Every finding on record at Piedmont Health & Rehab Center

Based on observations, record review, and interviews with staff, Contractor for safety systems, and the Medical Director, the facility failed to effectively supervise a resident, who had diagnoses including dementia and altered mental status and a history of falls, from exiting the facility unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was admitted to the facility on [DATE] and according to staff became increasingly confused during the shift which started at 7:00 PM. Resident #1 got out of bed multiple times and self-propelled in his wheelchair up and down the hall and was observed at the exit door looking out the window. Resident #1 was last seen by Nurse #1 in bed at approximately 4:00 AM on 4/26/26 and between 4:00 and 4:30 AM the Nurse Aide (NA) #1 noticed Resident #1 not in bed and immediately began to look for the resident and notified Nurse #1. No staff members recall hearing the 300-hall door alarm that night. NA #2 went out to her car between 4:30 and 4:45 a.m. on 4/26/26 and heard a man yelling for help from the other side of the parking lot. NA #2 could not see because it was dark outside and the area past the parking lot and down the embankment where the man called from was not lit. NA #2 indicated she was afraid to approach because the area felt unsafe, so she dialed 911 as she was walking back into the facility and told NA #3 what she heard and they went outside together. Resident #1 was found sitting on a gravel embankment at the edge of the parking lot, 100 feet from the 300- hall exit door and 200 feet from a four lane road with a 35 mph speed limit. Resident #1 was wearing only an adult incontinence brief and a gown lay on the ground next to him. He told the staff he had fallen and needed help getting up. The temperature outdoors was 60 degrees Fahrenheit with a light drizzle. Emergency Medical Services (EMS) was called, and the resident was taken to the Emergency Department (ED) hospital for an evaluation. Imaging of the head, spine, and chest were completed without acute findings, and laboratory studies were normal. A contusion (an injury to the tissues that does not break the skin and can cause bruising or discoloration) to the right hand was treated with cleansing and topical antibiotic ointment. He was discharged back to the facility 4/26/26 with diagnoses of fall, contusion to right hand, and dementia. It was determined by staff the 300-hall door alarm power cord was unplugged which disabled both the lock and wander-alarm system. This noncompliance had a high likelihood of causing serious injury or serious bodily harm.Findings included:Review of the hospital Discharge summary dated [DATE] revealed Resident #1 was admitted on [DATE] for recurrent falls and acute on chronic altered mental status. His diagnoses included type 2 diabetes, dementia, chronic kidney disease, generalized weakness, right leg pain and weakness, and encephalopathy. Hospital documentation stated he had not seen a physician for approximately one year and had not taken medications for two months. He reported multiple falls during the prior week, including one on 4/20/26 in which he remained on the floor until morning. He lived alone with minimal family support, and his baseline cognitive impairment had worsened. Imaging and blood work showed no acute abnormalities. Therapy evaluations beginning 4/21/26 documented confusion, disorientation, impaired processing time, and the need for contact guard assistance and full assistance for transfers. Therapy recommended skilled nursing placement. It included recommendations for skilled nursing care, skilled therapy services, and a referral to neurology for his cognitive deficits.Resident #1 was admitted to the facility on [DATE] at 12:41 p.m. with diagnoses including dementia, altered mental status, recurrent falls, and right lower extremity weakness and pain.Review of physician orders revealed Resident #1 was not prescribed a blood thinner.Nurse #2's admission Observation on 4/25/26 at 4:11 p.m. documented Resident #1 required moderate assistance with transfers, bed mobility, and activities of daily living. He had intermittent incontinence, groin redness, and right lower extremity weakness. Resident #1 was alert and oriented but intermittently confused. The elopement risk screening question asking if the resident was identified for risk(s) for elopement was not selected. An additional elopement risk screening question asked if the resident had any elopement risk factors. The risk factors included whether the resident was ambulatory, moved about independently in a wheelchair, had a history of attempted or actual elopement or unsafe wandering, exhibited exit seeking behavior, resident verbalized wanting to go home, go on a trip, or going to meet someone, resident wandered in and out of rooms and rummages in other's belongings, not accepting of present residency situation/location, or had an acute change in cognition. Nurse #2 documented that none of the risk factors listed were exhibited at that time.During a telephone interview on 5/8/26 at 9:33 a.m. with Nurse #2, she reported that she admitted Resident #1 on 4/25/26 around 1:00 p.m. She stated Resident #1 arrived via ambulance stretcher and transferred to the bed with one person assistance. Nurse #2 described him as pleasant, conversational, mildly confused, and easily redirected, with no exit seeking behavior. She reported Resident #1 ambulated short distances with assistance and verbal cues. Nurse #2 indicated she completed his admission assessment and informed Nurse #1 at shift change at 7:00 p.m. that Resident #1 was confused but did not exhibit elopement risks which were listed in the admission Observation. Nurse #2 explained when Resident #1 arrived on 4/25/26, he was pleasantly confused and family did not accompany him and had previously not provided any historical details for Resident #1. Nurse #2 had reviewed the 4/25/26 hospital discharge summary for his medical history, and it did not indicate he wandered or was exit seeking during his hospitalization. Nurse #2 reported she did not see him wander during her shift on 4/25/26, she reported he was admitted to their rehabilitation unit, 300 Hall, and had not observed him hanging around the door at the end of the 300 Hall. Nurse #2 reported that on 4/25/26 between 1:00 p.m. and the end of her shift at 7:00 p.m. Resident #1 did not interact with the other residents after her assessment was completed. Nurse #2 reported she allowed him time to settle in the room before she oriented him to the set-up of the facility, location of his bathroom, lights, explained the call bell, and told him when and how to call for help. Nurse #2 reported that Resident #1 talked a little with her during the assessment and ate dinner in his room. She reported that he needed verbal cues and his meal tray set up and he ate dinner independently. Nurse #2 reported Resident #1 spoke clearly and communicated his needs, and she provided stand by assist and verbal cues for his proper body mechanics and foot positioning as he stood and used a walker to go into the bathroom at the completion of the lengthy admission assessment.The baseline care plan initiated on 4/25/26 included safety monitoring. The Safety Monitoring portion of the care plan included approaches for fall prevention, toileting assistance, pain management, and therapy services. The fall prevention interventions included assisting Resident #1 with transfers as needed, keeping items within reach, and minimizing potential risk factors related to falls and injury.During a telephone interview on 5/7/26 at 4:56 p.m., Nurse #1 stated she received nurse to nurse shift report at 7:00 p.m. on 4/25/26 indicating that Resident #1 was confused. She stated that Nurse Aide (NA) #1 brought Resident #1 to the nurse's station in a wheelchair between approximately 11:00 p.m. and 12:00 a.m. for monitoring by she and the other staff entering notes and tasks completed at the desk. Nurse #1 reported the nurse's station is on the corner of the 200 and 300 Halls so if Nurse #1 or NA #1 or NA #3 were responding to a call light down or completing a task, Resident #1 could still be observed and in their direct view. Nurse #1 reported that Resident #1 became increasingly confused during her 7:00 p.m. to 7:00 a.m. shift as the evening progressed into midnight. She reported that Resident #1 got out of bed multiple times and wandered in a wheelchair up and down the 300 Hall hallway and was observed at the exit door looking out the window. She reported that NA #1 and NA #3 redirected Resident #1 and that he remained cooperative and easily redirected. She also reported that she completed walking rounds at the top of the hour, approximately every hour (e.g., 7:00, 8:00, 9:00, etc.). Nurse #1 reported that she observed NA #1 and NA #3 take Resident #1 back to his room around 1:30 a.m. Nurse #1 stated she last saw Resident #1 lying in bed awake at approximately 4:00 a.m. during her hourly round and did not observe him getting out of bed. When NA #1 informed her around 4:30 a.m. that Resident #1 was missing, she initiated Code Green. A Code [NAME] was the facility's emergency protocol announcing that a resident was missing. The facility's Elopement/Missing Person policy stated that once staff determined a resident was missing, they were to conduct a room by room search and complete a head count of all residents on all units. If the resident remained missing after these steps, staff were to announce a Code [NAME] which required a message to be broadcasted across the facility that included the resident's name, room number, and location in the building (e.g., 100 Hall, 200 Hall, 300 Hall). Nurse #1 reported that she and NA #1 began searching the 300 Hall, going room by room and taking a head count of all residents as they proceeded. After completing the search of the 300 Hall, she moved to the Dining Room and then to the 200 Hall. She stated that NA #1 informed her that staff outside had called 911 after hearing someone yelling for help. Nurse #1 recalled that NA #2 and NA #3 found Resident #1 outside around 5:00 a.m. She instructed NA #1 to continue checking to account for all residents. Nurse #1 indicated she exited the facility through the 200 Hall door and approached NA #2, NA #3, and Resident #1. She recalled that Resident #1 was seated on the dirt leading up to the edge of the paved parking lot with his back against the curb. She assessed him at the curbside, where he sat wearing only an adult incontinence brief, and she observed an abrasion on his right hand. Resident #1 told her he had fallen but did not know how he got out. Nurse #1 reported EMS arrived while she was exiting the building to assess Resident #1. Nurse #1reported the EMS and she were assessing Resident #1's condition at the same time. She stated she instructed EMS to transport him to the hospital due to a possible head injury. Nurse #1 reported she had not unplugged the power cord to the 300 Hall door lock and alarm and did not hear a door alarm. She stated that after ambulance personnel transported Resident #1, staff returned inside and checked the building to determine how Resident #1 had exited, as all doors were closed. She reported the 300 Hall door power cord was observed unplugged from the electrical outlet which disabled the door lock and alarm when unplugged. Nurse #1 reported staff plugged it back in. Nurse #1 stated she did not observe Resident #1 unplug the power cord for the door lock and alarm and that she had not unplugged it that night or at any time in the past. She recalled there was a sign above the outlet stating do not unplug and stated she had never seen staff unplug the cord. After observing the 300 Hall power cord unplugged, she reported that staff assumed Resident #1 likely unplugged it and then exited through the 300 Hall door because he had been observed earlier in a wheelchair at the door and window. Nurse #1 recalled seeing an empty wheelchair in the 300 Hall hallway during her last round at 4:00 a.m. but could not recall the exact location. She recalled Resident #1's room was a few doors down from the 300 Hall entry/exit door. She did not recall finding any other items outside near him and stated she was unsure how he ambulated up the sloped parking lot past the dumpsters.During a telephone interview on 5/7/26 at 4:35 p.m. with NA #1, she reported that her shift on 4/25/26 began at 11:00 p.m. and ended on 4/26/26 at 7:30 a.m. NA #1 reported she was assigned to multiple residents on the 300 Hall, which was the rehabilitation unit. She stated the rehabilitation unit had a quick turnover of residents because many stayed only short term for therapy before returning home, so she was not familiar with all the residents on the unit. NA #1 reported she was assigned to provide nurse aide care for Resident #1. NA #1 reported she normally completed hourly rounds opposite the nurse on the unit. NA #1 stated that her Charge Nurse, Nurse #1, informed her that Resident #1 was confused during the evening hours of 4/25/26. NA #1 reported that NA #3 worked with her on the unit and was assigned to the other residents on the 300 Hall and some residents on the 200 Hall. She stated that NA #3 assisted her with caring for residents who required two-person assistance and those who needed close observation or redirection. NA #1 reported that Resident #1 got out of bed and into a wheelchair around 11:00 p.m. and was observed sitting in a wheelchair at the end of the 300 Hall and watched out the window by the door. NA #1 redirected Resident #1 and put him back to bed. NA #1 stated that NA #3 assisted her with redirecting Resident #1 when he again wandered into the hall from his room shortly after she put him back to bed. NA #1 reported that around 12:00 a.m. Resident #1 got out of bed again, so she assisted Resident #1 into a wheelchair and brought him to the nurse's station for close observation. She stated that she worked with Nurse #1 and NA #3 to monitor Resident #1 closely due to his confusion and repeatedly getting out of bed and wandering. Nurse #1 advised NA #1 that Resident #1 said he wanted to go to bed around 1:30 a.m. and NA #3 assisted him back to bed because she was with another resident. NA #1 reported she left the unit only once during the shift, at approximately 3:45 a.m., to use the bathroom, and afterward went into the nourishment room to prepare her cups and supplies for the final round of the shift. She stated that between 4:00 a.m. and 4:30 a.m. she discovered Resident #1 was no longer in bed. NA #1 reported she did not recall hearing a door alarm. She stated she immediately searched the nurse's station, bathroom, and desk area on the 300 Hall, did not find Resident #1, and notified Nurse #1 at approximately 4:30 a.m., which triggered the facility's elopement procedures. NA #1 began to assist Nurse #1 with a complete head count of all residents in the facility, going room by room. NA #1 reported she did not recall seeing Resident #1 attempt to unplug the cord by the door, open the door, or exit the door at the end of the 300 Hall during her shift. She also reported she did not recall observing any staff unplug the door and denied unplugging the door herself to disable the lock and use it for exit or entry.During a telephone interview with NA #3 on 5/7/26 at 11:00 a.m., she reported on the night shift of 4/25/26 (from 11:00 p.m. on 4/25/26 until 7:00 a.m. on 4/26/26) Resident #1 had been monitored closely at the nurses station by her and his assigned NA (NA #1) through the evening and night because he became more confused and was wandering in the 300 Hall in a wheelchair and went to the window by the 300 hall door. NA #3 reported she did not recall observing Resident #1 unplug the 300 Hall door power cord. NA #3 indicated she did not recall seeing Resident #1 ambulate up or down the hallway and observed Resident #1 use a wheelchair for moving around the unit. NA #3 reported she assisted Resident #1 back to bed between 1:30 a.m. and 2:00 a.m. and he was easily redirected; this was the last time she observed Resident #1. NA #3 reported Resident #1 was confused at the beginning of the shift and was more confused as the night went on. NA #3 reported she thought he had sundowning (a state of confusion that occurs in the late afternoon and lasts into the night and can cause wandering, ignoring directions, or various behaviors) because he talked normally at the start of her shift but was more confused and wandered more as the night went on. She recalled Code [NAME] was paged overhead around 5:00 a.m. while she was on the 100 Hall charting care she provided to her assigned residents. NA #3 stated NA #2 approached her and asked for the facility's address because she heard someone yelling for help outside in the parking lot and was talking to 911. After the call, NA #3 accompanied NA #2 outside to identify who needed help and wait for EMS. They found Resident #1 between the parking lot and the white building beside the facility. NA #3 stated she initially did not think he was a resident but, upon seeing he was wearing only an adult brief with a hospital gown on the ground beside him, she had NA #2 go back inside the facility and notify Nurse #1. She reported she then called 911 to inform them it was a resident of the facility. NA #3 waited with the resident and police arrived shortly after. NA #3 reported Nurse #1 and the ambulance arrived soon after the police. NA #3 indicated the parking lot was dark and dimly lit along the side towards the white building next door, but light from the police car lit up the area well. NA #3 reported it surprised her that Resident #1 was able to ambulate past the 2 large dumpsters and up the parking lot in the dark. NA #1 stated the event happened so quickly, but she thought the ambulance took Resident #1 away soon after she and NA #2 found him. NA #3 recalled Resident #1 appeared calm when Nurse #1 assessed him and asked him questions. NA #3 reported she went back inside through the staff entrance door by the 200 Hall and began looking around to determine how Resident #1 was able to exit. She recalled staff observed the 300 Hall door's alarm and power cord unplugged from the outlet but does not recall if she, Nurse #1, or NA #2 were first to observe that. NA #3 denied unplugging the power cord for the door lock and alarm. NA #3 reported she always had someone waiting at the 300 Hall door to let her back in when taking out trash to the dumpsters near the 300 Hall door at the edge of the parking lot.During a telephone interview on 5/8/26 at 9:18 a.m. with NA #2, she reported on the night shift on 4/25/26 she worked on the 100 Hall on the opposite side of the facility. She recalled she exited the building at the staff entrance outside the Dining Room and 200 Hall and went to her vehicle in the parking lot around 4:30 to 4:45 a.m. for supplies. NA #2 reported she unlocked her car to get out her supplies and heard a man yell for help from the other side of the parking lot. She reported she could not see the man because it was dark outside and the area past the parking lot and down the embankment where the man called out from not lit. NA #2 stated she was afraid to approach because the area felt unsafe because of recurrent criminal activity in that area of the city. NA #2 stated she could not stop thinking about it as she went back to the employee entrance and decided to call 911 to report it. She called 911 around 5:00 a.m. as she returned inside, she told NA #3 what she heard, and both then went outside. NA #3 recognized the individual as a facility resident. NA #2 reported she was not sure how NA #3 knew it was a resident so quickly. NA #2 stated Resident #1 was sitting in gravel near the parking lot curb wearing only an adult incontinence brief and possibly one gripper sock, with his gown on the ground beside him. NA #2 did not observe a wheelchair near the resident. NA #2 reported Resident #1 calmly stated he fell and needed help getting up. She reported that NA #3 sent her inside to retrieve Nurse #1 while NA #3 remained with Resident #1 until EMS arrived. NA #2 did not recall hearing a door alarm. NA #2 indicated she entered and exited through the staff entrance door on the 200 Hall by the dining room when she retrieved Nurse #1 to assess Resident #1. She reported the location they found Resident #1 was on the side of the parking lot that was outside of the 300 Hall door, past the dumpsters at the edge of the parking lot. NA #2 denied that she unplugged the 300 Hall door power cord to exit or enter the facility through there.During a follow-up observational interview with NA #3 on 5/7/26 at 2:45 p.m. she pointed to the curb where she and NA #2 found Resident #1 sitting up with his back against the curb of the parking lot on 4/26/26 around 5:00 a.m. The location was approximately 100 feet from the 300-hall door exit. She reported that shortly after 5:00 a.m., while she was charting at the nurse's station on the 100-Hall, NA #2 approached her asking for the facility's address for a 911 call because she heard someone yelling for help outside and was afraid to check alone. NA #3 stated Resident #1 was new to the facility and staff were not yet familiar with him. NA #3 went over to the side of the parking lot and pointed to the area where she found him sitting. NA #3 described finding Resident #1 sitting upright with his back against the curb in an area covered with several jagged stones and dirt sloping downward from the parking lot. Resident #1's hospital gown was on the ground next to him, and he was wearing only an adult brief. A wheelchair was not observed outside or in the vicinity of where Resident #1 was found. She reported he was calm and spoke clearly. She stated the police arrived first, followed shortly after by Nurse #1, and the ambulance arrived within minutes and transported him to the emergency department. NA #3 reported the events happened quickly and she was doing her best to accurately recall the details. NA #3 recalled she had observed Resident #1 in a wheelchair by the 300 Hall door but had not observed Resident #1 walking around or standing by the door, unplugging the door power cord, or saying he wanted to leave. NA #3 reported Resident #1 was confused all night, was calm and pleasant, and was oriented only to his name. She reported some details were difficult to recall because her attention was focused on Resident #1 being outside in only his brief sitting on the stones and she was concerned he may have been seriously injured because of where they found him on the bank because there was also broken glass and the location was close to a street that was busy during the day time hours. She reported the ambulance arrived as Nurse #1 began assessing Resident #1. NA #3 recalled police asked her how Resident #1 was able to leave the facility and she told him she did not know because all the doors were locked. NA #3 stated on the night of the elopement she observed other staff using the main rear entry door and walking by the window by 300 Hall door where Resident #1 sat and looked outside. The occurred during the first part of the night shift (11:00 p.m. and 2:00 a.m.). NA #3 indicated she used entrance doors by the Dining Room on the 200 Hall to enter and exit during the incident. NA #3 reported once she, NA #2 and Nurse #1 went back inside and began to look for where Resident #1 exited the facility and one of them saw the 300 Hall door and alarm cord unplugged. Nurse #1's nursing note on 4/26/26 at 4:30 a.m. documented Resident #1 was found sitting on ground outside, Emergency Medical Services (EMS) was notified and took resident to emergency room as she was unsure if he had an injury or how resident got out of the building. Nurse #1 documented she attempted to notify family and no one answered. The Director of Nursing (DON) was notified of event. Review of the 911 Communications Log for 4/26/26 indicated the first call from NA #2 was received at 5:03 a.m. with reports of an unknown person in the back parking lot of the facility calling out for help and was reported to be in immediate danger, and 911 caller (NA #2) did not know where the unknown person came from. The 911 log further indicated the report was coded as a suspicious person and the police department were dispatched at that time, 5:03 a.m. The 911 communications log revealed a second call from NA #3 came in at 5:05 a.m. and NA #3 stated the person calling out for help was a resident of the facility. The 911 call log indicated the police arrived at the facility's back parking lot at 5:05 a.m. The log was updated at 5:11 a.m. to state an officer requested emergency medical services for an elderly male who they located out back of the facility in the wet grass, who was naked wearing only an adult incontinence brief, hospital gripper socks, and a medical bracelet from the facility. The 911 log indicated EMS were dispatched at 5:12 a.m. The 911 log further stated the callers who were employees of the facility came out and provided information on the resident, stated Resident #1 eloped from the facility and may have fallen outside. The callers reported they did not initially know the man calling out for help was theirs. The report also indicated employees stated they did not know how Resident #1 exited the building because all doors were locked.The Emergency Medical Services (EMS) dispatch report for 4/26/26 showed EMS were dispatched at 5:12 a.m. and arrived at the facility at 5:23 a.m. EMS documented no head, neck, chest, back, pelvic, or extremity abnormalities, and noted minor scratches. His vital signs and neurological assessment were normal. Resident #1 denied any injury or pain. He was alert but disoriented to time and place and believed he was in another city. He was oriented to person and what was happening and able to answer questions about himself and reported that he had fallen. He could not provide further details of his fall. Resident #1 reported no pain or injuries. EMS documented a primary impression of dementia, with no physical abnormalities. The resident was transported non emergently at 5:36 a.m.to the local hospital. No lights and sirens were used during transport. Upon arrival at the hospital, the final vital signs were all within normal ranges. Resident #1 had a pain level was 0 out of 10 (zero meaning no pain), blood pressure of 110/60 (normal is between 100/60 and 140/90), hear rate of 84 beats per minute (normal is between 60 and 100 beats per minute), he was alert, his condition remained unchanged.The Emergency Department (ED) records revealed on 4/26/26 EMS reported that Resident #1 had a fall and needed evaluation. Resident #1 was alert and oriented to self only and unable to provide details of the fall reported by EMS. Vital signs were within normal ranges with a blood pressure of 119/60, heart rate of 88 beats per minute, 16 breaths per minute (normal is between 12 and 20 breaths per minute), and no pain. Imaging of the head, spine, and chest were completed without acute findings. Laboratory studies were normal. A contusion (an injury to the tissues that does not break the skin and can cause bruising or discoloration) to the right hand was treated with cleansing and topical antibiotic ointment. He was discharged back to the facility 4/26/26 with diagnoses of fall, contusion to right hand, and dementia. There were no new medication or treatment orders. Resident #1 was to follow up with primary care in 3 days, around 4/29/26.During an observational interview on 5/7/26 at 11:45 a.m. with the facility's Regional Clinical Nurse Consultant, it was determined that the facility had a rolling measuring tape that was available to measure how far from the 300 Hall door exit that Resident #1 was found on 4/26/26. When communicating that a review of information from the telephone interview with NA #3 and report from the DON about location where Resident #1 was found, the Regional Clinical Nurse Consultant advised she requested the DON call NA #3 and ask NA #3 to report to the facility and physically demonstrate where she found the resident and provide further details from when she and NA #2 identified that he was one of the facility residents.On 5/7/26 at 6:00 a.m. an observation of the facility's rear parking lot revealed a sloped dark and dimly lit black-top paved parking lot that had an approximately 12-inch blacktop paved curb around the perimeter. There were large trees with heavy amounts of green foliage which made visibility difficult in the pre-dawn hour darkness of 5/7/26. The parking lot faced a 4-lane street which had two-way traffic with a posted speed limit of 35 miles per hour. The was a light on at the end of the facility building outside the 300 Hall door and at the other door designated as staff entrance. There was outdoor lighting that illuminated the sidewalk that went around the perimeter of the building and led to two large metal dumpsters located approximately 25 feet from the exit door at the bottom corner of the parking lot and the grassy lawn located adjacent to the 300 Hall.During a follow up observational interview with DON on 5/7/26 at 2:43 p.m. she stated her investigation and interviews led her to believe Resident #1 was found outside the door at the end of the sloped parking lot between the 300 hall exit and where the 2 dumpsters were located. The DON pointed to where she believed Resident #1 was found after the investigation was complete. The location was approximately 25 feet from the 300 Hall exit. The parking lot's perimeter had a black-top curb with jagged drainage stones on the unpaved side that were 2 to 4 inches in size. The stones sat atop dirt from the edge of the curb and down an approximately 8-foot sloped embankment. The first 50 feet of the embankment edge of the parking lot after the two dumpsters on the bottom corner led to a grassy lawn. The next 50 feet of the curb and embankment led to a paved parking lot behind a multiple unit residential building next door. The location where Resident #1 was found was measured by the state surveyor and the Regional Clinical Nurse Consultant and measured approximately 200 feet from the main street which had 4 lanes for traffic with a posted speed limit of 35 miles per hour. Review of the Weather Underground website recorded weather conditions for the facility's location on 4/26/26 between 4:00 a.m. and 5:35 a.m. indicated the temperature was 60 degrees Fahrenheit, and a light drizzle or rain, with wind gusts at 5 miles per hour.Review of Resident #1's record included a telephone order from Nurse Practitioner #1 dated 4/26/26 at 3:30 p.m. signed by the Director of Nursing for 1:1 observation and to initiate/apply wander guard.Review of Nurse #2's progress note dated 4/26/26 at 3:44 p.m. indicated Resident #1 returned to the facility and his family was present. Nurse #2 completed a full skin assessment, confirmed the right hand contusion, applied a wander guard device, and initiated 1:1 observation. It further stated she moved him to a room closer to the nurse's station for enhanced supervision.In the interview with Nurse #2 on 5/8/26 at 9:18 a.m., Nurse #2 reported when Resident #1 returned to the facility on 4/26/26 from the ED she moved him to a room on the 200 Hall which was closer to the nurse's station. She reported there was an order for 1:1 observation by staff and initiation of wander guard alarm. Nurse #2 reported that a wander alarm bracelet was applied to his ankle and staff were assigned for close 1:1 observation of Resident #1. She stated they sat in a chair in his room close to him. Nurse #2 reported 1:1 observation of Resident #1 continued for the remainder of her shift when she reported off to Nurse #1 when her shift ended at 7:00 p.m. on 4/26/26. In an interview on 5/7/26 at 9:45 a.m. with the Maintenance Director, the Maintenance Director reported approximately 10 months prior he reported to the previous Administrator that the 300 Hall door, located at the rear of the building, posed security concerns. He reported that the timed lock setting allowed extended periods of time each day/night when the door was unlocked. He reported the door was used by staff to take out trash, and anyone could enter/exit to the rear of the building when it was unlocked. A timed lock setting allowed a locked door to automatically unlock and remain unlocked during programm

Based on observations, and Dietitian and staff interviews, the facility failed to label and date leftover food items stored for use in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer and the dry goods storage area and failed to maintain clean food service equipment and flooring and failed to clean a thermometer probe before inserting the probe into food. These practices had the potential to affect food served to residents. The findings included:a. An observation of the walk-in refrigerator on 9/8/25 at 10:30 AM revealed an undated package of sliced ham that was not sealed. b. An observation on 9/8/25 at 10:41 AM revealed an open-to-air bag of chicken patties sitting in an open box, in the walk-in freezer and 4 bags of leftover hoagie rolls unlabeled and undated. c. An observation of the dry goods storage room on 9/8/25 at 10:50 AM revealed a bag of breadcrumbs in a clear plastic bag that was unlabeled and undated. An interview with the Dietary Manager (DM) on 9/8/25 at 10:53 AM indicated that whichever staff opened the packages they should label and date immediately when they are opened. She further stated that when taking the opened boxes from the kitchen to the freezer they should be inspected to make sure they were securely closedd. An observation of the plate covers on 9/10/25 at 11:57 AM prior to serving the line revealed the plate covers were dirty with food crumbs.e. An observation on 9/10/25 at 12:00 PM revealed [NAME] #1 removed a thermometer stored in a pitcher of ice to obtain the internal temperature of foods items. The thermometer probe was noted to have yellow food particles; the [NAME] proceeded to insert the thermometer probe into the creamed corn. [NAME] #1 did not clean the thermometer probe before inserting it into the creamed corn.An interview with [NAME] #1 on 9/10/25 at 12:00 PM indicated when asked about the cleaning of the thermometer, she said she was nervous and forgot to clean the probe and that she had just tested the food temperatures with the Dietitian and was trying to get the food ready to serve on time.An interview with the Dietary Manager on 9/10/25 at 12:26 PM revealed that the Dietitian had been in the kitchen prior and checked the food temperatures and that was why the thermometer probe contained food particles. She then revealed that [NAME] #1 had worked in the kitchen for 15 years and was just nervous, that she had done this thousands of times and always had her cloth and alcohol swabs laid out to clean the thermometer probe.An interview with the Dietitian on 9/10/25 at 3:00 PM indicated that she had been in the kitchen and had tested the food temperatures and that [NAME] #1 usually followed the correct procedure for taking the temperature of foods.f. Observations of the tea and coffee machines on 9/8/25 at 11:00 AM and 9/10/25 at 11:50 AM revealed the machines had dried splattered stains and sticky to touch substances on the outside walls and dried brown matter on the bottom. g. The dry goods storage area flooring was observed on 9/10/25 at 11:53 AM to have dirt, food debris and dust underneath the shelves. An Interview with the Dietary Manager on 9/10/25 at 2:54 PM revealed that the weekend staff did not clean well and she had to have a discussion with them so that they did a better job with cleaning. The DM further indicated that the dry good storage area floors were to be cleaned daily.An interview with the Administrator on 9/10/25 at 3:30 PM indicated that she expected the procedures in the kitchen to be correct and careful attention paid to food service to make sure the food not only tasted good but was sanitary and safe. The Administrator further stated she would talk with the Dietary Manager to make sure these corrections were made.

Based on record review, observations, and resident and staff interviews, the facility failed to ensure a resident was spoken to in a dignified manner when the resident expressed feelings of being frustrated and felt like he was spoken to in a childlike manner. This affected 1 of 3 residents reviewed for dignity and respect (Resident #30). The findings included:Resident #30 was admitted to the facility on [DATE]. Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. The resident was not documented as having behaviors.An observation was conducted during a resident council meeting on 09/10/25 at 2:25 PM in a small room with ten residents present sitting facing the Activity Assistant. The door to the room was opened to the hall. Resident #30 voiced the door needed to be closed during the meeting for privacy. Resident #30 attempted to explain to the Activity Assistant the door to the room needed to be closed so that the meeting could be private and issues could be discussed privately. The Activity Assistant was sitting in a chair and told Resident #30 to calm down in a condescending tone and did not shut the door. Resident #30 was observed shaking his head, and had a furrowed brow, and raised his voice stating, She [The Activity Assistant] did not listen to the residents, and I am tired of being spoken to like a child. The Activity Assistant then rolled her eyes and stated to Resident #30 again to calm down. Resident #30 and other residents appeared to have a confused look on their faces and did not say anything to the Activity Assistant. The Activity Assistant excused herself from the meeting to allow the residents to have a private meeting without staff present. The Activity Assistant shut the door on her way out. An interview conducted Resident #30 on 09/11/25 at 8:45 AM revealed on 09/10/25 he got upset because he felt that the Activity Assistant spoke to him like a child when she told him to calm down and felt she could care a less what concerns residents had. Resident #30 indicated he was frustrated and was glad the Activity Assistant had left the meeting so that residents could speak freely and not feel like anything would be used against them. An interview with the Activity Assistant on 09/11/25 at 8:40 AM revealed she did not usually participate in resident council meetings but had been conducting them because the Activity Director had been out since the beginning of August. The Activity Assistant indicated on 09/10/25 during the resident council meeting she was surprised Resident #30 had gotten upset because she did not think she had acted toward resident in a negative manner. The Activity Assistant revealed she was not aware she had spoken to the resident in an undignified manner nor was she aware she had rolled her eyes. The Activity Assistant stated if she did roll her eyes or have a tone it was because she was caught off guard and was shocked when Resident #30 had been so vocal. It was further revealed she told Resident #30 to calm down because she felt that he was getting worked up. In an interview with the Administrator on 09/11/25 at 2:20 PM she revealed she expected staff to walk away if situations escalated and not to reply in an unprofessional manner. It was further revealed she expected all staff to treat residents with dignity and respect.

Based on record review and staff interviews, the facility failed to update 2 of 3 residents advance directive information (Resident #15 and Resident #18).The findings included: 1. Resident #18 was admitted to the facility on [DATE]. A review of Resident #18's orders for advance directives revealed a physician's order dated [DATE] for Do Not Resuscitate (DNR, an order signed by a doctor that informs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a person's breathing stops or their heart stops beating). A review of Resident #18's face sheet and Medical Orders for Scope of Treatment (MOST) form dated [DATE], and both indicated he was a full code (meaning to perform life saving measures including CPR). An interview conducted with the Assistant Director of Nursing (ADON) on [DATE] at 12:10 PM revealed Resident #18 was initially admitted with orders to be a DNR but was recently changed to a full code status. The ADON further revealed she and the Director of Nursing (DON) updated and reviewed orders and should have caught that Resident #18's advance directives order had not been updated. During an interview conducted with the Director of Nursing (DON) on [DATE] at 9:20 AM, the DON stated Resident #18's physician order, face sheet, and MOST form should have matched. The DON further revealed the order in Resident #18's chart should have been updated to reflect the current MOST form for the resident to be a full code. An interview conducted with the Administrator on [DATE] at 2:20 PM revealed she expected advance directive information to match so that nursing staff had no confusion about what to follow in case of an emergency. It was further revealed Resident #18's physician order should have been updated to accurately match the resident's choice for code status. 2. Resident #15 was admitted to the facility on [DATE] with diagnosis of a seizure disorder. During a review of Resident #15's orders for advance directives a physician's order dated [DATE] indicated he was a full code. A review of Resident #15's face sheet, Do Not Resuscitate Form, and Medical Orders for Scope of Treatment (MOST) form were dated [DATE] and indicated he was a Do Not Resuscitate. An admission Minimum Data Set assessment dated [DATE] indicated Resident #15 was cognitively intact. On [DATE] at 9:56 AM Nurse #1 was interviewed, and she stated Resident #15's face sheet stated he was a DNR, and his physician's orders indicated he was a full code. Nurse #1 stated Resident #15's face sheet, Do Not Resuscitate form, and the physician's orders should match. An interview was conducted with the Assistant Director of Nursing on [DATE] at 12:04 PM and she stated each time a residents' code status changed she updated the book (where the DNR forms are kept at the nurses' station) to reflect the change. The book, face sheet and physicians' orders should match to reflect the residents' advance directives wishes. The Assistant Director of Nursing stated Resident #15's advance directives were to be DNR, but she failed to update the advance directives physician's order in the computer. The Director of Nursing (DON) was interviewed on [DATE] at 11:53 AM and she stated Resident #15's advanced directives physician's orders, face sheet, and the DNR form should have matched. The DON stated the physician's order should have been updated by the Assistant Director of Nursing when the DNR form was signed by the physician. On [DATE] at 1:45 pm the Administrator was interviewed and stated the nursing staff should ensure each residents' advance directives matched in the advance directives book at the nurses' station, and on the resident's face sheet and physician's orders to ensure the nurses were aware of the correct advance directives for each resident.

Based on record review, observations, and staff interviews, the facility failed to provide nail care for 3 of 4 residents that were dependent on staff for personal care (Resident #2, Resident #26, and Resident #18). Findings included: 1. Resident #2 was admitted to the facility on [DATE] with heart disease and weakness. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #2 was cognitively intact and required extensive assistance for personal hygiene. The assessment documented the resident did not have impairment to range of motion for the upper extremities. On 9/8/2025 at 11:43 am Resident #2 was observed in his room in bed, he had a dark brown substance under his nails, and the free edge of the nails were approximately 1/4 inch beyond the tip of the fingers for all 10 fingers. Resident #2 stated he received a shower twice a week and on days he does not receive a shower he was given a bed bath, but they did not clean under his nails after his showers, or after a bed bath, and he did not like for his nails to be long and dirty. On 9/8/2025 at 11:59 am an interview was conducted with Nurse Aide #2 who was assigned to Resident #2. Nurse Aide #2 stated Resident #2 required extensive assistance with nail care but did not refuse care. She stated Resident #2 was not scheduled for a shower on 9/8/25. She explained she had not noticed his nails had a dark brown substance under them and that they were long. Nurse Aide #2 stated Resident #2 did not tell her his nails needed to be trimmed and cleaned. An interview was conducted with Nurse #1 on 9/10/2025 at 9:43 am and she stated the Nurse Aides were responsible for cleaning and trimming residents' nails during their showers and when needed. During an interview with the Assistant Director of Nursing on 9/10/2025 at 9:52 am she stated the Activities Department does provide manicures on Thursday for residents that request a manicure, but the Nurse Aides should be cleaning and trimming the residents' nails when they provide the residents' showers as scheduled. The Director of Nursing was interviewed on 9/11/2025 at 11:57 am and stated the nurse aides and nurses were responsible for cleaning and trimming residents' nails with each shower and as needed. On 9/11/2025 at 1:45 pm the Administrator was interviewed, and she stated the residents' nails should be cleaned and trimmed with each shower and as needed. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses of fracture of the right humerus (the bone in the upper arm), stroke, and hemiplegia (weakness of one side of the body). An admission Minimum Data Set assessment dated [DATE] indicated Resident #26 was cognitively intact and required extensive assistance for personal hygiene. The assessment further indicated Resident #26 had weakness to his upper and lower extremities on one side. During an observation of Resident #26 on 9/8/2025 at 12:39 pm the free edge of his fingernails were approximately 1/4 inch beyond the tip of the finger and he stated his nails were trimmed when he was admitted to the facility but had not been trimmed since his admission. Resident #26 stated he did not like his nails to be long. On 9/8/2025 at 11:59 am an interview was conducted with Nurse Aide #2 who was assigned to Resident #26. Nurse Aide #2 stated Resident #26 was dependent on staff for nail care and all personal hygiene, and he did not refuse nail care. Nurse Aide #2 stated she had not given Resident #26 a shower on the day of the interview and was not aware his fingernails extended approximately 1/4 inch long beyond fingertips. Nurse Aide #2 stated Resident #26 did not tell her his nails needed to be trimmed. An interview was conducted with Nurse #1 on 9/10/2025 at 9:43 am and she stated the Nurse Aides were responsible for cleaning and trimming residents' nails during their showers and when needed. During an interview with the Assistant Director of Nursing on 9/10/2025 at 9:52 am she stated the Activities Department does provide manicures on Thursday for residents that request a manicure, but the Nurse Aides should be cleaning and trimming the residents' nails when they provide the residents' showers as scheduled. The Director of Nursing was interviewed on 9/11/2025 at 11:57 am and stated the nurse aides and nurses were responsible for cleaning and trimming residents' nails with each shower and as needed. On 9/11/2025 at 1:45 pm the Administrator was interviewed, and she stated the residents' nails should be cleaned and trimmed with each shower and as needed. 3. Resident #18 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, acute kidney failure, muscle weakness, chronic pain, and hypertension. Resident #18 quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required substantial and maximal assistance with personal hygiene. Resident #18's care plan revised on 07/15/25 revealed the resident was at risk for activities of daily living (ADL) self-care and mobility deficits. Resident #18's goal was his needs would be met with assistance if needed. Interventions included to check Resident #18's nail length, trim, and cleaning as needed. An interview and observation conducted with Resident #18 on 09/08/25 at 11:50 AM revealed the resident voiced complaints that his fingernails were long, and he had recently asked staff to trim them, but they had not been trimmed yet. Observations further revealed Resident #18's fingernails to be an estimated one inch long from the base to the tip of the nail with a brown substance under his nails. Resident #18 stated Nurse Aides (NAs) would not trim his fingernails because he was diabetic. An interview conducted with Nurse Aide (NA) #5 on 09/10/25 at 10:55 AM revealed she did not perform nail care on Resident #18 due to the resident being a diabetic. NA #5 further revealed she assisted Resident #18 with bathing and other hygiene needs but could not recall the length and shape of his nails. NA #5 stated the Activity Director (AD) or Nurses performed nail care for diabetic residents. NA #5 revealed if she had observed Resident #18's fingernails to be long she would have reported it to the assigned Nurse. An interview conducted with the Assistant Director of Nursing (ADON) on 09/09/25 at 12:10 PM revealed she had trimmed Resident #18's fingernails on this date due to being long. The ADON indicated that the Activity Director (AD) had been out of work since the beginning of August and normally did rounds and conducted nail care for all residents. The ADON stated Resident #18 had diabetes and Nurse Aides (NA) were not permitted to perform the care. ADON revealed the NAs should have reported long fingernails to nurses to assure nail care was being provided. Interview conducted with the Director of Nursing (DON) dated 09/01/25 at 10:35 AM revealed she was not aware Resident #18's fingernail had not been trimmed. The DON further revealed she expected all staff to observe residents and complete hygiene needs.

Based on record review, observations, and staff interviews, the facility failed to post cautionary signage for oxygen in use for 2 of 3 residents reviewed for respiratory care (Resident #25 and Resident #38).Findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnosis of respiratory disease. A Physician's Order dated 8/22/2025 indicated Resident #25 should be administered 2 liters of oxygen by nasal canula continuously. A Minimum Data Set admission assessment was in progress but not completed for Resident #25. The care plan for Resident #25 dated 8/22/2025 indicated he required oxygen continuously for respiratory disease. On 9/8/2025 at 12:27 pm an observation was conducted of Resident #25, and he was in bed, and his oxygen was delivered by nasal canula. Resident #25 did not have signage to designate he had oxygen in use posted on his room door. On 9/10/2025 at 10:00 am an observation was made of Resident #25 in bed with his oxygen delivered by nasal canula, without signage on his room door to designate he was on oxygen. Nurse #1 was interviewed on 9/10/2025 at 10:03 am and she stated Resident #25 should have an oxygen sign on his door and the nurse was responsible for placing the oxygen in use signage on the resident's door. Nurse #1 stated Resident #25 had orders for continuous oxygen. The Hospice Nurse was interviewed on 9/10/2025 and she stated Resident #25 was required hospice services due to a diagnosis of chronic respiratory disease and required oxygen continuously for comfort. During an interview with the Director of Nursing on 9/11/2025 at 11:57 am she stated Resident #25 should have signage to designate he had oxygen on his room door since he received oxygen, and the nursing staff was responsible for ensuring the signage was on the resident's room door. An interview was conducted with the Administrator on 9/11/2025 at 1:45 pm and she stated residents that receive oxygen should have signage on their door designating they were on oxygen. 2. Resident #38 was admitted to the facility on [DATE] with diagnoses which included unspecified acute lower respiratory infection, acute cough, wheezing, and congestive heart failure. Resident #38's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Physician order dated 09/08/25 revealed Resident #38 was ordered oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. An observation on 09/09/25 at 12:25 PM revealed Resident #38 was observed in her room sitting in her wheelchair with oxygen on. The Resident stated she was getting ready to leave for an outing. The observation indicated no oxygen signage outside the door. An observation on 09/10/25 at 10:00 AM revealed Resident #38 was observed in her room sitting in her wheelchair with oxygen on. The observation further revealed no oxygen signage outside the door. An observation and interview conducted with the Assistant Director of Nursing (ADON) on 09/10/25 at 11:40 AM indicated she was not aware Resident #38 did not have any oxygen signage up. The ADON further revealed she and the Director of Nursing (DON) normally post oxygen signage but must have missed it. The ADON indicated all residents who received oxygen were expected to have oxygen signage. An interview conducted with the Director of Nursing (DON) 09/11/25 at 9:20 AM revealed they were unaware Resident #38 did not have oxygen in use signage posted outside of their room. The DON indicated she was aware Resident #38 had been using continuous oxygen. It was further revealed the DON expected staff to ensure signage was posted when there was oxygen in use, or in resident rooms.

Based on record review, observations, staff, and physician interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #12). Nursing assistant (NA) #1 rolled Resident #12 away from her during incontinence care and Resident #12 rolled out of bed. Resident #12 sustained a fractured tibia and fibula (bones below the right knee). Resident #12 required a 2-day hospitalization for the fracture and returned to the facility with a leg brace in place. The findings included: Resident #12 was admitted to the facility 11/24/2023 with diagnoses to include heart failure, kidney disease, lung disease, and diabetes. The annual Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #12 to be cognitively intact. The MDS documented Resident #12 had no limits to her range of motion in her upper and lower body and required 1-person substantial assistance with bed mobility. The MDS documented Resident #12 required 2-person total assistance to transfer from her bed to a chair with the use of a mechanical lift. Review of the care plan for Resident #12 (no date) included an intervention for 1 person assistance for bed mobility. A nursing note dated 3/19/2024 at 4:27 PM written by Nurse #2 documented a fall on 3/19/2024 at 3:00 PM where Resident #12 was being provided incontinence care in the bed by Nursing Assistant (NA) #1. The note described Resident #12 rolling over in the bed and her legs slipped off the side of the bed causing her to slide to the floor and land on her knees. The note documented that Resident #12 reported pain below her right knee and her pain was rated 4 (on a 1-10 scale where 0= no pain; 10= severe pain). The note documented Resident #12 was administered over-the-counter pain medication and it was effective. Resident #12 was interviewed on 7/23/2024 at 12:00 PM and she reported she did not recall the details of the fall on 3/19/2024. Resident #12 reported 2 staff members assisted her with bed mobility since the fall, and she was doing just fine since the fall. Resident #12 explained her pain level was controlled by medication, and she was wearing the leg brace. NA #1 was interviewed on 7/23/2024 at 10:22 AM. NA #1 explained she was assigned to Resident #12 on 3/19/2024 and had been assisting her with incontinence care, when Resident #12 slipped off the bed and landed on the floor. NA #1 reported she had provided care to Resident #12 in the past and Resident #12 required only one staff member assistance at that time. NA #1 explained Resident #12 used the grab bars to pull herself over on her side. Regarding the incident on 3/19/2024, NA #1 reported she was on the left side of the bed and had helped Resident #12 to turn away from her on her right side for incontinence care. NA #1 described tucking a sheet under Resident #12's right hip and Resident #12 said, Oh, I'll turn over more. Resident #12 leaned further to the right, when her legs slipped off the mattress and she slid to the floor. NA #1 explained because of the weight of Resident #12's legs, the resident was unable to stop them from slipping off the mattress. NA #1 revealed she yelled for help and Nurse #2 and NA #2 arrived within a minute. NA #1 reported Resident #12 was on her knees at the side of the bed and was holding onto the upper grab rail and Resident #12 reported her right knee hurt. NA #1 explained that prior to this incident, Resident #12 had no problems rolling over in bed for care, but on 3/19/2024, her legs slipped off the mattress and this caused her to fall. An interview was conducted with NA #2 on 7/23/2024 at 9:53 AM. NA #2 reported she was not assigned to Resident #12 on 3/19/2024, but she assisted NA #1 and the nurse to get Resident #12 off the floor by a mechanical lift after the fall. NA #2 reported prior to the fall, Resident #12 required 1 person assistance with bed mobility, but after the accident, 2 people always assisted her. A phone interview was conducted with Nurse #2 on 7/23/2024 at 10:55 AM. Nurse #2 recalled the incident on 3/19/2024 when Resident #12 slid out of the bed during incontinence care. Nurse #2 described she was right outside of Resident #12's room when she heard NA #1 calling out for help and when she went in the room, found Resident #12 on the right side of the bed, by the window, on her knees and holding onto the bed rail. Nurse #2 reported Resident #12 expressed knee pain and she was given pain medication. Nurse #2 concluded by explaining she had called the physician, and he ordered an x-ray of Resident #12's right leg. The physician was interviewed by phone on 7/23/2024 at 11:05 AM and he reported he was notified of the incident on 3/19/2024. The physician noted that while Resident #12 had a fractured tibia, she could have been hurt much worse. X-ray results dated 3/19/2024 determined there was a proximal tibia and fibula fractures of the right leg just below the knee. A nursing note dated 3/19/2024 at 11:52 PM documented Resident #12 was sent to the hospital emergency room for evaluation. Hospital discharge orders dated 3/21/2024 documented Resident #12 had a traumatic closed displaced fracture of the proximal end of the right tibia (bone below the knee). Orders included no weightbearing on the right leg and Resident #12 was to wear a knee immobilizer until she followed up with the orthopedic surgeon. The most recent Quarterly MDS assessment dated [DATE] assessed Resident #12 to be cognitively intact. The MDS documented Resident #12 had range of motion impairment on both sides of her upper and lower body, and she required 2-person total assistance for bed mobility and required 2-person total assistance with a mechanical lift from bed to chair. The facility provided a plan of correction dated 3/21/2024 for accidents. How corrective action will be accomplished for those residents found to have been affected by the deficient On 3/19/2023 Resident #12 was in bed receiving incontinence care with the assist of NA #1. She rolled over to her right side and her feet slid out of bed. She was holding on to the grab bar and was unable to stop her feet from sliding. She landed on her knees. Upon assessment from the (former) Director of Nursing (DON #1), Resident #12 was noted to have bruising below right knee and was complaining of pain. The physician (MD) was notified and gave an order to obtain an x-ray of the right knee and leg. The knee and leg x-ray obtained and resulted on 3/19/2024 and was positive for a tibia fibula fracture. Resident #12 was sent to the hospital emergency department for evaluation and treatment on 3/19/2024. A head-to-toe assessment was completed on Resident #12 by Director of Nursing (DON #1). Education was provided to NA #1 regarding correct bed mobility and to roll a resident towards staff to prevent from rolling off the bed by the Assistant Director of Nursing (ADON) on 3/19/2024. A pain assessment was completed by Nurse #1 on Resident #12 at 3:20 PM, and she received pain medication that was effective. A fall assessment was completed by the ADON on 3/19/2024. The MD was made aware of the incident by Nurse #1 on 3/19/2024 at 3:32 PM. An X-ray was obtained on 3/19/2024, and the results received; Resident #12 was transferred to the hospital for evaluation and treatment on 3/19/2024 at 11:52 PM. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur. Identified residents with like care concerns and performed bed mobility evaluation on all residents, which was completed by 3/20/2024 by the ADON and DON #1. An ad-hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 3/20/2024 to discuss the incident, the corrective action plan, and to begin monitoring. Address how the facility will identify other residents having the potential to be affected by the same deficient. Education to the NA staff related to bed mobility provided by the ADON starting 3/20/24 with direction for checking the Kardex for resident care needs and reporting any care changes. This education will be presented to new hire nurses and NAs by the ADON. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will complete an observation of care for 3 residents weekly for 4 weeks, then monthly for 2 months to ensure that residents that require assistance of 2 people are cared for appropriately per the care plan. Results will be taken to QAPI for review and revision as needed. To monitor and maintain ongoing compliance, the DON/designee will audit point of care documentation (NA documentation of the amount of assistance a resident requires) 5 times a week for 8 weeks to ensure documentation is accurate for newly identified at risk residents, including new admissions and high fall risk. New fall risks and new admissions will be discussed daily during the morning meeting. Documentation will be compared to fall risk assessments and bed mobility assessments. Results will be taken to QAPI for review and revision as needed. The facility date of compliance: 3/21/2024 The facility date of compliance of 3/21/2024 was validated on 7/23/2024 by review of the education provided to nursing staff, reviewing audit forms, observation of bed mobility, review of the QAPI meeting notes, and interviews with nursing staff, physician, Director of Nursing, and Assistant Director of Nursing. During an interview with the Director of Nursing and Assistant Director of Nursing on 7/23/2024, they reported they were on the floor assisting staff with residents and provided hands on care, as well as oversight and observation during resident care to monitor for compliance. The Director of Nursing explained they monitored all residents. Incontinence care was observed on 7/21/2024 at 10:34 AM. Two staff members assisted Resident #12 with bed mobility and incontinence care.

Based on record review, observations, and staff interviews, the facility failed to provide routine medications for 1 of 3 residents reviewed for medication administration (Resident #2). The findings included: Resident #2 was admitted to the facility 12/1/2021 with diagnoses including diabetes and hypertension. The most recent quarterly Minimum Data Set assessment assessed Resident #2 to be moderately cognitively impaired. Review of the physician orders for Resident #2 revealed an order dated 12/1/2022 for glipizide (an oral hypoglycemic) 10 milligrams (mg) daily for diabetes. Additionally, physician orders for Resident #2 included the following hypoglycemic medications: Victoza 1.2 mg subcutaneous daily for diabetes ordered 11/11/2023 Metformin 1000 mg orally twice daily for diabetes ordered 12/1/2022 Sliding scale insulin as needed 3 times per day ordered 11/11/2023: give 2 units of insulin for blood sugars 200-250; give 4 units of insulin for blood sugars 251-200; give 6 units of insulin for blood sugars 301-350; give 8 units of insulin for blood sugars 351-400; give 10 units of insulin for blood sugars 401-450; give 14 units of insulin for blood sugars greater than 451 and call the physician. Review of the medication administration record for December 2023 revealed the following dates glipizide 10 mg was documented as not given and to see the nursing notes: 12/6/2023, 12/8/2023, 12/9/2023, 12/11/2023, and 12/14/2023. Nursing notes were reviewed for Resident #2 and the following was documented: 12/6/2023 documented by Nurse #1: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: unavailable. The note did not document the pharmacy had been contacted for refills. 12/8/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. 12/9/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. 12/11/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. 12/14/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. Blood glucose results for Resident #2 were reviewed with the following results: (normal results from 70-120) 12/6/2023: 5:36 AM 423 10 units of sliding scale insulin given 12/6/2023: 12:19 PM 423 10 units of sliding scale insulin given 12/6/2023: 4:35 PM 281 4 units of sliding scale insulin given 12/8/2023: 6:09 AM 231 2 units of sliding scale insulin given 12/8/2023 11:16 AM 254 4 units of sliding scale insulin given 12/8/2023 5:03 PM 225 2 units of sliding scale insulin given 12/9/202: 7:01 AM 211 2 units of sliding scale insulin given 12/9/2023: 10:37 AM 255 4 units of sliding scale insulin given 12/9/2023: 3:56 PM 236 2 units of sliding scale insulin given 12/11/2023: 5:42 AM 165 no sliding scale insulin given 12/11/2023: 11:16 AM 253 4 units of sliding scale insulin given 12/11/2023: 4:36 PM 163 no sliding scale insulin given 12/14/2023: 3:56 PM 235 2 units of sliding scale insulin given A pharmacy report of medication orders for Resident #2 in December 2023 documented glipizide 10 mg had been delivered on 12/18/2023. Multiple attempts were made to contact Nurse #2 for interview, but Nurse #2 did not return the calls. The former Director of Nursing (DON #1) was interviewed by phone on 7/22/2024 at 2:00 PM. DON #1 reported the facility had an automatic medication dispensing system that should have been stocked with routine medications for the residents. DON #1 explained staff nurses were instructed to look in the automatic medication dispensing system, then call the pharmacy and ask for the medication to be sent to the facility. DON #1 reported she did not recall Resident #2 missing several doses of glipizide because the medication was not available. Nurse #1 was interviewed by phone on 7/22/2024 at 3:48 PM. Nurse #1 reported she was no longer employed at the facility, but she had administered medications to Resident #2 in the past. Nurse #1 explained if the facility did not have medications in stock, she would have called the pharmacy and the physician. When reviewing documentation Nurse #1 completed on 12/6/2023, Nurse #1 reported she had no memory of the incident and did not know why she had not called the pharmacy. A phone interview was conducted with the facility physician (MD) on 7/23/2024 at 11:05 AM. The MD explained that because Resident #2 was on other hypoglycemic medications, missing the 5 doses of the medication most likely had not harmed her, however, she should have received the medication, and the pharmacy should have been notified the medication was not available. A Pharmacist was interviewed by phone on 7/23/2024 at 11:31 AM. The Pharmacist explained that the facility was using an automated refill system for routine medications that required completion of a form every month for the refills to be completed. The Pharmacist explained the automated refill process would not be completed if the form was incomplete, and the pharmacy records indicated the refill request for October and November 2023 were not completed and the refills were cancelled. The Pharmacist reported the automatic medication dispensing system had glipizide available as a stock medication and the facility had refilled the automatic medication dispensing system with 10 tablets of glipizide 10 mg on 12/10/2023, but they had not taken any out of the automatic medication dispensing system. The Pharmacist revealed no calls were documented from the facility from 12/6/2023 to 12/14/2023 requesting a refill of glipizide for Resident #2, and no medications were removed from the automatic medication dispensing system for her in December 2023. The Director of Nursing (DON #2) and Assistant Director of Nursing (ADON) were interviewed on 7/23/2024 at 12:44 pm. DON #2 reported she and the ADON did not start working for the facility until 2024 and they were not in the building when Resident #2 missed her medications in December 2023. DON #2 explained the ADON was completing the automated refill requests for the facility, so no refills were omitted. The ADON reported a daily report of missed medications was reviewed every morning to ensure that all residents were receiving their medications as the physician ordered. The Regional Director of Clinical Services was interviewed on 7/23/2024 at 1:13 PM and she reported a mock survey was conducted in March 2024 and the survey discovered multiple issues with medication administration, including the pharmacy was not being contacted for medications that were not in-house or stocked in the automatic medication dispensing system and a plan of correction has been developed. The facility provided a plan of correction dated 3/28/2024 for unavailable medications. 1. During Mock Survey on 3/26/2024 multiple documentations of medication unavailable in resident electronic medical records were identified. 2. To identify residents that have the potential to be affected the Director of Nursing/Designee immediately reviewed 100% electronic medication administration records for the past six months to ensure all residents medications were administered as ordered. 100% of residents affected with the documentation of medications unavailable during different months during this review time. Provider, Responsible party/Guardians (RP) were notified of findings and completed by 3/29/2024. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on 3/27/2024 to discuss findings, develop the plan of correction, and initiate monitoring. A Root cause analysis determined missed medications were due to nursing staff not following the procedure to obtain medications that were not in the medication cart, the medication storage room, or in the automated medication dispensing system. 3. To prevent this from happening again, on 3/27/2024, the Director of Nursing/Designee completed education with 100% of Licensed Nursing Staff and Current Agency Staff on the process of obtaining and administering medications .The education is inclusive of the process for ordering medication when supply is low, checking the medication storage room for over stock medications, using the automated medication dispensing system, to identify if medication is available, Notifying the pharmacy for STAT delivery to the facility, Notification to the DON/Nurse Manager if any issues with obtaining medications, Notifying the RP if applicable, Notifying the Provider if unable to obtain the prescribed medication and request an interchange if available in the automated medication dispensing system. Licensed Nurses and Medication Aides were educated on documentation and instructed not to use medication unavailable until all the above has been exhausted and Provider has given an order to hold until medication is available. Newly hired Licensed Nursing Staff to be educated during Orientation. Agency nursing to be educated before assigned shift on Medication Administration Guidelines. 4. To Monitor and Maintain Ongoing Compliance the facility will do the following: The DON/Designee will audit the medication administration records 5x's a week for 12 weeks to ensure all medications guidelines are followed and in compliance. The Administrator will report the results of the audits to the QAPI committee for review and recommendations for a minimum of three months. Date of Compliance: 03/29/2024. The facility date of compliance of 3/29/2024 was validated on 7/23/2024 by observation of medication administration, review of the education provided to nursing staff, reviewing audit forms, reviewing medication administration records, nursing notes, review of the QAPI meeting notes, and interviews with nursing staff, Physician, Director of Nursing, and Assistant Director of Nursing. A medication administration observation was conducted 7/22/2024 and 7/23/2024. The facility had 0 errors out of 25 opportunities.

Based on record review and staff interviews, the facility failed to notify the physician of missed medication administration for 1 of 2 residents reviewed for notification (Resident #2). The findings included: Resident #2 was admitted to the facility 12/1/2021 with diagnoses including diabetes and hypertension. Review of the physician orders for Resident #2 revealed an order dated 12/1/2022 for glipizide (an oral hypoglycemic) 10 milligrams (mg) daily for diabetes. Review of Resident #2's medication administration record for December 2023 revealed the following dates were documented as not given and to see the nursing notes: 12/6/2023, 12/8/2023, 12/9/2023, 12/11/2023, and 12/14/2023. Nursing notes were reviewed for Resident #2 and the following was documented: 12/6/2023 documented by Nurse #1: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: unavailable. The note did not document the physician had been notified the medication was not available. 12/8/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. 12/9/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. 12/11/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. 12/14/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. Multiple attempts were made to contact Nurse #2 for interview, but Nurse #2 did not return the calls. The former Director of Nursing (DON #1) was interviewed by phone on 7/22/2024 at 2:00 PM. DON #1 reported the facility had an automatic medication dispensing system that should have been stocked with routine medications for the residents and if the medication was not available, the physician should have been notified. The DON #1 reported she did not recall Resident #2 missing several doses of glipizide because the medication was not available and was not aware the physician was not notified. Nurse #1 was interviewed by phone on 7/22/2024 at 3:48 PM. Nurse #1 reported she was no longer employed at the facility, but she had administered medications to Resident #2 in the past. Nurse #1 explained if the facility did not have medications in stock, she would have called the pharmacy and the physician. When reviewing documentation Nurse #1 completed on 12/6/2023, Nurse #1 reported she had no memory of the incident and did not know why she had not called the physician. A phone interview was conducted with the facility physician (MD) on 7/23/2024 at 11:05 AM. The MD reported he had not been notified that glipizide 10 mg was not available for administration to Resident #2 and if he had been notified, he would have ordered a replacement medication. The MD explained that because Resident #2 was on other hypoglycemic medications, missing the 5 doses of the medication most likely had not harmed her, however, she should have received the medication, and he should have been notified she did not have 5 doses of the glipizide. The Director of Nursing (DON #2) and Assistant Director of Nursing (ADON) were interviewed on 7/23/2024 at 12:44 pm. DON #2 reported she and the ADON did not start working for the facility until 2024 and they were not in the building when Resident #2 missed her medications in December 2023. DON #2 explained the staff were educated to call the physician if a medication was not available to administer and she did not know why Nurse #1 and Nurse #2 had not contacted the MD about Resident #2's glipizide. The Regional Director of Clinical Services was interviewed on 7/23/2024 at 1:13 PM and she reported a mock survey was conducted in March 2024 and the survey discovered multiple issues with medication administration, including the physician was not notified for missed medications, and a plan of correction has been developed. The facility provided a plan of correction dated 3/28/2024 for unavailable medications. 1. During Mock Survey on 3/26/2024 it was identified Physician/Responsible Party were not notified of missed medications. 2. To identify residents that have the potential to be affected the Director of Nursing/Designee immediately reviewed 100% electronic medication administration records for the past six months to ensure all residents medications were administered as ordered. 100% of residents affected with the documentation of medications unavailable during different months during this review time. Responsible party/Guardians notified of findings. Medical Provider notified and reviewed findings and agrees no significant medication errors. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on 3/27/2024 to discuss findings, develop the plan of correction, and initiate monitoring. A Root cause analysis determined the lack of notification of the Physician and Responsible Party were due to nursing staff not following the procedure to notify. 3. To prevent this from happening again on 3/28/2024, the Director of Nursing/Designee completed education with 100% of Licensed Nursing Staff, Medication Aides and Current Agency Staff on the process of notification to the DON/Nurse Manager if any issues with obtaining medications, Notifying the Responsible Party if applicable, Notifying the Physician if unable to obtain the prescribed medication and request an interchange if available in the automated medication dispensing system. Licensed Nurses and Medication Aides educated on documentation and instructed not to use medication unavailable until all the above has been exhausted and Physician has given an order to hold until medication is available. Newly hired Licensed Nursing Staff to be educated during Orientation. Agency nursing to be educated before assigned shift on Medication Administration Guidelines. 4. To Monitor and Maintain Ongoing Compliance the facility will do the following: The DON/Designee will audit the medication administration records 5x's a week for 12 weeks to ensure all medications guidelines are followed and in compliance and to ensure medical provider notified if any medication availability issues are identified. The Administrator will report the results of the audits to the QAPI committee for review and recommendations for a minimum of three months. Date of Compliance: 03/29/2024. The facility date of compliance of 3/29/2024 was validated on 7/23/2024 by review of the education provided to nursing staff and medication aides, reviewing audit forms, reviewing medication administration records and nursing notes, review of the QAPI meeting notes, and interviews with nursing staff, Physician, Director of Nursing, and Assistant Director of Nursing.

Based on record review, observation, and staff interviews, the facility failed to handle soiled linens in a manner to prevent the spread of infection for 1 of 1 laundry room observation. The findings included: The facility policy Transmission-based Precautions and Isolation Policy dated 1/2014 with a revision date of 4/15/2024 read, in part: Handle resident care .laundry . with standard precautions . The facility laundry room was observed on 7/23/2024 at 12:05 PM. The Laundry Aide #1 was interviewed at the time of the observation. The soiled linen area was observed, and no personal protective equipment (PPE) was in the room. When asked to demonstrate moving soiled linen from the soiled linen bin, the Laundry Aide #1 demonstrated removing the soiled linen from a tied plastic bag and placed the soiled linen in the washing machine. Laundry Aide #1 reported she did not apply PPE when moving the soiled linen from the plastic bags into the washing machine and she did not have PPE in the laundry room. The Infection Control Nurse was interviewed by phone on 7/23/2024 at 12:33 PM. The Infection Control Nurse reported Laundry Aide #1 should be using PPE to move soiled linen from the plastic bags into the washing machine. The Infection Control Nurse explained she had provided training to Laundry Aide #1 including the use of PPE for soiled linens and the Infection Control Nurse did not know why the Laundry Aide #1 was not using the PPE. The Director of Nursing (DON) #2 was interviewed on 7/23/2024 at 12:41 PM and she reported she was not aware Laundry Aide #1 was not using PPE when moving soiled linens from the soiled linen bin to the washing machine. DON #2 explained she expected Laundry Aide #1 to use PPE to prevent the spread of infection when in contact with any soiled laundry. The Administrator was interviewed on 7/23/2024 at 1:13 PM and he reported Laundry Aide #1 had started to work at the facility about 1 month prior and she had received training on using PPE with soiled linen and he did not know why she was not using PPE.

Based on observations, record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessments for 7 of 14 residents reviewed for MDS accuracy. Resident #14 was not coded for Level II Preadmission Screening and Resident Review (PASRR) and inaccurately coded for daily restraint use. Residents #8, #5, #9, #13, #1 and Resident #6 were also inaccurately coded for daily restraint use. Findings included: 1a.Resident #14 was readmitted to the facility on [DATE] with diagnoses that included epilepsy. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #14 had no cognitive impairment and was noted as not coded for PASRR Level II at section A 1500 for Level II PASRR screening and Resident #14 was not coded at section A 1510 for Level II PASRR conditions as required by the RAI manual (Resident Assessment Instrument). A review of a PASRR Level II history detail report from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services revealed Resident #14 had been determined to require a Level II PASSR since 12/18/21. A letter dated 5/31/22 from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services to the facility revealed Resident #14 had been determined to require a Level II PASRR. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she never saw Level II PASRR documents in Resident #14's medical record and did not know Resident #14 had been determined to be a PASRR Level II. The MDS Nurse revealed she believed the Social Worker coded the section related PASRR Level II on the comprehensive MDS assessments. The Social Worker was interviewed on 9/27/23 at 10:31 AM. The SW revealed she was not responsible to complete any part of Section A on any MDS assessment and she believed the MDS Nurse reviewed the medical record and coded section A based on Level II PASRR status located in the medical record. The Regional Clinical Reimbursement Specialist was interviewed on 9/27/23 at 2:06 PM and revealed the PASRR status of Resident #14 should have been coded on the comprehensive MDS assessment by the MDS Nurse and the missed coding was likely an oversite by the MDS Nurse. 1.b.Resident #14 was readmitted to the facility on [DATE] with diagnoses that included epilepsy, muscle weakness and right above the knee amputation. Review of a comprehensive MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #14 had no cognitive impairment and was coded at section P 0100. Physical Restraints. Section P 0100. A was coded that Resident #14 required bed rails daily. An observation of Resident #14's bed conducted on 09/25/23 at 12:50 PM revealed there were no bed rails on Resident #14's bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The MDS Nurse revealed she was not aware that Resident #14 did not have bed rails on her bed and likely coded the bed rails on both MDS assessments in error. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 2.Resident #8 was admitted to the facility on [DATE] with diagnoses that included anxiety and dementia. A review of an annual MDS assessment dated [DATE] revealed Resident #8 had short term and long-term memory deficits. Resident #8 was coded at section P 0100. Physical Restraints. Section P 0100 A was coded that Resident #8 required bed rails daily. An observation conducted on 9/25/23 at 9:56 AM of Resident #8's bed revealed one grab bar in place to the left side of her bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The MDS Nurse revealed she was not aware that Resident #8 did not have bed rails on her bed and likely coded the bed rails on both MDS assessments in error. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 3.Resident #5 was admitted to the facility on [DATE] with diagnoses that included anxiety. A review of a quarterly MDS assessment dated [DATE] revealed Resident #5 had no cognitive impairment and was coded at section P 0100. Physical Restraints. Section P 0100. A was coded that Resident #5 required bed rails daily. An observation of Resident #5 conducted on 9/25/23 at 10:29 AM revealed she had a quarter side rail in place on one side of her bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The MDS Nurse revealed she was not aware that Resident #14 did not have bed rails on her bed and likely coded the bed rails on both MDS assessments in error. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 38129 Based on staff and resident interviews, observation, and record review, the facility failed to accurately code the quarterly Minimum Data Set in the area of restraints (Resident #s 9, and 13) and failed to accurately code the comprehensive Minimum Data Set in the area of restraints (Resident #s ). Findings included: 4. Resident #9 was admitted to the facility on [DATE] with the diagnosis of stroke. A review of Resident #9's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident required assistance to transfer out of the bed and Section P A100 Restraint was coded 2 with bed rail used daily. The corresponding care plan dated 6/14/23 documented Resident #9 had a quarter side rail for bed mobility as an enabler for self-movement in her bed. On 9/26/23 at 2:30 pm the MDS Coordinator was interviewed. She stated that Resident #9's quarterly MDS dated [DATE] Section P A100 Restraint was coded for bed side rail as a restraint. She further stated that the Director of Nursing (DON) informed her to code the side rails as a restraint. On 9/26/23 at 3:50 pm the DON was interviewed. The DON stated there were no restraints in the facility. The quarter side rails on the resident beds were for mobility only, they were not a restraint. The MDS Coordinator coded all residents with quarter side rails for their last MDS assessment in Section P as restraints in error. The quarter side rails were evaluated for each resident individually and used as an enabler for bed mobility. The DON further stated the staff used an informed consent form for side rail use. The resident or resident representative would be educated on the safe use and potential hazards and sign for consent of side rail use. None of the quarter side rails restrained a resident that can get out of bed to not be able to get out of bed. The DON further stated she was aware of the difference between a restraint and an enabler. 5. Resident #13 was admitted to the facility on [DATE] with the diagnosis of degeneration of the nervous system. The 8/29/23 quarterly Minimum Data Set (MDS) for Resident #13 documented the resident required assistance to transfer out of the bed and Section P A100 Restraint was coded 2 with bed rail used daily. The corresponding care plan dated 8/29/23 documented Resident #13 had a quarter side rail for bed mobility as an enabler for self-movement in her bed. On 9/26/23 at 2:30 pm the MDS Coordinator was interviewed. She stated that Resident #13's quarterly MDS dated [DATE] Section P A100 Restraint was coded for bed side rail as a restraint. She further stated that the Director of Nursing (DON) informed her to code the side rails as a restraint. Interview of the DON 9/26/23 at 3:50 pm. The DON stated that there were no restraints in the facility. The quarter side rails were for mobility only, they were not a restraint. The resident would be evaluated for side rail use and then the resident or resident representative were educated and signed an informed consent form for use of bed rails. The care plan was for quarter side rails used as an enabler for mobility. None of the rails restrained a resident that can get out of bed to not be able to get out of bed. The DON stated and explained she was aware of the difference between a restraint and an enabler. The MDS was incorrectly coded as side rails were used as a restraint. There was a miscommunication with the MDS Coordinator. The DON further stated that the MDS coded and care plan do not match, one as a restrain and one as an enabler. 37281 6. Resident #1 was readmitted to the facility on [DATE] with diagnoses to include diabetes and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 was cognitively intact, and she required extensive assistance for bed mobility and to transfer out of the bed. The MDS documented that bed rails were used daily as a restraint. Resident #1 was observed on 9/25/2023 at 11:07 AM. Resident #1 was in bed with both upper side rails in the up position. Resident #1 reported she used the side rails to assist her to move back and forth in the bed and it gave her something to hold on to when she transferred out of the bed. Resident #1 reported she required someone to stand by and supervise when she transferred in or out of the bed. The Director of Rehabilitation was interviewed on 9/27/2023 at 11:00 AM. The Director of Rehabilitation reported that Resident #1 was able turn herself in bed and was able to transfer out of bed with supervision. The Director of Rehabilitation explained that Resident #1 was discharged from therapy last month and she improved her activity level. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 7. Resident #6 was admitted to the facility on [DATE] with diagnoses to include stroke and traumatic brain injury. The significant change MDS dated [DATE] assessed Resident #6 to be moderately cognitively impaired. The MDS documented Resident #6 required extensive assistance for bed mobility and she had transferred once or twice in the past 7 days. The MDS documented that bed rails were used daily as a restraint. Resident #6 was observed on 9/25/2023 at 3:04 PM in bed. Resident #6 was grasping the side rail and turned her body towards the door. Resident #6 was not able to answer interview questions, but she did nod yes when asked if she used the side rails to move in bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded.

Based on record reviews, observations, resident, and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents investigated for abuse from resident-to-resident sexual abuse (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses to include intellectual disability and hypertension. A care plan dated 2/21/2023 addressed Resident #19's difficulty with communication related to his intellectual disability and included interventions to allow Resident #19 time to answer questions, and anticipate his needs, as he was not always able to express what he needed or wanted. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #19 to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The MDS documented Resident #19 had no behaviors. Resident #1 was admitted to the facility on [DATE] with the most recent readmitted [DATE]. Diagnoses for Resident #1 included bipolar disease, diabetes, and hypertension. A quarterly MDS dated [DATE] documented Resident #1 was cognitively intact with a BIMS of 15 out of 15. The MDS documented verbal behaviors occurred 1-3 days during the look-back period. A nursing note dated 4/14/2023 at 11:35 AM documented that Resident #1 was observed with Resident #19. Resident #19 had his pants down and Resident #1 was observed with her hands in Resident #19's genital area. The immediate intervention separated the two residents and placed both residents on 1:1 supervision. The note documented Resident #1 was anxious, upset, and agitated, and was yelling at staff. The note documented the physician, and the family member/responsible party were notified of the incident and no new orders were received. A nursing note dated 4/14/2023 at 11:40 AM documented that Resident #1 was tearful, and she refused a skin check by the nurse. The note documented the family member for Resident #1 returned the call and he reported Resident #1 liked men and liked to be sexual, and she could get upset when she cannot. The note documented Resident #1 told the nurse, Why are you trying to take my boyfriend away? A nursing progress note dated 4/14/2023 at 11:43 AM documented Resident #19 had experienced a sexual assault, and a head-to-toe assessment was completed. A facility reported incident dated 4/14/2023 at 11:45 AM documented an incident where Resident #1 was observed fondling Resident #19 inappropriately. The report documented the police department had been notified of the incident on 4/14/2023 at 12:49 PM. A nursing progress note dated 4/14/2023 at 11:45 AM documented Resident #19 had been observed with his pants down and with Resident #1's hands in his genital area. Immediate interventions included removing Resident #19 from the area and he was placed on 1:1 supervision. The note documented that Resident #19 was pleasant and cooperative and his physical assessment was within normal limits. The note documented that Resident #19's family/responsible party was notified of the occurrence and that Resident #19 was placed on 1:1 supervision. The note documented the physician was notified of the occurrence, and no new orders were received. A nursing note dated 4/14/2023 at 1:58 PM further documented Resident #1's refusal to permit a skin assessment, but she finally consented to allow an assessment of her neck, breasts, chest, and abdomen. No issues were identified. A nursing note dated 4/14/2023 at 3:57 PM documented Resident #1 continued to experience anxiety and was tearful and upset about not being able to talk to Resident #19. The note documented Resident #1 did not have an effective response to the scheduled antianxiety medication administered at 1:00 PM. A care plan dated 4/14/2023 addressed Resident #1 having inappropriate sexual behavior, with interventions included to discuss her feelings and inappropriate sexual behaviors with more appropriate options, observe for changes in mental status and reinforce unacceptability of inappropriate behaviors with other residents. A nursing note dated 4/15/2023 documented Resident #19 had no signs or symptoms of distress noted. A nursing note dated 4/16/2023 documented that Resident #19 had no signs or symptoms of distress. A psychiatry initial consultation dated 4/18/2023 documented Resident #19 was evaluated with another staff member present for inappropriate sexual behaviors. The note documented Resident #19 was alert to name, and pleasant. Resident #19 was able to answer yes/no questions. The note documented Resident #19 had no behaviors since the incident and there was no need to adjust or change medications. The facility 5-day investigative report dated 4/19/2023 documented on 4/14/2023 Resident #19 was found with his pants lowered and Resident #1 was observed removing her hands from his genital area. The report documented the police were notified of the incident, and Resident #19's responsible party was notified of the incident, and she did not want to press charges against Resident #1, but she did not want Resident #19 and Resident #1 to be around each other. Resident #19's responsible party was supportive of Resident #19 being moved to a facility that provided care for intellectually disabled adults. The report documented that an interview was conducted with Resident #19, and he reported he pulled down his pants because Resident #1 asked him. The report documented 100% staff education was provided on the abuse policy and 1:1 supervision was provided to both residents and would continue until either resident was placed (in another facility). A Quality Assessment Performance Improvement plan was developed and implemented. An interdisciplinary team meeting (IDT) note dated 4/21/2023 documented the team met to discuss the incident between Resident #19 and Resident #1. The note documented Resident #19 was on 1:1 supervision during the time Resident #1 was in the building and the plans included seeking placement for Resident #19 in an adult care home for intellectually disabled adults. A psychiatry progress note dated 4/18/2023 documented an evaluation of Resident #1 and when she was interviewed, she stated, I understand why they separated us, but I don't agree. The progress note documented Resident #1 was stable on her current medications and no changes would be made to her medications. A psychiatry progress note dated 5/16/2023 documented that no behaviors were reported for Resident #19, and he no longer required 1:1 care. Resident #19 was observed on 9/25/2023 at 3:17 PM. Resident #19 was in the dining room attending an activity. Resident #1 was in the dining room at the same time. Multiple staff members were noted supervising the activity and the residents. An observation of Resident #19 was conducted on 9/26/2023 in the activity room. Resident #19 was sitting at a table coloring pictures. Resident #1 was across the room. The activity director and the assistant activity director were supervising the residents. The Activity Director was interviewed at the time of the observation, and she reported the two residents were never to be left alone and were always supervised. The Activity Director reported she always had another staff member assist with activities to provide the supervision that was needed. Resident #19 was observed on 9/27/2023 in the dining room for an activity. Two staff members were noted to be attendance supervising the residents. Resident #19 was sitting close to the TV watching a movie and Resident #1 was noted to be seated far behind Resident #19. Resident #19 was observed on 9/28/2023 eating lunch alone at a table in the dining room. Resident #1 was not in the dining room. Several staff members were noted to be assisting residents with the lunch meal. A phone call was made to Resident #19's family member on 9/25/2023 at 3:15 PM and the family member did not return the phone call. During an attempt at an interview on 9/25/2023 at 3:17 PM, Resident #19 was unable to answer interview questions, but he did answer that yes he felt safe. An interview was conducted with the Business Office Manager (BOM) on 9/27/2023 at 10:18 AM. The BOM reported she had witnessed the incident between Resident #19 and Resident #1. The BOM described that she looked to her left into the front sitting room as she was leaving the conference room and saw Resident #19 standing in front of Resident #1. The BOM reported Resident #19's pants were pulled down to his upper thighs, and Resident #1 was removing her hands from his genital area. The BOM explained she did not see Resident #1 touching Resident #19, nor did she see his exposed genitals. The BOM described that Resident #1 was sitting in a wheelchair with her back to the door to the sitting room, and the BOM reported she saw that Resident #19's pants were pulled down to his upper thighs. The BOM reported she called Resident #19's name and he looked up at her and appeared startled and quickly pulled his pants up over his hips. The BOM reported Resident #1 turned around in her wheelchair and she had a big grin on her face. The BOM reported she had daily contact with both Resident #19 and Resident #1 and she had not witnessed any sexual behavior from either resident prior to this incident. The BOM explained that Resident #19 had no payor source, and the facility was awaiting Medicaid approval for them to make a referral to an adult care home for intellectually disabled adults. The BOM reported no facility would accept him without a payor source and the facility was providing room and board free of charge to Resident #19. Nursing assistant (NA) #1 was interviewed on 9/27/2023 at 1:20 PM. NA #1 reported she had not observed any sexual behaviors from Resident #1 or Resident #19, either before or after the incident. NA #1 reported she provided supervision to Resident #19. NA #1 reported Resident #19 was never left alone with Resident #1. An interview was conducted with NA #2 on 9/27/2023 at 1:40 PM. NA #2 reported Resident #19 and Resident #1 were always supervised and were not left alone. NA #2 explained she was on medical leave when the original incident occurred. NA #2 reported she had not observed Resident #1 exhibiting sexually inappropriate behaviors prior to the incident on 4/14/2023. The Assistant Director of Nursing (ADON) was interviewed on 9/27/2023 at 2:35 PM. The ADON reported she was working on 4/14/2023 when the incident occurred between Resident #19 and Resident #1, but she had not witnessed the incident. The ADON explained they put 1:1 supervision in place for both residents as well as 30-minute checks. The ADON reported that the staff make certain Resident #19 and Resident #1 are never alone together. An attempt was made to interview Nurse #1 who was on duty when the incident occurred, but she was not available. Resident #1 was interviewed on 9/25/2023 at 11:07 AM. Resident #1 stated, I can tell you they won't let me have a boyfriend! Resident #1 declined to answer further questions other than to state that the facility staff would not leave her and (Resident #19's name) alone, at all, ever. The Assistant Director of Nursing (ADON) was interviewed on 9/27/2023 at 2:35 PM. The ADON reported she was working on 4/14/2023 when the incident occurred between Resident #19 and Resident #1, but she had not witnessed the incident. The ADON explained they put 1:1 supervision in place for both residents as well as 30-minute checks. The ADON reported that the staff made certain Resident #19 and Resident #1 were never alone together. The ADON reported she had not observed Resident #1 exhibiting sexually inappropriate behaviors prior to the incident on 4/14/2023. Nurse #2 was interviewed on 9/28/2023 at 11:02 AM. Nurse #2 reported she had not observed Resident #1 exhibiting sexually inappropriate behaviors prior to the incident on 4/14/2023. The Director of Nursing (DON) was interviewed on 9/28/2023 at 1:38 PM. The DON reported that the BOM called out as she was witnessing the incident between Resident #19 and Resident #1. The DON explained that the residents were immediately separated, and both had assessments, the police department was notified, as well as the Department of Social Services. The DON reported the facility put both residents under 1:1 supervision to prevent any further incidents. The DON reported the psychiatrist was consulted to evaluate Resident #19 and to see Resident #1. The facility Quality Assessment and Performance Improvement Action Plan dated 4/14/2023 was reviewed. Included in the plan was immediate actions taken by the facility of separating the residents, performing head-to-toe assessments, notification of the family/responsible parties for both residents, putting both residents on 1:1 supervision, interviewing alert and oriented residents, performing 100% skin checks on all residents, auditing all care plans for residents with like care concerns or behaviors and making adjustments as needed, and interviewing family members/responsible parties for the residents with impaired cognition. The facility put into place audits to interview 10 cognitively intact residents per week for 4 weeks, then monthly for 2 months to identify any unreported incidents of abuse. Family interviews would be conducted on 7 cognitively impaired residents for 4 weeks and monthly for 2 months to identify any unreported incidents of abuse. Education was provided to all staff on 4/14/2023 and family members. The Quality Assessment and Performance Improvement Plan was reviewed, and each intervention had corresponding documentation to support the actions. Monitoring and audits were completed on 10 cognitively intact residents per week for 4 weeks, and then monthly for 2 months. Family interviews for 7 cognitively impaired residents were conducted for 4 weeks and then monthly for 2 months. Staff were interviewed and they acknowledged they had received education on 4/14/2023 regarding the residents right to be free from abuse. NA #2 reported she was on medical leave and the facility called her to provide her the education over the phone. The facility's date of compliance of 7/1/2023 was validated.

Based on record reviews, observations, resident and staff interviews, the facility failed to protect resident's bank debit cards, checks and credit cards from being accessed and used without resident permission for 3 of 3 residents reviewed for misappropriation of personal bank accounts (Resident #2,Resident #18, and Resident #14). The findings included: Resident # 2 was admitted to the facility on [DATE] with diagnoses that included chronic pain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 2 had no cognitive impairment. Resident #18 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease. A quarterly MDS assessment dated [DATE] revealed Resident #18 had no cognitive impairment. Resident #14 was readmitted to the facility on [DATE] with diagnoses that included polyneuropathy and epilepsy. A review of a quarterly MDS assessment for Resident #14 revealed she had no cognitive impairment. A facility reported incident dated 05/02/23 at 1:00 PM documented the Director of Nurses (DON) was notified by a Police Detective from another city that during a police investigation in the early hours of 05/02/23 banking items were discovered in the possession of an agency nurse that previously worked at the facility with names of three persons (Resident #2, Resident #18, and Resident #14). The DON confirmed the three residents did reside at the facility and was provided a verbal record of the financial items found. The DON immediately reported the information to the Administrator and a report was filed with the local police department at 2:00 PM on 05/02/23. Resident #2, Resident #18, and Resident #14 were interviewed on 05/02/23 by the Administrator and Director of Nursing (DON) about missing bank or credit cards or other financial activity on their accounts that might have been fraudulently made. An interview was conducted with Resident #2 on 09/25/23 at 10:55 AM. Resident #2 revealed the Administrator and DON informed her the facility received a police report that revealed random numbered bank checks with Resident #2's name on them had been discovered in the possession of an unknown person that may have worked at the facility in the past. Resident #2 went through her checkbook with the DON and discovered that some random unused bank checks were missing. The Administrator notified the bank for Resident #2 to report possible fraudulent activity on her account and to ensure the bank would continue to monitor the account. Resident #2 revealed that later that day a police officer came to talk to her and asked her if she recognized a lady in a photograph. Resident #2 revealed she told him she was not sure but thought the lady looked like a nurse that had taken care of her before and the police officer reported he believed they might have a video showing the lady trying to use one of the checks, but she was not able to do so. Resident #2 revealed no money was missing from her account and she was glad the facility informed her and did a good job investigating what happened because the nurse never came back again. Resident #2 revealed she was provided a lock box for her closet for her valuable items, and she kept the key on her person at all times. Resident #2 revealed she was safe at the facility and liked living there. Resident #2 revealed she had never given anyone permission to access her private bank account. Resident #18 was interviewed on 09/25/23 at 11:23 AM. Resident #18 revealed he managed his own banking and checked his account balance almost daily. Resident #18 revealed a few days before 05/02/23, he noticed some unknown activity in his bank account but was not missing his debit card. He reported the activity to his bank , cancelled his debit card and ordered a new debit card. Resident #18 revealed there were maybe 3 or 4 charges that he did not make that totaled about $97.00 from a local grocery store and department store. Resident #18 revealed he never reported it to the facility because it was not their concern and he handled it. On 05/02/23 Resident #18 explained the DON and Administrator informed him that a police report was received by the facility, and it included store receipts with his name and bank account information on them. Resident #18 explained he had already identified the activity and informed the facility the steps he had already taken. The Administrator reimbursed him $100.00, and he was given a lockbox and key to keep his valuable items in. Resident #18 revealed that also on 05/02/23 a police officer came to his room to discuss the bank account activity information with him and was shown a photo of a young lady that he told the officer he did not recognize. Resident #18 explained that he felt safe and was appreciative of the facility and police involvement and investigations Resident #18 revealed he was private with his bank information and never shared it with anyone or gave permission to others to use his bank information. Resident #14 was interviewed on 09/25/23 at 11:47 AM. Resident # 14 revealed her banking was done by her mother who was in possession of her checks and debit card. Resident #14 revealed she had a cash app card that had no money on it that she kept it in her wallet in her purse which she always carried and at night she covered her purse with the bed linens near her feet. Resident #14 revealed that she did not know the cash app card was missing until the DON came and asked her if she was missing a debit card or checks because a bank card was reportedly found in the possession of an agency nurse that had previously worked at the facility. Resident #14 revealed she opened her purse and wallet and did not find the cash app card. The DON assisted Resident #14 to search her room and they were not able to locate the cash app card. The Administrator and DON spoke to the mother of Resident #14 and confirmed the mother was in possession of the bank debit card of Resident #14 and the cash card had no funds available on it and she would contact the bank for Resident #14 and inform them of the ongoing investigation and have them monitor the bank account for fraudulent activity. Resident #14 revealed on the same day she was given a key and a lockbox from the facility to store her purse and other valuable items. Resident #14 revealed she felt safe at the facility, the facility had been informative and handled the situation very well which was calming to her and her mother both. Resident #14 denied giving anyone permission to access her bank account or the cash app card. The facility 5-day investigation report dated 05/05/23 documented on 05/02/23 through 5/4/23. On 05/02/23 Resident #2, Resident #18, and Resident #14 were interviewed by the Administrator and Director of Nursing (DON) about missing bank, credit cards or other financial information that might have indicated fraudulent activity. The DON and Administrator interviewed 100% of cognitively intact residents and 100% of cognitively impaired residents family/RPs from 05/02/23 through 05/05/23 and educated them to monitor bank accounts, debit cards and credit card accounts for fraudulent activity, the facility offered to assist if needed making the calls or inquiries to these entities. Lockboxes with keys were offered to all residents and family/RPs by the facility and education was provided to report any suspicious or unusual behaviors observed to the Administrator, DON, or Social Worker immediately. The facility received no negative findings or concerns. 100 % of staff was re-educated on the abuse policy, types of abuse and reporting of abuse and any suspicious behaviors observed. A Quality Assessment Performance Improvement plan was implemented. On 09/27/23 at 12:52 PM an interview with the DON was conducted and she presented documents for review that included the facility timecard of the nurse involved with a recorded last date and time the agency nurse worked at the facility a from 7:00 PM on 4/22/23 until 7:00 AM on 4/23/23. Other documents reviewed included a police report from the Police Department dated 05/02/23, a copy of the North Carolina Board of Nursing nurse license verification and a copy of abuse training received from the agency of hire signed and dated by the nurse on 9/14/22. The DON revealed that when the Detective spoke to her on 05/02/23 she immediately informed the Administrator, contacted the local police department, the physician, Adult Protective Services , the North Carolina Board of Nursing (NCBON) and the agency that employed the nurse. The DON reported she and the Administrator interviewed Resident #2, Resident #18, and Resident #14 and all 3 residents denied giving their bank debit card, cash cards or checks to anyone for use. The DON and Administrator interviewed 100% of alert and oriented residents and 100% of families/RPs of cognitively impaired residents No negative outcomes were reported. All residents, families/ RPs were offered a secured lockbox to store valuable items and banking documents in. A phone interview conducted with the Police Department Detective on 09/27/23 at 1:36 PM revealed a person identified as a traveling nurse was found to be in possession of bank checks, bank debit cards and credit information that belonged to other people. The person of interest reported she had been given the items from residents with permission to use the items to make purchases requested by the residents. The Detective contacted the DON and she confirmed Resident #2, Resident #18, and Resident #14 resided at the facility and she would notify the Administrator, residents, and local police department immediately and begin a full facility investigation. The Detective confirmed he received calls from the agency that employed the nurse and a North Carolina Board of Nursing investigator for detailed information of the police investigation. The Clinical Compliance Nurse Consultant of the agency that employed the nurse was interviewed via phone on 9/27/23 at 2:24 PM and revealed a report was received from the facility on 05/02/23 about the alleged incident involving a nurse employed by the agency. The DON requested a copy of the nurse license verification and most recent abuse training dated and signed by the nurse in question on 09/14/22. The Clinical Compliance Nurse Consultant revealed the DON informed the agency that the nurse was never to return to the facility, or any facility owned by the same corporation. The DON provided the contact information of the Detective and local police and after speaking to the Detective and conducting an investigation the agency mailed a termination of employment to the agency nurse effective 05/12/23. The Clinical Compliance Nurse Consultant of the agency that employed the nurse was interviewed on 9/27/23 at 2:24 PM and revealed a report was received from the facility on 05/02/23 about the alleged incident involving a nurse employed by the agency. The DON requested a copy of the nurse license verification and most recent abuse training dated and signed by the nurse in question on 09/14/22. The Clinical Compliance Nurse Consultant revealed the DON informed the agency that the nurse was never to return to the facility, or any facility owned by the same corporation. The DON provided the contact information of the Detective and local police to the agency and after speaking to the detective and conducting an independent investigation the agency mailed a termination of employment to the nurse at the agency effective 05/12/23. The Administrator was interviewed on 09/28/23 at 1:12 PM and revealed that the facility took immediate action when the report from the Detective was received on 05/02/23.The proper reports were made to all entities required, an investigation began, interviews and audits of 100% of all cognitively intact residents and 100% of cognitively impaired residents family/RPs was initiated on 05/02/23 through 05/05/23. The QAPI (Quality Assurance and Performance Improvement) committee met, and a Performance Improvement Plan (PIP) was put into place immediately. The facility Quality Assessment and Performance Improvement Plan initiated 05/02/23 by the QAPI committee team was reviewed. The plan included immediate actions that began 05/02/23 and included actions taken by the facility of interviewing 100% of alert and oriented residents and notification of 100% of family/ RPs of cognitively impaired residents. Residents and RPs were offered and provided with secured lockboxes to store valuable items and bank information, the facility offered assistance to notify resident's banks and creditors to ensure accounts were being monitored for fraudulent activity. The facility put into place audits to interview 3 cognitively intact residents weekly for 12 week and 2 cognitively impaired resident's family/RPs weekly for 12 weeks to inquire if any fraudulent activity of their personal bank or credit card accounts was identified. Education was provided to all staff, residents, family/RPs from 05/02/23 through 05/05/23 related to abuse, neglect, exploitation and immediately reporting of abuse, or suspicious behaviors. New staff would receive training during orientation. The Quality Assessment and Performance Improvement Plan was reviewed, each intervention had corresponding documentation to support the actions. Monitoring and audit tools were completed weekly for 3 cognitively intact residents and 2 cognitively impaired residents for 12 weeks. Residents were interviewed and revealed they felt safe at the facility and had no reports of identified fraudulent bank or credit card concerns. The DON and Administrator conducted education of all staff from 05/02/23 through 05/04/23 related to the abuse policy, reporting of abuse and suspicious behaviors. Staff were interviewed and revealed they received education about abuse, types of abuse, reporting abuse and suspicious behaviors immediately to the DON or Administrator. Staff reported they were not able to work until the education was received. Residents interviewed felt safe at the facility and had no fraudulent activity identified by their banks or credit card companies. The facility's date of compliance of 07/20/23 was validated.

Based on record reviews, observations, and staff interviews, the facility failed to assess injuries after an unwitnessed fall for 1 of 3 residents reviewed for accidents (Resident #6). The findings included: Resident #6 was admitted to the facility on [DATE] with traumatic brain injury and stroke. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #6 to be moderately cognitively impaired and she required total assistance of 2 people for bed mobility and transfers. The MDS did not document any falls in the past 2 months. A fall assessment dated [DATE] completed by Nurse #4 documented that Resident #6 was at high risk of falling with a score of 16. The assessment noted recent falls, need for toileting assistance, the inability to balance without assistance, and medications as having causative factors to increase fall potential of Resident #6. A nursing note written by Nurse #4 dated 7/24/2023 at 10:14 AM was marked through as being incorrect documentation. The note read, Writer was preparing medications in the hallway during morning med pass and witnessed resident scooting self onto floor mat beside bed. Writer went to stop resident but upon entering room, resident was already on the floor mat. Resident did not hit her head. Bed was in lowest position. No injuries noted. Vitals 122/272, 76, 18, 97.6, 96% on room air. Resident stated she was trying to walk. Resident Transferred into geri-chair via mechanical lift and 2 Nursing assistants. No complaints of pain noted. Resident Responsible Party (RP) called and made aware; physician made aware. A nursing note written by Nurse #4 dated 7/24/2023 at 6:23 PM documented that resident denied pain and her skin was normal, warm, and dry. A nursing note written by Nurse #4 dated 7/25/2023 at 6:35 PM documented that Resident #6 denied pain and her skin was warm and dry and normal. A skin assessment completed by Nurse #4 dated 7/25/2023 documented Resident #6 had no skin issues. A head-to-toe assessment dated [DATE] completed by Nurse #4 documented Resident #6 had a witnessed fall and her skin had normal tone and was warm and dry. A nursing note written by the Assistant Director of Nursing (ADON), dated 7/26/2023 at 9:13 PM documented that Resident #6 had a large bruise on her right shoulder that was red, purple, and yellow in color. The note documented an assessment was completed and the physician was notified, as well as the resident Responsible Party. The physician ordered x-ray for the right shoulder. A head-to-toe assessment of Resident #6 completed by the ADON dated 7/26/2023 at 9:13 PM documented the large bruise on the right shoulder that was red, purple, and yellow in color. X-ray results dated 7/27/2023 documented that there was no acute fracture or dislocation of the right shoulder. A nursing note dated 8/3/2023 at 5:10 PM documented that swelling to her right knee was noted with some yellow bruising. The condition of the knee was reported to the physician and an order was received to obtain an x-ray of the knee. The family was notified of the change in Resident #6 and the orders. A skin assessment dated [DATE] at 7:55 PM documented Resident #6 had yellow bruising to her right shoulder and right knee. A radiology report dated 8/5/2023 was reviewed and the x-ray determined there was a modest depression fracture of the right middle tibial plateau (the top of the tibia [ lower leg bone/shinbone] where it connected with the femur [long bone of the thigh]). The fracture was of undetermined age. A physician progress note dated 8/7/2023 was reviewed. The note documented that Resident #6 had an unwitnessed fall from bed on 7/24/2023 and was without pain after the fall, and on 8/3/2023 nursing noticed the right knee was swollen and bruised. The note documented that an x-ray obtained on 8/5/2023 determined there was a fracture of the right tibia plateau and Resident #6 did not report pain and did not have non-verbal expressions of pain. The note documented Resident #6's family did not want treatment for the fracture and declined to send her to the hospital or for an orthopedic referral. A Quality Assessment and Performance Improvement (QAPI) Action Plan dated 8/7/2023 documented that on 8/3/2023 Resident #6 was observed with a yellowing bruise and swelling to the right knee. The nursing staff notified the physician, and an x-ray of the right knee was ordered. The x-ray was ordered on 8/3/2023 but was not obtained until 8/5/2023 due to the radiology company not having enough staff to perform the x-ray on the date ordered, and the facility staff were not notified the x-ray would not be obtained until a later date. The facility was notified of the x-ray results on 8/5/2023, but staff did not notify the DON of the x-ray results. The DON became aware of x-ray results on 8/6/2023. The DON completed an injury of unknown origin report and notified the administrator, the regional director of clinical services, and the regional vice president of operations. An attempt was made to interview Nurse #4 on 9/27/2023 at 11:56 AM and the recording stated the number was unavailable. A text message was sent. Nurse #4 did not respond to the phone call or text. An interview was conducted with Nursing Assistant (NA) #2 on 9/27/2023 at 1:40 PM. NA #2 reported she was in the room with Resident #6 on 7/24/2023 when she fell out of bed, but NA #2's back was turned to Resident #6, and she did not see her fall. NA #2 reported Resident #6 was in bed ready to get up for the day. NA #2 was getting clothes out of the closet and when she turned around, Resident #6 was sitting on the floor beside her bed. NA #2 explained that Resident #6 had fall mats on the floor to protect her if she did fall, and the bed was low to the floor. NA #2 reported Resident #6 had not cried out or made any noise and she denied pain. NA #2 said she yelled for the other NA to go to get the nurse to come to the room to assess Resident #6. NA #2 reported Resident #6 did not appear to have any injuries after the fall, but a few days later she had a bruise on her right shoulder. During an interview on 9/27/2023 at 2:35 PM with the ADON she reported she was working on 7/24/2023 when Resident #6 fell , but she was not in the building when it happened, rather she arrived to work about 30 minutes later. The ADON explained that Nurse #4 documented that Resident #6's fall was witnessed and that she had assessed Resident #6. The ADON explained on 7/26/2023 the bruise was discovered on Resident #6's right shoulder and on 8/3/2023, a bruise on her right knee. The ADON reported that the bruise on the right knee appeared to be the same age as the right shoulder knee, and the facility felt Resident #6 obtained both bruises at the same time. The ADON reported on 8/3/2023 Resident #6's family member reported the bruise on her right knee. The ADON reported she had completed a skin assessment on Resident #6 on 7/26/2023 and she had noted the bruise on her right shoulder but had not seen the bruise on her knee. The DON was interviewed on 9/28/2023 at 1:41 PM. The DON explained that Nurse #4 had reported she had witnessed Resident #6's fall on 7/24/2023 and Nurse #4 had reported she had completed the post-fall assessment. After the bruise on her right knee was discovered on Resident #6 on 8/3/2023 and the x-ray results on 8/5/2023 determined Resident #6 had a fracture of her right tibia, the DON initiated an investigation. The DON explained she was not notified of the fracture until 8/7/2023 and she initiated her investigation on that date. The DON reported she interviewed NA #2 and discovered that NA #2 was in the room with Resident #6, but she had not seen her fall. Nurse #4 reported she had been right outside of the door, but NA #2 reported she had to send another NA to find the nurse. The DON reported the administrative staff watched video playback from the date of the initial fall on 7/24/2023 and discovered that Nurse #4 was nowhere near Resident #6's room and after questioning Nurse #4, the facility had determined she had not completed the head-to-toe assessment after the fall and had falsified her documentation. The DON reported that Nurse #4 was terminated because she had not documented the fall, had not reported the fall, and had failed to complete a full assessment of Resident #6 after the fall. The QAPI Action plan was reviewed, and the root cause was identified as staff did not follow procedures for the notification of an injury of unknown origin. The Action Plan detailed that on 8/3/2023 the physician was notified of the bruise and orders were received for an x-ray. A head-to-toe assessment was completed on Resident #6 on 8/3/2023. The x-ray was obtained on 8/5/2023 and results were called to the facility. Staff did not notify the DON until 8/7/2023, when she discovered it took 2 days for the x-ray to be taken due to issues with staffing at the radiology agency. On 8/7/2023 a full head to toe assessment was completed on Resident #6, an interview was conducted with the family member of Resident #6's family member and the plan of care was discussed. Nurse #4 and NA #2 were interviewed by the DON on 8/7/2023 and statements were obtained. A pain assessment was conducted on Resident #6 on 8/7/2023. Residents who had the potential to be affected were identified and skin assessments were completed on 8/7/2023. Current staff were educated by the DON regarding notification of the DON with x-ray results that showed fractures and documentation of incident reports after falls and education was completed by 8/8/2023. The facility instructed the radiology agency to communicate staffing issues that would affect the timeliness of x-rays directly to the DON in the future. Monitoring was put in place to conduct skin assessments on 4 residents weekly for 4 weeks, then monthly for 2 months to monitor for skin assessment documentation completed appropriately. Results of the monitoring to be taken to the QAPI committee for review and revision as needed. Additionally, the DON would review all skin documentation for 5 days per week for 12 weeks to ensure any concerns or change in condition. The facility date of completion will be 11/6/2023. The Action Plan was validated by reviewing the audits completed since 8/7/2023 and no issues were identified. Interviews were conducted with staff regarding education they received related to reporting, documentation, and procedures related to change in condition, injury of unknown origin, and falls. The ADON was interviewed on 9/27/2023 at 2:35 PM and she reported she is participating in monitoring by completing skin checks on residents and conducting audits on documentation. Nurse #6 was interviewed on 9/28/2023 at 11:02 AM and she reported she received education related to documentation of falls, reporting injuries of unknown origin and skin assessments. The facility's correction date of 8/31/2023 was validated.

Based on record reviews and staff interviews, the facility failed to protect residents and staff from COVID-19 exposure and infection after a medication aide (MA#1) reported to work with signs and symptoms of COVID-19 and worked her shift before testing positive for COVID-19. MA #1 failed to notify the facility administration of the positive test result. 11 out of 21 residents were reviewed for COVID (Resident #4, Resident #9, Resident #18, Resident #13, Resident #3, Resident #2, Resident #15, Resident #17, Resident #123, Resident #124, and Resident #19) and 6 out of 35 staff (MA #2, Nursing Assistant #3, Nursing Assistant #4, Assistant Director of Nursing, MA #3, and Maintenance Director) tested positive for COVID-19. The findings included: A review of the facility immunization report revealed that 84% of the census of 21 had been vaccinated for COVID-19 (3 resident refusals for the vaccine). A review of the staff immunization report revealed the 32 out of 35 staff members had been vaccinated for COVID-19 (3 staff approved exemptions for the vaccine). The facility Performance Improvement Plan dated 3/4/2023 identified that on 3/3/2023 MA #1 entered the facility with signs and symptoms of COVID. The root cause analysis documented MA #1 did not notify administration of her symptoms and did not wear a mask during her shift. The root cause analysis documented MA #1 tested herself for COVID approximately 4:30 AM on 3/4/2023 and she tested positive, but she did not notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the Administrator of the positive test. Resident #4 tested positive for COVID on 3/8/2023. Review of her medical record indicated Resident #4 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #9 tested positive for COVID on 3/8/2023. Review of her medical record indicated Resident #9 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #18 tested positive for COVID on 3/8/2023. Review of his medical record indicated Resident #18 was fully vaccinated and had a mild illness and did not require hospitalization . MA #2 tested positive to COVID on 3/8/2023. MA #2 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . Resident #13 tested positive for COVID on 3/11/2023. Review of her medical record indicated Resident #13 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #3 tested positive for COVID on 3/11/2023. Review of her medical record indicated Resident #3 was fully vaccinated and had a mild illness and did not require hospitalization . Nursing Assistant (NA) #3 tested positive for COVID on 3/15/2023. NA #2 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . Nursing Assistant (NA) #4 tested positive for COVID on 3/15/2023. NA #2 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . Resident #2 tested positive for COVID on 3/16/2023. Review of her medical record indicated Resident #2 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #15 tested positive for COVID on 3/15/2023. Review of his medical record indicated Resident #15 declined the COVID vaccine and had a mild illness and did not require hospitalization . Resident #17 tested positive for COVID on 3/15/2023. Review of his medical record indicated Resident #17 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #123 tested positive for COVID on 3/17/2023. Review of his medical record indicated Resident #123 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #124 tested positive for COVID on 3/17/2023. Review of his medical record indicated Resident #124 was fully vaccinated and had a mild illness and did not require hospitalization . Resident #19 tested positive for COVID on 3/17/2023. Review of his medical record indicated Resident #19 was fully vaccinated and had a mild illness and did not require hospitalization . The Assistant Director of Nursing (ADON) tested positive for COVID on 3/19/2023. MA #3 tested positive for COVID on 3/20/2023. MA #3 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . The Maintenance Director tested positive for COVID on 3/22/2023. The Maintenance Director was interviewed on 9/28/2023 at 8:34 AM and he reported he was fully vaccinated against COVID, but he tested positive in March of 2023. The Maintenance Director explained he had very mild symptoms and recovered without incident. The Maintenance Director reported he had been provided with education related to testing after COVID exposure and the signs and symptoms of COVID to report to the administration staff. An interview was conducted by phone with MA #1 on 9/28/2023 at 10:15 AM. MA #1 reported she came to work on 3/3/2023 with a cough and she reported she felt like she couldn't stop coughing. MA #1 explained she had COVID in the past, but it wasn't that bad. MA #1 reported she wore a blue surgical mask during her shift, and she was fully vaccinated for COVID. MA #1 explained she felt like she had a cold, but about 4:00 AM it occurred to her that she should test for COVID. MA #1 expressed that when the test resulted positive for COVID she didn't believe that the test was right. MA #1 reported she went out to complete her medication administration to the residents and after she was finished, she retested for COVID, and the results were again positive. MA #1 explained she stayed in the medication room until the change of shift at 7:00 AM and her relief MA #2 showed up. MA #1 stated she and MA #2 counted narcotics and then she called MA #2 into the medication room and showed her the positive COVID tests. MA #1 reported she went home and was sick for almost 10 days. MA #1 stated she had not called the DON, ADON, or Administrator to report the positive COVID test and her symptoms because she thought MA #2 would report to the DON for her. During an interview on 9/28/2023 at 11:02 AM, the ADON reported she had COVID in March 2023, but she was not hospitalized . Resident #18 was interviewed on 9/29/2023 at 11:54 AM. Resident #18 reported he had COVID in 2023 but did not remember the exact dates. Resident #18 reported he had a mild illness, It was nothing. An interview was conducted with the DON on 9/28/2023 at 1:38 PM. The DON reported that MA #1 had not called her to report her symptoms or the positive COVID test and later in the day on 3/4/2023 the DON had been notified by MA #2 that MA #1 had gone home at 7:00 AM after testing positive for COVID. The DON explained she called MA #1 and took a statement regarding the positive COVID test, her symptoms, and the residents and staff she was in contact with on 3/3/-3/4/2023. The DON explained they initiated contact tracing and tested anyone who had worked with MA #1 and residents she provided care to during her shift. The DON reported all residents tested negative on 3/4/2023, but on 3/10/2023 MA #2 started having symptoms of COVID and tested positive. The DON reported on 3/4/2023 they initiated a plan of correction to prevent any further incidents or risk resident exposure to COVID by a staff member with signs and symptoms of the infection. The facility Performance Improvement Plan dated 3/4/2023 was reviewed. The facility identified MA #1 reported for work on 3/3/2023 with signs and symptoms of COVID and did not report her symptoms to the administrative staff. MA #1 worked until 4:00 AM and then took a COVID test, which was positive. MA #1 continued to work her shift and passed medications before taking another COVID test, which was positive. MA #1 did not wear a mask during her shift, and she did not notify the DON, ADON, or the Administrator of the positive COVID test. The facility contacted MA #1 on 3/4/2023 to obtain a list of her close contacts and testing was performed on those residents and staff on day 1, day 3, and day 5 after exposure. The facility identified that all residents had the potential to be affected by the deficient practice. The facility conducted education to 100% of the staff on the signs and symptoms of COVID, the COVID policy, and the testing requirements after exposure. The facility put a monitoring plan in place to maintain ongoing compliance that included daily audits on mask compliance, and monitoring all callouts for signs and symptoms of COVID to ensure testing for COVID was completed per the guidelines. The facility continued this monitoring 5 days per week for 12 weeks. The results of the audits were reported to the Quality Assurance Performance Improvement committee for review and recommendations during the monitoring period and the results were reviewed for 3 months. The facility Performance Improvement Plan was validated by reviewing the education provided to the staff and interviews with staff to validate the education. NA #1 was interviewed on 9/27/2023 at 1:20 PM. NA #1 reported she had received education related to COVID, mask use, testing, and signs and symptoms to report. An interview was conducted with NA #2 on 9/27/2023 at 1:40 PM. NA #2 reported she had received education related to COVID, mask use, testing, and signs and symptoms to report. Nurse #3 was interviewed on 9/27/2023 at 2:14 PM and she reported she was newly hired and in orientation. Nurse #3 reported she had received COVID education in orientation, including signs and symptoms to report and testing requirements. The Maintenance Director was interviewed on 9/28/2023 at 8:34 AM. The Maintenance Director reported he had been provided with education related to testing after COVID exposure and the signs and symptoms of COVID to report to the administration staff. The ADON was interviewed on 9/28/2023 at 11:02 AM, and she reported she provided education and monitoring of mask and personal protective equipment by the staff on all nursing units. The facility correction date of 6/14/2023 was validated.

Based on observations, record review and staff interviews, the facility failed to store medications that required refrigeration in accordance with the manufacturer's instructions and to monitor refrigerator temperatures in 2 of 2 medication refrigerators (east hall and west hall). The facility also failed to date a multiple use medication vial when opened in 1 of 1 medication storage room (west hall). Findings included: The facility's temperature logs indicated the medication refrigerator temperature should be kept at ,d+[DATE] degrees (°) Fahrenheit (F). The facility's 'Administering Medication' policy dated [DATE] indicated a multi-dose medication should be dated and recorded on the container when opened. 1. On [DATE] at 9:15 AM the west hall medication refrigerator was checked with Nurse #1 in attendance. The medication room refrigerator temperature was checked and noted to be within normal range of ,d+[DATE] °F. Review of the May and [DATE] refrigerator temperature logs revealed no temperatures were documented for [DATE], 4, 5, 9, 10, 11, 12, 16, 17, 18, 19, 23, 24, 25, 26, 30, 31 and [DATE] and 2. The instructions at the bottom of the Refrigerator temperature log read: 'drug room ,d+[DATE]°F.' An interview was completed on [DATE] at 9:16 AM with Nurse #1 and she stated night shift was responsible for checking the temperatures in the medication refrigerator. She noted several dates in [DATE] and the two dates in [DATE] that temperatures were not recorded. Medications that were stored in the west hall refrigerator included in part: - [MEDICATION(S)] (TB) purified protein [MEDICATION(S)] unit (tu)/0.1ml, 5 milliliters (ml) vial which was opened, dispensed on [DATE] and expired on [DATE]. This was facility stock for [MEDICATION(S)] skin tests. Instructions indicated it was to be stored between ,d+[DATE]°, dated when opened and discarded after 30 days. An interview was done on [DATE] at 9:18 AM with Nurse #1 regarding the opened and undated medication vial. She stated she was not aware when the TB test vial was opened, and she would have to check on how long the medication was good for once it had been opened. She acknowledged there was no date on the bottle, or the box and it was to be stored between ,d+[DATE] °F. The following additional medications were in the refrigerator on the west hall and required a storage temperature of ,d+[DATE] °F: - [MEDICATION(S)] 20,000 ml-1 vial - Novalog prefilled pen-1 - [MEDICATION(S)] insulin 100 units (u)/ml-1 On [DATE] a phone interview was attempted with Nurse #3 that worked nights [DATE], [DATE], [DATE] and [DATE], and had not recorded temperatures. She was unable to be contacted after two attempts on [DATE] at 9:32 AM and 4:36 PM. An interview was conducted on [DATE] at 9:41 AM with the Nurse #4 that worked nights usually on the west hall. She noted she checked the medication refrigerator each night. The Director of Nursing (DON) was interviewed on [DATE] at 4:58 PM regarding medication storage. She stated she would expect the medications to be stored within the manufacturer's recommended temperature range, medications that were opened were to be dated and that staff followed the manufacture guidelines for dating the vial or label the multi-dose vial. The DON added the temperature logs were to be completed each night and staff were to ensure that the temperatures were within range and signed. She noted maintenance should be notified with any temperature concerns. An interview with Administrator #1 was done on [DATE] at 5:17 PM in reference to the medication refrigerator on west hall. She was informed of concerns with the refrigerator log not being completed on several dates for May and [DATE], and the opened and undated multidose vial of [MEDICATION(S)] (TB) test solution. She stated she would expect temperatures in the medication refrigerator to be checked daily, monitored that they were in range and the TB vaccine solution would be dated when opened and discarded per manufacturer's guidelines or the facility policy. 2. The Temperature logs for May and [DATE] were reviewed for the east hall and revealed no temperatures were documented on [DATE] or [DATE]. Temperatures were documented below the required range of ,d+[DATE] degrees Fahrenheit (°F) on all dates in [DATE] except [DATE], [DATE] and [DATE]. These dates and temperatures were as follows: - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 30°F - [DATE]: 30°F - [DATE]: no temperature documented - [DATE]: no temperature documented - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 34°F - [DATE]: 34°F - [DATE]: 31°F - [DATE]: 31°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 30°F East hall medication refrigerator temperature logs were reviewed for [DATE] temperatures and noted to be below the required range on [DATE] (32°F), [DATE] (32°F), and [DATE] (31°F). These 3 dates had been checked by Medication Aide #1. No comments were listed of actions taken for the temperatures that were out of range. The instructions at the bottom of the Refrigerator log read: 'the drug room refrigerator temperature should be ,d+[DATE]°F. On [DATE] at 4:15 PM a review of the east side medication refrigerator was conducted with Medication Aide #3 in attendance from 4:,d+[DATE]:30 PM, and Nurse #5 in attendance from 4:,d+[DATE]:40 PM. Medications that were stored in the east hall refrigerator that required a storage temperature of ,d+[DATE] °F per the medication packaging included in part: - [MEDICATION(S)] flextouch pen-1 - [MEDICATION(S)] injection flex pen -10 - [MEDICATION(S)] solution injection pen -2 - Insulin [MEDICATION(S)] pens -2 - [MEDICATION(S)] sol 0.005% eye drops - [MEDICATION(S)] pens 4.,d+[DATE].5 milliliter (ml) solution-4 - [MEDICATION(S)] injection 140 milligram (mg)/ml syringe -1 An interview was conducted with Nurse #5 on [DATE] at 4:15 PM regarding the medication refrigerator temperature logs. She stated the night shift checked the medication refrigerator temperatures and Nurse #5 verified several of the medications in the refrigerator required the storage temperature of ,d+[DATE]°F. Medication Aide (MA) #1 was interviewed via phone on [DATE] at 2:32 PM that worked nights and covered the east hall. The MA stated she checked the refrigerator in the morning when it had not been opened for a while, and thought the temperature range should be ,d+[DATE]°F. She was asked when she recorded the temperature of 31°F on [DATE] night shift what actions were taken. The MA stated she meant to tell maintenance before she left and forgot. She was asked if she had the option to have submitted a written request and she said yes. She revealed she had not completed a written request. She was also asked about the [DATE] date when she had signed the log, but no temperature was logged and MA #1 stated she must have overlooked it. Medication Aide #1 was asked about the dates in May that she documented temperatures below range ([DATE], 4, 9,10, 11, 12, 16, 17, 18, 23, 24, 25, 30, and 31). She stated she should have had maintenance check them and completed a request, but she had not done so. The Director of Nursing (DON) was interviewed on [DATE] at 3:20 PM. She stated she had just been made aware of the medication refrigerator temperature logs being out of range and too cold for the east hall. She noted the staff should have adjusted the temperature independently and rechecked the temperature. The DON also indicated staff should have notified maintenance immediately if it was not corrected. An interview with the Director of Maintenance was done on [DATE] at 3:15 PM regarding the medication refrigerator temperatures. He said there were no requests for the refrigerator temperatures being out of range in the medication rooms. He also noted that staff had a mailbox on each hall they could put the maintenance requests in, but they did not use it. The Maintenance Director stated he was at the facility before night shift left in the morning, made rounds each day and was not told of any issues. An interview was done on [DATE] at 4:42 PM with Administrator #2 regarding the east side medication refrigerator temperatures. He stated the temperatures should have been reported to maintenance when temperatures were logging below the appropriate level. He noted some reeducation should be done to ensure staff know what the appropriate actions should be.

Based on an observation of the lunch meal tray line, interviews with staff and record review, the facility failed to serve a 4-ounce portion of fried rice and a 3-ounce portion of mechanical soft pineapple chicken per the menu. This failure had the potential to affect 21 of 23 residents. The findings included: An observation of the lunch meal tray line in progress occurred on 06/09/22 at 12:08 PM. The lunch menu included pineapple chicken and fried rice. Dietary Staff (DS) #1 (AM cook) was observed to plate both fried rice and mechanical soft pineapple chicken with a 2-ounce serving utensil for each item. Review of the menu, approved and signed by the Registered Dietitian (RD), revealed residents should receive a 4-ounce portion of fried rice and residents with a physician order for a mechanical soft diet should receive a 3-ounce portion of mechanical soft pineapple chicken. DS #1 was interviewed on 06/09/22 at 12:10 PM and stated that she worked at the facility for the past [AGE] years and currently worked 4 days one week and 3 days the next week. DS #1 stated she referred to the menu when serving food and that she knew that the menu recorded to serve a 4-ounce portion of fried rice and a 3-ounce portion of mechanical soft pineapple chicken, but that she chose to use a 2-ounce serving utensil for each because the portions on the menu was too much for the residents. DS #1 stated that she watched how much food came back uneaten by the residents and when she noticed that residents were not eating all of their food, she started cutting back on the portions. The Certified Dietary Manager (CDM) was interviewed on 06/09/22 at 12:15 PM and stated that DS #1 had been a cook for [AGE] years, so the CDM stated she did not check behind her that often because DS #1 knew what to do and she knew to serve the portions as recorded on the menu. The CDM stated she was unaware that DS #1 served smaller portions because she was usually in the dining room during meals when DS #1 plated the foods. The CDM was observed to provide DS #1 with the correct size serving utensils and advised her that she was required to serve residents foods in the portions recorded on the menu. A telephone interview with the RD occurred on 06/09/22 at 1:20 PM and revealed she reviewed/approved each cycle menu and expected the menus to be followed. The RD stated that if a resident requested smaller/larger portions, the facility should obtain a physicians order for that and that plate waste was not an appropriate reason to serve smaller portions to residents. The RD stated that she expected dietary staff to let her know if they felt that residents did not eat the portions of foods provided for further discussion, otherwise, residents should receive the portions according to the menu. An interview with the Regional Nurse Consultant/Director of Nursing 06/09/22 at 4:00 PM revealed she expected residents to be served portions of food according to the menu that was reviewed/approved by the RD.

Based on a family interview, staff interviews, and record review, the facility failed to invite the responsible party of a cognitively impaired resident to participate in the planning of the residents' care for 11 months. This occurred for 1 of 3 sampled residents reviewed for care plan meetings (Resident #9). The findings included: Resident #9 was readmitted to the facility 11/11/19. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed the responsible party (RP) for Resident #9 was last invited and attended an interdisciplinary care plan conference on 06/02/21 to discuss the Resident's care. Medical record review revealed Resident #9's cognition was assessed as severely impaired on quarterly Minimum Data Set (MDS) assessments dated 8/17/21, 11/8/21, 1/31/22 and on an annual MDS assessment dated [DATE]. There was no record that the RP was invited to discuss the care for Resident #9 during these assessments. A family interview occurred on 06/07/22 at 1:46 PM and revealed the RP had not been invited to participate in a care plan meeting regarding Resident #9's care in several months. The RP stated he did not recall being invited to participate in a care plan meeting either in person or by phone and he wanted to discuss concerns he had regarding the Resident's recent weight gain. On 06/09/22 at 09:48 AM a phone interview with the MDS Nurse revealed she retired in July 2021, and then returned back to work on a part-time basis about 4 weeks ago. The MDS Nurse stated she was responsible to invite residents and their RP to care plan meetings which occurred in conjunction with the MDS assessment. She stated she mailed a letter to the RP and gave a copy of the invitation to the resident. The MDS Nurse further stated that before she retired in July 2021, she invited the RP for Resident #9 to attend care plan meetings, but he did not respond to the letter and he did not attend. The MDS Nurse could not recall the specific month when this occurred. She also stated that when the RP had questions about Resident #9, he called the facility to get his questions answered. An interview with the Regional Nurse Consultant/Director of Nursing (RNC/DON) on 06/09/22 at 10:00 AM revealed she had no further documentation to support that the RP for Resident #9 was invited to participate in care plan conferences in the last year. The RNC/DON stated that the last care plan meeting that the RP was invited to was 06/02/21. The RNC/DON stated that when the MDS Nurse retired about 1 year ago, the facility experienced a lot of staffing changes, the RNC/DON took on multiple responsibilities at the facility and although she was a prior MDS Nurse, her focus during this time was on the clinical needs of the residents. The RNC/DON stated she contacted the RP for Resident #9 to advise him of changes in the Resident's condition, but she could not explain why the RP was not invited to care plan meetings during each MDS assessment.

Based on observations and staff interviews, the facility failed to label, and date opened food and drinks in 2 of 2 coolers observed. Findings included: The kitchen was observed on [DATE] at 9:43 AM. The 2-door cooler was observed to have open and undated drinks: Thick and Easy Milk (expiration date [DATE]), [MEDICATION(S)] Thick water (expiration date [DATE]), nectar thick apple juice (expiration date [DATE]) and nectar thick ice tea (expiration date [DATE]). The 3-door cooler was observed to have open and undated food: ,d+[DATE]-gallon size Hickory Smoke BBQ sauce, 2 containers of pimento cheese (expiration date [DATE]); ½ gallon size of Ranch dressing (expiration [DATE]). The Dietary manager (DM) was interviewed on [DATE] at 10:01 AM. The DM reported all food and drinks were to be dated when the items were opened and discarded after 5 days. The DM reported the kitchen used colored stickers to date all food items and sometimes those stickers fell off the food containers due to moisture in the coolers. The DM reported a dietary aide (DA) was responsible for checking the coolers daily to make certain all foods were had an open date sticker. The DM reported she did not know if the stickers fell off the drink and food containers or if the items were not dated when they were opened. DA #1 was interviewed on [DATE] 9:59 AM. DA #1 reported he was responsible for checking the coolers daily. DA #1 reported he looked for expired foods and drinks and checked to make certain all open foods or drinks were dated. DA #1 reported sometimes the colored tags fell off the food or drink containers and sometimes the kitchen staff forgot to label the food when they opened the containers. DA #1 reported he had not checked the coolers on [DATE] for expired or undated food or drink items. The DM was interviewed on [DATE] at 10:02 AM. The DM reported she felt that because the colored stickers were small and had a tendency to fall off, the cooking staff had a difficult time using that system and she had purchased larger stickers that had a different adhesive to prevent the stickers from falling off in the cooler. The DM reported she expected all food and drink items to be labeled with the date the item was opened. An interview was conducted with the Administrator on [DATE] at 11:36 AM. The Administrator reported it was her expectation that any opened containers of food or drink were labeled and dated appropriately.

Based on record review and staff interviews, the facility failed to convey funds within 30 days for 1 of 2 residents (Resident #123) and failed to send conveyed funds to the individual or probate jurisdiction administering the resident's estate for 2 of 2 residents (Resident #123 and Resident #23) reviewed for personal funds. Findings included: 1. Resident #123 was admitted to the facility [DATE] and discharged to the hospital on [DATE]. Hospital records were reviewed and revealed a date of death of [DATE]. A review of the resident #123 ' s personal funds account managed by the facility revealed a facility check dated [DATE] in the amount of $928.58 was paid to the order of Social Security. The regional Business Office Manager (BOM) was interviewed on [DATE] at 2:33 PM. The BOM reported Resident #123 ' s funds were not conveyed until [DATE] because she was out sick, and she was the only BOM for the facility. The BOM reported the facility had received a check from the Social Security Administration for Resident #123 after his death and the funds were sent back to the Social Security Administration. The BOM reported she was aware that personal funds needed to be conveyed within 30 days of a resident ' s death or discharge. A follow up interview was conducted with the BOM on [DATE] at 11:27 AM. The BOM stated she was not aware the resident ' s personal funds should have been released to the individual or probate jurisdiction administering the resident's estate. The Administrator was interviewed on [DATE] at 11:36 AM. The Administrator reported it was her expectation that resident funds were conveyed within 30 days of a resident death or discharge and that the funds were sent to the estate of the deceased or discharged resident to be distributed to the correct entities. 2. Resident #23 was admitted to the facility [DATE] and died on [DATE]. A review of the resident #23 ' s personal funds account managed by the facility revealed a facility check dated [DATE] was paid to the order of Social Security for $2574.10. An interview was conducted with the BOM on [DATE] at 11:27 AM. The BOM reported that $770.10 was received by the facility from the Social Security Administration after Resident #23 ' s death. The BOM explained that $1804.10 was personal funds and should have been sent to the estate of Resident #23. The BOM stated she was not aware all residents personal funds should have been released to the individual or probate jurisdiction administering the resident's estate. The Administrator was interviewed on [DATE] at 11:36 AM. The Administrator reported it was her expectation the resident personal funds were sent to the estate of the deceased or discharged resident to be distributed to the correct entities.

Based on observations, record review and staff interviews, the facility failed to ensure safe smoking to prevent a resident from burning his cervical collar (neck brace) for one of four residents reviewed for safe smoking (Resident #1). Resident #1 had portions of his neck brace burned while smoking with and without supervision while at the facility. Immediate jeopardy began on 4/23/18 when resident #1 was documented in a nurses' note as having had burned a few holes in his neck brace. The immediate jeopardy was removed on 5/4/18 at 8:48 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Resident #1 was admitted to the facility 4/20/18 with [DIAGNOSES REDACTED]. A review of Resident #1's Minimum Data Set (MDS) revealed the most recent completed assessment was an admission assessment with an Assessment Reference Date (ARD) of 4/27/18. The MDS assessment indicated Resident #1 had no cognitive impairment. The resident was coded as having had rejected care for 1-3 days during the seven day look back period of the assessment. The resident was coded as having had required extensive assistance of one person for bed mobility, transfer (such as from the bed to a chair), dressing, toilet use, and personal hygiene. The resident was coded as using tobacco during the assessment period. The resident was coded as having had a surgical wound. A review of the facility supplied list of smoking residents provided on 5/2/18 revealed Resident #1 was listed as a supervised smoker. A review of the Safe Smoking Evaluation for Resident #1 dated 4/23/18 revealed the Interdisciplinary Team's determination was the resident was an unsafe smoker and needed supervision. The evaluation stated to see the resident's care plan for further details. The Safe Smoking Evaluation for Resident #1 was completed by Nurse #2. Review of Resident #1's baseline care plan, dated 4/24/18, revealed an update on the same day which documented the resident was a supervised smoker and was to wear an apron. There was an additional update dated 4/22/18 which documented the resident was refusing to wear the smoking apron. There were no additional approaches or interventions listed due to the resident's refusal to wear the smoking apron. A review of the medical record for Resident #1 revealed a nurses' note written by the Director of Nursing (DON), dated 4/24/18, which read in part: Late entry for 4/23/18. Resident had been evaluated for safe smoking and was a supervised smoker. The resident was documented as having been smoking other residents' cigarettes. The resident was educated on supervised smoking and being noncompliant with his need for supervision. The resident was documented as having had actually burned a few holes in his neck brace which was in place. A nurses' note dated 4/24/18 at 7:28 PM written by the Director of Nurses (DON) documented Resident #1 had a fall in the facility hallway. The resident had been documented as having had fallen when he was attempting to pick up a pack of cigarettes off of the floor he had dropped. The resident was informed he was unable to keep cigarettes on his person due to having been assessed to have been an unsafe smoker. A nurses' note dated 4/25/18 at 6:52 PM written by the DON documented Resident #1 continued to independently go outside and obtain cigarettes from other residents and the resident was a supervised smoker. The intervention put into place was a wandering transmitter was placed on the resident to alert staff for the need for supervision when the resident exited the door which lead to the resident smoking area. An interview was conducted with the DON on 5/2/18 at 12:31 PM. The DON stated she was contacted on the weekend, Sunday, 4/22/18, by Nurse #2 and was informed Resident #1 was receiving cigarettes from other residents and smoking other resident's cigarettes. The DON stated she told the nurse who was at the facility to complete a smoking assessment on the resident. Nurse #2 was unavailable for interview at the time of the investigation due to being on Medical Leave. A continuous observation was made on 5/2/18 from 9:45 AM to 10:03 AM of Resident #1. The observation revealed the resident was sitting outside at the smoking area. The resident was sitting in his wheelchair. The resident was wearing a cervical collar or neck brace. The neck brace protruded forward from under the resident's chin forward and up for approximately 3-4 inches. To the left of the resident's mouth there was a semi-circular portion of the neck brace foam missing which was approximately golf ball sized. In addition to the area on the left, there were two smaller areas, approximately pea sized missing to the right of the resident's mouth on the neck brace. At 9:57 AM the lit portion of the cigarette was observed to be setting and making contact with the foam of the neck brace as the resident held the other end of the cigarette in his mouth. The resident would periodically point the cigarette up with his mouth, but inevitably the lit end of the cigarette would return to rest upon the portion of the neck brace where the foam was missing to the left of the resident's mouth. The resident was observed to not be wearing a smoking apron. Through the whole observation period, the only time the resident removed the cigarette from his mouth was when he disposed of the cigarettes in the ash tray. The resident was not observed ashing the cigarette with his hands. The resident moved the cigarette up and down using his mouth and lips. The Maintenance Director (MD) was present during the observation. The MD was observed supervising the resident through the whole observation. The MD gave the resident a second cigarette and lit it for him during the observation. The MD was not observed to have placed a smoking apron on the resident. The MD was not observed assisting the resident to ash his cigarette. The MD did not intervene when the lit portion of the cigarette came into contact with the foam of the neck brace. An interview was conducted with the MD on 5/02/18 at 9:54 AM while he was supervising Resident #1 smoking. The MD stated he was outside supervising Resident #1. The MD stated Resident #1 was a sometimes supervised smoker and sometimes Resident #1 could come out on his own to smoke independently. An interview was conducted with Medication Aide (MA) #1 on 5/2/18 at 11:57 AM. MA #1 stated Resident #1 was a supervised smoker and due to being a supervised smoker the resident was not allowed to keep his cigarettes or a lighter. The MA stated staff members light the resident's cigarettes, the resident did not light his own cigarettes. The MA stated the resident did not and refused to use his hands to ash the cigarette. The MA stated the resident moved the cigarette up and down using his lips and the cigarette would bump the collar sometimes. The MA stated the resident refused to wear a smoking apron. The MA stated she did not recall seeing burn marks on the collar when the resident arrived from the hospital. An interview conducted with the DON on 5/2/18 at 12:05 PM revealed Resident #1 was initially not believed to be a smoker at the time of his admission. The DON stated the resident started to go outside to the smoking area and getting cigarettes from another resident. The DON stated she had encouraged the resident to be a safe smoker. She further stated the resident had been observed thumping the lit cigarette end of the cigarette on the foam part of his neck brace. The DON stated the way the lit end of the cigarette was resting on his neck brace she could see the burned area was getting bigger on his neck brace. The DON stated there was only a one little burn mark on Resident #1's neck collar when he was first admitted to the facility. During an interview conducted on 5/2/18 at 12:12 PM, MA #1 stated the resident was receiving cigarettes from other residents and was not being supervised when he was smoking when he first arrived at the facility. The MA stated the resident did not have any cigarettes in his possession when he first arrived to the facility. The MA stated she believed most of the area which was burned away from the neck brace occurred when the resident had not been supervised and was receiving cigarettes from other residents. An interview was conducted with Nurse #1 on 5/2/18 at 12:20 PM. The nurse stated Resident #1 had gone out to the smoking area and set his neck collar on fire with a lit cigarette while she was supervising him. The nurse stated the resident refused to wear the smoking apron. The nurse stated the resident went outside to smoke about once per hour. The nurse stated the resident did not use his hands to smoke. The nurse stated when the resident would sit and smoke the lit end of the cigarette would come into contact with the neck brace and that has caused foam areas of the neck brace to burn away. The nurse stated when the resident first arrived to the facility there were no burned areas on the neck brace. The nurse stated the resident ashed his cigarette by moving his mouth and moving his head. The nurse further stated she had been supervising the resident when he was smoking on one occasion and the lit end of the cigarette had come into contact with the foam on the neck brace. The nurse stated on that occasion the foam on the neck brace had started to smolder, there were not flames, however the areas started to burn, turn red, and was smoking. The nurse stated she had to reach over and put it out with her fingers and that was one of the times in which parts of the brace were burned away. An observation was conducted of Resident #1 on 5/2/18 at 12:42 PM. The resident was eating lunch in the dining room. The resident's neck brace was observed to be off of the resident. The burned areas of the neck brace were much more visible when the neck brace was not on the resident. A phone interview was conducted with a company representative from the manufacturer of the neck brace on 5/2/18 at 3:03 PM. The representative stated the neck collar worn by Resident #1 was not made from a fire resistant type of material. Multiple attempts were made to interview Resident #1 throughout the investigation. Responses to questions were nonsensical or the resident refused to be interviewed. During an interview conducted on 5/4/18 at 4:36 PM the administrator stated it was her expectation for residents who smoke to smoke safely. The Administrator was informed of Immediate Jeopardy on 5/2/18 at 6:40 PM. On 5/4/18 at 8:48 AM, the facility provided the following Credible Allegation of Immediate Jeopardy Removal: ALLEGATION OF IMMEDIATE JEOPARDY REMOVAL F-689 The deficient practice is the failure to provide supervision to prevent accidents and injuries to the resident. This practice occurred due to staff not fully understanding the proper positioning of the resident's c-collar, the need for the smoking apron, and the need to ensure that they were assisting the resident by ashing his cigarettes to ensure that no hot ashes were falling between the c-collar and the resident's neck. Staff did not fully understand due to a lack of clear communication from staff members on the proper positioning of the c-collar, the need for the smoking apron, and the need to ash the resident's cigarettes for him. The supervised smoking plan for this resident is he is to wear a smoking apron and staff are to ensure that the c-collar is positioned correctly so that the tip of the cigarette does not touch the c-collar. Additionally, staff will be required to remove the cigarette from the resident's mouth and to ash the cigarette to ensure that no ashes are falling into the space between the resident's face and the c-collar. On (MONTH) 3, (YEAR), Physical Therapy will in-service all staff on the proper fit of the resident's c-collar so that staff are aware of when it needs to be adjusted before the resident goes out to smoke. Also, the resident's current care plan will be reviewed with all staff and each staff member will sign off on the care plan to state understanding of the resident's smoking status, the need for the smoking apron, and that they will need to ash the resident's cigarette for him to ensure that no ashes fall in between the resident's neck and the c-collar. As a supervised smoker, the resident will only be smoking at designated times (7:00am, 9:30am, 11:00am, 1:30pm, 4:00pm, 6:00pm, 8:00pm). In order to monitor the plan of correction and to ensure that the resident's c-collar and smoking apron are in place, Administrative Staff do visual inspections during these designated times to make sure that the apron and c-collar are properly in place and that staff are assisting the resident by ashing the cigarette for him. The Administrator will be responsible for implementing this plan of correction. The credible allegation was verified on 5/4/18 at 5:00 PM as evidenced by staff interviews and an observation of Resident #1 smoking, wearing a smoking apron, and staff ashing the cigarette of the resident as needed. The lit end of the cigarette was not observed to come into contact with the resident's neck collar and the collar was covered with the smoking apron. Staff education was initiated on 5/3/18 regarding the supervised smoking plan for Resident #1 to wear a smoking apron and staff are to ensure that the c-collar is positioned correctly so that the tip of the cigarette does not touch the c-collar. Additionally, staff will be required to remove the cigarette from the resident's mouth and to ash the cigarette to ensure that no ashes are falling into the space between the resident's face and the c-collar. All staff interviewed (nursing and non-nursing staff, administrative staff) stated Resident #1 was to be supervised whenever he smoked, he was to wear a smoking apron, the lit portion of the cigarette was not to come into contact with the neck brace, and they were to ash the cigarette for the resident. Verification of education for staff regarding the education regarding wandering residents was completed on 5/4/18.

Based on observations, record review and staff interviews, the administration failed to provide oversight and leadership to facility staff to maintain a safe environment and ensure safe and supervised smoking for one of four residents reviewed for safe smoking (Resident #1). Resident #1 had portions of his neck brace burned while smoking with and without supervision while at the facility. Immediate jeopardy began on 4/23/18 when resident #1 was documented in a nurses' note as having had burned a few holes in his neck brace. The immediate jeopardy was removed on 5/4/18 at 8:48 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Cross Refer to F689: Based on observations, record review and staff interviews, the facility failed to ensure safe smoking to prevent a resident from burning his cervical collar (neck brace) for one of four resident reviewed for safe smoking (Resident #1). Resident #1 had portions of his neck brace burned while smoking with and without supervision while at the facility. During an interview conducted on 5/4/18 at 4:36 PM the administrator stated it was her expectation for safe smoking recommendations to be communicated effectively to front line staff. The Administrator was informed of Immediate Jeopardy on 5/2/18 at 6:40 PM. On 5/4/18 at 8:48 AM, the facility provided the following Credible Allegation of Immediate Jeopardy Removal: ALLEGATION OF IMMEDIATE JEOPARDY REMOVAL F-835 This deficiency was cited due a lack of full and proper communication from Administration to the floor staff. Staff were not correctly following the facility policy for supervised smokers and were therefore not ensuring that the resident's c-collar was positioned correctly, that the smoking apron was in place each time, or ashing the resident's cigarette to prevent ashes from falling between the c-collar and the resident's neck. A review of this incident shows that there was a failure to properly inservice staff to policy and procedure as it applies to this specific resident's safety needs. On (MONTH) 3, (YEAR), facility staff were inserviced on the proper placement of the c-collar, the resident's specific safety needs of the smoking apron and ashing of the cigarette As a supervised smoker, the resident will only be smoking at designated times (7:00am, 9:30am, 11:00am, 1:30pm, 4:00pm, 6:00pm, 8:00pm). In order to monitor the plan of correction and to ensure that the resident's c-collar and smoking apron are in place, Administrative Staff (Cathy Almon, Sheila Coughenour, Cathy Perry, Angie Harrington, Kim Nichols, Sid Maguire, Debbie Marsh, Robin Jones, Laura Hedrick) will do visual inspections during these designated times to make sure that the apron and c-collar are properly in place and that staff are assisting the resident by ashing the cigarette for him. The facility Administrator will be responsible for implementing this plan of correction. The credible allegation was verified on 5/4/18 at 5:00 PM as evidenced by staff interviews and an observation of Resident #1 smoking, wearing a smoking apron, and staff ashing the cigarette of the resident as needed. The lit end of the cigarette was not observed to come into contact with the resident's neck collar and the collar was covered with the smoking apron. Staff education was initiated on 5/3/18 regarding the supervised smoking plan for Resident #1 to wear a smoking apron and staff are to ensure that the c-collar is positioned correctly so that the tip of the cigarette does not touch the c-collar. Additionally, staff will be required to remove the cigarette from the resident's mouth and to ash the cigarette to ensure that no ashes are falling into the space between the resident's face and the c-collar. All staff interviewed (nursing and non-nursing staff, administrative staff) stated Resident #1 was to be supervised whenever he smoked, he was to wear a smoking apron, the lit portion of the cigarette was not to come into contact with the neck brace, and they were to ash the cigarette for the resident. Verification of education for staff regarding the education regarding wandering residents was completed on 5/4/18.

Based on record review, resident interview, and staff interview the facility failed to protect a resident (Resident # 5) from verbal and physical intimidation from a staff member, for one of three resident reviewed for abuse. Findings included: Resident #5 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. Resident #5's most recent Minimum Data Set (MDS) was a comprehensive admission assessment with an Assessment Reference Date (ARD) of 4/26/18. The resident was coded as having had no cognitive loss. The resident had a Brief Interview for Mental Status (BIMS) score of 15. The resident had no behaviors coded for the assessment period. The resident was coded as requiring extensive assistance of one person for bed mobility, toilet use, and two people for transfer (i.e. from the bed to the chair). The resident was coded as having had received antidepressant medication for one day of the assessment period and no other [MEDICAL CONDITION] medications. The resident was coded as having received oxygen during the assessment period. Resident #5 had a baseline care plan in place which was most recently updated on 4/24/18. The resident's baseline care plan included the following areas: Therapy services, Activities of Daily Living (ADLs), oxygen use, incontinence, insulin use, pain, and the resident was to be long-term at the facility. Review of the physicians' orders revealed the resident had been prescribed [MEDICATION NAME] 10 milligrams (mg) orally one time a day for anxiety on 4/19/18, the date of admission. A nurses' note for Resident #5 dated 4/20/18 which was documented as a late entry for 4/19/18, the date of admission, at 9:00 PM included documentation the resident was alert and oriented and was able to verbalize needs. The resident was documented as having been observed to have no acute distress. Nurses' notes for Resident #5 dated 4/21/18, 4/22/18, 4/23/18, 4/24/18, 4/25/18, 4/26/18, 4/27/18, 4/28/18, 4/29/18, and 4/30/18 documented the resident was alert and oriented and was able to make needs known to staff. A Daily Skilled Nursing Evaluation for Resident #5 dated 4/24/18 documented the resident was alert and oriented to time, place, and person. The resident had no short or long-term memory deficits. The resident was capable of independent cognitive skills for daily decision making. The resident had no impairment in communication. The resident was on oxygen via nasal cannula at 3.5 liters per minute. The resident was documented as having had no abnormal behaviors. A Family/Resident Concern (grievance) form dated 4/24/18 for Resident #5 was reviewed. The form was completed by the facility Social Worker (SW). The form documented the resident made an allegation Nursing Assistant (NA) #1 grabbed the resident's face with both hands, shook her head, and told the resident to go to sleep on 4/23/18. The form documented the resident had stated she had rang her call bell because she had needed assistance. In addition the resident informed the SW it took a long time for NA #1 to answer her call light and when NA #1 did answer her call light, NA #1 was short with her and rude. The form further documented the resident stated NA #1 was rough with her while cleaning her after a bowel movement. The final documentation of the resident's concern or grievance was Resident #5 stated NA #1 makes her feel unsafe. The grievance form was investigated by the administrator and the corrective action listed on the form was NA #1 was terminated for abuse. The investigation was signed by the administrator on 4/30/18. A 24 Hour Initial Report for an Allegation of abuse was faxed to the Health Care Personnel Registry on 4/24/18 from the facility. The alleged incident occurred on 4/23/18 at approximately 9:00 PM. The allegation description was Resident #5 reported NA #1 grabbed her on both sides of her face, shook her and told her to go to sleep after she had rang her call bell for assistance. The employee was documented as having been placed on suspension and was removed from the schedule pending the outcome of the investigation. The report was signed by the administrator and dated 4/24/18. A nurses' note for Resident #5 dated 4/25/18 at 12:26 PM documented the resident was alert and oriented. The note further documented the resident was weepy about being at the facility. The nurse documented she spoke with the resident at the bed side multiple times. The nurse documented the resident stated that she had just wanted someone in the room with her all of the time. The nurse provided further documentation she checked on the resident several times during the shift. A nurses' note for Resident #5 dated 4/30/18 documented the resident was alert and oriented and had been feeling anxious during the shift. A review of the 5-Working Day Report submitted by the facility for an allegation of abuse to the Health Care Personnel Registry on 5/1/18 was reviewed. The report documented on 4/23/18 at approximately 9:00 PM Resident #5 alleged NA #1 grabbed her face with both hands, shook her head, and told her to go to sleep. Resident #5 was documented as having been alert and oriented to time, place, and person. The allegation was documented as having been investigated and substantiated by the facility administrator. The investigation end date was 4/27/18. NA #1 was documented as having been terminated as a result of the investigation on 5/1/18. (Please note the employee was suspended as a result of the allegation on 4/24/18 per the 24 hour report submitted on 4/24/18.) The report was signed by the administrator on 5/1/18. An interview was conducted with the administrator on 5/4/18 at 10:51 AM. The administrator stated she received the grievance with the allegation of abuse from Resident #5 regarding NA #1 the morning of 4/24/18 shortly after she arrived to the facility. The administrator stated she initiated an investigation immediately regarding abuse and suspended NA #1 also on the same date. The administrator stated the SW had interviewed other alert and oriented residents and NA #1 was identified as having been rough with them during care. The administrator stated as a result of the investigation the allegation of abuse in regards to NA #1 was terminated on 5/1/18. The administrator stated a 24 hour report and 5 day report were completed and faxed to the Health Care Personnel Registry regarding the allegation, suspension, investigation, substantiation, and termination. In addition the administrator stated the Health Care Personnel Registry had contacted the facility and had informed the administrator an onsite investigation would be completed by the Health Care Personnel Registry. An interview was conducted with Resident #5 on 5/4/18 at 11:50 AM. The resident stated she reported on 4/24/18 NA #1 had put her hands on both sides of the resident's face, held her face, and told the resident forcefully to go to sleep. The resident stated the NA scared her a little bit when she had done that. The resident stated she had been ringing her call light because she had had some confusion about where she was at. The resident stated she did not ring her call light after interaction with the NA. The resident stated it had happened in the evening of 4/23/18 but she could not remember an exact time. The resident further clarified the NA did not squeeze or shake her head but was not being gentle. The resident stated there was no one else in the room to witness the interaction. The resident further stated the NA had only acted in that manner one time and the NA had not acted like that in the past. The resident finally stated she had had no bad experiences with any of the other staff members at the facility. A phone interview was conducted with NA #1 on 5/4/18 at 1:10 PM. The NA stated Resident #5 was sweating and she had felt both sides of her head with hands. The NA stated when she was feeling the resident's head the resident jumped up moving her head and shoulders up and made the statement, I know my blood sugar, I know it's high. NA #1 stated she did not tell the resident to go to sleep. The NA stated she had not done anything forceful with the resident. The NA stated the resident was behaving oddly. The NA stated the resident's hair was very sweaty and wet. The NA also stated she did not tell the resident to stop ringing her call light. The NA stated the resident continued to ring her call light through the evening. An interview was conducted with the administrator on 5/4/18 at 2:15 PM. The administrator stated the social worker had conducted the interview with Resident #5 and conducted interviews with other alert and oriented residents regarding abuse. The administrator stated when she had informed NA #1 on 4/24/18 the NA stated she knew who had made an allegation without the administrator informing her. The administrator stated when she had interviewed the NA the NA stated she had not grabbed the resident's face but had attempted to check the resident for a fever by placing her hand on the resident's face. The administrator stated there was no physical injury to the resident. The administrator stated the SW conducted interviews with other alert and oriented residents regarding abuse. The administrator stated no other residents had made an allegation of abuse but four residents on NA #1's assigned hall had made statement that NA #1 was rough with them, spoke harshly to them, was rough with their roommate, or was spoke harshly to their roommate. The administrator further stated she substantiated the allegation of abuse for NA #1 from Resident #5 based on the allegation received from Resident #5 on 4/24/18, NA #1 pre-emptively identifying the victim, and the results from resident interviews which yielded statements from other residents in which they had identified NA #1 having been rough with them. An interview was conducted with the Social Worker (SW) on 5/4/18 at 2:39 PM. The SW stated she had interviewed Resident #5 on 4/24/18 and the resident informed the SW she had rang her call light during the evening of 4/23/18 and when NA #1 answered her call light, NA #1 grabbed the resident's face with her hands and had told her to go to sleep. The SW stated the resident continued during the interview and told the SW NA #1 was in a hurry to get out of the room and was rude when she needed help. The SW stated the resident also stated NA #1 was rough with her when she had cleaned her. The SW stated the resident told her that was the only time the NA had grabbed her face. The SW stated she went back and interviewed the resident on 4/25/18 and the resident's story was consistent. The SW stated there was nothing wrong with Resident #5's mind, her mind was sharp. On 5/4/18 the administrator provided an investigation timeline in regards to the allegation of abuse made by Resident #5 about NA #1. The conclusion of the timeline documented the determination of the investigation was NA #1 had abused Resident #5 on 4/23/18. The timeline further documented abusive behavior had been substantiated related to the allegation from Resident #5 regarding the incident on 4/23/18. The timeline documented NA #1 was terminated for abuse and had been report to the Healthcare Personnel Registry. During an interview conducted on 5/4/18 at 4:36 PM the administrator stated it was her expectation that abuse should not occur.

Based on record review, observation and physician and staff interview, the facility failed to call for help for an acute assessment of Resident #1 who fell from a wheelchair during van transportation. The resident hit his left stump on the floor during the fall resulting in active bleeding that was stopped after staff applied a pressure dressing. Staff repositioned the resident back into the wheelchair and continued the transport to the facility. Following initial treatment to the stump, there was no evidence that the resident was monitored after the fall. This problem affected one (Resident #1) of one sampled resident who was transported using the nursing home's van. Immediate jeopardy began on 1/19/17 when Resident #1 was moved prior to having a qualified person assessed/examined the resident for possible injuries after the fall in the van during transport and was removed on 1/26/17 at 2:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff members were in-serviced on the facility's policy and procedure on accidents/incidents and in-serviced all nurses on timely assessment, monitoring and reporting of any accidents/incidents. Findings included: The facility's policy and procedure on accidents/incidents (undated) was reviewed. The policy read in part should you witness an accident or find it necessary to aid an accident victim, you should render immediate assistance. Do not move the victim until he/she has been examined by a registered nurse for possible injuries. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The hospital discharge summary dated 12/19/16 indicated that Resident #1 underwent left above the knee amputation on 12/9/16. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had moderate cognitive impairment and needed extensive assistance with transfers. The assessment also indicated that the resident had no falls since admission or the last assessment. Resident #1's care plan dated 1/6/17 was reviewed. One of the care plan problems was the resident was at risk for falls and fall related injury as he was totally dependent on the staff for transfers due to bilateral [MEDICAL CONDITION]. The goal was the resident will follow safety guidelines by using the call bell for assistance with transfers and toileting and will be free from major injury should any fall occur through the next review. The approaches included assistance will be provided with all transfers as needed, monitor for attempts to get out of bed or wheelchair unassisted, and therapy to train staff on proper transfers as needed. Resident # 1's nurse's notes were reviewed. The notes dated 1/23/17 at 3:02 PM indicated that on 1/19/17 approximately 12:30 noon Nurse #1 was called to the front of the building to assess Resident #1 due to a fall that occurred in the van following an appointment. The resident fell on the floor and active bleeding was noted from the left amputated leg. Nurse #1 observed Resident #1 in the wheelchair and appeared out of it and had a flat affect. The notes indicated that the bleeding had stopped when pressure was applied after several minutes and the treatment nurse cleaned and wrapped the left amputated leg. Review of the doctor's orders revealed that on 1/20/17, Resident #1 had an order to be sent to the emergency room due to hemoglobin of 6.7 and hematocrit of 20.7. The nurse's notes dated 1/22/17 at 6:37 AM indicated that Resident #1 was discharged to the hospital on [DATE]. The hospital records dated 1/20/17 were reviewed. The principal [DIAGNOSES REDACTED]. The plan was to transfuse 2 units of packed red blood cell (PRBC). On 1/24/17 at 1:40 PM, the Director of Nursing (DON) was interviewed. The DON indicated that she was made aware of the accident in the van involving Resident #1 on 1/19/17. She stated that the resident's name was not listed on the accident/incident log because Nurse #1 (assigned to Resident #1) had not completed the incident report yet. She added that Nurse #1 was coming early that night (1/24/17) to complete the incident report and to provide a written statement regarding the accident with Resident #1. She revealed that written statements were obtained from the driver and the nursing assistant (NA) #1 who accompanied the resident during the transport. The DON was not able to provide a statement from Resident #1. She added that the nurses were still adjusting with the electronic documentation. She was aware that Nurse #1 did not document the van accident involving Resident #1 in the nurse's notes timely but the nurse was asked to document a late entry on 1/23/17. The DON also stated that Resident #1 was monitored by the nurses after the fall but the nurses failed to document the monitoring in the resident's medical records. The DON stated that she and the Administrator had written their investigation time line after the accident. The investigation time line was reviewed. The time line did not reveal the root cause of the resident s fall. The time line included: 1/19/17 at 9:30 AM - The Administrator was called by the driver to come outside the facility to the van. She saw NA #1 standing in front of Resident #1 and was holding the resident s stump that was bleeding. When she questioned what happened, she was told that the resident had released his belt and he fell out of his chair onto the floor. The Administrator immediately went inside and got Nurse #1 and NA #2. They brought the treatment cart and they cleaned him up and brought him inside the facility. Nurse #1 informed her the resident was okay and for her to complete an incident report and to get statements from the driver and NA #1 and to make sure that the information were given to the DON. 1/19/17 at 11:30 AM - The DON informed Nurse #1 to complete her documentation of the incident and when the statements were obtained to complete the incident report and to notify the family and to get back with her. The DON also requested the NP (Nurse Practitioner) to see Resident #1. 1/19/17 at 5:30 PM -The DON informed the resident's family of the incident. 1/20/17 at 1:00 PM - The DON called Nurse #1 and inquired regarding the incident report. 1/20/17 at 5:00 PM - The family of Resident #1 came and picked him up to visit a family member. 1/20/17 at 7:00 PM - The NP called and ordered to send the resident to the hospital to receive 2 units of Packed Red Blood Cell (PRBC). Around 10:30 PM, when the resident returned to the facility, EMS was called to transfer him to the hospital. 1/23/17 at 12:45 PM - The DON reminded NA#1 to write her statement of the incident. The driver provided his statement to the Administrator and forwarded it to the DON. The driver was re-educated on the transportation policy and demonstrated competency of the physical restraint system according to the manufacturer by the VP of Operation. 1/23/17 at 2:00 PM - The Nurse Manager called the hospital to check the status of the resident. She was informed that the resident was referred to orthopedic to see his stump. 1/24/17 at 1:00 PM - The DON called Nurse #1 and informed her that she needed to complete the incident report. 1/24/17 at 1:30 PM - The DON requested NA #2 to write a report on the status of the resident's wounds (stump). The conclusion written on the time line read the action plan initiated 1/25/17 on the next 20 transports per the facility van, every other transport will be inspected prior to leaving the facility and upon return to the facility by either the Administrator or the DON to ensure that the resident is properly secured in the van and seat belt is properly attached and locked in place. If any issues are found with the proper securing of the resident while being transported, the van driver will not be allowed to transport future residents. The findings of the Administrator and the DON will be reported to the QA Committee for follow up and recommendations to ensure the corrective actions is achieved and sustained. On 1/25/17 at 8:20 AM, NA #1 was interviewed. She indicated that she was asked by the administrator on 1/19/17 to accompany Resident #1 to the hospital for IV infusion. She was at the back of the van with the resident. It was about 2 miles away from the facility when the driver had to quickly step on the brake and the resident slid out of his wheelchair. Resident #1 ended kneeling with his L stump on the floor. The driver pulled over, and she assessed the resident and noted that his left stump was bleeding through the dressing. She applied pressure on the dressing to stop the bleeding. She and the driver lifted the resident up, put him back in the wheelchair and the driver proceeded to drive back to the facility. The driver pulled in front of the facility and called the nurse. Nurse #1 came out and assessed the resident. NA #2 also came out and changed the dressing to the resident's left stump. NA #1 further stated that she was instructed not to move a resident after an accident until assessed by a nurse but they did not have any choice, they have to put him back in wheelchair in order to drive back to the facility. NA #1 also stated that the driver should be the one to call the facility and inform them about the accident. On 1/25/17 at 10:40 AM, the van driver was interviewed. He stated that he had been driving the facility van for 2 years. He was trained by the maintenance person on transportation safety which included the proper procedure in securing residents and the wheelchair in the van before he started driving the van. The van driver indicated he was transporting Resident #1 to the hospital on [DATE] for IV infusion. It was about a mile away from the facility, when a car pulled out in front of him, he applied the break with more force than normal and then he heard something on the back of the van and saw the resident on the floor. He pulled over and asked the resident if he was okay and he replied that he was fine. His buttock was on the floor and his left stump was bleeding. With the help of NA #1, they lifted the resident and put him back in his wheelchair. NA #1 applied pressure on the stump to stop the bleeding. The van driver stated that he can move a resident as long as the resident was saying that he was okay. He also stated that he did not call the facility because he was a mile away from the facility. On 1/25/17 at 10:50 AM, the facility transport van was observed with the van driver and the administrator. The van was equipped with a shoulder strap and a lap belt. The driver demonstrated on how to apply the shoulder strap and lap belts on the resident and on how to secure the wheelchair to the floor. He also showed where the resident and NA #1 were sitting. When asked if the shoulder strap and the lap belt were applied to the resident he replied I neglected to apply the shoulder strap because he thought the resident would be fine with the NA with him at the back of the van. Attempted to call Nurse #1 but she did not return the call. On 1/25/17 at 11:01 AM, the Administrator was interviewed. She stated that she was called to go outside in front of the building to see a resident who fell on the floor of the van. She thought Resident #1 fell while the van was parked. She was not informed that the resident fell on their way back to the facility. She immediately called the nurse to assess the resident and to change the dressing on the resident's left stump. She stated that it was okay for the staff to move the resident before a nurse or any qualified person had assessed the resident as long as the resident was alert and oriented and was able to tell that he/she was okay. The Administrator also indicated that she did not expect the driver to call the facility because they were a mile away from the facility when the accident happened. She also indicated that the driver and NA#1 were re-educated on transportation safety (video of manufacturer on properly securing the resident on 1/23/17. The records of the van driver were reviewed. The driver had signed the facility's commercial auto fleet policy and fleet driver's commitment on 1/13/15 which included seat belt utilization is required of all drivers and passengers in company owned vehicles and in vehicles operated on company business. The records also indicated that the driver was trained on 3/21/16 regarding transportation safety using the manufacturer's instruction on how to secure the wheelchair and the resident in the van. On 1/25/17 at 2:10 PM, the attending physician of Resident #1 was interviewed. She stated that the staff had informed her of the van accident involving Resident #1 and the resident was assessed by the Nurse Practitioner the day of the fall. She stated that the next day the resident was transferred to the emergency room due to low hemoglobin/hematocrit level which was not related to the fall. She also indicated that she expected the staff to move the resident from the floor and to get somebody from the facility to assess the resident. On 1/25/17 at 4:53 PM, the Administrator was again interviewed. She stated that she started as administrator of the facility in May 2016. She expected the staff to follow the facility's policy and procedure on accidents/incidents. On 1/25/17 at 2:35 PM, the Administrator and the VP of Operation were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 1/26/16 at 2:20 PM. The credible allegation indicated: The resident was evaluated by a registered nurse on January 19, 2017 and initiated first aid treatment to the stump which included assessment to ensure bleeding had stopped and a new dressing was applied. The resident who was alert and oriented denied any injuries. The Nurse Practitioner evaluated the resident on January 19, 2017 and no injuries from the fall were noted. The resident was discharged to the hospital on January 20, 2017 for health issues unrelated to the fall. The nursing staff stated to the Director of Nursing that the resident was monitored for the fall however the nurses notes do not reflect the monitoring. The nurses who should have documented have received a disciplinary action for failing to document any falls or events that occur. All nurses will be in-serviced today, January 26, 2017 by the Director of Nursing to include the following: 1. Timely assessment of residents; 2. Timely completion of incident/accident reports; 3. Monitoring of residents using the Acute Episode charting guidelines 4. Communication with the Director of Nursing and Administrator concerning any falls or events that occur. For any nurse not in-serviced today they will not be allowed to work until the in-service is completed with the Director of Nursing. Incident reports were reviewed on January 24, 2017 for the past three (3) months by the Administrator and Vice President of Operations to determine if there have been any other accidents/incidents involving the transportation of residents and there were no other residents were affected. The Transportation driver and Certified Nursing Assistant were re-educated January 24, 2017 by the Administrator and Vice President on the accident and incident policy which states that a resident is not to be moved if there is an accident while on the facility van, and that 911 should be called to make determination if medical attention is required and transportation to the hospital is necessary. The Transportation Driver also has demonstrated competency to the Administrator of the physical restraint systems on the van according to the manufacturer specifications. All staff will be in-serviced on today January 26, 2017 by the Administrator on the following: 1. The transportation safety and the accident and incident policy to ensure anyone who assists with transports is aware of the proper policy and procedure which includes proper securement of the restraints system. 2. Accidents and Incidents that occur with any resident within the facility to include assessment of the resident by a licensed nurse prior to moving the resident if a fall occurs. For any employee not in-serviced today, will not be allowed to work until the in-service is completed with the Administrator and/or Director of Nursing. The facility will ensure safe driving training provided includes proper use of cell phones , what to do in the event of a mechanical breakdown of vehicle, what to do in the event of an accident and resident safety during event. The training will also include who to report an incident to and how to report to the administrator. The Administrator will ensure annual reviews of driver records for all authorized drivers by contacting the insurance company for the facility to receive the results of the drivers check. This information will be maintained in a file in the administrator ' s office. The facility will visibly conduct quality assurance checks to ensure that drivers are fastening restraints appropriately and safely and document the results of the quality assurance checks in the Quality Assurance log. This will be done for the next twenty (20) transports per the facility van, every other transport will be inspected prior to leaving the facility and upon return to the facility by the Administrator or Director of Nursing to ensure the resident is properly secured in the van and seat belt is properly attached and locked in place. If any issues are found with the proper securing of the resident while being transported, the van driver will not be allowed to transport any future residents and will receive disciplinary action up to and to include termination of employment. A Quality Assurance review of all of the Accident/Incident reports will be completed daily by the Administrator at which time if interventions have not be initiated the Administrator will instruct the Interdisciplinary Team to initiate interventions to prevent further incidents. The Director of Nursing will instruct the MDS/Care Plan Coordinator to update the Care Plan to reflect the interventions. The credible allegation of compliance was verified on 1/26/17 at 2:30 PM by interviewing the staff including the van driver that they have received in-service on the facility's accident/incident policy and procedure. The in-service records were reviewed and the in-service on accident/incident policy and procedure was started on 1/26/17.

Based on record review, observation and physician and staff interview, the facility failed to secure a resident in the van during transport according to manufacturer's recommendations causing the resident to fall for 1 (Resident #1) of 1 sampled resident who was transported using the nursing home's van. Resident #1 hit his left stump on the floor during the fall resulting in active bleeding that was stopped after staff applied a pressure dressing. Immediate jeopardy began on 1/19/17 when Resident #1 fell in the van during transport and was removed on 1/26/17 at 2:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff members were in-serviced on the facility's policy and procedure on accidents/incidents and all nurses on timely assessment, monitoring and reporting of any accidents/incidents. Findings included: The manufacturer's instructions for restraining the occupant in the van was reviewed. The instruction included how to attach the combination lap and shoulder belt. The instruction read under caution to always ensure that the shoulder belt is properly extended over the shoulder and across the upper torso of the occupant. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The hospital discharge summary dated 12/19/16 indicated that Resident #1 underwent left above the knee amputation on 12/9/16. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had moderate cognitive impairment and needed extensive assistance with transfers. The assessment also indicated that the resident had no falls since admission or the last assessment. Resident #1's care plan dated 1/6/17 was reviewed. One of the care plan problems was the resident was at risk for falls and fall related injury as he was totally dependent on the staff for transfers due to bilateral below the knee amputation. The goal was the resident will follow safety guidelines by using the call bell for assistance with transfers and toileting and will be free from major injury should any fall occur through the next review. The approaches included assistance will be provided with all transfers as needed, monitor for attempts to get out of bed or wheelchair unassisted and therapy to train staff on proper transfers as needed. The incident/accident log for the last 3 months (November and December 2016 and January 2017) was reviewed. Resident #1 was not listed on the log as having a fall. The doctor 's progress notes dated 1/19/17 indicated that Resident #1 had chronic anemia and chronic kidney disease stage 4 being followed by the nephrologist and was awaiting a graft placement for dialysis and for iron infusion. Resident # 1's nurse's notes were reviewed. The notes dated 1/23/17 at 3:02 PM indicated that on 1/19/17 approximately 12:30 PM Nurse #1 (assigned to Resident #1) was called to the front of the building to assess Resident #1 due to a fall that occurred in the van following an appointment. The notes further indicated that Nurse #1 was informed that the resident was scooting continuously towards the front of the chair and was instructed by the driver to stay in his seat. The resident was non- compliant and did not listen to the driver and when the van was parked in front of the building, the resident fell on the floor and active bleeding was noted from the left amputated leg. Nurse #1 observed Resident #1 in the wheelchair and appeared out of it and had a flat affect. The notes indicated that the bleeding had stopped when pressure was applied after several minutes and the treatment nurse cleaned and wrapped the left amputated leg. The nurse's notes dated 1/20/17 at 12:03 AM indicated that Resident #1 was referred and was seen by the physician provider group on 1/19/17 due to thick greenish sputum and post fall from the wheelchair in the van during transport. New orders were written for chest x-ray and complete blood count (CBC). On 1/20/17, there was a doctor's order to send Resident #1 to the hospital due to low hemoglobin/hematocrit. The nurse's notes dated 1/22/17 at 6:37 AM indicated that Resident #1 was discharged to the hospital on [DATE]. The doctor's progress notes at the hospital dated 1/20/17 were reviewed. The principal [DIAGNOSES REDACTED]. The plan was to transfuse 2 units of packed red blood cell (PRBC). On 1/24/17 at 1:40 PM, the Director of Nursing (DON) was interviewed. The DON indicated that she was made aware of the accident in the van involving Resident #1 on 1/19/17. She stated that the resident's name was not listed on the accident/incident log because Nurse #1 has not completed the incident report yet. She added that Nurse #1 was coming early that night (1/24/17) to complete the incident report and to provide a written statement regarding the accident with Resident #1. The DON indicated that Resident #1 went to the hospital on [DATE] to have an intravenous (IV) access for iron infusion. She revealed that the accident happened on the way back to the facility and she had obtained written statements from the driver and the nursing assistant (NA) #1 who accompanied the resident during the transport. The DON was not able to provide a statement from Resident #1. She added that she didn't know the cause as to why the resident fell during transport but she and the administrator had written their investigation time line after the accident. The investigation time line was reviewed. The time line did not reveal the root cause of the resident's fall. The time line included: 1/19/17 at 9:30 AM - The Administrator was called by the driver to come outside the facility to the van. She saw NA #1 standing in front of Resident #1 and was holding the resident's stump that was bleeding. When she questioned what happened, she was told that the resident had released his belt and he fell out of his chair onto the floor. The Administrator immediately went inside and got Nurse #1 and NA #2. They brought the treatment cart and they cleaned him up and brought him inside the facility. Nurse #1 informed her the resident was okay and for her to complete an incident report and to get statements from the driver and NA #1 and to make sure that the information were given to the DON. 1/19/17 at 11:30 AM - The DON informed Nurse #1 to complete her documentation of the incident and when the statements were obtained to complete the incident report and to notify the family and to get back with her. The DON also requested the NP (Nurse Practitioner) to see Resident #1. 1/19/17 at 5:30 PM -The DON informed the resident's family of the incident. 1/20/17 at 1:00 PM - The DON called Nurse #1 and inquired regarding the incident report. 1/20/17 at 5:00 PM - The family of Resident #1 came and picked him up to visit a family member. 1/20/17 at 7:00 PM - The NP called and ordered to send the resident to the hospital to receive 2 units of Packed Red Blood Cell (PRBC). Around 10:30 PM, when the resident returned to the facility, EMS was called to transfer him to the hospital. 1/23/17 at 12:45 PM - The DON reminded NA#1 to write her statement of the incident. The driver provided his statement to the Administrator and forwarded it to the DON. The driver was re-educated on the transportation policy and demonstrated competency of the physical restraint system according to the manufacturer by the Vice President (VP) of Operation. 1/23/17 at 2:00 PM - The Nurse Manager called the hospital to check the status of the resident. She was informed that the resident was referred to orthopedic to see his stump. 1/24/17 at 1:00 PM - The DON called Nurse #1 and informed her that she needed to complete the incident report. 1/24/17 at 1:30 PM - The DON requested NA #2 to write a report on the status of the resident's wounds (stump). The conclusion written on the time line read the action plan initiated 1/25/17 on the next 20 transports per the facility van, every other transport will be inspected prior to leaving the facility and upon return to the facility by either the Administrator or the DON to ensure that the resident is properly secured in the van and seat belt is properly attached and locked in place. If any issues are found with the proper securing of the resident while being transported, the van driver will not be allowed to transport future residents. The findings of the Administrator and the DON will be reported to the QA Committee for follow up and recommendations to ensure the corrective actions is achieved and sustained. The written statements from the staff were reviewed. The statement from NA #1 was dated 1/19/17 and read that Resident #1 had been to the hospital for a procedure and on the way back to the facility, he kept messing with his seat/lap belt across his wheelchair. When the driver had to stop suddenly, he slid himself out of his wheelchair and bumped his left stump while going to floor of the van. The driver helped put him back into wheelchair. Noticed the stump bleeding. Applied pressure to stop the bleeding. Upon returning to the building, the wound care nurse came to the van. We undressed the old bandage, cleaned and redressed the stump according to wound care direction. Assisted resident off the van and back into the building. The written statement of the van driver dated 1/20/17 read in part on January 19, 2017 I picked up Resident #1 from the hospital around 9:30 AM to transport him back to the facility. Resident #1 was being transported in his wheelchair in the back of the van which was strapped down front and back with the appropriate safety straps and was wearing his lap belt. On the way back to the facility, I pressed the break slightly harder than normal but not slamming on them to avoid another vehicle that had pulled out in front of me. When this happened, I heard a noise in the back of the van and asked NA#1 in the back with the resident what the noise was and she stated that he had fallen out of his wheelchair. Immediately, I pulled over on the side of the road and got in the back of the van to help NA #1 get the resident back into his wheelchair. We asked him if he was hurt anywhere and he stated no but I did notice that his leg was bleeding at the amputation site through the bandage. After I noticed that his leg was bleeding, I gave NA #1 some wipes and she started applying pressure to the area. I then drove them back to the facility and reported the incident immediately to my administrator. At this time, the wound care nurse and the nurse on the unit went to the van and they unwrapped the resident's bandage on his leg and treated the area that was bleeding and by then the bleeding stopped. The wound was treated and re-bandaged. He did state several more times that he was not hurt or injured during this time. He did not display any apparent signs of pain. The written statement of Nurse #1 dated 1/24/16 read in part on January 19, 2017 I was working the medication cart on the west unit of our facility when the administrator asked NA #2 (treatment NA) and myself to assist a resident in the front of the building. I ran to the front of the building with NA #2 and noted the van parked in the front driveway loop with the doors open and Resident #1 in his wheelchair sitting in the van. The transport driver was outside of the van and NA #1 was in the van applying pressure to the resident's left stump. Blood was noted on the van floor, around his stump as well as on the bandages that he was wearing at the time of this incident. NA #2 got into the van and began taking off the dirty bandages and instructed me to go get the treatment cart. I ran down the hall and brought the treatment cart to the front of the building outside of the van. NA #2 immediately treated the area. While this was happening, the resident had a flat affect and no expression on his face. He did not appear to be in pain or in any sign of distress. Upon the treatment being finished, all parties were asked to write statements. At this time an incident report was not immediately completed as I was waiting on the completion of the other party's statements. I would like to add that following this incident, Resident #1 was outside of the facility smoking with his daughter. I was called out to them to light his cigarette as he did not have a lighter. At this time I had a long conversation with both of them regarding his overall status and I advised that he should go to the hospital if he felt there were any changes in his health or condition. Both of them were informed of their right that he could go to the hospital at any time if he would inform the staff and I would be willing to assist them in doing so at any time as I was working that day, the following day and 12 hour shifts all weekend. Both of them stated that he did not need to go to the hospital as it was not necessary in their opinion at this time. An attempt was made to call Nurse #1, but she did not return the call. On 1/25/17 at 8:20 AM, NA #1 was interviewed. She indicated that she was asked by the administrator on 1/19/17 to accompany Resident #1 to the hospital for IV infusion. She was at the back of the van with the resident. NA #1 reported that the resident was confused that day. It was before 9:30 AM, the driver was driving the van back to the facility. She observed Resident #1 kept scooting towards the edge of the wheelchair and was messing with his lap belt. She reminded him to sit back and to stop messing with his lap belt. She observed the resident's hands on the lap belt so she could not see if the resident had unbuckled the belt or not but she kept telling him to leave his lap belt alone. It was about 2 miles away from the facility when the driver had to quickly step on the brake and the resident slid out of his wheelchair. Resident #1 ended up kneeling with his left stump on the floor. The driver pulled over, and she assessed the resident and noted that his left stump was bleeding through the dressing. She applied pressure on the dressing to stop the bleeding. She and the driver lifted the resident up, put him back in the wheelchair and the driver proceeded to drive back to the facility. The driver pulled in front of the facility and called the nurse. Nurse #1 came out and assessed the resident. NA #2 also came out and changed the dressing to the resident's left stump. NA #1 further stated that she was instructed not to move a resident after an accident until assessed by a nurse but they did not have any choice, they had to put him back in wheelchair in order to drive back to the facility. NA #1 also stated that the driver should be the one to call the facility and inform them about the accident. At 11:05 AM, NA #1 was again interviewed and she stated that she could not remember if the shoulder strap was applied by the driver to Resident #1 during the transport on 1/19/17. On 1/25/17 at 10:40 AM, the van driver was interviewed. He stated that he had been driving the facility van for 2 years. He was trained by the maintenance person on transportation safety which included the proper procedure in securing residents and the wheelchair in the van before he started driving the van. The van driver indicated he was transporting Resident #1 to the hospital on [DATE] for IV infusion. The hospital had requested to have a staff member to sit with the resident during the infusion and so NA #1 went with him. He went back to the hospital to pick up Resident #1 because the hospital was not able to insert an IV access to the resident. It was about 9:30 AM, he loaded the resident, secured his wheelchair to the floor and put his belt on. He proceeded to drive back to the facility. It was about a mile away from the facility, when a car pulled out in front of him. He applied the break with more force than normal and then he heard something on the back of the van and saw the resident had fallen to the floor. He pulled over and asked the resident if he was okay and he replied that he was fine. His buttock was on the floor and his left stump was bleeding. With the help of NA #1, they lifted the resident and put him back in his wheelchair. NA #1 applied pressure on the stump to stop the bleeding. The van driver stated that he could move a resident as long as the resident was saying that he was okay. He also stated that he did not call the facility because he was a mile away from the facility. On 1/25/17 at 10:50 AM, the facility transport van was observed with the van driver and the administrator. The van was equipped with a shoulder strap and a lap belt. The driver demonstrated how to apply the shoulder strap and lap belts on the resident and on how to secure the wheelchair to the floor. He also showed where the resident and NA #1 were sitting. When asked if the shoulder strap and the lap belt were applied to the resident he replied I neglected to apply the shoulder strap because he thought the resident would be fine with the NA with him at the back of the van. On 1/25/17 at 11:01 AM, the Administrator was interviewed. She stated that she was called to go outside in front of the building to see a resident who fell on the floor of the van. She thought Resident #1 fell while the van was parked. She was not informed that the resident fell on their way back to the facility. She immediately called the nurse to assess the resident and to change the dressing on the resident's left stump. The Administrator also revealed that the driver did not inform her that the shoulder strap was not applied during the transport. She indicated that she had written the driver up on 1/25/17 for not following the transportation safety on properly securing the resident during transport. She stated that it was okay for the staff to move the resident before a nurse or any qualified person had assessed the resident as long as the resident was alert and oriented and was able to tell that he/she was okay. The Administrator also indicated that she did not expect the driver to call the facility because they were a mile away from the facility when the accident happened. She also indicated that the driver and NA#1 were reeducated on transportation safety (video of manufacturer on properly securing the resident) and the facility policy and procedure on accident and incident on 1/23/17. She revealed that she had created a monitoring tool to observe the driver prior to and upon returning to facility from appointments to ensure that the resident and the wheelchair were properly secured. The monitoring to be done by the Administrator or the DON on every other transport starting 1/25/17. The records of the van driver were reviewed. The driver had signed the facility's commercial auto fleet policy and fleet driver's commitment on 1/13/15 which included seat belt utilization is required of all drivers and passengers in company owned vehicles and in vehicles operated on company business. The records also indicated that the driver was trained on transportation safety using the manufacturer's instruction on how to secure the wheelchair and the resident in the van on 3/21/16. On 1/25/17 at 2:10 PM, the attending physician of Resident #1 was interviewed. She stated that the staff had informed her of the van accident involving Resident #1 and the resident was assessed by the Nurse Practitioner the day of the fall. She stated that the next day the resident was transferred to the emergency room due to low hemoglobin/hematocrit level which was not related to the fall. She also indicated that she expected the staff to move the resident from the floor and to get somebody from the facility to assess the resident. On 1/25/17 at 2:35 PM, the Administrator and the Vice President (VP) of Operation were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 1/26/16 at 2:20 PM. The credible allegation indicated: The resident was evaluated by a registered nurse on January 19, 2017 and initiated first aid treatment to the stump which included assessment to ensure bleeding had stopped and a new dressing was applied. The resident who was alert and oriented denied any injuries. The Nurse Practitioner evaluated the resident on January 19, 2017 and no injuries from the fall were noted. The resident was discharged to the hospital on January 20, 2017 for health issues unrelated to the fall. The nursing staff stated to the Director of Nursing that the resident was monitored for the fall however the nurses notes do not reflect the monitoring. The nurses who should have documented have received a disciplinary action for failing to document any falls or events that occur. All nurses will be in-serviced today, January 26, 2017 by the Director of Nursing to include the following: 1. Timely assessment of residents; 2. Timely completion of incident/accident reports; 3. Monitoring of residents using the Acute Episode charting guidelines 4. Communication with the Director of Nursing and Administrator concerning any falls or events that occur. For any nurse not in-serviced today they will not be allowed to work until the in-service is completed with the Director of Nursing. Incident reports were reviewed on January 24, 2017 for the past three (3) months by the Administrator and Vice President of Operations to determine if there have been any other accidents/incidents involving the transportation of residents and there were no other residents were affected. The Transportation driver and Certified Nursing Assistant were re-educated January 24, 2017 by the Administrator and Vice President on the accident and incident policy which states that a resident is not to be moved if there is an accident while on the facility van, and that 911 should be called to make determination if medical attention is required and transportation to the hospital is necessary. The Transportation Driver also has demonstrated competency to the Administrator of the physical restraint systems on the van according to the manufacturer specifications. All staff will be in-serviced on today January 26, 2017 by the Administrator on transportation safety and the accident and incident policy to ensure anyone who assists with transports is aware of the proper policy and procedure which includes proper securement of the restraints system. For any employee not in-serviced today the employee will not be allowed to work until the in-service is completed with the Administrator. All authorized employees who provide transportation have been trained; however, no other employee will be allowed to drive the transportation van until they have received the in-service. Any new authorized drivers who transport residents are required to demonstrate comprehension and provide documented evidence of proper use and competency of the physical restraint systems on the facility van according to manufacturer specifications (to be done when added to drivers list and annually thereafter) to the Administrator or Director of Nursing. The facility will ensure safe driving training provided includes proper use of cell phones , what to do in the event of a mechanical breakdown of vehicle, what to do in the event of an accident and resident safety during event. The training will also include who to report an incident to and how to report to the administrator. The facility will ensure annual reviews of driver records for all authorized drivers by contacting the insurance company annually for driving record review and negative findings for authorized drivers. Drivers with negative findings will not be allowed to drive company vehicles or facility van. This information will be maintained in a file in the administrator ' s office. The facility will visibly conduct quality assurance checks to ensure that drivers are fastening restraints appropriately and safely and document the results of the quality assurance checks in the QA log. This will be done for the next twenty (20) transports per the facility van, every other transport will be inspected prior to leaving the facility and upon return to the facility by the Administrator or DON to ensure the resident is properly secured in the van and seat belt is properly attached and locked in place. If any issues are found with the proper securing of the resident while being transported, the van driver will not be allowed to transport any future residents and will receive disciplinary action up to and to include termination of employment. The credible allegation of compliance was verified on 1/26/17 at 2:30 PM by interviewing the staff including the van driver that they have received in-service on the facility's accident/incident policy and procedure. The in-service records were reviewed and the in-service on accident/incident policy and procedure was started on 1/26/17. The in-service records for the van driver was reviewed and he was reeducated on the transportation safety and in properly securing the resident during transport on 1/23/17 by the VP of Operation. He also watched a video of the manufacturer instruction on how to properly secure the resident. The monitoring tool was also reviewed and the administrator had observed the driver prior to and upon return from appointments to ensure that the driver was properly securing the resident.

Based on record review, observation and physician and staff interview, the facility's administration failed to operationalize manufacturer's recommendations for transporting a resident in the transportation van resulting in a fall with a bleed on the left leg stump needing a pressure dressing. The facility administration failed to enforce a policy that would address communication with licensed staff and assessment from licensed staff in cases of incidences within the transportation van. After the resident fell in the van, the facility staff moved the resident back into the wheelchair and drove him back to the facility without assessment from licensed staff for potential injury. This was evident in 1 (Resident #1) of 1 sampled resident who was transported using the nursing home's van. Immediate jeopardy began on 1/19/17 when Resident #1 fell in the van during transport. The staff put the resident back into the wheelchair and drove him back to the facility without assessment for potential injury. The immediate jeopardy was removed on 1/26/17 at 2:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff members were in-serviced on the facility's policy and procedure on accidents/incidents and all nurses on timely assessment, monitoring and reporting of any accidents/incidents. Findings included: This example was a cross reference to: F323 - Based on record review, observation and physician and staff interview, the facility failed to secure a resident in the van during transport according to manufacturer's recommendations causing the resident to fall for 1 (Resident #1) of 1 sampled resident who was transported using the nursing home's van. Resident #1 hit his left stump on the floor during the fall resulting in active bleeding that was stopped after staff applied a pressure dressing. On 1/25/17 at 11:01 AM, the Administrator was interviewed. She stated that she started working at the facility as administrator in May 2016. The Administrator added that she was not informed by the van driver that the resident was not secured with a shoulder strap during the transport. She further stated that the van driver might have not used the shoulder strap because it was uncomfortable for the resident. F309 - Based on record review, observation and physician and staff interview, the facility failed to call for help for an acute assessment of Resident #1 who fell from a wheelchair during van transportation. The resident hit his left stump on the floor during the fall resulting in active bleeding. Staff repositioned the resident back into the wheelchair and continued the transport to the facility. Following initial treatment to the stump, there was no evidence that the resident was monitored after the fall. This problem affected one (Resident #1) of one sampled resident who was transported using the nursing home's van. On 1/24/17 at 1:40 PM, the Director of Nursing (DON) was interviewed. She stated that the nurses were still adjusting with the electronic documentation. She added that Resident #1 was monitored by the nurses after the fall but the nurses failed to document the monitoring in the resident's medical records. On 1/25/17 at 11:01 AM, the Administrator was interviewed. She stated that she started working at the facility as administrator in May 2016. The Administrator stated that she did not expect the van driver to call the facility to inform about the van accident because they were a mile away from the facility. She also indicated that it was okay for the staff to put the resident back into the wheelchair after the fall because the resident was alert and oriented and he was able to tell that he was okay. On 1/25/17 at 2:35 PM, the Administrator and the Vice President (VP) of Operation were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 1/26/16 at 2:20 PM. The credible allegation indicated: The Administrator is responsible to ensure the facility is attaining and maintaining the highest practicable physical, mental, and psychosocial well - being of each resident. The Administrator is responsible to ensure that the staff is trained according to the policies of the facility upon employment, annually and as the need arises to: 1. All authorized drivers who transport residents demonstrate comprehension and provide documented evidence to proper use of the physical restraint systems on the facility van according to manufacturer specifications (to be done when added to drivers list and annually thereafter) 2. All authorized drivers will be required to participate in training which will include the Accident and Incident policy as well as proper use of the physical restraint system on the facility van. 3. Ensure safe driving training provided includes proper use of cell phones , what to do in the event of a mechanical breakdown of vehicle, what to do in the event of an accident and resident safety during event. The training will also include who to report an incident to and how to report to the administrator. 4. Ensure annual reviews of driver records for all authorized drivers by contacting the insurance company for the facility to receive the results of the drivers check. This information will be maintained in a file in the administrator ' s office. 5. To review all incident/ accident reports to ensure the Safety Committee is implementing interventions to prevent falls. The Vice President of Operations will be responsible to: 1. Re-educate the Administrator concerning the importance of following and implementing facility policies which was completed on January 24, 2017; 2. Review all new employee records for the next three (3) months to ensure training has been completed on the transportation and accident/incident policies. 3. Review the QA Committee minutes to ensure the facility is addressing issues identified at the Safety Committee. 4. Review 30% of all of the Accident/Incident reports for the next fourteen (14) days, then 15% for seven (7) days and then 5% for seven (7) days. If at that time there are no issues the accident/incident reports will be reviewed on an as needed basis, which was initiated on January 24, 2017. 5. If an accident occurs the Administrator or Director of Nursing is required to report to the Vice President of Operations and incident will be reviewed to ensure correct protocol is being followed. If the Vice President of Operations determines that compliance is not achieved and sustained it is the responsibility of the Vice President of Operations to re-educate or arrange education for the Administrator. If after re-education is completed and compliance is not sustained then disciplinary action will be taken. The Administrator and/or Director of Nursing and Vice President of Operations initiated the above interventions on January 24, 2017 and will continue to complete the interventions as they come due. The credible allegation was verified on 1/26/17 at 2:30 PM by interviewing the staff including the van driver that they have received in-service on the facility's accident/incident policy and procedure. The in-service records were reviewed and the in-service on accident/incident policy and procedure was started on 1/26/17. The in-service records for the van driver was reviewed and he was re-educated on the transportation safety and in properly securing the resident during transport on 1/23/17 by the VP of Operation. The van driver also watched a video of the manufacturer's instruction on how to properly secure the resident. The monitoring tool was also reviewed and the administrator had observed the driver prior to and upon return from appointments to ensure that the driver was properly securing the resident.

Based on record review, observation and physician and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedure and failed to monitor the intervention put into place following the 8/14/15 and 8/4/16 recertification surveys. The facility has repeat deficiency on accidents (F323) on the recertification surveys of 8/4/15 and 8/14/16 and on a complaint investigation survey of 1/26/17. The continued failure of the facility during the three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Immediate jeopardy began on 1/19/17 when Resident #1 fell in the van during transport and was removed on 1/26/17 at 2:20 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure all staff members were in-serviced on the facility ' s policy and procedure on accidents/incidents and all nurses on timely assessment, monitoring and reporting of any accidents/incidents. Findings included: This tag is cross referred to: F323 - Accidents - Based on record review, observation and physician and staff interview, the facility failed to secure a resident in the van during transport according to manufacturer's recommendations causing the resident to fall for 1 (Resident #1) of 1 sampled resident who was transported using the nursing home's van. Resident #1 hit his left stump on the floor during the fall resulting in active bleeding that was stopped after staff applied a pressure dressing. During the recertification survey of 8/14/15 and 8/4/16, the facility was cited F323 for not securing the side rails to the bed frames. On 1/25/17 at 4:53 PM, the Administrator was interviewed. She stated that she started as administrator of the facility in May 2016 and she was the head of the facility's quality assurance (QA) committee. The members were the department heads, Medical Director, Pharmacist, Registered Dietician and herself. The committee had met quarterly. She stated that she was aware that accident was a repeat tag but there had been no other incident involving the van except on 1/19/17. On 1/25/17 at 2:35 PM, the Administrator and the VP of Operation were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 1/26/16 at 2:20 PM. The credible allegation indicated: The facility currently has and maintains a quality assessment and assurance committee. Added to the responsibilities of the QA committee will be the following: (1) The Van Driver has been re-educated by the Administrator and Vice President of Operations that any accident, no matter how minor, occurring while placing a resident in the van and properly applying and securing the vehicle restraint system, during actual transport and during un-securing the restraint system and disembarking of the resident from the van MUST be reported immediately by phone or in person to the administrator. In the absence of the Administrator or inability of to reach the administrator, the van driver must report the incident verbally to the Director of Nursing. If unable to reach the Director of Nursing the Van Driver must immediately report the incident to the Vice President of Operations. He has also been re-educated on not moving the resident until the resident has received proper assessment and care. (2) Any new Van Driver or anyone else transporting a resident will be educated on the above before being allowed to transport a resident. (3) The facility administrator will review of all of the Accident/Incident reports daily for proper interventions for all incident and accidents and will report to the QA Committee any interventions not properly taken by staff at time of the incident. (4) Staff will be re-in serviced immediately by the Administrator/Director of Nursing/Vice President of Operations on the interventions that should have been taken. (5) The Administrator and/or Director of Nursing will inspect every other transport for the next twenty (20) transports prior to the van leaving the facility campus and upon returning to the facility campus for proper attachment of all vehicular restraint systems properly attached in the facility van. After the first ten have been inspected, the Administrator and/or Director of Nursing will inspect four (4) per month for the next three (3) months, three (3) per month for the following three (3) months and then two (2) per month thereafter. The inspections will be logged on an inspection form and will be submitted to the Safety and Quality Assurance Committees. (6) The Safety Committee will review the Van Log information listed under bullet point (5) above to ensure compliance with safety regulations as recommended by the manufacture of the van. (7) Any deviation from the manufactures procedures for properly securing the chair and resident in the van prior to transportation will result in termination for the van driver. (8) The Quality Assurance Committee will be responsible to review the Safety Committee Minutes to ensure that interventions have been initiated and to ensure that solutions are achieved and sustained. (9) The Vice President will review the Safety Committee and Quality Assurance Committee Minutes along with the van log to ensure compliance for the next twelve (12) months. The credible allegation was verified on 1/26/17 at 2:30 PM. Review of in-service records revealed the van driver was re-educated on transportation safety and in properly securing residents during transport on 1/23/17. Interview with staff members including nurses, nursing assistants and van driver revealed that they have received in-service on the facility's accident/incident policy and procedure starting on 1/26/17. Interview with the Administrator revealed that she was responsible for making sure that incident and accidents reports and the van monitoring log were reviewed daily by the safety committee and interventions were put in place. Interview with the VP of Operation revealed that she was responsible for reviewing the QA minutes to ensure interventions put into place were implemented. On 1/26/17 the van's monitoring log was reviewed and interview with the Administrator revealed she had observed the van driver prior to him leaving the facility and upon his return from appointments on 1/26/17 to ensure that the driver was properly securing the resident in the van.

Based on record review and staff interview the facility failed to update the care plan and add an intervention to relieve pressure and prevent a pressure ulcer on the right outer thigh that progressed to an unstageable pressure ulcer for 1 or 2 residents reviewed for pressure ulcers (Resident#28) and 2 of 3 residents reviewed for positioning (Resident #77 and #15). Findings included: 1. Resident #28 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment with an assessment reference date of 7/1/15 revealed that Resident #28 was cognitively intact and required extensive assistance with activity of daily living (ADL ' s). The MDS further indicated that Resident #28 was at risk for pressure ulcers and had two stage 4 pressure ulcers present on admission and 7 unstageable present on admission. The most severe with eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges). The care plan initiated on 7/16/15 indicated a problem of impaired skin integrity-pressure ulcer stage 4, has history of infections to ulcers and refuses care at times, incontinent care and dressing changes. The approaches included monitor diet, medicate per order, measure and record weekly, inform physician of changes, encourage to be off site as much as possible, [MEDICATION NAME] low air loss mattress at all times for pressure reduction and comfort, monitor for signs and symptoms of infection, temperature, change in condition, incontinent care timely- resident refuses incontinent care at times, evaluate plan of treatment if not improvement or worsening noted 2-4 weeks time, reassess the treatment plan, pressure reduction cushion in wheelchair to assist with pressure reduction at all times. The weekly wound and skin status report dated 8/13/15 revealed an area to the right outer thigh that was facility acquired on 7/1/15 described as a blister that opened, measurements .5 cm in length , 1.5 cm in width and depth .10 cm. The measurements on 8/11/15 revealed measurements of 7.5 cm in length, 4.5 cm in width and 1.5 cm in depth described as unstagable with 50% slough and 50% eschar. The care plan was not updated on 8/4/15 to identify a new unstageable pressure ulcer on the right outer thigh with specific interventions for pressure reduction and positioning for Resident #28 ' s thighs while in the wheelchair. The physical therapy progress note dated 7/31/15 revealed that Resident #28 was treated 7/2/15-7/31/15 for muscle weakness. The discharge summary indicated under clinical impression that Resident #28 would benefit from being in a larger wheelchair where he would fit better and his lower extremities would be in a better position with patient refusing to go into a larger wheelchair at this time. The discharge summary further indicated that Resident #28 was educated on why he should go into a larger wheelchair with instructing him it would help with position on his lower extremities and keep him from pressing against the sides of the wheelchair and if patient continues to sit in his wheelchair the way he is he will most likely develop pressure sores and his lower extremities will get stiffer and it will become harder to do ADL ' s. A review of the physicians progress note dated 8/4/15 indicated the visit was for a wound check and patient was noted to have a new wound on his right lateral thigh. The wound has a black area and has significant drainage, redness and warmth around the new wound. Per staff the patient is sitting in his wheelchair all day and his legs pressed against the metal bar of the arm rest. Patient shows no signs of pain. The right lateral thigh is unstagable with thick eschar. A physicians order dated 8/4/15 indicated to give [MEDICATION NAME] 300 milligrams 2 tablets by mouth every day for 10 days for infected thigh wound and treat thigh wound with santyl (enzyme [MEDICATION NAME] ointment), calcium alginate (antimicrobial action that absorbs drainage) and cover with occlusive dressing. During an interview with the wound care nurse on 8/13/15 at 10:00 AM revealed that all of Resident #28 ' s wounds were present on admission and have improved and decreased in size. The right lateral thigh is facility acquired and about a week ago the nurse aide reported a blister on the right outer thigh caused by wheelchair armrest. The patients thigh rest against the armrest. The patient gets up in the morning and wants to stay up all day. The physical therapist recommended foam to be applied and maintenance applied foam to both armrest bars on 8/4/15. An observation on 8/13/15 at 10:38 AM revealed Resident #28 being self-mobile in the reclining wheelchair and interacting with other residents in the hall. The pressure reduction cushion was in the wheelchair and both armrest were covered with foam. Resident #28 was positioned in the center of the chair and there was approximately a 2 inch space between his thighs and the wheelchair armrest. During an interview with Resident #28 he indicated that he felt his thigh pressing on the arm rest and reported it and that is when the foam was applied by maintenance. Resident #28 indicated that the area on his thigh was a blister and now it is a large area they are treating. He stated that if staff would position him in the center of the wheelchair his thighs did not touch the bars. He did not want another wheelchair because he was comfortable in the one he had. During an interview with Nurse Aide (NA) #1 on 8/13/15 at 1:30 PM indicated that she was aware to keep Resident #28 thighs away from the wheelchair armrest. The Daily Care Guide is used to inform the NA ' s on the resident care needs. An interview with Nurse #1 at 2:30 PM on 8/13/15 indicated that the area on Resident #28 ' s right thigh started as a blister and was treated with skin prep. It was reported that the area was caused by the wheelchair. Nurse #1 further indicated that therapy checked the wheelchair and recommended foam covering in the bars. The NA ' s are aware to report any skin changes to the nurse and use the Daily Care Guide to inform them of the resident care needs. An interview with the MDS coordinator on 8/13/15 at 2:07 PM revealed that the care plan is updated each morning by the report from morning clinical meeting and review of pink physician ' s telephone orders. She further indicated that she was not aware of a new pressure ulcer on Resident #28 ' s right thigh that needed pressure reduction when in the wheelchair from wheelchair armrest bars. During an interview with the Director of Nurses on 8/13/15 at 3:20 PM revealed that it is her expectation that the NA ' s report any skin changes to the nurse on duty and to keep resident turned and repositioned as indicated on their Daily Care Guide . It is her expectation that care plans be updated each morning with residents change in condition by the MDS coordinators. During an interview with the physical therapist #1 on 8/14/15 at 11:00 AM revealed that Resident #28 was discharged from therapy on 7/31/15 and she recommended a wider wheelchair which the resident totally refused and the physician asked her to look at the wheelchair for pressure relief and she asked maintenance to get some foam on the arm rest bars and it has been applied. There is a space on each side between his legs and the arm rest bars, it depends on his positioning. 2. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #15 had moderate impairment with memory and cognition, no behaviors were exhibited and she required extensive assist of 2 staff for bed mobility, transfers and toileting. This MDS assessed her balance for transfers as unsteady without human assistance. Review of the care plan dated 7/22/15 indicated Resident #15 had problems of right [MEDICAL CONDITION], poor balance, curvature of the spine and weakness. The approaches for this problem included the use of a standard high back reclining wheelchair which was to be positioned to recline at 10 degrees for comfort. This care plan included a problem of being at risk for decline in range of motion which required restorative nursing. The approaches for restorative included application of a posture vest which was to be worn every day as tolerated when seated in the wheelchair. A soft neck collar was to be applied after range of motion was provided to her neck. Review of the most recent physician's order [REDACTED]. Observations of Resident #15 on 8/13/15 at 11:30 AM revealed she was seated in a standard wheelchair without a soft neck collar or the posture vest. Interview with the Administrator on 8/13/15 at 2:45 PM revealed care plans should be updated as needed when changes occur. Interview with the MDS nurse on 08/14/15 at 9:27 AM revealed the restorative care plan was not updated. The interventions were no longer required for the resident. A previous MDS nurse may have missed it due to human error. The MDS nurse also missed it as she was in training. The MDS nurse further explained Resident #15 was the first care plan she had updated while in training. 3. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] indicated Resident #77 was severely impaired with communication, decision making abilities and did not respond verbally to questions. Total assistance was required by one to two staff for transfers, toileting, hygiene and bed mobility. Resident #77 was unable to walk. The MDS indicated functional limitation of the extremities could not be determined. The care plan dated 5/21/15 included problems of totally dependent on staff for all care needs and was incontinent of bowel and bladder. The care plan included a problem that she did not give any indication that she realizes anything is going on around her and does not respond unless direct care is being done. Approaches included staff were to provide bathing, dressing, grooming/hygiene and incontinence care as needed. The care plan addressed a problem of at risk for injury due to left side flaccid and receives an anticoagulant. The care plan was updated on 8/4/15 due to Resident #77 had her left leg caught in the side rail. The approaches included padding of both side rails. Observations on 8/11/15 at 9:57 AM revealed the left full side rail was padded. The right full side rail was not padded. Observations o 08/13/15 at 8:12 AM revealed the right side rail did not have padding. Observations on 8/13/15 at 9:36 AM revealed Resident #77 was sideways in the bed. Her legs were positioned to the right side of the bed with her right foot pushed against the inside of the full side rail. The right side rail was not padded. Observations on 08/13/15 at 9:59 AM revealed Resident #77 moved her right foot freely, and put the right foot through the side rail. Resident #77 was able to remove the foot from the side rail. On 8/13/15 at 2:38 PM an interview was conducted with the Director of Nursing (DON). Interview with the DON revealed Resident #77 was to have the left side rail padded. She was not aware the care plan included the right side rail. Further interview revealed she favored the left side of the bed and would turn to that side. Observations on 8/14/15 at 7:56 AM and 8/14/15 at 8:08 AM revealed Resident #77 was lying in bed with her legs and feet on the right side of the bed. Observations were made with the DON on 8/14/15 at 8:08 AM. The DON observed the resident with her legs and feet sideways towards the right side rail. The DON was informed the resident had her foot on the side rail at a previous observation that morning. On 8/14/15 at 9:24AM an interview was conducted with the MDS nurse regarding the care plan updates for padding to both side rails. The MDS nurse explained she wrote both side rails during a morning staff meeting when the incident occurred with Resident #77 ' s foot through the side rail. She had written to use padding on both side rails. Further interview revealed the incident involved the left side rail and she favored that side rail. The MDS nurse explained she may have updated the care plan incorrectly.

Based on observation, record review, staff and resident interviews the facility failed to ensure a clean and sanitary pressure ulcer on the right heel and failed to implement an intervention to relieve pressure and prevent a pressure ulcer on the right outer thigh that progressed to an unstageable pressure ulcer for 1 or 2 residents reviewed for pressure ulcers. (Resident#28) Findings included: Resident #28 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment with an assessment reference date of 7/1/15 revealed that Resident #28 was cognitively intact and required extensive assistance with activity of daily living (ADL ' s). The MDS further indicated that Resident #28 was at risk for pressure ulcers and had two stage 4 pressure ulcers present on admission and 7 unstageable present on admission. The most severe with eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges). The care plan initiated on 7/16/15 indicated a problem of impaired skin integrity-pressure ulcer stage 4, has history of infections to ulcers and refuses care at times, incontinent care, dressing changes. The approaches included monitor diet, medicate per order, measure and record weekly, inform physician of changes, encourage to be off site as much as possible, [MEDICATION NAME] low air loss mattress at all times for pressure reduction and comfort, monitor for signs and symptoms of infection, temperature, change in condition, incontinent care timely- resident refuses incontinent care at times, evaluate plan of treatment if not improvement or worsening noted 2-4 weeks time, reassess the treatment plan, pressure reduction cushion in wheelchair to assist with pressure reduction at all times. The care plan was updated on 7/28/15 and a problem was added- maggots in wound right foot. The approach added was -removed (maggots)-no roommate x 7 weeks and room cleaned daily. The weekly wound and skin status report dated 8/13/15 revealed an area to the right heel that was present on admission (6/5/15) that was unstageable, 90% necrotic, measurements 2 centimeters (cm) in length, 1.6 cm in width and depth was undetermined. The measurements on 8/11/15 revealed measurements of 2cm in length,2cm in width, .5cm in depth at a stage 4 with 25% granulation and 75% slough and skin edges well defined and healthy. The weekly wound and skin status report dated 8/13/15 revealed an area to the right outer thigh that was facility acquired on 7/1/15 described as a blister that opened, measurements .5 cm in length , 1.5 cm in width and depth .10 cm. The measurements on 8/11/15 revealed measurements of 7.5 cm in length, 4.5 cm in width and 1.5 cm in depth described as unstagable with 50% slough and 50% eschar. Review of the physicians progress note dated 7/28/15 revealed that Resident #28 had black eschar on the right heel last week, today the area has a large amount of maggots coming in and out of the wound and the black eschar has completely resolved. The resident was taken to the bathroom and the wound was cleaned out with [MEDICATION NAME] and Dakin ' s solution and all the maggots were removed from the wound. The wound bed was clean with good granulation tissue. A physician's order [REDACTED]. The physical therapy progress note dated 7/31/15 revealed that Resident #28 was treated 7/2/15-7/31/15 for muscle weakness. The discharge summary indicated under clinical impression that Resident #28 would benefit from being in a larger wheelchair where he would fit better and his lower extremities would be in a better position with patient refusing to go into a larger wheelchair at this time. The discharge summary further indicated that Resident #28 was educated on why he should go into a larger wheelchair with instructing him it would help with position on his lower extremities and keep him from pressing against the sides of the wheelchair and if patient continues to sit in his wheelchair the way he is he will most likely develop pressure sores and his lower extremities will get stiffer and it will become harder to do ADL ' s. A review of the physicians progress note dated 8/4/15 indicated the visit was for a wound check and patient was noted to have a new wound on his right lateral thigh. The wound has a black area and has significant drainage, redness and warmth around the new wound. Per staff the patient is sitting in his wheelchair all day and his legs pressed against the metal bar of the arm rest. Patient shows no signs of pain. The right lateral thigh is unstagable with thick eschar. A physicians order dated 8/4/15 indicated to give [MEDICATION NAME] 300 milligrams 2 tablets by mouth every day for 10 days for infected thigh wound and treat thigh wound with santyl (enzyme [MEDICATION NAME] ointment), calcium alginate (antimicrobial action that absorbs drainage) and cover with occlusive dressing. During an interview with the wound care nurse on 8/13/15 at 10:00 AM revealed that all of Resident #28 ' s wounds were present on admission and have improved and decreased in size. The right lateral thigh is facility acquired and about a week ago the nurse aide reported a blister on the right outer thigh caused by wheelchair armrest. The patients thigh rest against the armrest. The patient gets up in the morning and wants to stay up all day. The physical therapist recommended foam to be applied and maintenance applied foam to both armrest bars. The wound care nurse indicated that on 7/28/15 the maggots were noted by Nurse # 1 who was doing wound care that day. The wound care nurse further indicated that Resident #28 sits outside a lot to smoke and he also will refuse his showers. An observation on 8/13/15 at 10:38 AM revealed Resident #28 being self-mobile in the reclining wheelchair and interacting with other residents in the hall. The pressure reduction cushion was in the wheelchair and both armrest were covered with foam. Resident #28 was positioned in the center of the chair and there was approximately a 2 inch space between his thighs and the wheelchair armrest. During an interview with Resident #28 he indicated that he felt his thigh pressing on the arm rest and reported it and that is when the foam was applied by maintenance. Resident #28 indicated that the area on his thigh was a blister and now it is a large area they are treating. During an interview with Nurse Aide (NA) #1 on 8/13/15 at 1:30 PM indicated that she was aware to keep Resident #28 thighs away from the armrest. NA #1 further indicated that there has been a problem with fly ' s because of the door going out to the smoking area. She has seen fly traps hanging in other rooms but never in his room. An interview with Nurse #1 at 2:30 PM on 8/13/15 indicated that the area on Resident #28 ' s right thigh started as a blister and was treated with skin prep. It was reported that the area was caused by the wheelchair. Nurse #1 further indicated that therapy checked the wheelchair and recommended foam covering in the bars. Nurse #1 revealed that she was doing wound care the morning of 7/28/15 and when she removed the wound dressing she saw his skin crawling with approximately 15 maggots (fly larvae) and she immediately got the physician who was in the facility. Resident #28 was taken to the shower and all the wounds were irrigated with Dakin ' s solution and the room was deep cleaned by housekeeping. Nurse #1 revealed that flies have been noticed on the halls and it was reported to maintenance and fly strips were placed in a few rooms at the end of the hall. She further stated that Resident #28 goes outside a lot to smoke and flies could have got on his wound outside, he is independent with wheelchair mobility. During an interview with the Director of Nurses on 8/13/15 at 3:20 PM revealed that it is her expectation that the NA ' s report any skin changes to the nurse on duty and to keep resident turned and repositioned as indicated on their Daily Care Guide . An interview with the physician assistant on 8/14/15 at 11:00 AM confirmed that there were maggots in Resident #28 ' s right heel and there is significant improvement since that day. She further indicated that wounds are seen by the medical staff on a weekly basis. During an interview with the physical therapist #1 on 8/14/15 at 11:00 AM revealed that Resident #28 was discharged from therapy on 7/31/15 and she recommended a wider wheelchair which the resident totally refused and the physician asked her to look at the wheelchair for pressure relief and she asked maintenance to get some foam on the arm rest bars and it has been applied. There is a space on each side between his legs and the arm rest bars, it depends on his positioning.

Based on record review, observation and staff and resident interviews, the facility failed to provide other medically related social service interventions, aside from mental health services to 1 (Resident #6) of 3 sampled residents with known inappropriate sexual, physical and wandering behaviors. The findings include: Immediate Jeopardy was identified on Resident #6 starting August 5, 2010 and the Immediate Jeopardy was brought to the administrator on January 6, 2011 at 8:50 AM. The immediate jeopardy was not removed prior to exit due to lack of a credible allegation of compliance. The findings include: 1. An undated facility policy entitled "Unmanageable Residents" read: "Each resident will be provided with a safe place of residence. Policy Interpretation and Implementation 1. Should a resident become unmanageable in any way that would jeopardize his or her safety, or the safety of others, the charge nurse must immediately: a. Provide for the safely of all concerned. b. Notify the attending physician. c. Notify the director of nursing. d. Notify the resident responsible party. 2. The charge nurse has the authority to initiate a 24-hour restraint with a physician order. 3. Should the resident pose an immediate danger beyond the control of the facility, local law enforcement may be called for assistance. 4. Every effort must be made to calm the resident. 5. Unmanageable residents will not be maintained by the facility. Discharge proceedings will be implemented by the attending physician/medical director and in accordance with current laws and regulations governing discharges. 6. Should the resident's behavior become uncontrollable the director of nursing shall have the authority to contact the family and request that they remain with the resident until the resident calms down or is transferred. 7. Completed documentation of the incident must be recorded in the resident's record, as well as an incident report filed with the administrator". Resident #6 was admitted to the facility on [DATE] with multiple diagnoses. Resident #6 had behavioral problems. He was evaluated for Level II PASRR (Preadmission Screening and Resident Review). The recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #6 was rarely/never understood under the section "cognitive patterns". The assessment further indicated that the resident had no behavior problems and was independent on locomotion on and off unit. The Resident Assessment Protocol (RAP) summary for Behavior Problem dated 07/13/10 indicated "Nature of Condition - resident (res) is alert but mostly oriented with some confusion. Resident has behavior issue of touching other females and will go in rooms and masturbate. Complications and Risks - He is at risk for causing issues with other resident if goes in their room. Factors to consider - Resident is redirected to his room and is cued not to touch other female resident and staff. Psych has seen resident. MD (Medical Doctor) is aware. Social is involved. Referral - none further at this time". The care plan for Behavior Problem dated 07/14/10 was reviewed. The problem was "(name of the resident) has some inappropriate sexual behavior" and the goal was "(name of resident) will have no inappropriate sexual behavior with staff ". The approaches were "complete behavior sheets as indicated, encourage resident to take medications as ordered, if mood can't be altered and he begins to resist care, leave him in a safe environment and return later to attempt care, refer to psych for eval (evaluation) if indicated and remind resident that behavior should not happen". The care plan for Behavior Problem dated 10/14/10 was reviewed. The care plan problem, goal and approaches were the same with the 07/14/10 care plan with the addition of "he does go in other rooms" to the care plan problem and "redirect if goes in other rooms" to the care plan approaches. The current Medication Administration Record (MAR) for January, 2011 was reviewed. The MAR revealed that the resident was currently receiving Paxil (antidepressant medication) 40 mgs (milligram) daily (started 06/15/10), Trileptal (anticonvulsant medication) 150 mgs twice a day (started 08/09/10) and Seroquel (antipsychotic medication) 250 mgs twice a day (increased on 12/29/10) to control his behaviors. The MD (Medical Doctor) progress notes of Resident #6 were reviewed. The notes dated 09/07/10, 10/05/10, 10/12/10, 11/09/10 and 12/13/10 did not address/mention any behavior problems. The MD (Medical Doctor) progress notes of Resident #6 were reviewed. The notes dated 09/07/10, 10/05/10, 10/12/10, 11/09/10 and 12/13/10 did not address/mention any behavior problems. The social worker and the nurse's notes were reviewed. The notes revealed the resident had continued to exhibit inappropriate sexual, physical and wandering behaviors. In April, 2010, the resident had 3 inappropriate sexual behaviors documented (04/13/10, 04/21/10 and 04/28/10). In June, 2010, the resident had 5 inappropriate sexual and physical behaviors/wandering behavior documented (06/04/10, 06/07/10, 06/16/10, 06/18/10 and 06/29/10). In July, 2010, the resident had two inappropriate sexual behaviors documented (07/13/10 and 07/14/10). In August, 2010, the resident had two documented inappropriate sexual behaviors/wandering behavior documented (08/05/10 and 08/09/10). In October, 2010, the resident had three inappropriate sexual and physical behaviors/wandering behavior documented (10/01/10, 10/02/10 and 10/28/10). In November, 2010, the resident had one inappropriate sexual/physical behavior documented (11/11/10). In December, 2010, the resident had three inappropriate sexual and physical behaviors documented (12/08/10, 12/20/10 and 12/3010). In January, 2011, the resident had one documented inappropriate sexual behavior (01/04/11). Review of the care plan revealed that there were no changes to the approaches as of 01/06/11 to consider other behavioral interventions. On 01/05/11 at 11:05 AM, the social worker was interviewed. She stated that the inappropriate behaviors reported to her by the nurses and the residents were reported to the administration. She further stated that the resident was being seen by the mental health provider and the Nurse Practitioner. On 01/05/11 at 11:50 AM, the administrative staff #1 was interviewed. She stated that she was aware of the resident's inappropriate sexual and physical behaviors. She stated that mental health had been working with the resident's medications, the Nurse Practitioner was notified and resident had been sent to the emergency room due to his behaviors. She also stated that the emergency room would send the resident back without doing anything. On 01/05/11 at 12:05 PM, administrative staff #2 was interviewed. She stated that she was not aware of the resident's inappropriate sexual and physical behavior until today. She further stated that after talking with the staff, the staff indicated that they had discharged other residents with behavior problems and had not been to Resident #6 yet. Interview with Nurse #1 on 01/05/11 at 2:50 PM revealed that she had informed the administration of the Resident #6's inappropriate behaviors. On 01/05/11 at 3:05 PM, administrative staff #3 was interviewed. She stated that she was aware of some of the resident's inappropriate sexual and physical behaviors but not all of them. She stated that mental health was working with the resident, the Nurse Practitioner was made aware of his behaviors and he had been sent to the emergency room for evaluation of his behavior. Interview with Nurse #1 on 01/05/11 at 4:40 PM revealed that she had informed the administration of the Resident #6's inappropriate behaviors. On 01/06/11 at 11:20 AM, the Nurse Practitioner was present during the QA (Quality Assurance) interview. The Nurse Practitioner acknowledged that she was aware of some inappropriate sexual and physical behaviors of Resident #6 but not all. She stated that mental health was working with the resident and she also indicated that the resident had a history of [REDACTED].#6's behaviors were not mentioned/addressed in the MD progress notes. On 01/06/11 at 2:17 PM, a staff member from mental health was interviewed. She stated that she had started working with Resident #6 in 2010. She revealed that she was aware of behaviors reported to her by nurses. She stated that when staff reported behaviors, she gives recommendation and the Nurse Practitioner decides to agree or not to agree to the recommendation. She also indicated that these behaviors were typical behaviors of a resident with Mental Retardation or Schizophrenia.

Based on survey results dated January 6, 2011, the facility failed to provide other medically related social service interventions, aside from mental health services to 1 of 3 sampled residents with known inappropriate sexual, physical and wandering behaviors. Immediate Jeopardy (IJ)began on August 5, 2010. The Immediate Jeopardy was identified on January 6, 2011. The facility provided an acceptable credible allegation on January 25, 2011. The immediate jeopardy was removed on January 20, 2011 during the survey of January 26, 2011. The credible allegation was validated on January 26, 2011. Validation of the Credible Allegation of Compliance was accomplished through observation and interviews with nursing assistants, nursing staff, social worker, director of nursing and administrator. The facility provided evidence of in-services on reporting inappropriate behaviors, defining inappropriate behaviors and how to identify and manage residents with sexually aggressive, wandering and physically aggressive behavior. Validation process included record review and observation of sampled residents. The validation process included review of the facility's monitoring tools, which demonstrated active and ongoing monitoring for sexually aggressive and wandering behaviors. Based on staff interviews and record review, the immediate jeopardy was removed during the January 26, 2011 survey . The facility remains out of compliance at a Scope and Severity level E which constitutes a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assurance committee.