and #242) sampled residents reviewed for outpatient dialysis prior to transportation without an escort outside the facility for medical services. The failure of the facility to provide the appropriate safety assessment/reassessment and safety plans for transportation resulted in Immediate Jeopardy for Resident #58; a resident who was blind in both eyes, and a bilateral lower extremity amputee (surgical removal of both legs), when the resident sustained [REDACTED]. This fall resulted in the resident being hospitalized , declining while in the hospital and death of the resident during hospitalization on [DATE], with [DIAGNOSES REDACTED]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F323-K which is Substandard Quality of Care. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the IJ, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F323-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits (a defect in the function of one or more of the senses, such as blindness) . The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . The Dialysis Services Agreement documented, .Operator (Facility) shall be responsible for making arrangements to transport the patient to Provider's (Dialysis) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#58 being a bilateral lower extremity amputee (surgical removal of both legs). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x (of) 2 for transfers and extensive staff assist x 1 for locomotion, walking did not occur, was not steady for surface to surface transfers, and was only able to stabilize with human assistance. No use of mobility device was documented. The physician's orders [REDACTED].Dialysis Tuesday-Thursday-Saturday continuous (name of dialysis clinic) . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer to Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. The care plan dated [DATE] documented, .Dialysis on 3 days/week (verify schedule) is still Tu (Tuesday) /Th (Thursday) /Sa (Saturday) at .(Name of Dialysis Clinic); transported by w/c (wheel chair) van . The facility was unable to provide documentation an assessment/reassessment had been performed to determine the resident's ability to participate safely in a transportation van service independently or a safety plan developed and implemented for using a transportation van service for medical reasons for Resident #58, who was blind in both eyes and a bilateral amputee (surgical removal of both legs). The Physical Therapy (PT) progress notes dated [DATE] at 8:44 AM documented, .Pt (patient) presents with increased swelling with RUE (right upper extremity) which is limiting use and support required . The PT progress notes dated [DATE] at 2:23 PM documented, . Comments: Pt demonstrates fair participation with poor to fair tolerance to therapy sessions. Pt has dialysis Tue (Tuesday), Thurs (Thursday), and Sat (Saturday) in the am (AM). Treatment on those days cont (continue) to be performed post treatment in the pm in which pt demonstrates increased fatigue/weakness post dialysis treatments and tolerance/participation is limited. Pt presents with increased swelling with RUE which is limiting use and support required . The physician's orders [REDACTED].Discharge .PT service at this time to restorative care (therapies provided by nursing staff) . The Clinical Notes Report dated [DATE] at 1:51 PM documented, .resident returned from access center .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he (Resident #58) did slide out of wheelchair . Review of the care plan dated [DATE] revealed no revisions to Resident #58's care plan with interventions associated with the fall on [DATE] while riding in the wheelchair van. The facility was unable to provide documentation that a fall investigation was conducted or that a fall risk assessment was completed after the fall on [DATE]. Review of the Transfer To Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. There was no documentation of a re-assessment for Resident #58, who was blind in both eyes and a bilateral lower extremity amputee with swelling to his RUE (right upper extremity) which limited use of his RUE, for safety risk for transport via wheelchair van without an escort to dialysis after sliding out of his chair during transport on the wheelchair van. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . Interview with PT #1 on [DATE] at 1:15 PM, in the conference room, PT #1 was asked when Resident #58 was discharged from PT. PT #1 stated on [DATE]. PT #1 stated Resident #58 was reaching a plateau and was more fatigued, and he was discharged to restorative nursing for that week. The physician's office history and physical dated [DATE] documented, .Assessment .Common bile duct stone .Discussion/Summary .Pt (patient) was scheduled for an ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that enables your physician to examine the pancreatic and bile ducts using a bendable lighted tube inserted through the mouth into the stomach and the small intestine) .Tues [DATE] .After pt has Dialysis . The Clinical Notes dated [DATE] at 5:49 AM, documented, .res (resident) is LOA (leave of absence) to dialysis via wheelchair van . The Clinical Notes dated [DATE] at 10:05 PM, documented, .nurse from (name of hospital) called this evening giving report on resident stating that O2 (oxygen) levels were low coming out of surgery but as soon as they were stable resident would be on way with new orders for ABT (antibiotic) and clear liquids . The Clinical Notes dated [DATE] at 1:55 PM, documented, .resident returned from hospital . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 14, indicating Resident #58 was at moderate risk (score ,[DATE]) for falls. The physician's orders [REDACTED].PT clarification order for 5 to 7 x a week include there (therapeutic) ex (exercise), there act (activity) . Review of the Transfer To Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral amputee, to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to dialysis after the change in condition which required a surgical procedure with an overnight hospital stay, with return to the facility on [DATE]. Review of the Clinical Notes dated [DATE] at 10:35 PM, documented, .received new order from md (medical doctor) office to send to ER (emergency room ) to tx (treatment) and evaluation due to recent episodes of confusion .prior to transfer resident's O2 % (percent) was 83 (normal range ,[DATE]%). Oxygen .was applied by this nurse. ems (emergency medical services) came and was taken by ems to hospital around 4pm . The Hospital History and Physical dated [DATE] documented, .was transferred from nursing home with confusion and hypoxia (low oxygen level) to the 80s (Normal range is ,[DATE] percent) on room air .also .right upper extremity swelling .Impression Metabolic [DIAGNOSES REDACTED] (Temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired) .Acute hypoxemic respiratory failure (Fluid build-up in the air sacs in the lungs) .Thrombocytopenic disorder (A low number of platelets in the blood) .End stage renal disease . The Clinical Notes dated [DATE] at 5:42 PM, documented, .Resident returned to facility after dialysis, pt discharged from hospital this am . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 16, indicating Resident #58 was at moderate risk (score ,[DATE]) for falls. Review of the Transfer To Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral amputee (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to dialysis after the change in condition which required an overnight hospital stay, with return to the facility on [DATE] with [DIAGNOSES REDACTED]. The Clinical Notes Report dated [DATE] at 5:41 AM, documented, .Res LOA to dialysis via w/c van . The Clinical Notes Report dated [DATE] at 11:06 AM, documented, .received call from (name of clinic) dialysis that resident was in the process of being picked up by (name of company) transportation and w/c tipped backwards (off the lift gate on the van) with resident in it; this nurse was informed that resident hit head during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval and tx (treatment) . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient states: was getting in van the driver was lifting his wheelchair and fell out of wheelchair backward (from the lift gate on the van) and hit his head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient sustained injury to the head, patient was at dialysis and they were getting him into there (their) van and there chir (their chair) flipped (off the lift gate of the van) and hit .(Resident #58's) head .Differential Diagnoses: [REDACTED].Fairly extensive bilateral temporal subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for a higher level of care). [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 10:31 AM, in the conference room, the DON was asked how it was determined the resident could safely travel in the transport van without an escort. The DON stated, You're going to have to read the PT note .There's no assessment to see if he was safe to go in the van . The DON was asked how the facility assessed Resident #58 for safety to travel in the wheelchair van without an escort after he was readmitted from having the second lower extremity amputation [DATE], after he fell during transport on [DATE], and after his changes in condition and return from hospitalization s [DATE] and [DATE]. The DON stated, We don't do an assessment to say he can travel .when therapy picked him up, if he wasn't safe to be up in the chair, they would have told us. There was one little period he got weak . The DON was asked how was it determined whether residents need an escort to ride with them during transport in the wheelchair van. The DON stated, .people just don't go with them .you're not going to see that documented . The DON was asked whether she would expect the residents to be assessed/reassessed for traveling to appointments or treatments alone or without escorts after change in status, hospitalization s, or falls. The DON stated, .I would expect therapy to re-evaluate him. When we call to make the transportation and all of that, they would not go out there and assess him to put him on the van. If they felt like he was not safe to ride the van, they would let us know . The DON was asked to explain the process to determine what type of transportation the residents need for transport. The DON stated, .It goes more by the certification and necessity . Resident #58 was not receiving therapy (PT) at the time of the second fall [DATE]. The PT Discharge Summary dated [DATE] documented, .Pt currently with max (maximum) potential established with mod (moderate) A (assist) for bed mobility with use of handrails, transfer with use of hoyer lift with max A x ,[DATE]. PT services have been DC to restorative care . Interview with the Rehabilitation (Rehab) Manager on [DATE] at 11:36 AM, in the conference room, the Rehab Manager was asked how residents were assessed to safely travel without an escort in the wheelchair van. The Rehab Manager stated, .We don't assess them getting on the van because it is a lift. They don't transfer them. He never leaves that wheelchair. He gets on the lift, and they strap him in . The facility was unable to provide documentation that Resident #58, a vulnerable resident who was blind in both eyes and had bilateral lower extremity amputations (surgical removal of both legs), received a safety assessment to travel without an escort to dialysis after the following: a. after a significant change in status when Resident #58 returned to the facility [DATE] after a Left above the Knee Amputation, changing his status to a bilateral amputee (surgical removal of both legs); b. after Resident #58 sustained a fall while traveling in the transportation van on [DATE]; c. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after a surgical procedure and hypoxia (low oxygen level); d. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after episodes of confusion and hypoxia. The failure of the facility to ensure safe conditions were provided for transport, failure to assess a resident for ability to participate in transport, and failure to provide a plan for safe transport to and return from dialysis treatments for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity amputee (surgical removal of both legs), resulted in IJ for Resident #58 when the resident sustained [REDACTED]. During the resident's hospitalization , Resident #58 declined, became comatose and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment, required extensive assistance with transfers, was unsteady with walking and transfers, and had 2 or more falls since prior assessment. The care plan dated [DATE] documented, .Risk For Falls R/T spasmodic [DIAGNOSES REDACTED]/sudden abnormal movements; very determined to be independent-avoids asking for help . Review of the Nurse's Event Notes revealed Resident #14 fell on [DATE], [DATE], and [DATE], with no injuries. The facility was unable to provide documentation that a fall risk assessment was completed after the falls on [DATE] or [DATE]. Interview with Nurse Consultant #3 on [DATE] at 6:40 PM, in the DON's Office, Nurse Consultant #3 confirmed that Resident #14 was not assessed for fall risk after the falls on [DATE] and [DATE]. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 30 day MDS dated [DATE] revealed Resident #41 had a BIMS score of 5, indicating severe cognitive impairment, required total dependence of 2 for transfers, walking was unsteady, was only able to stabilize with assistance from staff for moving from seated to standing position and surface to surface transfers, had impairment on one side to upper and lower extremities, and used a wheelchair for mobility. The care plan dated [DATE] documented, .Has history of falls prior admission . Review of the nurses' notes revealed Resident #41 had a witnessed fall in her room on [DATE] with no injury. The quarterly fall risk assessment dated [DATE] was incomplete, with no documentation to address Resident #41's balance, vision, health conditions and risk scale. Interview with the DON on [DATE] at 9:36 AM, in the conference room, the DON was asked if the quarterly fall risk assessment for Resident #41 should have been completed. The DON stated, Yes. Medical record review revealed Resident #127 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed Resident #127 had a BIMS score of 15, indicating no cognitive impairment, required extensive assistance of 2 with transfers, walking was not steady, was only able to stabilize with staff assistance, used walker and wheelchair for mobility, and had no falls since prior assessment. The care plan dated [DATE] documented, .history of Falls Prior r/t (related to) advancing Parkinson's Disease, sudden abnormal involuntary movements; periods of confusion/delirium at onset of UTI (Urinary Tract Infection) . Review of the physician's orders [REDACTED].) every 12 hours, Lisinopril (an antihypertensive medication) daily, Ropinirole (a Parkinson's medication) three times daily, and Seroquel (an antipsychotic medication) every night at bedtime. Review of the Nurse's Event Note(s) revealed Resident #127 fell on [DATE] and [DATE]. Review of the post fall Fall Risk Assessment completed [DATE] revealed inaccurate documentation that Resident #127 only received ,[DATE] high risk medications. The post fall risk assessment documented a total score of 8, with a score between 1 and 10 indicating the resident was at low risk for falls. The Fall Risk Assessment did not accurately reflect Resident #127's medication use. Observations in the Dining Room on [DATE] at 11:46 AM, and in Resident #127's room on [DATE] at 4:36 PM, [DATE] at 7:57 AM and 5:12 PM, [DATE] at 7:59 AM, and [DATE] at 8:20 AM, revealed Resident #127 sitting in a wheelchair. Interview with MDS Coordinator #1 on [DATE] at 1:00 PM, in the Skilled MDS Office, the MDS Coordinator confirmed that the [DATE] Fall Risk Assessment was incorrect, and should have reflected Resident #127 was a moderate risk for falls. Medical record review revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed age of [AGE] years, a BIMS score of 6, indicating severe cognitive impairment, required extensive staff assistance for activities of daily living, and walking did not occur. The MDS documented Resident #142's balance was not steady, was only able to stabilize herself with staff assistance, had range of motion impairment on one side of lower extremities, and had 1 fall with a fracture in the past month prior to admission. Review of the care plan with an effective date of [DATE] revealed Resident #142 was at risk for falls, and had a history of [REDACTED]. Review of the physician's orders [REDACTED].#142 required furosemide (a diuretic medication), metformin (a hypoglycemic medication), trazodone (an antidepressant medication), buspirone (an antianxiety medication), lactulose (a laxative medication), metoprolol tartrate (an antihypertensive medication), lisinopril (an antihypertensive medication), hydralazine (an antihypertensive medication), risperidone (an antipsychotic medication), cetirizine (an antihistamine medication), and docusate sodium (a laxative medication) at least daily. Review of the August Medication Administration Record (MAR) revealed Resident #142 received furosemide, metformin, trazodone, buspirone, lactulose, metoprolol tartrate, lisinopril, hydralazine, risperidone, cetirizine, and docusate sodium at least daily from [DATE]-[DATE]. Review of the admission Fall Risk Assessment completed [DATE] revealed inaccurate documentation that Resident #142 only received ,[DATE] high risk medications. The admission risk assessment documented a total score of 14, with a score between 11 and 19 indicating the resident was at moderate risk for falls. The Fall Risk Assessment did not accurately reflect Resident #142's medication use. A NURSE'S EVENT NOTE dated [DATE] documented, .Unobserved Fall . Review of the post fall Fall Risk Assessment completed [DATE] revealed inaccurate documentation that Resident #142 had no falls in the past 90 days, and only received ,[DATE] high risk medications. The post fall risk assessment documented a total score of 7, with a score between 1 and 10 indicating the resident was at low risk for falls. The Fall Risk Assessment did not accurately reflect Resident #142's fall history or medication use. Interview with the DON on [DATE] at 9:44 AM, in the conference room, the DON was asked whether Resident #142's fall risk assessment should have gone from moderate to low after she sustained a fall on [DATE], the day after the admission fall risk was completed. The DON stated, It's inaccurate. Medical record review revealed Resident #167 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment, required limited to extensive staff assistance for activities of daily living, was unsteady, and was only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfers, had 1 fall in the last month prior to admission, and 1 fracture related to a fall in the past 6 months prior to admission. Review of the care plan with an effective date of [DATE] revealed Resident #167 was at risk for falls and had a history of [REDACTED]. The admission fall risk assessment dated [DATE] was incomplete. Interview with Registered Nurse (RN) #2 on [DATE] at 8:49 AM, at the ,[DATE] Nurses' Station, RN #2 was asked what the fall risk assessments determined. RN #2 stated, How much assistance the patient needs when transferring .whether they're able to ambulate with or without assistance, are they visually impaired at all .if they have any verbal impairment, like are they able to call out for help. Those type of things cause them to score higher, if they have any physical impairment, like swelling, any type of braces. RN #2 was asked whether the fall risk assessments were used to determine the level of care the resident needs. RN#2 stated, Yes. We fill out a care plan . RN #2 was asked whether it was important to ensure the fall risk assessments were done and were accurate. RN #2 stated, Yes. It's of high importance. Interview with the Director of Nursing (DON) on [DATE] at 9:36 AM, in the conference room, the DON was asked about Resident #167's incomplete admission fall risk assessment dated [DATE]. The DON stated, This is when the computer went crazy . The DON was asked what should have been done if the computer was not functioning. The DON stated, You can print a form. The facility was unable to provide the completed admission fall risk assessment for Resident #167 for [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment, and received dialysis while a resident at the facility. The Care Plan Report dated [DATE] documented, .Dialysis on Tues, Thurs, Sat .goes by community van in her w/c: BE AWARE she occasionally needs extra day of dialysis . The Physician order [REDACTED].Dialysis Tuesday-Thursday-Saturday . The facility was unable to provide documentation that Resident #1 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to dialysis. Medical record review revealed Resident #240 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment and received dialysis. The physician's orders [REDACTED].Dialysis

Based on review of the Administrator's job description and the Director of Nursing's (DON) job description, policy review, medical record review, and interview, the administrator failed to administer the facility in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, when they failed to recognize safety concerns during transportation to outside facilities ([MEDICAL TREATMENT]); failed to assess residents for safety during transportation; failed to ensure a system was implemented for the monitoring of residents during the transportation process; and failed to investigate and implement interventions for falls during transport, which resulted in immediate jeopardy (IJ) when 1 of 4 (Resident #58) sampled residents receiving [MEDICAL TREATMENT] transportation via wheelchair van sustained a serious head injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F490-K. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the IJ, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F490-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: Review of the Administrator's job description documented, .The purpose of this position is to establish and direct the facility's overall day-to-day operation, both internal and external, and coordinate these operations in accordance with current existing federal, state and local standards, as well as in accordance with the established policies and procedures for (Named Corporation) .to maximize high standards of care to patients .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Recognize and respond to changes in patients' conditions and report observations to nursing/medical staff and other departments as needed .Authorize and direct the admission, transfer and discharge of patients .Develop, maintain and periodically update policies and procedures that govern the day-to-day functions of the facility .Direct various committees of the facility, such as care plan, infection control, pharmaceutical, budget quality assessment and assurance .Maintain alliances with hospitals and other health care facilities in the community, and coordinate services through working and transfer agreements . Interview with the Administrator on [DATE] at 10:19 AM, in the Administrator's Office, the Administrator was asked when was the problem with [MEDICAL TREATMENT] transportation for Resident #58 identified. The Administrator stated, After that last fall on ,[DATE]. That week we had tried contacting (named Transportation Company) to find out more information. They did say that they were doing their own investigation, and they couldn't give us more details .They wanted us to meet and discuss the outcome and assess his transport needs when he returned to the facility. At that time, we didn't know his condition. The Administrator was asked whether that meeting had taken place. The Administrator stated, No . The Administrator confirmed Resident #58 did not return to the facility. The Administrator was asked whether the Medical Director was involved in the QA (Quality Assurance) process, and whether she was aware of Resident #58's fall. The Administrator confirmed the Medical Director was aware, and reviews falls at quarterly QA meetings, as well as was involved in initiating/implementing new fall preventions measures. The Administrator was asked about the role of the facility's governing body. The Administrator stated the governing body is involved in management and oversight of the facility, and help if the facility needs consulting or outside services. The Administrator confirmed the governing body was made aware of Resident #58's fall. Interview with the Regional Administrator on [DATE] at 10:45 AM, in the Administrator's Office, the Regional Administrator was asked whether there was a QA assessment of Resident #58's fall during transport from [MEDICAL TREATMENT] on [DATE]. The Regional Administrator stated, Yes .we did a root cause analysis .determined it was driver negligence. The Regional Administrator was asked whether other residents that required transportation outside the facility were assessed. The Regional Administrator stated, Yes. We didn't see anybody else with any issues. When a nurse does an assessment, they assess the entire patient to make sure they are safe. The Regional Administrator was asked whether a systematic problem was identified. The Regional Administrator stated, No. We identified it as driver neglect .we felt because it was a risk to our residents, we did find a root cause, and since it wasn't in our building, we felt there was nothing else we could do . The Regional Administrator was asked whether any new interventions or processes were implemented. The Regional Administrator stated, No, because we do not think we did anything wrong. We assessed our system. We had transported him and many others hundreds of times, and never had an issue of putting him on the van. After he had [MEDICAL TREATMENT], he was weak, and he was transporting back when the slide happened (Resident #58's fall from wheelchair during transport [DATE]). We questioned whether they even had the seatbelt on him, because if they are on, he could not have slid out of that chair. We had therapy reassess him that afternoon, and he had another assessment on ,[DATE] ([DATE]). We could not find any way we could have prevented this or any way that our processes didn't work. We transferred this patient after his bilateral amputations over 59 times. He has not had an occurrence or a fall related to that wheelchair . The Regional Administrator was asked whether the facility still uses this particular transportation company. The Regional Administrator stated, We do not have a choice who we use .we have not been allowed access to that contract to certify that they have appropriate training . The Administrator, Medical Director, and the Governing Body were aware of the serious head injury sustained by Resident #58 during transport on [DATE]. No safety assessment procedures were developed or implemented by the facility. The Director of Nursing's job description documented, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures .ESSENTIAL DUTIES AND RESPONSIBILITIES .Recognize and respond to changes in patients' conditions and document observations, interventions, and outcomes .Arrange for and oversee the admission, transfer, and discharge of patients .Develop, maintain and periodically update written policies and procedures that govern the day-to-day functions of the nursing department .Facilitate the coordination of nursing services and other departments to maintain quality care for patients .Participate in various committees of the facility; such as care plans .quality assessment and assurance .Monitor the workplace for possible health and safety hazards . The facility's Fall Risk/Fall Prevention Guidelines policy documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . Administration failed to identify, develop and implement appropriate plans of action to ensure care plans were revised to include falls, and failed to ensure fall prevention interventions were implemented for residents with falls, which resulted in IJ for Resident #58. Refer to F280. Administration failed to ensure the implementation of professional standards of practice related to resident assessments, which resulted in IJ for Resident #58 when the resident sustained [REDACTED]. Refer to F281. Administration failed to ensure safety assessments were completed prior to transportation without an escort outside the facility for medical services. The failure of the facility to provide the appropriate safety assessment/reassessment resulted in Immediate Jeopardy for Resident #58 when the resident sustained [REDACTED]. Refer to F309. Administration failed to ensure falls were thoroughly investigated with the implementation of new fall prevention interventions; and failed to properly assess/re-assess each resident for safety to transport independently/without an escort on the wheelchair van to [MEDICAL TREATMENT]/medical treatment outside the facility, which resulted in IJ for Resident #58 when he sustained a second fall during transport with a serious injury. Refer to F323. Administration failed to ensure the provision of management and oversight of the facility by the Governing Body, including failure to implement and monitor resident assessments and monitoring during transportation for medical care outside the facility. Refer to F493. Administration failed to ensure the Medical Director implemented resident care policies related to care plan revision to include fall prevention interventions, and to ensure resident assessments and monitoring during transportation for medical care outside the facility. Refer to F501. Administration failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of correction for repeat deficiencies, including accident hazards. Refer to F520. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which remove the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F490-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the Administrator's job description, the Director of Nursing's (DON) job description, policy review, medical record review, and interview, the Governing Body failed to ensure falls were thoroughly investigated with the implementation of new fall prevention interventions, and the Governing Body failed to demonstrate responsibility to the residents by failing to ensure staff followed established standards of practice related to resident assessments in a manner that enabled the use of its resources effectively and efficiently to prevent serious injury during transport via a wheelchair van without an escort, placing 1 of 4 (Resident #58) sampled residents receiving [MEDICAL TREATMENT] transportation via wheelchair van in Immediate Jeopardy (IJ), when Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs) sustained a fall with a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined into a comatose state during hospitalization , and expired in the hospital on [DATE] with [DIAGNOSES REDACTED]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F493-K. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F493-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: Review of the Administrator's job description documented, .The purpose of this position is to establish and direct the facility's overall day-to-day operation, both internal and external, and coordinate these operations in accordance with current existing federal, state and local standards, as well as in accordance with the established policies and procedures for (Named Corporation) .to maximize high standards of care to patients .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Recognize and respond to changes in patients' conditions and report observations to nursing/medical staff and other departments as needed .Authorize and direct the admission, transfer and discharge of patients .Develop, maintain and periodically update policies and procedures that govern the day-to-day functions of the facility .Direct various committees of the facility, such as care plan, infection control, pharmaceutical, budget quality assessment and assurance .Maintain alliances with hospitals and other health care facilities in the community, and coordinate services through working and transfer agreements . The Director of Nursing's job description documented, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures .ESSENTIAL DUTIES AND RESPONSIBILITIES .Recognize and respond to changes in patients' conditions and document observations, interventions, and outcomes .Arrange for and oversee the admission, transfer, and discharge of patients .Develop, maintain and periodically update written policies and procedures that govern the day-to-day functions of the nursing department .Facilitate the coordination of nursing services and other departments to maintain quality care for patients .Participate in various committees of the facility; such as care plans .quality assessment and assurance .Monitor the workplace for possible health and safety hazards . The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . The Governing Body failed to ensure services were provided to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the plan of care by not revising the care plan to include falls, and failed to ensure fall prevention interventions were implemented for residents with falls, which resulted in IJ for Resident #58. Refer to F280. The Governing Body failed to ensure the implementation of professional standards of practice related to resident assessments, which resulted in IJ for Resident #58 when the resident sustained [REDACTED]. Refer to F281. The Governing Body failed to ensure policies and procedures for safety assessments were in place and completed prior to transportation without an escort outside the facility for medical services. The failure of the facility to provide the appropriate safety assessment/reassessment resulted in Immediate Jeopardy for Resident #58 when the resident sustained [REDACTED]. Refer to F309. The Governing Body failed to ensure falls were thoroughly investigated with the implementation of new fall prevention interventions; and failed to properly assess/re-assess each resident for safety to ride independently/without an escort on the wheelchair van to [MEDICAL TREATMENT]/medical treatment outside the facility, which resulted in IJ for Resident #58 when he sustained a second fall during transport with a serious injury. Refer to F323. The Governing Body failed to ensure Administration was responsible for the identification, development, and implementation of appropriate plans of actions and ensure the effective and efficient use of its resources to maintain the highest practicable well-being of all residents with falls, resulting in Immediate Jeopardy. Refer to F490. The Governing Body failed to ensure the Medical Director implemented resident care policies related to care plan revision to include fall prevention interventions, and to ensure resident assessments and monitoring during transportation for medical care outside the facility. Refer to F501. The Governing Body failed to ensure an effective Quality Assurance (QA) Committee that identified, evaluated, and addressed ongoing concerns regarding resident care policies and procedures for all residents residing in the facility at risk for falls; and failed to ensure the QA program was effective in maintaining plans of correction for repeat deficiencies, including accident hazards. Refer to F520. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. Corrective actions validated on [DATE] included the following: The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F493-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on contract review, policy review, review of The Lippincott Manual of Nursing Practice, 10th Edition, review of job descriptions, [MEDICAL TREATMENT] contract review, medical record review, and interview, the facility failed to ensure the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns, coordinating the medical care and providing clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for the residents residing in the facility. The facility failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care of the residents residing in the facility by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related accidents/falls during transportation for medical care outside the facility, and failed to ensure the facility investigated and implemented appropriate interventions after falls during transport, resulting in Immediate Jeopardy (IJ) for 1 of 4 (Resident #58) sampled residents, when Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs) sustained a fall with a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE] with [DIAGNOSES REDACTED]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment or death for resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F501-K. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F501-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Medical Director Agreement documented, .The Medical Director shall be responsible for the implementation of resident care policies and coordination of medical care in the nursing home in compliance with all Medicaid, Medicare, and other applicable state and federal regulations. The Medical Director shall .Review reports of all incidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator .Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control . The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON (Director of Nursing) or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits . Review of the [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . The Medical Director failed to ensure implementation of basic care policies and coordination of medical care related to care plan revision to reflect falls with implementation of interventions for fall prevention, resulting in IJ. Refer to F280. The Medical Director failed to advise and consult with facility Administration on matters regarding medical care, surveillance, and professional standards of practice related to resident assessments, resulting in IJ. Refer to F281. The Medical Director failed to ensure policies and procedures for safety assessments were in place and completed prior to transportation without an escort outside the facility for medical services related to [MEDICAL TREATMENT]. The failure of the facility to provide the appropriate safety assessment/reassessment resulted in IJ. Refer to F309. The Medical Director failed to ensure services were provided to ensure identification of potential hazards to the health and safety, and failed to recommend appropriate corrective actions to facility Administration related to conducting safety assessments for transporting residents in a wheelchair van unattended, resulting in IJ. Refer to F323. The Medical Director failed to ensure the facility followed their policies and procedures regarding an effective Administration. Refer to F490 The Medical Director failed to ensure the Governing Body provided effective surveillance and oversight to ensure policies and procedures were initiated and implemented related to concerns of hazards to health and safety, resulting in IJ. Refer to F493 The Medical Director failed to ensure an effective Quality Assurance Committee recognized concerns with hazards to health and safety and failed to implement effective interventions and monitoring to resolve concerns of hazards to health and safety, resulting in IJ. Refer to F520. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F501-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on review of the Administrator's job description, review of the Medical Director agreement, review of the Director of Nursing's job description, policy review, review of The Lippincott Manual of Nursing Practice, 10th Edition, review of the [MEDICAL TREATMENT] contract, medical record review, and interview, the facility failed to ensure an effective Quality Assurance (QA) program recognized concerns with hazards to health and safety, identified the root cause of the problems, and ensured systems and processes were developed and consistently followed by staff to address quality concerns. The QA committee failed to address concerns to ensure residents at risk for falls and/or accidents were properly assessed for safety, that the facility was administered in a manner that enabled it to use its resources effectively and efficiently, that the Medical Director assisted the facility with identifying evaluating, and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight regarding the implementation of resident care policies and procedures for safety and accident hazards. Failure of the facility to implement and/or provide safety assessments after significant change in status and after a fall during transport for medical care outside the facility resulted in an immediate jeopardy (IJ) when Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), sustained a fall with a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined to a comatose state during hospitalization , and expired in the hospital on [DATE] with [DIAGNOSES REDACTED].#58 when the resident was not assessed or reassessed for safety before transferring without an escort to [MEDICAL TREATMENT] in the transportation van after a significant change in status, after a fall during transport, and after changes in the resident's condition requiring hospitalization , resulting in IJ. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F520-K. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F520-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: Review of the Administrator's job description documented, .The purpose of this position is to establish and direct the facility's overall day-to-day operation, both internal and external, and coordinate these operations in accordance with current existing federal, state and local standards, as well as in accordance with the established policies and procedures for (Named Corporation) .to maximize high standards of care to patients .Meet with personnel as required and scheduled to assist in identifying and correcting issues, and/or the improvement of services .Recognize and respond to changes in patients' conditions and report observations to nursing/medical staff and other departments as needed .Authorize and direct the admission, transfer and discharge of patients .Develop, maintain and periodically update policies and procedures that govern the day-to-day functions of the facility .Direct various committees of the facility, such as care plan, infection control, pharmaceutical, budget quality assessment and assurance .Maintain alliances with hospitals and other health care facilities in the community, and coordinate services through working and transfer agreements . Interview with the Administrator on [DATE] at 10:19 AM, in the Administrator's Office, the Administrator was asked when was the problem with [MEDICAL TREATMENT] transportation for Resident #58 identified. The Administrator stated, After that last fall on ,[DATE]. That week we had tried contacting (named Transportation Company) to find out more information. They did say that they were doing their own investigation, and they couldn't give us more details .They wanted us to meet and discuss the outcome and assess his transport needs when he returned to the facility. At that time, we didn't know his condition. The Administrator was asked whether that meeting had taken place. The Administrator stated, No . The Administrator confirmed Resident #58 did not return to the facility. The Administrator was asked whether the Medical Director was involved in the QA process, and whether she was aware of Resident #58's fall. The Administrator confirmed the Medical Director was aware, and reviews falls at quarterly QA meetings, as well as was involved in initiating/implementing new fall preventions measures. The Administrator was asked about the role of the facility's governing body. The Administrator stated the governing body is involved in management and oversight of the facility, and help if the facility needs consulting or outside services. The Administrator confirmed the governing body was made aware of Resident #58's fall. Interview with the Regional Administrator on [DATE] at 10:45 AM, in the Administrator's Office, the Regional Administrator was asked whether there was a QA assessment of Resident #58's fall during transport from [MEDICAL TREATMENT] on [DATE]. The Regional Administrator stated, Yes .we did a root cause analysis .determined it was driver negligence. The Regional Administrator was asked whether other residents that required transportation outside the facility were assessed. The Regional Administrator stated, Yes. We didn't see anybody else with any issues. When a nurse does an assessment, they assess the entire patient to make sure they are safe. The Regional Administrator was asked whether a systematic problem was identified. The Regional Administrator stated, No. We identified it as driver neglect .we felt because it was a risk to our residents, we did find a root cause, and since it wasn't in our building, we felt there was nothing else we could do . The Regional Administrator was asked whether any new interventions or processes were implemented. The Regional Administrator stated, No, because we do not think we did anything wrong. We assessed our system. We had transported him and many others hundreds of times, and never had an issue of putting him on the van. After he had [MEDICAL TREATMENT], he was weak, and he was transporting back when the slide happened (Resident #58's fall from wheelchair during transport [DATE]). We questioned whether they even had the seatbelt on him, because if they are on, he could not have slid out of that chair. We had therapy reassess him that afternoon, and he had another assessment on ,[DATE]. We could not find any way we could have prevented this or any way that our processes didn't work. We transferred this patient after his bilateral amputations over 59 times. He has not had an occurrence or a fall related to that wheelchair . The Regional Administrator was asked whether the facility still uses this particular transportation company. The Regional Administrator stated, We do not have a choice who we use .we have not been allowed access to that contract to certify that they have appropriate training . The Administrator, Medical Director, and the Governing Body were aware of the serious head injury sustained by Resident #58 during transport on [DATE]. No safety assessment procedures were developed or implemented by the facility. The Medical Director Agreement documented, .The Medical Director shall be responsible for the implementation of resident care policies and coordination of medical care in the nursing home in compliance with all Medicaid, Medicare, and other applicable state and federal regulations. The Medical Director shall .Review reports of all incidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator .Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control . The Director of Nursing's job description documented, .The purpose of this position is to manage the nursing department and administer the nursing programs in compliance with state and federal regulations as well as company policy and procedures .ESSENTIAL DUTIES AND RESPONSIBILITIES .Recognize and respond to changes in patients' conditions and document observations, interventions, and outcomes .Arrange for and oversee the admission, transfer, and discharge of patients .Develop, maintain and periodically update written policies and procedures that govern the day-to-day functions of the nursing department .Facilitate the coordination of nursing services and other departments to maintain quality care for patients .Participate in various committees of the facility; such as care plans .quality assessment and assurance .Monitor the workplace for possible health and safety hazards . The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits . Review of the [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . The facility's Quality Assurance committee failed to identify, develop and implement appropriate plans of action to ensure care plan interventions were implemented after a fall that resulted in IJ to Resident #58. Refer to F 280 The facility's Quality Assurance committee failed to identify and follow current standards of practice related to ensuring the completion of safety risk assessments after significant change in status and after falls that resulted in IJ to Resident # 58. Refer to F281 The QA committee failed to ensure adherence to the [MEDICAL TREATMENT] contract by facility staff when a resident was transferred to a [MEDICAL TREATMENT] center without an escort and without proper safety assessment after a significant change in status and after a previous fall during transport, which resulted in IJ for Resident #58. Refer to F309 The facility's Quality Assurance committee failed to investigate and implement appropriate interventions to prevent further falls after a fall during transport, which resulted in IJ for Resident #58. Refer to F323 The facility's Quality Assurance committee failed to identify, develop and implement appropriate plans of actions and to follow up on the implementation of the plan to ensure the facility was administered in a manner to use its resources effectively and efficiently to maintain the highest practicable well being of all residents residing in the facility at risk for falls. The failure of the Quality Assurance committee to identify, develop, and implement appropriate plans of action for safety assessments, and failure to follow up on the implementation of the plan to ensure the facility was appropriately investigating falls and implementing interventions to prevent further falls resulted in IJ for Resident #58. Refer to F490 The facility's Quality Assurance committee failed to ensure the Governing Body provided appropriate management and oversight of the facility, including failure to implement and monitor resident assessments and monitoring during transportation for medical care outside the facility. Refer to F493 The facility's Quality Assurance committee failed to ensure the Medical Director assisted with identifying, evaluating and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight regarding the oversight of the implementation of resident care policies and procedures that reflect the current standards of practice for all residents residing in the facility at risk for falls. The failure of the Medical Director to identify, evaluate, and address clinical safety concerns and implement appropriate plans of action for safety assessments and fall resulted in IJ for Resident #58. Refer to F501. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective action were validated onsite by the surveyors Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F520-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.

Based on policy review, medical record review and interview, the facility failed to revise the care plan to reflect falls for 1 of 7 (Resident #58) sampled residents reviewed for falls. The facility's failure to develop and implement an individualized plan of care that included interventions to address a vulnerable resident, who was blind in both eyes and had bilateral lower extremity amputations (surgical removal of both legs), safety for travel independently/without an escort on a wheelchair van resulted in Immediate Jeopardy (IJ) for Resident #58. Resident #58 sustained a fall during transport, resulting in a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the Conference Room. The facility was cited an Immediate Jeopardy at F280-J. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F280-D for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The facility's Fall Risk/Fall Prevention Guidelines policy dated [DATE], documented, .Post Fall Management is an opportunity to conduct a root cause analysis (RCA) of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will .implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .The Interdisciplinary Team .will .Modify the patient's plan of care as needed . The facility's Care Plan policy dated [DATE], documented, .GENERAL INFORMATION Care planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care. Many people view the care plan solely as nursing domain, but to be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of the patient. The care plan process must begin upon admission into the facility and be fluid and changeable representing the patient's status until patient is discharged from the facility or is deceased .COMPREHENSIVE CARE PLANS .The care plan .Must be reviewed every 90 days and as needed. As needed may mean .When there is a change in patient status . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, which indicated Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], and the quarterly MDS dated [DATE], revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x (of) 2 for transfers, extensive staff assist x 1 for locomotion, walking did not occur, was not steady for surface to surface transfers, and was only able to stabilize with human assistance. No use of mobility device was documented. The care plan dated [DATE] documented, .At risk for falls R/T (related to) legally blind, poor balance d/t (due to) right BKA (below knee amputation) .(and recent) Left AKA (above knee amputation) . Review of the Clinical Notes Report dated [DATE] at 1:51 PM revealed, .resident returned from access center (an outpatient surgery center) .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he did slide out of wheelchair . The current care plan dated [DATE] revealed no revisions to the care plan with interventions associated with the cause of the fall on [DATE] while Resident #58 was riding in the wheelchair van, or a Post Fall Management Root Cause Analysis (RCA) per facility policy. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. There was no documentation of a re-assessment for Resident #58, a vulnerable blind and bilateral [MEDICAL CONDITION] resident, for safety risk for transport via wheel chair van without an escort to or from [MEDICAL TREATMENT] after sliding out of his chair during transport on the wheelchair van. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . The Clinical Notes Report dated [DATE] at 11:06 AM, documented, .received call from (name of [MEDICAL TREATMENT] clinic) that resident was in the process of being picked up by (name of company) transportation and w/c (wheelchair) tipped backwards (off the lift gate of the van) with resident in it; this nurse was informed that resident hit head (on concrete) during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval (evaluation) and tx (treatment) . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient (Resident #58) states: .was getting in van the driver was lifting his wheelchair and (Resident #58) fell out of wheelchair backward (off the lift gate of the van) and hit his head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient (Resident #58) sustained injury to the head, patient was at [MEDICAL TREATMENT] and they were getting him into there (their) van and there chir (their chair) flipped (fell off the lift gate of the van) and hit .head (on concrete) .Differential Diagnoses: [REDACTED].Per Radiologist's finding(s): 1. Fairly extensive bilateral temporal Subarachnoid Hemorrhage, greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for higher level of care). [DIAGNOSES REDACTED]. Review of Hospital #2's physician progress notes [REDACTED]. The facility failed to ensure safe conditions were provided for transport, failed to assess a resident for ability to safely participate in transport, and failed to provide a plan of care for safe transport to and return from [MEDICAL TREATMENT] treatments for Resident #58; a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs). The failure of the facility to conduct a RCA and develop and implement a plan of care for transportation safety resulted in an IJ for Resident #58 when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined to a comatose state during hospitalization , and expired in the hospital on [DATE] with a [DIAGNOSES REDACTED]. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A(NAME)), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A(NAME) was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A(NAME) were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The facility was cited an Immediate Jeopardy at F280-J. The noncompliance continues at F280-D for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.