Every finding on record at Pinehurst Healthcare & Rehabilitation Center

Based on observations and staff interviews, the facility failed to label, date, and seal leftover food stored ready for use in 1 of 1 walk-in refrigerator, 1 of 1 walk-in freezer and 1 of 1 reach-in refrigerator. This practice had the potential to affect food served to residents.The findings included: a. Accompanied by Dietary Aide #1, an observation was made of the walk-in refrigerator on 4/27/26 at 6:30 AM. An undated piping bag, partially filled with whipped topping, was sitting on the shelf of the walk-in refrigerator. Dietary Aide #1 stated the whipped topping was likely used on desserts from the previous day. b. An observation was conducted of the walk-in freezer on 4/27/26 at 6:32 AM which contained one undated and open-to-air bag of twenty biscuits and one undated partially used bag of hash browns. Dietary Aide #1 was unable to state when the packages had been opened. c. An observation was conducted of the reach-in refrigerator on 4/27/26 at 6:34 AM. The reach-in refrigerator contained one bag of opened and undated turkey lunchmeat and seven undated zipper sealed bags of food containing a sandwich, marshmallow pie, oatmeal pie, and peanut butter crackers labeled dialysis ready. Dietary Aide #1 was unable to state when the lunchmeat had been opened or when the bags of food had been prepared. An interview was conducted with Dietary Aide #1 on 4/27/26 at 6:35 AM who stated all foods should have been wrapped and sealed, dated, and labeled with their contents. On 4/27/26 at 6:38 AM [NAME] #1 was interviewed and stated he was unaware when the zipper sealed storage bags labeled dialysis ready were prepared and explained they should have been dated. On 4/27/26 at 12:45 PM Corporate Dietitian #1 was interviewed and stated all foods should have been wrapped and dated when they were opened or prepared. On 4/28/26 at 11:37 AM the Dietary Manager (DM) was interviewed and stated she was responsible for monitoring the freezer and refrigerators to ensure food items were properly dated and labeled. The DM stated she was unsure why the items were not dated when they were opened. The Director of Nursing was interviewed on 4/30/26 at 10:57 AM and stated all foods should be covered and stored correctly and dated if they were opened.

Based on record review, resident, Nurse Practitioner (NP), and staff interviews, the facility failed to speak to a resident in a dignified manner causing the resident to feel shocked, angry, hurt and embarrassed for 1 of 1 resident reviewed for dignity (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE]. A review of the nursing progress notes dated 2/3/26 at 1:52 PM revealed a note written by Nurse #9 that read: When the resident was asked about taking his morning medications Nurse #9 bumped his bed several times to wake him up and offer his morning medication along with getting his blood sugar reading. The Resident had covers pulled over his head and refused to respond. He was asked several times before breakfast. When the reporting nurse came in again at lunch time, looked behind the privacy curtain and resident was in the same spot. He did allow his blood sugar reading to be done by another staff member. Resident requested his medication that was pulled and when approached resident in his room at bedside he stated, oh so you brought me my medications huh? Reporting nurse I came in several times and called your name and bumped your bed to wake up and you haven't/wouldn't respond. Resident stated, You are a lying bit*h, you haven't brought me sh*t Again, reporting nurse was holding the cup of medications to offer them to him but stated to the resident, If I try to wake you up and you decide not to respond then I can't do anything but go on. Resident stated, naw bit*h that's your job to wake me up. Reporting nurse, Considering you have to choose to be noncompliant and continue to refuse your medications all I can do is try and wait, but I will not leave medications in your room at bedside. Resident then stated (something to this effect), bit*h get out my room and take them da*n meds with you, you lying bit*h, you did try to wake me up. Reporting nurse was already at door and walked out and showed unit manager cup of medications and explained to her what happened. Review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #1 as cognitively intact. Resident #1 was coded as displaying verbal behavioral symptoms towards others between 1 to 3 days during the look back period.An interview was conducted with Resident #1 on 4/27/26 at 9:58 AM who stated back in February 2026 Nurse #9 argued with him about whether she had given him his morning medications before ultimately calling him a crippled motherf****r before walking out of his room and slamming the door. In a follow-up interview with Resident #1 on 4/29/26 at 10:42 AM, the resident stated he was shocked at first then became angry and hurt when Nurse #9 called him that. Resident #1 stated it hurt his feelings because he is completely dependent on others for his care, and it embarrassed the resident to be called crippled because other people were in the room and heard her say those words. Resident #1 stated Nurse #9 told him she was going to feed him the same energy he fed her you crippled motherf****r.On 4/28/26 at 5:20 PM a phone interview was conducted with Nurse #9 who stated she recalled the exchange she had with Resident #1 although she was unsure of the date. According to Nurse #9 she had never been cussed out so bad by a resident before, and it caused her to become so enraged that she could neither confirm nor deny that she called him a derogatory term.A phone interview was conducted with Nurse Aide (NA) #1 on 4/28/26 at 5:28 PM who stated she remembered the incident between Resident #1 and Nurse #9 well. NA #1 affirmed she was assisting Resident #1 to get ready for an appointment when Nurse #9 walked into the resident's room. According to NA #1, Resident #1 was upset because he had not received his morning medications and was calling Nurse #9 every name in the book. NA #1 stated Nurse #9 was trying to be professional and asked the resident to stop cursing at her when Resident #1 called her a really derogatory name. NA #1 stated Nurse #9 informed Resident #1 she was about to give him the same energy he was giving her and then called the resident a crippled motherf****r and walked out. NA #1 stated she was in shock about what had happened and went to the Director of Nursing to report the exchange as soon as she helped Resident #1 get dressed.On 4/29/26 at 10:55 AM the Nurse Practitioner (NP) was interviewed and stated he spoke with Resident #1 the day of the incident with Nurse #9, and the resident told him the phrase she used (he could not recall the exact words) against him. The NP indicated he thought Resident #1 might have been saying things out of anger or frustration, but he reported what Resident #1 told him to the Director of Nursing after the conversation was complete. According to the NP, the Director of Nursing later told him she had investigated the incident and what Resident #1 reported was true.The Director of Nursing (DON) was interviewed on 4/30/26 at 10:34 AM and stated back in February 2026 NA #1 reported she felt Nurse #9 spoke badly to Resident #1. According to the DON, NA #1 informed her Nurse #9 was calm and polite to Resident #1 when she told him she had tried to give his morning medications earlier that day but Resident #1 accused Nurse #9 of lying to him. The DON stated NA #1 further stated Nurse #9 told Resident #1 that he would not like it if she was giving him the same energy he was giving her and proceeded to call him a crippled motherf****r. The DON explained she was unable to speak with Resident #1 immediately because he had already left for an appointment. However, when Resident #1 returned from his appointment the DON interviewed him. According to the DON, Resident #1 informed her Nurse #9 could call him a motherf****r, but she could not call him crippled, and that he was mad. The DON stated she then called Nurse #9 to the office and the nurse informed her she had her back to Resident #1 and did not think he could hear her, but Nurse #9 admitted to calling Resident #1 a crippled motherf****r. The DON indicated she then walked Nurse #9 out of the building. The facility submitted a plan of correction that was reviewed but did not meet the standard for past non-compliance due to not focusing on dignity or including monitoring of the residents in section 4 of the plan of correction.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of hospice participation (Resident #4), medications (Resident #2) and Preferences for Customary Routine and Activities (Resident #101). This deficient practice affected 3 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. A review of Resident #4's active physician orders included an order dated 3/27/26 for hospice services related to Alzheimer's disease. A Significant Change in Status MDS assessment 4/2/26 revealed Resident #4 was marked with an active diagnosis of Alzheimer's disease and a prognosis of less than six months but not coded with receiving hospice care. During an interview with MDS Nurse #1 on 4/29/26 at 12:19 PM, she confirmed Resident #4 received hospice services and verified that hospice care was not marked on the MDS assessment dated [DATE]. She indicated that MDS Nurse #2 completed that section and felt it was an oversight not to have marked hospice care. Attempts made to interview MDS Nurse #2 were not successful. An interview was conducted with the Director of Nursing (DON) on 4/30/26 at 10:07 AM, who stated it was her expectation for the MDS assessment to be coded accurately. 2. Resident #2 was admitted to the facility on [DATE] with a diagnosis that included history of cerebral infarction (stroke) without residual deficits. Review of Resident #2's January 2026 Physician orders and Medication Administration Record (MAR) did not include an order for anticoagulant medication or anticonvulsant medication. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2's cognition was intact. The medications section was coded that she was receiving an anticoagulant medication and anticonvulsant medication on a routine basis. On 04/30/26 at 11:40 AM, an interview occurred with the MDS Nurse #2. MDS Nurse #2 stated she completed Resident #2's quarterly MDS assessment dated [DATE]. MDS Nurse #2 reviewed the quarterly MDS assessment along with January 2026 medication orders for Resident #2 and verified she incorrectly coded the area of medications for the use of anticoagulant and anticonvulsant medications. MDS Nurse #2 indicated she was unsure why she incorrectly coded the medications and felt it was an oversight. An interview was completed on 04/30/2026 at 12:01 PM with the Director of Nursing (DON). She stated she was unaware Resident #2's MDS assessment had been coded incorrectly and she expected the assessments to be coded accurately. 3. Resident #101 was admitted to the facility on [DATE] with medical diagnoses that included hypertension, major depressive disorder, and anxiety disorder. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was cognitively intact. The Preferences for Customary Routine and Daily Activities section was marked with dashes (-) indicating it was not assessed. The dashes had been entered into the assessment by MDS Nurse #1. During an interview with the Activities Director on 4/30/26 at 8:55 AM, she stated she typically completed the MDS section which addressed the Preferences for Customary Routine and Activities. She reported that she did not complete Resident #101's admission assessment because she was on vacation at that time and in her absence the MDS Nurse was to complete that section. An interview was conducted on 4/30/26 at 10:51 AM with MDS Nurse #1. MDS Nurse #1 stated the Preferences for Customary Routine and Activities section was typically completed by the Activities Director and the Activities Assistant could complete the assessment in the Director's absence. MDS Nurse #1 explained during the period when Resident #101's assessment was due; she was working alone and did not have time to complete it and filled it in with dashes. MDS Nurse #1 explained that the MDS assessment schedule was available and she sent emails to remind staff when the assessment reference date (ARD, the last day of the assessment period) was approaching. She stated these were things done to ensure each department had time to complete their sections prior to scheduled days off. MDS Nurse #1 indicated she had assumed the Activity Assistant would complete the assessment. During an interview with the Activity Assistant on 4/30/26 at 10:58 AM she stated she had been employed as the Activity Assistant for approximately six months. She reported she had not completed any MDS assessments and had not been trained or asked to complete them. The Activity Assistant explained that the Activity Director had always been the one to complete them. During an interview with the Director of Nursing (DON) on 4/30/26 at 11:55 AM she explained that the facility's assessment schedule was available to staff and allowed sufficient time for each department to complete their assigned portions of the MDS prior to any planned vacation days. She stated it was her expectation that all sections of the MDS assessments be completed.

Based on record reviews, and interviews with the Nurse Practitioner and staff, the facility failed to administer medications at the scheduled time for 2 of 6 residents reviewed for medication administration (Residents #102 and #92). The findings included: 1. Resident #102 was admitted to the facility on [DATE] with diagnoses that included hypertension. A review of Resident #102's active physician orders for April 2026 included the following: An order dated 4/8/25 for Hydralazine 100 mg one tablet by mouth three times a day for hypertension. An order dated 4/10/25 for Metoprolol Tartrate 25 mg one tablet by mouth two times a day for hypertension. A review of the April 2026 Medication Administration Record (MAR) and Medication Administration Audit Report dated 4/28/26, for Resident #102 revealed the following: Hydralazine (used to treat hypertension or high blood pressure) was scheduled for 9:00 AM. Nurse #1 documented the medication was administered at 11:17 AM on 4/28/26. Metoprolol Tartrate (used to treat hypertension or high blood pressure) was scheduled for 9:00 AM. Nurse #1 documented the medication was administered at 11:18 AM on 4/28/26. An interview with Nurse #1 on 4/28/26 at 11:15 AM revealed she was an agency nurse who worked at the facility intermittently. Nurse #1 stated that she fell behind on the morning medication administration on 4/28/26 and did not administer Resident #102's scheduled morning medications until 11:00 AM. She reported she did not request assistance to ensure medications were given on time. On 4/30/26 at 9:35 AM, the Nurse Practitioner (NP) was interviewed. He reviewed Resident #102's medical record and confirmed she experienced no ill effects related to the late administration of her medications (Hydralazine and Metoprolol) on 4/28/26. He stated Resident #102's vital signs remained within normal limits and she appeared clinically unaffected. The NP acknowledged the facility's requirement that medications be administered within one hour before or after the scheduled time and stated he expected staff to follow this requirement, especially with medications that were ordered to be given more than once a day. The Director of Nursing (DON) was interviewed on 4/30/26 at 10:07 AM and stated Resident #102's medications were expected to be administered on time since these medications were ordered more than once a day. The DON reported Nurse #1 was an agency nurse and that agency staff had been instructed to request assistance if they fell behind with medication administration. The DON stated she didn't know why Nurse #1 did not request assistance the morning of 4/28/26 as the medications should have been given one hour before or one hour after their scheduled time to remain in an acceptable timeframe. 2. Resident #92 was admitted to the facility on [DATE] with diagnoses that included neuropathic pain. A review of Resident #92's active physician orders for April 2026 included an order dated 9/16/25 for Neurontin 300 mg one capsule by mouth two times a day for neuropathic pain. A review of the April 2026 Medication Administration Record (MAR) and Medication Administration Audit Report dated 4/28/26, for Resident #92 revealed Neurontin was scheduled for 9:00 AM. Nurse #1 documented the medication was administered at 12:06 PM on 4/28/26. An interview with Nurse #1 on 4/28/26 at 1:00 PM revealed she was an agency nurse who worked at the facility intermittently. Nurse #1 stated that she fell behind on the morning medication administration on 4/28/26 and did not administer Resident #92's scheduled morning medications until 12:00 PM. She reported she did not request assistance to ensure medications were given on time. On 4/30/26 at 9:35 AM, the Nurse Practitioner (NP) was interviewed. He reviewed Resident #92's medical record and confirmed he experienced no ill effects related to the late administration of his medication (Neurontin) on 4/28/26. He stated Resident #92's vital signs remained within normal limits and he appeared clinically unaffected. The NP acknowledged the facility's requirement that medications be administered within one hour before or after the scheduled time and stated he expected staff to follow this requirement, especially with medications that were ordered to be given more than once a day. The Director of Nursing (DON) was interviewed on 4/30/26 at 10:07 AM and stated Resident #92's medications were expected to be administered on time since the medication was ordered more than once a day. The DON reported Nurse #1 was an agency nurse and that agency staff had been instructed to request assistance if they fell behind with medication administration. The DON stated she didn't know why Nurse #1 did not request assistance the morning of 4/28/26 as the medications should have been given one hour before or one hour after their scheduled time to remain in an acceptable timeframe.

Based on observation and staff interviews, the facility failed to maintain a safe environment as evidenced by a housekeeping staff member mopping the entire width of the lower 300 hallway (Rooms 304 through 312) which would have required residents, staff, and visitors to walk on a wet floor. This deficient practice occurred on 1 out of 5 resident hallways.Findings included:A continuous observation was conducted on 4/29/26 from 2:47 PM to 2:51 PM of Housekeeper #1 mopping the entire length and width of the floor at the lower end of the 300 hallway. The total area mopped was approximately 4-foot x 10-foot, and the floor was completely wet across the hall. There was a wet floor sign located at the end of the hallway near room [ROOM NUMBER].An interview was conducted with Housekeeper #1 on 4/29/26 at 2:51 PM who stated she usually mopped across the entire floor then followed up with a dry mop to go back over the area. She explained she understood about safety and had placed a wet floor sign at the end of the hallway to warn residents, staff, and guests to be careful when they walked across the floor. Housekeeper #1 remarked she should have left a dry area for others to walk on for safety. On 4/29/26 at 3:01 PM the Director of Housekeeping was interviewed and stated Housekeeper #1 should have only mopped one side of the floor on the 300 hallway to leave a dry area for residents, staff, and visitors to walk on. He stated a wet floor cautionary sign should have been placed at the end of the wet floor area to warn others to use the other side of the hallway. The Director of Housekeeping further stated mopping was not normally the responsibility of the housekeepers unless there was a spill that needed attention. According to the Director of Housekeeping, the facility has floor technicians who clean the floors every day, and if Housekeeper #1 saw the entire floor needed to be cleaned, she should have reached out to the floor technician.On 4/30/26 at 9:39 AM Floor Technician #1 was interviewed and stated he used a floor cleaning machine to clean all the hallways every morning. He explained the machine was equipped with scrubbers that clean the floor as well as a vacuum and squeegee to dry the floor immediately after. Floor Technician #1 indicated he cleaned one half of the floor at a time and left half of the floor dry for others to walk on. Then he repeated the process on the other half of the hall once the first half was dry. Floor Technician #1 stated the only time housekeeping would need to mop the hall was if there was a minor spill or stickiness on the floor. He stated the floor technician team would clean up any major spill.The Director of Nursing was interviewed on 4/30/26 at 10:50 AM and specified Housekeeper #1 should have left a dry clear path for residents, staff, and visitors to walk on, and she should have only mopped one half of the hallway floor at a time.

Based on observations, record reviews, and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 3 of 3 residents reviewed for respiratory care (Resident #44, Resident #84, and Resident #123).The findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses of unspecified asthma and dependence on supplemental oxygen. The care plan revised on 2/2/26 had a focus area for Resident #44 requiring supplemental oxygen secondary to asthma with a flow rate of 3 liters per minute (lpm). An intervention read to give medications as ordered. A review of the active orders for Resident #44 included an order for supplemental oxygen at 3 lpm continuous by nasal cannula dated 2/16/26. A review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #44 as cognitively intact and she was coded for using supplemental oxygen. On 4/27/26 at 8:00 AM an observation was conducted of Resident #44's oxygen concentrator. It was noted the oxygen concentrator flow rate was set at 1.5 lpm when viewed at eye level. Resident #44 was resting in bed with oxygen via nasal cannula and denied any shortness of breath or respiratory distress. On 4/28/26 at 10:00 AM a follow-up observation was conducted of Resident #44's oxygen concentrator. It was again noted the flow rate was set at 1.5 lpm when viewed at eye level. Resident #44 was using oxygen via nasal cannula while resting in bed and denied any respiratory distress. A review of the April 2026 Medication Administration Record (MAR) revealed an entry for oxygen at 3 liters per minute continuously every shift for oxygen supplement. The MAR had a daily check mark and staff initials for all three shifts on 4/27/26. The MAR was initialed by Nurse #7 on 4/27/26 and the MAR was initialed by Nurse #1 on 4/28/26. An observation and interview were conducted with Nurse #1 on 4/28/26 at 3:47 PM who worked the 7:00 AM to 7:00 PM shift and was assigned to Resident #44 that day. She stated she had checked Resident #44's oxygen concentrator setting during her medication pass that morning. Nurse #1 was asked to observe Resident #44's oxygen concentrator. Nurse #1 stood over the concentrator to view the setting and stated she could not clearly see it. When Nurse #1 bent down to view the concentrator at eye level, she stated it was set at 1.5 lpm and must have been bumped sometime during the day. Nurse #1 then adjusted the flow rate to 3 lpm. Nurse #7, who was assigned to Resident #44 on 4/27/26 from 7:00 AM to 7:00 PM was unable to be reached by telephone for an interview. The Nurse Practitioner was interviewed on 4/29/26 at 10:55 AM and stated there was always the potential for a problem to arise if supplemental oxygen orders were not followed correctly. After reviewing Resident #44's medical record and oxygen saturation levels recorded in her record, he indicated Resident #44 did not appear to have suffered any ill effects from the oxygen concentrator being set at 1.5 lpm instead of the 3 lpm as ordered. The Director of Nursing (DON) was interviewed on 4/30/26 at 10:48 AM and stated she assumed Nurse #1 was standing over the oxygen concentrator when she checked the flow rate. She stated her expectation was that nurses should assess the oxygen concentrator at eye level to determine if the flow rate matched the physician's order. 2. Resident #84 was admitted to the facility on [DATE] with diagnoses of emphysema, chronic obstructive pulmonary disease (COPD), and acute and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues which causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate and bluish skin). A review of Resident #84's active medication orders revealed an order dated 1/23/26 for supplemental oxygen at 3 liters per minute (lpm) continuous by nasal cannula. A review of the significant change Minimum Data Set (MDS) dated [DATE] assessed Resident #84 as being significantly cognitively impaired and she was coded as using supplemental oxygen. The care plan revised on 4/28/26 had a focus area for Resident #84 to receive supplemental oxygen secondary to COPD. On 4/27/26 at 11:05 AM an observation was conducted of Resident #84's oxygen concentrator. It was noted that the oxygen concentrator flow rate was set at 3.5 lpm when viewed at eye level. Resident #84 was using oxygen via nasal cannula while resting in bed and did not appear to be in respiratory distress. A follow-up observation of Resident #84's oxygen concentrator conducted on 4/28/26 at 3:46 PM revealed the flow rate was again set at 3.5 lpm. Resident #84 was using oxygen via nasal cannula while resting in bed and did not appear to be in respiratory distress. A review of the April 2026 Medication Administration Record (MAR) revealed an entry for oxygen at 3 liters per minute continuously every shift for oxygen supplement. The MAR had a daily check mark and staff initials for all three shifts on 4/27/26. The MAR was initialed by Nurse #7 on 4/27/26 and the MAR was initialed by Nurse #1 on 4/28/26. An observation and interview were conducted with Nurse #1 on 4/28/26 at 3:47 PM who worked the 7:00 AM to 7:00 PM shift and was assigned to Resident #84. Nurse #1 stated she had checked Resident #84's oxygen concentrator during the morning medication pass and verified it was set at 3 lpm. When Nurse #1 observed the concentrator with the surveyor she stood over the concentrator and stated it was set between 3 and 4 lpm. When Nurse #1 viewed the concentrator setting at eye level, she stated the flow rate was set at 3.5 lpm and adjusted the setting to 3 lpm as ordered. Nurse #1 stated she didn't know why the concentrator was not set correctly unless a resident or visitor had messed with it. Nurse #7, who was assigned to Resident #44 on 4/27/26 from 7:00 AM to 7:00 PM was unable to be reached by telephone for an interview. On 4/29/26 at 10:55 AM the Nurse Practitioner (NP) was interviewed and stated it could have been problematic if the oxygen order for Resident #84 was not followed. However, he stated since her oxygen flow rate was set above the ordered flow rate, he did not feel the resident suffered any ill effects. The NP reviewed Resident #84's oxygen saturation levels documented in her record and noted they were within her expected range. The Director of Nursing (DON) was interviewed on 4/30/26 at 10:48 AM and stated she assumed Nurse #1 was standing over the oxygen concentrator when she checked the flow rate. According to the DON, she expected the nurse to assess the oxygen concentrator at eye level to determine if the flow rate matched the physician's order. 3. Resident #123 was readmitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. A review of Resident #123's active physician orders included an order dated 3/9/26 for oxygen at 3 liters continuous via nasal cannula. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #123 was cognitively intact and was coded for oxygen use. Resident #123's active care plan, last reviewed 3/30/26, included the following focus areas: I have congestive heart failure. One of the interventions was to administer oxygen as ordered. I require oxygen continuously due to COPD and acute/chronic respiratory failure. One of the interventions was to give oxygen therapy as ordered. I have altered cardiovascular status related to congestive heart failure and hypertension. One of the interventions was to give oxygen as ordered. A review of the April 2026 Medication Administration Record (MAR) revealed an entry for oxygen at 3 liters per minute continuously every shift for oxygen supplement. The MAR had a daily check mark and staff initials for all three shifts. The MAR was initialed by Nurse #7 on 4/27/26. On 4/27/26 at 12:23 PM, Resident #123 was observed sitting up in her wheelchair reading with oxygen on via a nasal cannula. She stated that oxygen was used all the time. The oxygen flow regulator on the concentrator was set at 2 liters when viewed at eye level. The oxygen concentrator was noted to not be within Resident #123's reach. On 4/29/26 at 9:43 AM, Resident #123 was observed sitting up in bed reading with oxygen on via a nasal cannula. The oxygen regulator on the concentrator was set at 2 liters flow when viewed horizontally, eye level. An observation and interview occurred with Nurse #4 of Resident #123's oxygen concentrator on 4/29/26 at 11:45 AM. Nurse #4 stated she was the assigned nurse and had glanced at the oxygen concentrator that morning when she delivered Resident #123's morning medications but had not signed off on the MAR yet. She stated the oxygen regulator on the concentrator was set at 3 liters when viewed standing over and 2 liters when viewed horizontally at eye level. Nurse #4 acknowledged she should have been looking at the concentrator at eye level rather than standing over the machine to verify the oxygen flow was set at the correct rate. Nurse #4 verified Resident #123 should be using oxygen at 3 liters and adjusted the flow. Attempts to contact Nurse #7, who had been assigned to Resident #123 on 4/27/26 were unsuccessful. The Director of Nursing was interviewed on 4/30/26 at 10:07 AM and indicated it was her expectation for oxygen to be delivered at the ordered rate. She acknowledged that nursing staff should be observing the oxygen concentrator at eye level for the correct setting of the flow rate.

Based on record review, and Nurse Practitioner and staff interviews, the facility failed to hold blood pressure medications per the parameters in the physician order for 2 of 7 residents whose medications were reviewed (Residents #44 and #123). The findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included paroxysmal atrial fibrillation (an irregular heart beat). Review of Resident #44's active physician orders included an order dated 2/19/26 for metoprolol tartrate (a medication that controls the heart rhythm) 25 milligrams (mg). Give half a tablet by mouth two times a day for paroxysmal atrial fibrillation. Hold for heart rate less than 60 or systolic (top number of blood pressure reading) blood pressure (SBP)) less than 120. The March 2026 and April 2026 Medication Administration Records (MARs) were reviewed and revealed Resident #44 had received metoprolol tartrate despite the SBP being below 120 on the following dates:3/4/26 the SBP was 102 at 9:00 AM and was administered by Nurse #2. 3/17/26 the SBP was 110 at 9:00 AM and 5:00 PM and was administered by Nurse #1. 3/18/26 the SBP was 98 at 5:00 PM and was administered by Nurse #1. 4/5/26 the SBP was 112 at 9:00 AM and was administered by Nurse #4. 4/6/26 the SBP was 118 at 9:00 AM and was administered by Nurse #6. 4/12/26 the SBP was 101 at 9:00 PM and was administered by Nurse #8. 4/21/26 the SBP was 106 at 9:00 AM and was administered by Nurse #5. 4/23/26 the SBP was 105 at 9:00 AM and was administered by Nurse #1. 4/24/26 the SBP was 119 at 9:00 AM and was administered by Nurse #3. A phone interview occurred with Nurse #2 on 4/29/26 at 9:38 AM, who stated she was aware Resident #44 had parameters to hold the metoprolol tartrate. She stated she would have taken the blood pressure, recorded it on the MAR, and held the medication as needed per the parameter. The administration on 3/4/26 at 9:00 AM, was reviewed with Nurse #2 when the metoprolol tartrate was administered despite the SBP being below 120. She stated it was an oversight. Nurse #3 was interviewed on 4/29/26 at 9:46 AM. The April 2026 MAR was reviewed with him where the metoprolol tartrate was administered on 4/24/26 despite the SBP being below 120. He felt that this was an oversight and the medication should have been held per the parameter ordered. Nurse #4 was interviewed on 4/29/26 at 11:42 AM. The April 2026 MAR was reviewed with her where the metoprolol tartrate was administered on 4/5/26 despite the SBP being below 120. She stated the documentation on the MAR indicated the medication was administered but should have been held per the order. She stated it was a mistake. A phone interview was conducted with Nurse #1 on 4/29/26 at 3:18 PM. The March 2026 and April 2026 MARs were reviewed with Nurse #1 where metoprolol tartrate was administered despite the SBP being below 120 on 3/17/26, 3/18/26 and 4/23/26. She indicated she would have taken the blood pressure, recorded it on the MAR and should have held the metoprolol tartrate per the ordered parameter. Nurse #1 stated it was an oversight. Nurse #8 was interviewed via phone on 4/29/26 at 3:50 PM. The April 2026 MAR was reviewed with her where the Metoprolol tartrate was administered on 4/12/26 despite the SBP being below 120. Nurse #8 indicated the medication should have been held per the ordered parameter and stated it was an oversight. An interview occurred with Nurse #5 on 4/30/26 at 10:19 AM. The April 2026 MAR was reviewed with her showing the metoprolol tartrate was administered on 4/21/26 despite the SBP being below 120. She stated that she took the blood pressure, documented it on the MAR and should have held it per the ordered parameter. She indicated it was an error. Attempts to contact Nurse #6 were made without success. The Nurse Practitioner was interviewed on 4/30/26 at 9:35 AM and stated he didn't feel Resident #44 would have suffered any serious harm by receiving the metoprolol tartrate outside the ordered parameter to hold, however he would expect the nursing staff to follow the orders for the metoprolol tartrate hold parameter as written. The Director of Nursing was interviewed on 4/30/26 at 10:07 AM and stated she expected the nurses to follow physician orders including blood pressure medications with parameters to hold. 2. Resident #123 was admitted to the facility on [DATE] with diagnoses that included localized edema, coronary heart disease, and hypertension. Resident #123 was hospitalized from [DATE] through 3/6/26. Review of Resident #123's active physician orders included the following: An order dated 3/6/26 for Cozaar (a medication used to treat high blood pressure) 25 mg one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure (SBP) less than 120. An order dated 3/13/26 for acetazolamide (a medication used to treat fluid retention) 250 mg one tablet by mouth one time a day for edema. Hold for SBP less than 110. An order dated 3/13/26 for Cardizem CD (Controlled Delivery- a medication used to treat high blood pressure and symptoms related to heart disease) 360 mg one capsule by mouth one time a day for coronary heart disease. Hold for SBP less than 110. The March 2026 and April 2026 Medication Administration Records (MARs) were reviewed and revealed Resident #123 had received acetazolamide and Cardizem CD despite the SBP being below 110 as well as Cozaar despite the SBP being below 120, on the following dates: 3/15/26 the SBP was 111. Nurse #7 administered Cozaar. 3/16/26 the SBP was 108. Nurse #7 administered Cozaar. 3/19/26 the SBP was 115. Nurse #7 administered Cozaar. 3/20/26 the SBP was 100. Nurse #7 administered Cozaar. 4/9/26 the SBP was 118. Nurse #3 administered Cozaar. 4/20/26 the SBP was 102. Nurse #7 administered acetazolamide, Cardizem CD and Cozaar. Nurse #3 was interviewed on 4/29/26 at 9:46 AM. The April 2026 MAR was reviewed with him where the Cozaar was administered on 4/9/26 despite the SBP being below 120. He stated that this was an oversight and the medication should have been held per the parameter ordered. Attempts to contact Nurse #7 were made without success. The Nurse Practitioner was interviewed on 4/30/26 at 9:35 AM and stated he didn't feel Resident #123 would have suffered any serious harm by receiving the acetazolamide, Cardizem CD and Cozaar outside the ordered parameters to hold, however he would expect the nursing staff to follow the orders for the acetazolamide, Cardizem CD and Cozaar hold parameters as written. The Director of Nursing was interviewed on 4/30/26 at 10:07 AM and stated she expected the nurses to follow physician orders including blood pressure medications with parameters to hold.

Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to provide effective supervision for a cognitively impaired resident when Resident #1 left the facility through the locked main entrance door. The resident was outside without staff knowledge for approximately twenty minutes and the staff found her sitting in her wheelchair between the covered main entrance and the first parked car in the parking lot. Resident #1 was assessed with no injuries noted. This deficient practice was identified for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia with mood disturbance, anxiety disorder, and brain cancer. Review of the significant changes Minimum Data Set (MDS) assessment, dated 1/31/25, revealed Resident #1 had severe cognitive impairment, and wandering behaviors were indicated to occur daily. The MDS also indicated Resident #1 was non-ambulatory and used a wheelchair. Review of the physician's orders for Resident #1, dated 1/4/25, revealed the order to check the wanderguard bracelet is on every shift and a wanderguard battery check every day shift. Review of the recent wandering assessment, dated 4/23/25, revealed that Resident #1 was at high risk for elopement. Review of the plan of care, dated 4/24/25, revealed Resident #1 was a wanderer and at risk for elopement due to wandering and exit-seeking behavior, with a goal to minimize risks for elopement through current interventions over the next 90 days. Interventions included the wanderguard placement to her left ankle, redirection away from exits as needed, and notifying the Director of Nursing (DON) of exit-seeking behaviors. On 5/8/25 at 2:15 PM, during an interview, Nurse Aide #1 indicated that on 5/3/25, approximately at 11:55 AM, she went to her car in the parking lot. She found Resident #1 between the main entrance and the first parked vehicle. The resident was in her wheelchair, in a good mood, smiling, and could not explain why and how she went outside of the facility. Nurse Aide #1 did not observe a wanderguard bracelet on the resident. Nurse Aide #1 pushed the resident in the wheelchair back to the facility and notified Nurse #1. Review of the nurses' notes provided by Nurse #1, dated 5/3/25 at 2:36 PM, revealed that Resident #1 was observed in a front parking lot with no wanderguard bracelet. The resident was returned to the facility immediately, assessed, and no injuries were noted. The resident remained in bed until the new wanderguard applied. Review of the written statement, provided by Nurse #1, dated 5/3/25, indicated that on 5/3/25 (no time was documented), Resident #1 was noted outside the facility and immediately returned to the facility. She did not have her wanderguard on. The new wanderguard was applied and checked for efficiency. The physician on call and family were notified. During a phone interview on 5/7/25 at 11:40 AM Nurse #1 indicated that on 5/3/25, she was assigned to Resident #1 on the 7:00 AM to 7:00 PM shift. Nurse #1 was aware of Resident #1's elopement risk, but became busy and did not check the placement of the wanderguard at the beginning of her shift on 5/3/25. At approximately at 11:40 AM Nurse #1 observed Resident #1 in the middle of the hallway, and the resident was at her baseline behavior, self-propelling in the hallway. At approximately 12:00 PM, Nurse Aide #1 brought Resident #1 in the wheelchair to the nurses' station, and she reported that she found the resident unattended in the parking lot without a wanderguard bracelet. Nurse #1 indicated Resident #1 was assessed and had no injuries, was not in distress, and did not have her wanderguard bracelet on. Resident #1 could not explain how she left the facility or where she went. The interview further revealed Resident #1 remained in her room for about thirty minutes until the new wanderguard was applied to her left ankle and checked for functionality. Nurse #1 stated she notified Nurse 2, Nurse Supervisor, the provider on call, and the family member. An interview with Nurse #2 (Nurse Supervisor) on 5/7/25 at 11:50 AM revealed that after 12:00 PM on 5/3/25 Nurse #1 reported that Resident #1 was found unattended in front of the main entrance. She was not wearing her wanderguard bracelet. Together with Nurse #1, Nurse #2 assessed the resident and did not find injuries. The resident was not in distress and could not explain where she went when leaving the facility. Nurse #2 stated a new wanderguard bracelet was applied to the resident's left ankle. On 5/7/25 at 11:55 AM, during the phone interview, Nurse Aide (NA) #2 indicated that she was assigned to Resident #1 on 5/3/25 for the 7:00 AM to 3:00 PM shift. The resident always wore her wanderguard, but Nurse Aide #2 could not remember if she had the wanderguard on her ankle on 5/3/25. NA #2 indicated at approximately at 11:30 AM she provided incontinence care for Resident #1, placed her in the wheelchair, and observed Resident #1 self-propelling in the hallway. NA #2 stated she was in other residents' rooms and did not witness how Resident #1 left the building. NA #2 indicated she learned about the incident after 2:00 PM. On 5/7/25 at 12:20 PM, during an interview, Nurse Practitioner (NP #1) expected the staff to check the wanderguard placement and functioning according to the order. At the time of the incident with Resident #1, the staff assessed her for injury, placed the new wanderguard, and notified the provider and family. On 5/7/25 at 12:35 PM, during an interview and observation of the facility's wanderguard system, completed with the Maintenance Director, he indicated that the front lobby door was locked automatically every day from 8:00 PM to 7:00 AM, and a code was needed to unlock the keypad and open the door. He continued that during the day, there was a receptionist that monitored the door to keep the residents from wandering outside. He demonstrated that when a person wearing a wanderguard got within approximately 7 feet of the exit door or closer, the alarm would chirp loudly, and it would automatically lock. The Maintenance Director mentioned that the facility and the parking lot are located far from the highway, on a street with no traffic except visitors to the facility. Receptionist #1 was interviewed on 5/7/25 at 1:10 PM and indicated that she was responsible for preventing residents with wanderguards from exiting the building. She worked Monday through Friday, and when Resident #1 left the faciity on Saturday, she was not in the building. Another receptionist worked on weekends from 4:00 PM to 8:00 PM and the main lobby exit door was locked if nobody was at the front desk. Receptionist #1 said she checked the elopement book on the front desk daily to ensure nobody had left or had been added to the list. Receptionist #1 stated Resident #1 was in the elopement book, with her name, room number, serial number of the wanderguard, and an expiration date. Resident #1 was not allowed to go outside without supervision. Receptionist #1 mentioned that she usually tried to distract the residents from setting off the alarm and got them away from the door. On 5/8/25 at 1:15 PM an observation of the parking lot revealed it was enclosed by a fence and a stretch of woods, which separated the facility from the surrounding area. There was one driveway that provided access in and out with slow traffic of occasional vehicles. On the left and right sides of the main entrance, there were several parked cars in designated spaces. An observation and interview with Resident #1 on 5/7/25 at 2:10 AM revealed Resident #1 was in her wheelchair in the middle of the hallway. She had her wanderguard on the left ankle. The resident indicated that she did not leave the facility last weekend. An interview with the Director of Nursing (DON) on 5/8/25 at 10:20 PM revealed that over the last two weeks Resident #1 was in the hospital Emergency Department twice for an evaluation. At the time of the transfer to the hospital, the wanderguard was removed and reapplied at return to the facility. On 4/30/25, since Resident #1 returned from the hospital, the staff observed her with the wanderguard on. The DON indicated it was unclear why Resident #1 was not wearing a wanderguard bracelet on 5/3/25. When this was determined, the nurses immediately replaced it with the new wanderguard bracelet. DON confirmed that all the staff were responsible for monitoring residents with the wanderguard to prevent them from leaving the building unattended. The Administrator indicated during an interview on 5/8/25 at 12:45 PM he expected staff to check the wanderguard placement and functionality as ordered. He indicated that the facility employed a receptionist who worked Monday through Friday from 8:00 AM to 4:30 PM and another who usually worked from 4:30 PM to 8:00 PM. The incident with Resident #1 occurred on the weekend. At the time of the incident, there was no weekend receptionist at the front door. The Administrator mentioned that it was everyone's responsibility to monitor the front door and respond if a wanderguard alarm was going off, preventing residents with wanderguards from exiting the building. The facility provided the following Corrective Action Plan. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 05/03/2025, it was discovered that the Resident #1 exited the facility without staff escort or authorization. Resident #1 was identified as a wander risk and was assigned a wander guard transmitter. The Health Information Manager (HIM) staff previously identified that the wander guard transmitter was in place. Resident #1 was observed by Certified Nursing Assistant (CNA) #1 outside in the parking area adjacent to the front door of the facility at 12:05 PM who immediately assisted Resident #1 to safely return to the facility. Upon return to the facility the wander guard transmitter was not present on the resident. At the time of the event Nurse #1 had not confirmed placement of the wanderguard for her shift and it is unclear whether the resident was wearing her assigned wanderguard transmitter. On 05/03/2025, The Resident #1 was placed on 1:1 monitoring until a wanderguard was placed and staff ensured there were no exit seeking behaviors. Nurse #1 completed a total body assessment to identify any injury and there were no injuries observed. On 05/03/2025, the Director of Nursing (DON) completed a risk assessment that includes a wandering risk scale. The risk assessment identified that Resident #1 as at risk for wandering. On 05/03/2025, the Provider and Responsible Party were both notified of the event by Nurse #1. The DON also talked with the responsible party on 05/03/2025 to discuss the event. The Nurse Consultant reviewed the care plan to ensure it reflected the wandering risk, which it did. The wander guard was placed by the Treatment Nurse on 05/03/2025 to the left ankle. On 05/03/2025, the DON validated that Resident #1's picture was in the facility elopement risk book. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 05/05/2025 a 100% audit/search was initiated and completed by the DON and the Licensed Practical Nurse (LPN) Support Nurse to assure all current residents were present and accounted for on the premises. The results included: All 116 current residents were accounted for. On 05/05/2025, the Nurse Consultant reviewed the current residents admitted since 04/08/2025 to ensure that each resident had a risk assessment that would completed and if the risk assessment indicated risk to wander that a wander guard was placed, and order for wander guard was entered into the Electronic Medical Record, and that a care plan was initiated for wandering risk if not already in place. This was completed on 05/05/2025. The results indicated that 3 residents required a risk assessment to be completed, the risk assessments had previously been started and not finalized. A corrective action was completed on 05/06/2025 when the risk assessments were completed for the 3 residents who required a risk assessment to be completed. None of the 3 residents who required a risk assessment to be completed triggered as being at risk for wandering therefore no interventions were required. On 05/05/2025, the DON, LPN Support Nurse, Nurse Consultant, and Social Services (SS) Director began identification of residents that were potentially impacted by this practice by completing an audit of all current residents at risk for elopement. This was accomplished by reviewing residents' risk assessment scores (9 & above indicating high risk) to ensure a care plan was in place. This was completed on 05/05/2025. The results included: There were 6 care plans that were required to be initiated or updated. On 05/05/2025 a corrective action was initiated by the SS Director to add or update the plan of care to include risk for wandering. On 05/05/2025, the HIM completed a review of all residents with current wander guard orders. This audit consisted of a review to ensure the wander guard was physically in place and functioning by testing each wander guard. The serial numbers and expiration date of each wander guard was reviewed and updated on the facility elopement risk book for each resident. This was completed on: 05/05/2025. The results included: One resident required her wander guard to be replaced due to the battery functioning and reading battery level was low. One resident was added to the wander guard list. Corrective action was completed on 05/05/2025 when wander guards were placed for these residents, orders were validated, and care plan was updated. The DON or designee will be responsible for checking the wander guard and wander guard battery expiration date including updating the elopement risk book with any new residents identified as a wandering risk. On 05/05/2025, the DON, LPN Support Nurse, Nurse Consultant, and SS audited the facility elopement risk book to ensure all moderate and high-risk residents had a current picture/face sheet in the facility elopement risk book identifying their risk for elopement and the serial number and expiration date of the wander guard. This was completed on 05/05/2025. The results included: All current residents with orders for wander guards had a picture and the serial number and expiration date in place. New residents who had wander guards initiated were also added to the facility elopement risk book. On 05/03/2025 and 05/04/2025, the Maintenance Director completed an audit of the wander guard system doors to ensure appropriate functioning. The results included: All wander guard doors were functioning properly. As of 05/05/2025 all of the above areas related to the elopement process were in compliance. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 05/03/2025, the DON or designee began in-servicing of all staff (full time, part time, including agency) from all departments (department directors, nursing, environmental, and dietary) on Elopement Prevention and Management to include: - Elopement Prevention Response - How to identify residents at risk for elopement - What are exit seeking behaviors - What do we do for residents that are high risk for elopement - What else can we do for residents that are high risk - What should we do if the wanderguard system alarm sounds - What to do if a resident is missing During this training staff were educated on the importance of monitoring and supervising residents who may be at risk for elopement or wandering. This monitoring should include the identification of exit seeking behaviors such as sitting for long periods of time at the doors, packing clothes, trying to open the doors/windows and other activities that involve trying to leave the facility and verbalizing that they want to leave or are going to leave. They were also educated on techniques to implement if exit seeking behaviors are identified. This may include 1:1 supervision, monitoring more frequently, redirecting residents, addressing physical causes such as toileting, hunger, thirst, and/or pain, and activities, as well as appropriate functioning of the wander guard system and immediate notification of the Administrator of any concerns related to functioning of the wander guard system. Additionally, the Quality Assurance (QA) Committee whose members include: Administrator, Director of Nursing, MDS Coordinator, Therapy, HIM, and Dietary Manager discussed adding an additional layer of safety by having the department directors to monitor the wander guards for functioning and wander guard doors for functioning at a frequency agreed upon. At this time the frequency will be daily and will be validated in daily stand up meeting. Any changes to the frequency will go through the QA Committee. As of 05/06/2025, the DON will ensure that any of the above identified staff who does not complete the in-service training will not be allowed to work until the training is completed. The DON or designee will ensure this education is reviewed for all new hires during general orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. Beginning on 05/05/2025 the DON or designee will monitor this issue using the Elopement Risk Process Quality Assurance Tools for compliance with the elopement process to include that a risk assessment is completed and if wandering risk is identified that a wander guard is physically in place, that the wanderguard is functioning, that an order for a wanderguard is entered into the Electronic Medical Record (EMR), and that a care plan is in place for the wandering risk. This will be completed weekly times 3 weeks beginning on 05/05/2025 then monthly times 2 months or until resolved by QA Committee. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action was initiated as appropriate. Compliance will be monitored and the ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Therapy, HIM, and Dietary Manager. Compliance Date: 05/06/2025 The Corrective Action plan was validated onsite on 5/8/25 when staff interviews revealed they had recently received education on Elopement Prevention and Management. In-service reports and sign-in sheets were used to verify this information. The facility provided the audit tools to ensure all current residents were present and accounted for on the premises. The audit tools for all current residents at risk of elopement were reviewed. This audit consisted of a review to ensure the wanderguard was physically in place and functioning by testing each wanderguard. Review of the documents, provided by the facility revealed the audit to make sure the facility elopement risk book to ensure all moderate and high-risk residents have a current picture/face sheet in the facility elopement risk book identifying their risk of elopement and the serial number and expiration date of the wanderguard. The audit, completed by the Maintenance Director, of the wanderguard system doors to ensure appropriate functioning. Multiple staff interviews revealed they could verbalize education training provided in reference to the Elopement Prevention and Management process. The facility's completion date of 5/6/25 for the Corrective Action plan was validated on 5/8/25.

Based on record reviews, observations, and interviews with staff and the Nurse Practitioner, the facility failed to provide care in a safe manner for 1 of 7 residents reviewed for falls (Resident #72). On 8/26/24 Resident #72 slid out of the bed to the floor while care was being provided by Nurse Aide (NA) #9. The incident resulted in a cut and swelling to the left eyelid. Resident #72 was sent to the emergency department (ED) and required 3 dissolvable sutures to close the wound over his left eye. On 1/12/25 Resident #72 was placed on his side during incontinence care by NA #3 and fell off the bed hitting his head on the side table when the NA reached for cream. Resident #72 was sent to the ED and required sutures to repair a laceration on his left upper eyelid. This deficient practice affected one of seven residents reviewed for falls (Resident #72). The findings included: Resident #72 was originally admitted to the facility on [DATE] with diagnoses that included a stroke with left hemiplegia (paralysis on one side of the body). A review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed that Resident #72 was severely cognitively impaired without mood or behavioral concerns. He was dependent on staff for toileting, bed mobility, personal hygiene, oral hygiene, bathing, and dressing. The care plan for Resident #72, last revised/reviewed on 8/7/24, included the following focus areas: - A focus area for requiring assistance due to the resident being dependent on staff for activities of daily living (ADL) care related to a stroke. The interventions initiated on 4/22/22 included that Resident #72 was dependent on staff for toileting, totally dependent on 2 staff for repositioning and turning in bed. - A focus area for risk for falls due to a previous fall with risk for additional falls. This care area was initiated on 4/22/22. The interventions stated staff were to ensure the call light and frequently used objects were within the resident's reach. a) An Event Summary Report dated 8/26/24 written by Nurse #3 indicated Resident #72 had a witnessed fall in his room during ADL care. The narrative of the incident indicated Nurse Aide #9 (NA) was performing personal care for Resident #72 when he slid off the bed. The NA was unable to stop the fall. Resident #72 was noted with swelling and a cut on his left eyelid. Multiple attempts were made to contact NA #9 for an interview by phone. NA #9 no longer worked for the facility, and he was unable to be reached. Multiple attempts were made to contact Nurse #3 for an interview by phone. She no longer worked for the facility, and she was unable to be reached. A physician note dated 8/26/24 indicated Resident #72 sustained an eye injury while he had received care from NA #9. The resident was observed on the floor by nursing staff who had reported Resident #72 slid from the bed during morning care. He was assessed with swelling and a cut on his left eyelid. The resident was sent to the emergency department (ED) for evaluation. The physician indicated that the facility would take all necessary precautions to prevent recurrences, and the note stated that the care plan should be reviewed for ways in which to prevent additional falls. Resident #72 was evaluated at the emergency department on 8/26/24. A cat scan (A computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) was completed and did not reveal any acute fractures of the facial bones. Resident #72 received 3 dissolvable sutures to close the wound over his eye and was deemed safe to return to the nursing facility on 8/26/24 On 1/23/25 at 3:00 PM, the Administrator and Director of Nursing (DON) were interviewed. The Administrator stated that Resident #72 fell from bed during care being provided by one staff member (NA #9) when there should have been two staff members present while providing personal care as outlined in the Kardex. b) A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was severely cognitively impaired without mood or behavioral concerns. He was coded as requiring assistance of 2 people for bed mobility and was dependent on 2 people for bathing, dressing and toileting. The Kardex for Resident #72 dated 1/12/24 indicated under the category of safety, the resident should always be a two-person assist for personal care. It further stated under the category of mobility, that the resident was totally dependent on two-person staff for repositioning and turning in bed. Review of hospital records revealed Resident #72 was transferred and assessed at the hospital on 1/12/25 around 11:12 PM. A cat scan was completed and did not reveal any acute fractures of the facial bones. The ED summary indicated the resident had a laceration through the superficial tissue on the lateral aspect of the left upper eyelid which extended approximately 2.5 centimeters. Resident #72 received sutures to repair the laceration and then the emergency department physician deemed the resident safe for transfer back to the facility at 2:49 AM on 1/13/25. A nursing progress note dated 1/13/25 at 2:02 AM indicated Nurse #1 observed Resident #72 lying on the floor next to the right side of the bed. She documented NA #3 told her that he had the resident lying on his side on rolled-up linen while he was completing incontinent care for Resident #72. When NA #3 reached for cream the resident rolled off the bed hitting the left side of his head on the side table and then fell on to the floor. The resident had a laceration to the left eye with a moderate amount of bleeding. The progress note revealed that Nurse #1 notified the Nurse Practitioner, Administrator, Director of Nursing, and the responsible party about the fall. Resident #72 was sent to the ED. A progress note written by the Nurse Practitioner (NP#1) dated 1/13/25 at 10:10 PM indicated Resident #72 had a witnessed fall in his room on 1/12/25. The narrative indicated Resident #72 had left periorbital (around the eye) swelling with crusted blood. The note revealed that the left eye was swollen shut. NA #3 was interviewed on 1/23/25 at 6:01 PM. He stated that he checked on Resident #72 shortly after he went on duty due to him being a heavy wetter, and he noted that he was very wet. NA #3 stated that he did not want the resident to lay in a wet bed, so he decided to go ahead and change him and his bed linens. The NA indicated that he had his left hand placed on the resident's hip and that the resident was facing him. NA #3 stated that the barrier cream he applied with incontinent care for Resident #72 was at the foot of the bed. The NA stated he reached for the cream with his right hand. He stated while he opened the cream the resident fell forward. The NA reported that the side table was pulled forward and caused Resident #72 to catch the corner of the table with his eye. The NA indicated that he tried to control the motion of the fall. NA #3 stated he had completed Resident #72's care by himself multiple times in the past. He indicated that he had read the Kardex and thought that the two-person assistance for the resident referred to transfers and not ADL care. Nurse #1 was interviewed on 1/23/25 at 7:02 PM. She was the nurse on duty the night Resident #72 fell . She stated she had just left the resident's room after providing care to his roommate. She stated NA #3 was providing care for Resident #72. Nurse #1 indicated she heard a noise from the hall and went back into Resident #72's room. She stated that Resident #72 was lying on the floor bleeding from his eye. She stated she instructed the NA to notify the other nurse to call emergency medical services while she held pressure to stop the bleeding. She stated that Resident #72 was supposed to have two people assisting with his ADL care, and that information is recorded on the Kardex for the resident's care. She indicated that she was not aware that the NA was providing ADL care to the resident by himself. On 1/24/25 at 10:21 AM an interview was conducted with the Nurse Practitioner (NP). He stated that he assessed Resident #72 the day after his fall. He indicated that the resident's left eye was swollen shut and had scattered areas of dried blood around the eye area. He stated he could visualize the eyelids and did not note an excessive amount of bloody drainage in the area. The Administrator was interviewed in conjunction with the Director of Nursing (DON) on 1/24/25 at 12:40 PM. The Administrator stated falls were discussed every morning in their stand-up meeting. She stated those who attended the meeting included herself, DON, the therapy department, social work, nurse managers, activities, and the physician or nurse practitioner. The team discussed residents at risk for falls and developed interventions and updated their care plans. She stated that NAs were supposed to check the Kardex of each resident before working with them and providing care to determine what their level of care included. The Administrator stated the DON and nurse managers were monitoring for use of the Kardex, and that the Quality Assurance team had updated the Kardex to make it more interactive and that the NAs would have to begin checking it off in documentation each shift. She stated NA #3 should have had another staff member assisting with Resident #72's care as his Kardex indicated. The facility provided the following corrective action with a compliance date of 1/21/25: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 1/12/25, Resident #72 was assessed by Nurse #1 and observed with a laceration to the left eye, no signs of pain, vital signs were obtained. Subsequently, immediately after the assessment, the nurse completed notifications to the doctor and responsible party (RP) for the resident. She received orders to send the resident to the emergency room (ER) for evaluation. Resident #72 was sent to the ER for evaluation on 1/12/25 and returned to the facility within a few hours on 1/13/25 with orders carried out from the ER visit after visit summary. The cat scan was negative. The physician and RP were updated by the primary nurse. NA #3 was placed on leave until the investigation was completed. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 1/14/25 the Nurse Consultant completed an audit of all current residents with falls in the last 7 days to identify any residents with injuries sustained from a fall during bed mobility. This audit was completed on 1/16/25. The result concluded that 0 of 11 residents sustained an injury from a fall during bed mobility during care. From 1/14/25 through 1/20/25, the Director of Nurses, Registered Nurse (RN) Support, and RN Supervisor completed random observations and demonstrations of bed mobility on different shifts, different days, to ensure Certified Nursing Assistants were providing bed mobility using the Kardex to ensure care was provided according to the plan of care. This was completed on 1/20/25. This audit consisted of random observations or demonstrations to identify if staff were able to demonstrate proper bed mobility, if there were any concerns with the bed mobility, and if there was any injury or change in condition observed. The results included: - Staff were able to demonstrate proper bed mobility - Staff utilized the Kardex prior to performing care - Staff utilized the correct number of providers for performing bed mobility - Concerns with the bed mobility - Observations of any injury or change in condition observed The DON implemented corrective action to include immediate education and training on Kardex and bed mobility with return demonstration to ensure care was provided according to the plan of care. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 1/14/25, the DON began in-servicing all full-time, part-time, and as needed (PRN) registered nurses and licensed practical nurses, certified nursing assistants, medication aides, including agency staff, on preventing falls. This training included: - Preventing falls from bed during care - Common causes of falls - Identifying falls risk - General falls prevention strategies - How to access the Kardex - Nursing immediate actions - Post fall documentation and ongoing assessment The DON or designee will ensure falls education is included as a part of general orientation. The DON will ensure that any of the above identified staff who do not complete the in-service training by 1/20/25 will not be allowed to work until the training is completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Quality Assurance committee met on 1/14/25 and agreed to begin utilizing the QA monitoring tool to audit all staff to ensure they provided safe bed mobility, correct use of the Kardex, and falls prevention strategies. The DON and nurse management will monitor bed mobility compliance weekly times three weeks and monthly for two months or until resolved by the Quality Assurance (QA) Committee. The monitoring included observations of 4 or more aides on various shifts to include the weekends. Reports will be presented to the QA Committee by the Administrator or Director of Nursing to ensure corrective action was initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the monthly QA meeting. The monthly QA meeting is attended by the Administrator, DON, MDS Coordinator, therapy, Health Information, and the Dietary Manager. Reports were presented to the monthly quality assurance (QA) committee to ensure compliance and corrective action. Include dates when corrective action will be completed. The date of compliance was 1/21/25. As part of the validation process completed on 1/24/25, the plan of correction was reviewed and verified through review of the plan of correction audit sheet completed by the facility, the in-service records, and staff interviews. Observations and interviews were conducted with Nurse Aides (NAs) and NAs were observed as they reviewed the Kardex before providing resident care. The NAs stated that they reviewed the Kardex for each resident to determine the level of care the resident required. They indicated that they had received in-service education regarding fall and accident prevention and using the Kardex to provide accurate resident care. Interviews with nurses revealed they had received in-service training related to fall and accident prevention and use of the Kardex to provide accurate resident care. The validation process verified the facility's date of correction of 1/21/25.

Based on record reviews, observations, and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of skin treatments (Resident #9). This was for 1 of 21 MDS records reviewed. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnosis that included a stage 3 pressure ulcer. Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was intact and she had range of motion limitations to one side of her lower extremity. The area for skin conditions for Resident #9 was coded for 1 stage 3 pressure ulcer that was present upon admission/entry or reentry, and no pressure reducing device for chair was noted. Review of Resident #9's care plan, last revised on 11/11/24, included a focus area that read Resident #9 was at risk for pressure ulcer development related to impaired mobility and her comorbidities. The interventions included pressure reducing mattress on her bed and for staff to encourage her to shift her weight frequently when sitting up in chair. An observation and interview were conducted on 01/23/25 at 10:38 AM with Resident #9. She stated she had a pressure reducing cushion for her wheelchair. She pointed at her wheelchair and stated, That's it right there as she pointed at a cushion in her wheelchair, it's been there since I was admitted to the facility. An observation revealed a pressure reducing cushion in the seat of Resident #9's wheelchair. An Interview was conducted on 01/24/25 at 11:10 AM with the MDS Coordinator. She verified the MDS quarterly dated 11/11/24 was not coded for Resident #9 having a pressure reducing device for her wheelchair. The MDS Nurse indicated it was an oversight that was not coded correctly. An Interview was conducted on 01/24/25 at 12:14 PM with the Administrator. She indicated the MDS assessment should be accurately coded in all care areas.

Based on record review, observation, and resident and staff interviews, the facility failed to ensure a resident who was dependent on staff assistance for nail care received assistance when needed for 1 of 4 residents (Resident #11) reviewed for activities of daily living (ADL). The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Resident #11's annual Minimum Data Set assessment dated [DATE] indicated her cognition was severely impaired. There were no refusals of care, and no behaviors coded. Resident #11 was dependent on staff for oral hygiene, toileting hygiene, shower/bath, dressing, personal hygiene, bed mobility, and transfers. She had range of motion limitations on both sides of her upper and lower extremities. She was coded as receiving hospice services. Resident #11's active care plan, last revised on 11/17/24, included the focus area of an activity of daily living (ADL) self-care deficit and required assistance with ADL. Interventions included she required total assistance with bathing. There were no interventions for nail care. A review of Resident #11's nursing progress notes from 11/26/24 to 01/21/25 revealed no refusals of nail care documented. A review of Resident #11's shower schedule revealed she refused her shower on 12/30/24 and 01/20/25. An observation occurred of Resident #11 on 01/21/25 at 9:50 AM and 12:49 PM. She was lying in bed with her eyes open and was humming a song. Fingernails to both hands were medium in length, past the tips of fingers, and 6 out of 10 fingernails were jagged on the tips with a brown substance under her ring finger and middle finger of the left hand. An interview was conducted on 01/23/25 at 11:15 PM with Nursing Assistant (NA) #6. She stated she provided nail care on resident's shower days and as needed. NA #6 indicated when she provided showers, she tells the residents it's a spa day so she can get the nails as well. Normally she did not have any refusals. She could not recall the last time she provided Resident #11's nail care. She was unable to state why her nail care had not been completed. NA #6 confirmed she was Resident #11's direct care NA on 01/21/24 but she did not remember if she looked at her nails that day. An observation occurred of Resident #11 on 01/23/25 at 11:50 AM and at 2:45 PM. She was still lying in bed with her eyes open, smiling, and was humming a song. Fingernails to both hands were medium in length, past the tips of fingers, and 6 out of 10 fingernails were jagged on the tips with a brown substance under her ring finger and middle finger of the left hand. An observation and interview were conducted on 01/23/25 at 1:20 PM with Nurse #4. She stated Resident #11's fingernails needed to be cut, shaped up, and cleaned. Resident #11 was observed eating pudding with her fingers. An interview was conducted on 01/23/25 at 1:39 PM with NA #7 who was familiar with Resident #11. She stated she tried to look at Resident #11's nails when she worked with her because she would put her hands in her brief at times. She stated she provided nail care on residents' shower days and as needed. An interview was conducted on 01/23/25 at 1:50 PM with NA #8. She was familiar with Resident #11 and was assigned to care for her. She stated it was Resident #11's shower day today which she had not yet provided, and she would provide nail care at that time. An interview was conducted on 01/24/25 at 12:15 PM with the Director of Nursing (DON). She stated nails should be groomed during showers and as needed, to include Hospice residents. The DON indicated the NAs used hand wipes prior to the resident eating meals so Resident #11's jagged and dirty nails should have been discovered.

Based on observations, record review, and staff interviews, the facility failed to maintain a walk-in cooler that was clean and in good repair for 1 of 1 walk-in cooler and failed to store food off the floor in the walk-in cooler. These practices had the potential to affect food served to 100 of 104 residents. The findings included: 1. An observation of the walk-in cooler on 3/26/24 at 11:31 am revealed a black and brown substance on the walls in the form of drip marks that appeared to be dry. There was also dust buildup on the ceiling of the walk-in cooler and to the vents in the walk-in cooler. A vent that contained 3 fans had dust build up. When the ceiling was touched the hanging dust was observed to fall to the cooler floor. The cooler storage rack had dust and had a color of black, white and green. Food items in the walk-in cooler were observed to be covered. An observation and interview with the Dietary Manager on 3/26/24 at 11:34 am revealed it was his second day of employment and he was unaware of any issues involving cleanliness in the walk-in cooler. Upon observation the Dietary Manager indicated the walk-in cooler needed to be cleaned and it appeared to have dust buildup. An observation and interview were conducted with the Administrator and Maintenance Director on 3/26/24 at 11:44 am. The Administrator was observed to rub the ceiling of the walk-in cooler and dust was observed to fall to the ground. Dust was observed to the walk-in cooler vents. The walls were observed to have dried brown and black substance. The Administrator indicated the kitchen had been deep cleaned previously. The Administrator revealed she was aware the walk-in cooler fans created dust per the previous Maintenance Director which indicated the dust was coming from the fans. 2. An observation of the walk-in cooler on 3/26/24 at 11:31 am revealed the floor had 3 tiles not affixed to the floor. The wall to the rear of the walk-in cooler was black, yellow, and brown in color and was crumbling. An observation and interview with the Dietary Manager on 3/26/24 at 11:34 am revealed it was his second day of employment and he was unaware of any issues involving loose tile or moisture in the walk-in cooler. An observation and interview with the Administrator and Maintenance Director on 3/26/24 at 11:44 am revealed they were unaware of the loose tile in the walk-in cooler. Review of maintenance request from January 2024 through March 2024 revealed no maintenance request for the walk-In cooler. An interview with Dietary Staff #2 on 3/27/24 at 1:43 pm indicated the walk-in cooler needed a good cleaning. He indicated he had told the previous Dietary Manager about concerns with cleanliness and needed repairs. He stated the previous Dietary Manager had indicated the walk-in cooler was in the process of being repaired. He stated the substance on the walls was possibly a combination of mold, dust and dirt. He stated a couple of months ago the kitchen had been deep cleaned but not in the walk-in cooler. He stated he believed it was moisture. The previous Dietary Manager had been gone for 2 months. 3. An observation and interview with the Dietary Manager on 3/27/24 at 10:44 am revealed boxes of food items on the floor of the walk-in cooler that included 4 boxes of milk, a bag of onions, a box of lettuce, a box of eggplant and a box of mushrooms. The Dietary Manager stated the food items should not have been stored on the floor. The food items were observed as covered. Interview with the Administrator on 3/27/24 at 3:00 pm revealed there should not be any food items stored on the floor in the walk-in cooler.

Based on observations, record review and staff interviews, the facility failed to date multi-use medications upon opening in 1 of 1 medication storage room and on 2 of 2 medication carts (100 hall and 200 hall medication carts) reviewed. Findings included: A. An observation was conducted on [DATE] at 9:28 AM of the East Wing medication storage room in the presence of Nurse #1. The observation revealed one multi use vial of Tuberculin purified protein with no opened date on vial. The vial appeared to be about less than half full of solution and located in the refrigerator. Nurse #1 confirmed the medication did not have an open date and discarded the vial. B. An observation was conducted on [DATE] at 1:30 PM of the medication cart on 200 Hall in the presence of Nurse #3. The observation revealed no opened date on the following multi-dose medications: 1. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation vials. 2. One multi-dose package of Levalbuterol Nebulizer Solution 1.25mg inhalation vials. 3. One multi-dose Advair HFA AER Inhaler. 4. One multi-dose Albuterol AER PFA inhaler. 5. One multi-dose 10ml bottle of Systane Balance 0.6% solution eye drops. 6. One multi-dose 10ml bottle of Bepreve DRO 1.5% solution eye drops. Nurse #3 confirmed the medications were not dated and she removed them from the medication cart and discarded them. She indicated nurses were to write the date on multi-dose medications upon opening and check dates prior to administration. She stated she had been off the last two days and did not realize they were not dated. C. An observation was conducted on [DATE] at 1:48 PM of the medication cart on 100 Hall in the presence of Nurse #2. The observation revealed no opened date on the following multi-dose medications: 1. Two multi-dose packages of Retasis Emu 0.05% eye drops. 2. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation vials. 3. One multi-dose package of Albuterol Sulfate Nebulizer Treatment 2.5mg/3ml inhalation vials. 4. One multi-dose Symbicort AER ,d+[DATE].5 inhaler. 5. One multi-dose albuterol inhaler. 6. One multi-dose Advair HFA AER inhaler. Nurse #2 confirmed the medications were not dated and she removed them from the medication cart and discarded them. She indicated nurses were to write the date on multi-dose medications upon opening and check dates prior to administration. She stated she did not realize they were not dated. She also stated that the pharmacy consultant checked medication carts for expired and undated medications although she was unsure how often. An interview was conducted on [DATE] at 2:04 PM with the Director of Nursing (DON). She stated nurses were to date multi-dose medications upon opening and they should be checking for dates daily prior to administration. During an interview with the Administrator on [DATE] at 3:57 PM she stated the nursing staff were to label all multi-use medications upon opening and they should be checking for dates daily prior to administration. Pharmacy consultants checked medication carts and storage rooms every couple of months for expired and undated medications.

Based on record reviews, observations, resident and staff interviews, the facility failed to develop an individualized and comprehensive care plan for contracture management (Resident #15) and skin impairment (Resident #1). This was for 2 of 19 residents reviewed. The findings included: 1) Resident #15 was admitted to the facility on [DATE] with diagnoses that included a history of traumatic brain injury and muscle spasms. An Occupational Therapy (OT) Evaluation and Plan of Treatment dated 2/3/23 indicated that Resident #15 was being seen due to progressive contracture of the left hand and fingers. She had flexion contractures present to the second to fifth fingers on the left hand. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively with limited range of motion present to her bilateral lower extremities. A review of the September 2023 active physician orders included an order to place resting hand splint to the left hand for four hours as tolerated every day. Resident #15's active care plan, last reviewed 7/17/23, was reviewed and revealed there was no care plan developed to address the left-hand finger contracture or use of the left-hand splint. An observation and interview occurred on 9/11/23 at 2:30 PM of Resident #15, who was lying in bed. She stated she wore a splint to the left hand on most days for about two to four hours. She was noted with flexion contractures to the second to fifth fingers and had difficulty grasping objects with her left hand. On 9/13/23 at 12:00 PM, an interview occurred with the MDS Nurse, who reviewed Resident #15's active care plan. She confirmed a care plan was not present for the left-hand finger contractures or use of the left-hand splint but should have been developed. She felt it was an oversight. The Administrator was interviewed on 9/13/23 at 3:57 PM, and stated it was her expectation for the care plan to be person centered and should have included Resident #15's left finger contractures and use of the hand splint. 46095 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included a history of persistent vegetative state, traumatic brain injury, and moderate protein-calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was in a persistent vegetative state with limited range of motion present to her bilateral lower and lower extremities. A review of the September 2023 active physician orders included an order to cleanse left lateral neck wound with normal saline, apply collagen sheet with silver (collagen gel wound dressing with silver oxide), hydrofera blue (manages absorption of secretions in the wound) and cover with a super absorbent dressing. Change every 2 days on day shift. Resident #1's active care plan, last reviewed 7/02/23, was reviewed and revealed there was no care plan developed to address the wound to Resident #1 ' s neck. An observation of wound care was completed on 09/13/23 at 11:02 AM with the Wound Physician. Resident #1 was observed to have a wound to the left lateral neck approximately quarter sized. The area was cleaned, measured and a dressing was applied. On 9/13/23 at 2:40 PM, an interview occurred with the MDS Nurse, who reviewed Resident #1's active care plan. She confirmed a care plan was not present for the non-pressure wound to Resident #1 ' s left lateral neck and she stated she thought she had added the wound to the active care plan. She felt it was an oversight. The Administrator was interviewed on 9/13/23 at 3:57 PM and stated the care plan should be person centered and should have included the non-pressure wound to Resident #1 ' s neck.

Based on record reviews, observations, staff and resident interviews, the facility failed to ensure fall mats were in place as ordered (Resident #83) and failed to store smoking supplies in a safe manner (Resident #58). This was for 2 of 7 residents reviewed for accidents. The findings included: 1) Resident #83 was admitted to the facility on [DATE] with diagnoses that included dementia and a stroke with ataxia (limited muscle control in extremities). A record review revealed Resident #83 had the following falls by his bed: On 5/31/23 was found between the wheelchair and his bed on the floor. On 6/4/23 was found on the floor by his bed. On 6/7/23 was found lying on the floor of his room. On 6/15/23 was found sitting beside his bed. On 6/25/23 was found at the foot of his bed on the floor. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 had severe cognitive impairment and required limited to extensive assistance for Activities of Daily Living (ADLs). A wheelchair was used for mobility, and he was coded with 2 or more falls with no injury and 1 fall with minor injury since the last assessment. A record review revealed Resident #83 was observed lying on the floor by the bed on 8/29/23. A review of the September 2023 active physician orders included an order dated 8/31/23 for nursing to place fall mat beside patient's bed due to recent falls. Resident #83's active care plan, last reviewed 9/6/23, included a focus area for having had an actual fall with risk for further due to poor balance and unsteady gait. The interventions included fall mat at bedside while in bed that was initiated on 8/31/23. A record review revealed Resident #83 was noted on the floor beside his bed on 9/6/23. On 9/7/23 Resident #83 was moved to the 400 hall for increased visibility for safety. An observation occurred of Resident #83's bed on 9/11/23 at 11:20 AM. The bed was in the lowest position with a concave mattress present. There were no fall mats located in the room or bathroom. On 9/11/23 at 12:18 PM, Resident #83 was observed lying in bed. There was no fall mat to the bedside nor in the room or bathroom. Nurse Aide (NA) #4 was interviewed on 9/11/23 at 12:30 PM, who was assigned to Resident #83. She indicated staff monitor for safety as Resident #83 will try to transfer from the bed to the wheelchair on his own, as well as keeping the bed in the lowest position. When asked about fall mats, she stated she was unsure and had not seen any fall mats being used for Resident #83. On 9/12/23 at 10:12 AM, an observation was made of Resident #83 lying in bed. There was no fall mat present to the side of the bed, in the room or the bathroom. An observation was made of Resident #83 on 9/13/23 at 9:20 AM while he was lying in bed. There was no fall mat present to the side of the bed, in the room or bathroom. An interview occurred with Certified Medical Assistant (CMA) #1 on 9/13/23 at 12:06 PM, who was assigned to Resident #83. She was unsure if a fall mat was being used currently but recalled seeing one when Resident #83 was in a different room. The interim Director of Nursing (DON) was interviewed on 9/13/23 at 12:11 PM and stated that Resident #83 was recently moved to the 400 hall as it was a high traffic area and greater visibility for safety. She stated the fall mats were to be discontinued at that time and felt it was an oversight. On 9/13/23 at 3:57 PM, the Administrator was interviewed and stated it was her expectation for the fall mat to be in place if the order was present. 41437 2.Resident #58 was admitted to the facility 7/24/2020. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment. The facility provided a paper copy of the Smoking Policy, last revised 1/2023. The policy read in part: Resdients that have been assessed by the interdisciplinary care team as cognitively intact and safe may keep cigarettes and lighters in a locked box in their room. The box must be locked at all times and must not be accessivle to confused residents. The resident's medical record included a smoking assessment was completed 7/6/2023. Resident was evaluated and deemed a safe smoker. The resident's comprehensive care plan was last updated on 7/6/2023 and included a focus for risk of injury related to his preference to smoke. The interventions included storing smoking items (cigarettes, pipes, lighters) in secure locations such as nursing stations, medication carts, or locked in room). The intervention was dated 7/6/2023. On 9/12/2023 at 10:10 AM Resident#59 was observed in his room with 7 lighters and one partial pack of cigarettes on his bedside table. When asked about a lock box, he stated he did not have one. On 9/12/2023 at 10:15 AM writer entered Resident #58's room with the Director of Nursing (DON). The DON asked Resident #58 where his lock box was. He did not answer. The DON looked in the resident's drawers and his closet but did not find a lock box. The DON stated per policy, smoking supplies were to be secured at the nurse station, in the medication cart, or in a lock box in their room. She did not know why the resident did not have a lock box. Nurse Assistant (NA)#6 was interviewed 9/12/2023 at 10:30AM. She stated she had been in Resident #58's room several times that morning and had not noticed the smoking supplies on his bedside table. She further stated the resident was mostly independent and was a safe smoker so she did not spend a lot of time in his room. On 9/13/23 at 3:57 PM the Administrator was interviewed. She stated they have completed regular auditing of smoking supplies at least weekly. The audit was completed by the DON and included checking each resident who smoked for safe storage of smoking supplies. She further stated Resident #58 has a history of borrowing lighters from other residents and not returning them. She did not believe the lighters were functional. It was her expectation that smoking supplies be kept secure.

Based on observations, record review, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification surveys dated 5/26/22 and a complaint investigation dated 10/13/21 for two deficiencies in the area of accurate coding the Minimum Data Set (641), comprehensive care planning (656) and in supervision to prevent accidents (F689). The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F641- Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of pain assessment for 1 of 1 (Resident #28) resident reviewed for pain. During the recertification survey dated 5/26/22 the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of bowel and bladder and medications. During the complaint investigation dated 10/13/21 the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of falls for 2 of 3 sampled residents reviewed for accidents. F656-Based on record reviews, observations, resident and staff interviews, the facility failed to develop an individualized and comprehensive care plan for contracture management (Resident #15) and skin impairment (Resident #1). During the recertification survey dated 5/26/22, the facility failed to develop a comprehensive care plan for the use of an as needed psychotropic medication and the use of oxygen. residents reviewed. During the complaint investigation dated 10/13/21, the facility failed to implement the interventions for falls as care planned 2 of 3 sampled residents reviewed for falls. F689- Based on record reviews, observations, staff and resident interviews, the facility failed to ensure fall mats were in place as ordered (Resident #83) and failed to store smoking supplies in a safe manner (Resident #58). During the recertification survey dated 5/26/22 the facility failed to provide wound care in a safe manner that resulted in a resident fall with injury during wound care and sustained a distal femur fracture. In addition, the facility failed to complete an investigation of the fall. The facility also failed to lift a non-ambulatory resident with a mechanical sling lift according to the manufacturer instructions resulting in a distal femur fracture. During the complaint investigation dated 10/13/21, the facility failed to implement the care plan interventions for falls and failed to modify the interventions after each fall to prevent further falls for 2 of 3 sampled residents reviewed for accidents. An interview was completed on 9/13/23 at 3:20 PM with the Administrator. She stated it was obvious that the facility had issues with the MDS coding and care planning and stated she was uncertain why the failure continued but acknowledged it was human error. The Administrator stated the repeat citation for accidents were unrelated but felt the repeat citation for accidents was due to staff turnover.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the area of pain assessment for 1 of 1 (Resident #28) resident reviewed for pain. The findings included: Resident #28 was admitted to the facility on [DATE]. Resident #28's active physician orders included the following; Complete pain assessment every shift. Ask the resident if they are in pain according to a 1-10 scale. Document response. The order had a start date of 3/8/2023. Give Oxycodone-Acetaminophen Tablet 10-325 milligram (MG). Give 1 tablet by mouth every 6 hours for pain. The order had a start date of 3/8/2023. Give Gabapentin, 100 MG, 2 capsules by mouth three times a day for chronic pain. The order had a start date of 3/8/2023. The Resident's medical record revealed a progress note by the provider dated 8/18/2023 indicating the resident continued to have concerns regarding uncontrolled pain and would be referred to local pain clinic. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident received opioid medication 7 out of 7 days during the assessment period. The MDS was coded no for staff assessment of pain. Additionally, the areas of pain frequency, presence of pain, intensity of pain, and effects on function were not assessed. On 9/12/2023 at 2:00 PM an interview was conducted with the MDS nurse. She reviewed Resident #28's quarterly MDS dated [DATE] and stated she did not know why pain was not assessed. She stated she was on vacation during his assessment period and section J was completed by a MDS nurse from corporate (floater). She stated she did not review the section before she locked and transmitted the MDS. The section for pain should have been assessed and completed.

Based on observations, resident, staff and Medical Director (MD) interviews, the facility failed to provide wound care in a safe manner that resulted in a resident fall with injury. Resident #54 fell during wound care and sustained a distal femur fracture. In addition, the facility failed to complete an investigation for Resident #54's fall. The facility also failed to lift a non-ambulatory resident with a mechanical sling lift according to the manufacturer instructions resulting in a distal femur fracture (Resident #3). This was for 2 of 3 residents reviewed for accidents. The findings included: 1. Resident #54 was admitted on [DATE] with [CONDITION(S)] and a history of a left knee arthroplasty (knee replacement). She was readmitted on [DATE] with a closed distal femur fracture to her left leg after a fall. Resident #54's quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact, non-ambulatory and required the assistance of 2 persons with transfers. Resident #54's incident report dated 3/20/22 at 6:30 PM completed by Nurse #5 read Treatment Nurse (TN) #2 was providing care to the resident when she had to assist her to the floor. There were no initial complaints of pain but later stated her left knee was painful. The MD was notified and ordered an x-ray on 3/21/22. The follow up note dated 3/21/22 read the incident was discussed during the clinical meeting. Resident #54 was receiving wound care and lowered to the floor by TN #2. New intervention was to educate TN #2 to perform wound care while the resident was in the bed. A nursing note dated 3/20/22 at 7:03 PM completed by Nurse #5 read TN #2 was providing wound care to Resident #54 and assisted her to the floor. There were no noted abnormalities and the note did not have any documentation regarding pain. The MD was notified and ordered an x-ray to her left knee on the following morning (Monday 3/21/22). Resident #54's fall care plan last revised 3/21/22 read she sustained an actual fall with the new intervention of educating TN #2 to provide wound care with resident in the bed. The x-ray results dated 3/21/22 indicated a possible distal femur fracture of the left knee. A nursing note dated 3/21/22 at 4:30 PM read the MD was notified and an orthopedic consult was recommended. She was scheduled to see the orthopedist on 3/25/22. A nursing note dated 3/24/22 at 12:07 AM Resident #54 was sent out to the vascular clinic on 3/24/22 for a left lower extremities arteriogram. Resident #54 was admitted to the hospital at this time. Resident #54's hospital history and physical dated 3/24/22 read she presented to the hospital for an elective aortogram to her left lower extremity when her left knee was noted swollen and painful. Imaging revealed a periprosthetic distal femur fracture. She was admitted to the hospital and orthopedic surgery was consulted. Resident #54's hospital discharge summary dated 3/31/22 read a nonoperative strategy was pursued for her fracture and she was fitted with a knee immobilizer with follow up at orthopedic surgery. She was discharged back to the facility with orders to be non-weight bearing to her left lower extremity and a knee immobilizer. Review of Resident #54's active Physician orders included an order dated 3/31/21 for her to be transferred using a mechanical sling lift and non-weight bearing to her left lower extremity while wearing a leg brace for movement. Resident #54 was interviewed on 5/23/22 at 1:48 PM. Resident #54 stated she was non-ambulatory prior to the fall and was being transferred using the sit-to-stand lift. She stated TN #2 was changing the dressing to her sacral wound while she leaned over the side of the bed when her knees gave out. Resident #54 stated TN #2 did not use the sit-to-stand lift but rather lifted her by the shoulder to the standing position. Resident #54 stated TN #2 was the only nurse who completed her sacral wound care that way on the weekends. She stated had a history of a left knee replacement in the past and her knee was swollen and slightly painful prior to being admitted to the hospital on 3/24/22. Resident #54 stated TN #2 got assistance then she and an aides assisted her back to bed using the mechanical sling lift. An interview was completed on 5/25/22 at 2:35 PM with NA #5. She stated she was assigned Resident #54 on Sunday 3/20/22 at the time of her fall. NA #5 stated she went into the room and she had already been placed in bed. She stated Resident #54 complained of pain at the time of her fall to her left knee and an x-ray was ordered. She stated Resident #54 was unable to stand independently so she was transferred using the sit-to-stand lift prior to the fall. NA #5 stated TN #2 did not ask for assistance with using the sit-to-stand lift to assist Resident #54 to bed for her wound care but rather was attempting to complete her wound care while Resident #54 was holding herself upright while leaning against her bed. She stated since the fall, Resident #54 had to be transferred using a mechanical sling lift. NA #5 stated Resident #54's electronic Kardex indicated she was a sit-to-stand for transfers at the time of the fall and TN #2 did not ask her for any assistance to transfer Resident #54 to her bed for wound care. An interview was completed on 5/25/22 at 2:49 PM with NA #1. She stated TN #2 stepped out of Resident #54's doorway and stated she needed help quickly. NA #1 stated when she entered the room Resident #54 was on both knees beside her bed. She stated TN #2 stated Resident #54 did not fall but was assisted to the floor. NA #1 stated TN #2 did not transfer Resident #54 to bed for her wound care but rather stood her up from her wheelchair and had Resident #54 lean up against her bed while she completed wound care to her sacrum. NA #1 stated prior to her fall, she was a sit-to-stand lift and now was a mechanical sling lift transfer. NA #1 stated Resident #54's electronic Kardex indicated she was a sit-to-stand for transfers at the time of the fall and TN #2 did not ask her for any assistance to transfer Resident #54 to her bed for wound care. An interview was completed on 5/25/22 at 3:46 PM with Unit Manager (UM) #1. She stated TN #2 was doing Resident #54's wound care to her sacrum while having Resident #54 stand up and brace herself against the bed with her hands when her knees gave out and TN #2 assisted her to the floor. UM #1 stated Resident #54 was known to be unable to support her own weight or stand independently and staff transferred Resident #54 using the sit-to-stand lift. An interview was completed on 5/25/22 at 11:35 AM with the MD. He stated he was not aware of the circumstances involving Resident #54's fall but he ordered an x-ray for the following morning since she was not complaining of pain and the nurse said there was no obvious injuries. The MD stated Resident #54's fall could have been prevented if TN #2 had used the sit-to-stand lift to put her to bed and completed her wound care. Attempts to interview the Nurse #5 assigned Resident #54 on 3/20/22 were unsuccessful. A telephone interview was completed on 5/26/22 at 11:34 AM with the former DON. She stated TN #2 informed her that Resident #54 did not have a fall but was assisted to the floor onto her knees. The former DON stated Resident #54 was supposed to be transferred using the sit-to-stand lift at that time but she was not aware that TN #2 was not utilizing the lift at the time of the fall. She stated she did not complete an investigation because it was not considered a fall according to TN #2. A telephone interview was completed on 5/26/22 at 11:43 AM with TN #2. She stated she stood Resident #54 up from her wheelchair by lifting her under her arm and leaned her against the side of her bed. TN #2 stated she always completed Resident #54's sacral dressing changes that way on the weekends. TN #2 stated Resident #54 preferred to have her sacral wound care completed while standing because if the sit-to-stand lift was used to transfer her back to bed for her wound care, the staff would not get her back up. TN #2 stated she did not use the sit-to-stand to transfer Resident #54 back to bed or did she ask for another staff member to transfer her back to bed to complete her wound care. TN #2 stated Resident #54's legs gave out and she assisted her to floor onto her knees but what happened was not a fall. She stated she informed the former DON and she didn't ask her anything about the circumstances since she did not consider it a fall. An interview was conducted on 5/26/22 at 1:00 PM with the Administrator and DON. The DON stated anytime a resident was assisted to the floor, it was considered a fall and the circumstances involving an assisted fall should be thoroughly investigated to ensure the staff did not do something wrong resulting in a fall. 2. Review of the manufacture instructions for use of the mechanical sling lift dated 3/2020 read as follows on page #25: when lowering the spreader bar, ensure that the resident's legs and feet were well clear of moving mast to avoid injuries. Resident #3 was admitted on [DATE]/20 with Dementia and [CONDITION(S)]. Resident #3's quarterly Minimum Data Set, dated dated dated [DATE] indicated severe cognitive impairment, non-ambulatory and total staff assistance of 2 with transfers. Resident #3's revised care planned for a risk of falls dated 8/5/21 read she was a mechanical sling transfer with the assistance of 2 staff. Review of an undated electronic Kardex indicated Resident #3 was a full mechanical sling lift for all transfers. Reviews of Resident #3's nursing notes included a note dated 10/26/21 at 2:03 PM that read 2 staff were using the mechanical sling lift to transfer her when she complained of left knee pain. There was no redness or swelling noted. She was given Tylenol and the Medical Director (MD) ordered a knee x-ray. Resident #3's left knee x-ray results dated 10/26/21 read there was no evidence of a fracture but soft tissue swelling the medical aspect of her left knee. Review of a nursing note dated 11/5/21 at 12:18 PM read Resident #3 complained of increased pain to her left knee. The MD ordered an orthopedic consult to check on her left knee replacement hardware. Review of the orthopedic consult note dated 11/9/21 read Resident #3's leg was caught when being transferred from the wheelchair and had been painful since. Additional x-rays revealed a left periprosthetic distal femur fracture. She was to return to the orthopedic in 4 weeks. Review of a nursing note dated 11/9/21 at 6:07 PM read Resident #3 returned from the orthopedic consult and was noted to have a left femur fracture treated with a knee immobilizer. Review of an undated Investigation Guide completed by the former Director of Nursing (DON) read Resident #3 was sitting in her wheelchair at 2:30 PM on 10/26/21. The aides used the mechanical sling lift to transfer Resident #3 back to bed. She complained of knee pain after being laid down. The MD was notified and an x-ray was ordered. Review of the conclusions with root cause analysis read the incident occurred due to [CONDITION(S)], [CONDITION(S)] and a total left knee replacement. She was referred to orthopedics. Attached to the Investigation Guide were staff written statements all written on 11/10/21. Review of the written statement dated 11/10/21 was completed by agency Nursing Assistant (NA) #9 read she and agency NA #10 were putting Resident #3 back to bed using the mechanical sling lift and while doing so, her legs were on each side of the lift mast (hydraulic motor and battery pack part of a lift attached to the sling bar). The statement read Resident #3 was pulled back and her legs moved to get the lift mast from between her legs when she complained of pain. Review of a written stated dated 11/10/21 completed by agency NA #10 read NA #9 asked her to assist her with transferring Resident #3 back to bed using the mechanical sling lift. She indicated NA #9 hooked sling to the lift bar and began to lift her up while her legs were on each side of the lift mast. NA #9 pulled Resident #3 back so the mast would not be between her legs and then placed her on the bed. She complained of pain once in bed. Review of the written statement dated 11/10/21 completed by Nurse #1 read Resident #3 asked to be put to bed after lunch and NA #9 and NA #10 used the mechanical sling lift to transfer her to the bed when she yelled out in pain. There was no redness or swelling and the MD was notified with orders for an x-rays and her as needed Tylenol. An observation was completed on 5/23/22 at 11:52 AM of Resident #3. She was lying in bed and easily aroused. She recalled an incident when a girl was putting her to bed using the lift when she heard a snap. She said her left knee was immediately painful. Resident #3 stated there was only one staff member transferring her and she didn't think NA #9 knew what she was doing. An interview was completed on 5/25/22 at 11:35 AM with the MD. He stated he was not aware of the circumstances involving Resident #3's left knee injury but he ordered an x-ray and an orthopedic consult. The MD stated there was no evidence of a fall involving Resident #3 on 10/26/21. An interview was completed on 5/25/22 at 3:46 AM with Unit Manager (UM) #1. She stated Resident #3 was being transferred by 2 agency aides that no longer worked at the facility. She began to complain of pain and was sent for an orthopedic evaluation. Attempts to interview the Nurse #1 assigned Resident #54 on 3/20/22 were unsuccessful. A telephone interview was completed on 5/26/22 at 9:06 AM with Nurse #3. She recalled writing the nursing note dated 11/5/21. She stated the aides were changing her on when she complained of left knee pain and she never complained. She stated she notified the MD and received orders for the orthopedic consult. Nurse #3 stated she was aware that Resident #3 had orthopedic hardware in her left knee and heard that something happened to her leg during a lift transfer. She said it wasn't long after that they were in-serviced on the proper use of the mechanical sling lift. An observation was completed of the facility's mechanical sling lift was completed on 5/26/22 at 10:20 AM with NA #1. She stated there always had to be 2 staff member present while using the lift. She demonstrated how a lift pad was attached to the sling bar and lifted using the hydraulic pump on the lift mast. NA #1 stated anytime performing a mechanical sling lift, the resident must be facing the person operating the lift. NA #1 stated the reason the resident must face the person operating the lift was to ensure the resident was tolerating the transfer safely and also to prevent any injuries related to striking the lift mast. A telephone interview was completed on 5/26/22 at 11:23 AM with NA #10. She stated she was only the spotter during the lift transfer. When questioned about her written statement, she stated she did not recall if Resident #3's legs were on either side of the mast before she was lifted. NA #10 stated she was not trained on the proper use of the facility's mechanical sling lift until after the incident involving Resident #3. Multiple telephone messages were left for NA #9 to return call to discuss the circumstances involving Resident #3's injury were unsuccessful. A telephone interview was completed on 5/26/22 at 11:34 AM with the former DON. She recalled completing the investigation involving Resident #3 and it was determined that the aides hit her left knee on the side of the lift mast. She stated all the staff were in-served on the correct use of the mechanical sling lift but there was no ongoing monitoring or resident observations for the correct way to use the lift. An interview was conducted on 5/26/22 at 1:00 PM with the Administrator and DON. The Administrator provided evidence of training on the mechanical sling lift for NA #9 and NA #10 dated 11/11/21 after the incident. The Administrator stated she expected all the nursing staff use the mechanical sling lift properly to prevent resident injuries.

Based on staff interviews and record review, the facility failed to provide documented evidence 2 of 2 agency nursing assistants (NA's) (NA #9 and NA #10) were trained on the safe use of the facility's mechanical sling lift resulting in a distal femur fracture (Resident #3). This was for 2 of 3 residents reviewed for accidents. The findings included: The findings included: Resident #3 was admitted on [DATE]/20 with dementia and [CONDITION(S)]. Resident #3's quarterly Minimum Data Set, dated dated dated [DATE] indicated severe cognitive impairment, non-ambulatory and total staff assistance of 2 with transfers. Resident #3's revised care planned for a risk of falls dated 8/5/21 read she was a mechanical sling transfer with the assistance of 2 staff. Review of the manufacture instructions for use of the mechanical sling lift dated 3/2020 read as follows on page #25: when lowering the spreader bar, ensure that the resident's legs and feet were well clear of moving mast to avoid injuries. Reviews of Resident #3's nursing notes included a note dated 10/26/21 at 2:03 PM that read 2 staff were using the mechanical sling lift to transfer her when she complained of left knee pain. There was no redness or swelling noted. She was given Tylenol and the Medical Director (MD) ordered a knee x-ray. Resident #3's left knee x-ray results dated 10/26/21 read there was no evidence of a fracture but soft tissue swelling the medical aspect of her left knee. Review of a nursing note dated 11/5/21 at 12:18 PM read Resident #3 complained of increased pain to her left knee. The MD ordered an orthopedic consult to check on her left knee replacement hardware. Review of the orthopedic consult note dated 11/9/21 read Resident #3's leg was caught when being transferred from the wheelchair and had been painful since. Additional x-rays revealed a left periprosthetic distal femur fracture. Review of an undated Investigation Guide completed by the former Director of Nursing (DON) read Resident #3 was sitting in her wheelchair at 2:30 PM on 10/26/21. The aides used the mechanical sling lift to transfer Resident #3 back to bed. She complained of knee pain after being laid down. The MD was notified and an x-ray was ordered. Review of the conclusions with root cause analysis read the incident occurred due to [CONDITION(S)], [CONDITION(S)] and a total left knee replacement. She was referred to orthopedics. Attached to the Investigation Guide were staff written statements all written on 11/10/21. Review of the written statement dated 11/10/21 was completed by agency Nursing Assistant (NA) #9 read she and agency NA #10 were putting Resident #3 back to bed using the mechanical sling lift and while doing so, her legs were on each side of the lift mast (hydraulic motor and battery pack part of a lift attached to the sling bar). The statement read Resident #3 was pulled back and her legs moved to get the lift mast from between her legs when she complained of pain. Review of a written stated dated 11/10/21 completed by agency NA #10 read NA #9 asked her to assist her with transferring Resident #3 back to bed using the mechanical sling lift. She indicated NA #9 hooked sling to the lift bar and began to lift her up while her legs were on each side of the lift mast. NA #9 pulled Resident #3 back so the mast would not be between her legs and then placed her on the bed. She complained of pain once in bed. An interview was completed on 5/25/22 at 3:46 AM with Unit Manager (UM) #1. She stated Resident #3 was being transferred by 2 agency aides that no longer worked at the facility. UM #1 stated she did not recall if the agency staff received training on the use of the facility's mechanical sling lifts upon hire. A telephone interview was completed on 5/26/22 at 11:23 AM with NA #10. She stated she was only the spotter during the lift transfer. When questioned about her written statement, she stated she did not recall if Resident #3's legs were on either side of the mast before she was lifted. NA #10 stated she was not trained on the proper use of the facility's mechanical sling lift until after the incident involving Resident #3. Multiple telephone messages were left for NA #9 to return call to discuss the circumstances involving Resident #3's injury were unsuccessful. A telephone interview was completed on 5/26/22 at 11:34 AM with the former DON. She stated she completed an investigation and it was determined that the aides hit her left knee on the side of the lift mast. She stated all the staff were in-served 11/11/21 on the correct use of the mechanical sling lift and she did not recall if the agency NA #9 and NA #10 received training on the use of the facility's mechanical sling lifts prior to the injury on 10/26/21. An interview was conducted on 5/26/22 at 1:00 PM with the Administrator and DON. The Administrator provided evidence of training on the mechanical sling lift for NA #9 and NA #10 dated 11/11/21 after the incident. The Administrator stated she expected all the nursing staff to be trained and knowledgeable on the use of mechanical sling lift to prevent resident injuries.

Based on record reviews, observations, resident and staff interviews, the facility failed to trim and clean dependent residents' fingernails (Residents #41, #78, #96 and #44) for 4 of 4 residents reviewed for Activities of Daily Living (ADL). The findings included: 1. Resident #41 was admitted to the facility on [DATE] with a stroke affecting the right dominant side and [CONDITION(S)]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 had severe cognitive impairment and had no behaviors or refusal of care. He required extensive assistance with personal hygiene and bathing tasks and was coded with limited range of motion affecting one upper extremity and both lower extremities. A review of Resident #41's active care plan, last reviewed 4/7/22, included the following focus areas: - Potential for impairment to skin integrity. The interventions included to keep fingernails short. - ADL self-care performance deficit, with an intervention to check nail length, trim and clean as necessary. A review of Resident #41's nursing progress notes from 1/1/22 to 5/24/22 revealed no refusals of nail care documented. On 5/23/22 at 10:25 AM, Resident #41 was observed while lying in bed watching TV. He was noted to have long fingernails on both hands with a dark substance under them. Resident #41 was observed on 5/24/22 at 11:05 AM while lying in bed watching TV. His nails on both hands remained unchanged from previous observations. On 5/24/22 at 3:30 PM, an interview was completed with NA #4, who was familiar with Resident #41, and assigned to care for him that day. She explained nail care would be completed when needed but had not rendered nail care to Resident #41 in a while. An observation of Resident #41's nails occurred with NA #4 who verified they were long with a dark substance under them and stated, well they do need clipping. I'll have to find some clippers. On 5/25/22 at 8:51 AM, an observation was made of Resident #41's hands, which revealed fingernails remained long with a dark substance under them. Resident shook his head no when asked if anyone had offered to complete his nail care. Another observation was made of Resident #41 on 5/25/22 at 1:55 PM. He was lying in bed with his eyes closed and hands resting on top of the covers. His fingernails on both hands were long with a dark substance under them. On 5/26/22 at 9:40 AM, an interview occurred with NA #2 who was assigned to care for Resident #41 on 5/26/22. She stated a group came around to provide nail care to the residents, but she would clean nails if they were dirty. She denied providing recent nail care to Resident #41. An interview was held with NA #6 on 5/25/22 at 11:00 AM and stated she provided nail care when there was a need, unless the resident was a diabetic, then she would let the nurse know. She was unable to state if she had provided nail care to Resident #41. On 5/25/22 at 2:25 PM, an interview was completed with NA #5 and NA #8, who stated nails were to be cleaned and trimmed on shower days or when there was a need. Diabetic fingernails were cared for by the nurse. They were unaware of Resident #41 refusing nail care in the past but had not cared for him in a while. The Administrator and Director of Nursing (DON) were interviewed on 5/26/22 at 1:10 PM and stated they would expect nail care to be rendered during personal care or shower assistance. The DON further added if a NA was unable to complete the task she would expect the nurse to be notified of the need. The Administrator and DON were unable to explain why nail care had not occurred for Resident #41 as there was no documentation to show this had or had not been completed or attempted. 2. Resident #78 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 had moderately impaired cognition and had no behaviors or refusal of care. He required extensive assistance with personal hygiene and bathing tasks. A review of Resident #78's active care plan, last reviewed 5/20/22, included a focus area for ADL self-care performance deficit. One of the interventions was to provide assistance with grooming and personal hygiene. A review of Resident #78's nursing progress notes from 1/19/22 to 5/24/22 revealed no refusals of nail care documented. On 5/23/22 at 10:15 AM, an interview occurred with Resident #78 while he was sitting in a wheelchair in his room. He was noted to have long fingernails with a dark substance under them. Resident #78 stated he didn't like his nails that long and had been a while since they were cut. He added he would bite them, but it would have left them jagged. Resident #78 was observed on 5/24/22 at 11:07 AM while lying in bed watching TV. His nails on both hands remained unchanged from previous observations. On 5/24/22 at 3:30 PM, an interview was completed with NA #4, who was familiar with Resident #78, and assigned to care for him that day. She explained nail care would be completed when needed but she had not rendered nail care to Resident #78 in a while. An observation of Resident #78's nails occurred with NA #4 who verified they were long with a dark substance under them and stated she would care for them. On 5/25/22 at 8:54 AM, an observation was made of Resident #78's hands, which revealed fingernails remained long with a dark substance under them. Resident stated no one had offered to provide nail care to him this week. Another observation was made of Resident #78 on 5/26/22 at 11:00 AM. He was sitting in the wheelchair looking out his window. His fingernails remained long with a dark substance under them. On 5/26/22 at 9:40 AM, an interview occurred with NA #2 who was assigned to care for Resident #78 on 5/26/22. She stated a group came around to provide nail care to the residents, but she would clean nails if they were dirty. She denied providing recent nail care to Resident #78. An interview was held with NA #6 on 5/25/22 at 11:00 AM and stated she provided nail care when there was a need, unless the resident was a diabetic, then she would let the nurse know. She was unable to state if she had provided nail care to Resident #78. On 5/25/22 at 2:25 PM, an interview was completed with NA #5 and NA #8, who stated nails were to be cleaned and trimmed on shower days or when there was a need. Diabetic fingernails were cared for by the nurse. They were unaware of Resident #78 refusing nail care in the past but had not cared for him in a while. The Administrator and Director of Nursing (DON) were interviewed on 5/26/22 at 1:10 PM and stated they would expect nail care to be rendered during personal care or shower assistance. The DON further added if a NA was unable to complete the task she would expect the nurse to be notified of the need. The Administrator and DON were unable to explain why nail care had not occurred for Resident #78 as there was no documentation to show this had or had not been completed or attempted. 3. Resident #96 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 had severely impaired decision-making skills and had no behaviors or refusal of care. She required extensive to total assistance with all ADL and had limited range of motion to all her extremities. A review of Resident #96's active care plan, last reviewed 5/20/22, included a focus area for potential for impairment to skin integrity with an intervention to keep fingernails short. A review of Resident #96's nursing progress notes from 1/19/22 to 5/24/22 revealed no refusals of nail care documented. The nursing progress notes also indicated Resident #96 could nod her head to yes/no questions. On 5/23/22 at 10:40 AM, Resident #96 was observed lying in bed listening to music. She was noted to have contractures to her hands with her fingernails to the right hand long and touching the palm of her hand. Fingernails on her left hand were short in length. There was no skin break down observed. Resident #96 was observed on 5/24/22 at 11:15 AM while lying in bed listening to the radio. Her fingernails to the right hand remained unchanged from previous observations. An interview occurred with Nurse Aide (NA) #7 on 5/24/22 at 3:05 PM. She indicated she was not aware of the facility's policy on nail care and was not sure when nail care would be performed. On 5/24/22 at 3:30 PM, an interview was completed with NA #4, who was familiar with Resident #96, and assigned to care for her that day. She explained nail care would be completed when needed but she had not rendered nail care to Resident #96 in a while. An observation of Resident #96's nails to the right hand occurred with NA #4 who confirmed they needed attention. On 5/25/22 at 9:00 AM, an observation was made of Resident #96's hands, which revealed fingernails to her right hand remained long and touching her palm. Resident #96 shook her head no when asked if anyone offered to provide nail care this week. Another observation was made of Resident #96 on 5/26/22 at 9:34 AM who was lying in bed listening to the radio. Her fingernails to the right hand remained long and she indicated with a nod of her head that no one had offered to trim them. On 5/26/22 at 9:40 AM, an interview occurred with NA #2 who was assigned to care for Resident #96 on 5/26/22. She stated a group came around to provide nail care to the residents, but she would clean nails if they were dirty. She denied providing recent nail care to Resident #96. An interview was held with NA #6 on 5/25/22 at 11:00 AM and stated she provided nail care when there was a need, unless the resident was a diabetic, then she would let the nurse know. She was unable to state if she had provided nail care to Resident #96. On 5/25/22 at 2:25 PM, an interview was completed with NA #5 and NA #8, who stated nails were to be cleaned and trimmed on shower days or when there was a need. Diabetic fingernails were cared for by the nurse. They were unaware of Resident #96 refusing nail care in the past but had not cared for her in a while. The Administrator and Director of Nursing (DON) were interviewed on 5/26/22 at 1:10 PM and stated they would expect nail care to be rendered during personal care or shower assistance. The DON further added if a NA was unable to complete the task she would expect the nurse to be notified of the need. The Administrator and DON were unable to explain why nail care had not occurred for Resident #96 as there was no documentation to show this had or had not been completed or attempted. 4. Resident #44 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired vision and required extensive assistance with all activities of daily living. Resident #44's comprehensive care plan had a focus for risk of inability to perform activities of daily living and at risk of self-care deficits related to [CONDITION(S)] and [CONDITION(S)]. On 5/23/2022 at 10:50 AM Resident #44 was observed sitting in his wheelchair. His fingernails were long with a black substance under the nails on both hands. Resident #44 stated his family trim his nails when they come to visit. He further stated he had asked the nurse assistants (NA) about trimming his fingernails and they stated they would trim his nails when they had time. He could not identify the NAs he had asked to assist with fingernail care. The resident stated he was aware his nails were long but due to his vision loss, he was not able to see that they were dirty. On 5/24/2022 at 11:13 AM Resident #44 was observed sitting in his wheelchair. His fingernails were long and had a black substance under the nails on both hands. An interview was conducted with NA #7 on 5/24/2022 at 3:05 PM. She stated she was assigned to Resident #44 and was familiar with him. NA #7 observed Resident #44's fingernails and stated the nails were long and dirty. She stated the resident did need nail care. She further stated she was an agency nurse and did not know the facility's policy for nail care. She knew the resident was a diabetic and some facility's do not allow NAs to provide nail care to diabetic residents. An interview was conducted with NA #6 on 5/25/2022 at 11:01 AM. She stated she worked in all areas of the facility and was familiar with Resident#44. She stated nail care is done as needed and NAs were allowed to perform nail care on fingernails but not toenails for diabetic residents.

Based on record review, observation, resident and staff interviews, and physician interview the facility failed to transfer a resident from the chair to the bed using 2 staff members and a mechanical lift as specified in her plan of care for 1 of 4 residents reviewed for accidents (Resident #2). During this transfer Resident #2's leg got caught in the aide's clothing and the resident was diagnosed at the hospital with a fractured left femur. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the active Nurse Tech Information Kardex showed the resident needed a mechanical lift and the help of 2 people for transfers. The resident's most recent Minimum Data Set (MDS) coded as a quarterly assessment and dated 4/16/19 revealed the resident was cognitively intact. Resident #2 received extensive assistance of one person for bed mobility and extensive assistance of 2 people for transfers. Impairment was present to bilateral lower extremities. The resident's active care plan dated 4/16/19 revealed a care plan present for the risk of falls related to [MEDICAL CONDITION] and bilateral lower extremity amputation status. Interventions included to use mechanical lift for all transfers. A nursing progress note dated 5/16/19 at 2:07pm stated, the nurse aide came to nurse and stated that while she was putting the resident into bed (transferring resident from the wheelchair to the bed) her leg went into the aide's scrub pocket and she heard a crunching noise and a pop. Resident currently in the bed stating her left leg above knee was a 10 out of 10 pain level. MD (physician) was notified and ordered the resident to be sent to the ED (Emergency Department). Emergency contact was notified as the resident was her own responsible party. The facility's initial investigation report dated 5/16/19 noted the aide was transferring the resident from the wheelchair (WC) to the bed. When the resident was placed in the bed she related pain and was sent to the ED for x-rays. The staff member was suspended pending the outcome of the investigation. The Emergency Department (ED) progress note dated 5/16/19 noted the resident injured her left leg while being transferred from the wheelchair, apparently it got stuck and a crunch was heard. The resident complained of severe pain in the distal femur and knee area. Pain medications were given in route to the ED. She was alert and oriented. Significant tenderness was present to the left leg over the distal femur (she has amputation below the knee). X-rays were completed and revealed a distal femur fracture. Orthopedics was consulted and ordered immobilization and follow-up with their clinic. Review of the 5-day investigation report dated 5/21/19 read: On 5/16/19 at roughly 2:00pm, the resident related pain at a 10 out of 10 following a transfer from chair to bed. The aide reported to the nurse immediately and the resident was sent to the ED for evaluation and treatment. The Unit Manager and Administrator were notified, and the aide was immediately suspended pending investigation that was initiated at that moment. The resident returned to the facility on the evening of 5/16/19. [MEDICAL CONDITION] arthritis, arthropathy, osteopenia and other comorbidities diminished the bone density of the resident. It was reported the resident's left stump got caught in the aide's scrub top and this was likely the cause of the fracture. All staff were in serviced on abuse and neglect and safe transfers pursuant to the Kardex and care plan. All Kardex's and care plans were reviewed for transfer accuracy. On 6/10/19 at 9:00am the resident was observed lying in her bed listening to the TV. She was able to recall the events of 5/16/19 and stated, my leg got broke. She explained, on the day of the incident, the aide was putting her back to bed from the wheel chair. Instead of using a mechanical lift the aide picked the resident up by herself and the resident felt extreme pain to her left stump area when she placed in the bed. Resident #2 stated the other staff used a lift for her transfers out of the bed, but she didn't say anything to the aide because she was so nice to me. She stated that she had pain to the left upper leg when she moved or during transfers, however pain medication helped to relieve it. A phone interview was completed with NA #3 on 6/10/19 at 12:30pm. She indicated she was the aide that transferred Resident #2 at the time of the incident on 5/16/19. NA #3 explained that she was transferring the resident from the wheel chair to the bed in the afternoon of 5/16/19. She stated that the resident grabbed her around the neck and she used her arms to lift the resident under the buttocks. The resident's left stump became stuck in her scrub top pocket and when she was laid down in the bed a noise was heard and Resident #2 began to complain of severe pain. She went on to say that once the resident was in the bed safely she went to retrieve the nurse. NA #3 stated she had never used the mechanical lift when transferring the resident, used the assistance of another aide or had the transfer technique questioned by the resident. She was able to recall that the resident's Kardex indicated full body lift for transfers but had never obtained clarification from a nurse or manager. On 6/10/19 at 12:42pm a telephone interview was conducted with Nurse #1. She indicated she was the nurse on duty at the time of the incident on 5/16/19. Nurse #1 recalled the aide came out of Resident #2's room distraught and asked her to come to see the resident. The resident was laying in the bed and complained of severe pain to left stump area. She stated the aide had picked up the resident to transfer her back to the bed from the WC instead of using a mechanical lift and the resident's left stump got caught in the pocket of her scrub top. Nurse #1 stated she contacted the physician and emergency contact and the resident was sent to the ED for evaluation and treatment of [REDACTED]. She was able to recall the resident's Kardex indicated she was a full body lift of 2 people for all transfers. Nurse #1 added the same day of the incident, she received an in-service on abuse and neglect as well as proper transfer techniques and was required to participate in demonstration of transfers. An interview occurred with Nurse Aide (NA) #1 on 6/10/19 at 9:15am who stated she was a regular caregiver to Resident #2. NA #1 explained Resident #2 needed a mechanical lift with 2 staff members for all transfers out of the bed. She further stated that she had recently received an in-service on abuse and neglect as well as proper resident transfers and had to demonstrate transfers with mechanical lifts and sit to stand. On 6/10/19 at 9:30am an observation was made of NA #1 and NA #2 providing a transfer to Resident #2. She was observed being transferred out of bed to a gerichair with the use of a mechanical lift. Staff were observed speaking to the resident during the transfer with proper technique noted. No complaints of pain were expressed at the time of the transfer. The administrator was interviewed on 6/10/19 at 12:45pm. He explained the nurse reported the incident to management as soon as the resident was cared for. At that time corrective action was taken by the facility, the NA was suspended, and the investigation was started. The administrator added it was his expectation for the staff to follow the transfer guidance on the Kardex and care plan. On 6/10/19 at 4:30pm an interview was held with NA #4. She stated she was familiar with Resident #2 who needed a mechanical lift with 2 staff members for all transfers. She indicated that each resident's transfer needs were on the Kardex inside their closets and if she had any questions or concerns regarding their transfer she would seek clarification from the nurse or unit manager. NA #4 stated when using a mechanical lift, 2 staff members were required. She recalled receiving a recent in-service on abuse and neglect as well as proper transfer techniques and had to provide demonstration of the transfers. NA #5 was interviewed on 6/10/19 at 4:50pm. She indicated that she was an agency aide that had been helping in the facility off and on for the past 2 months. NA #5 stated each resident's Kardex, located in their closets, indicated their transfer status. She was able to recall recent in-services on abuse and neglect as well as transfer techniques with returned demonstration required. On 6/10/19 at 4:55pm NA #6 was interviewed. She stated each resident has a Kardex located in their closet indicating their transfer assistance. If she didn't feel comfortable or had a question about what was listed, she would seek out guidance from the nurse or unit manager. She indicated she had received a recent in-service on abuse and neglect as well as proper transfer techniques with return demonstration required. The Staff Development Coordinator (SDC) was interviewed via phone on 6/10/19 at 5:00pm. She stated on the afternoon of 5/16/19 she began in-services immediately with the staff in the facility regarding abuse and neglect, proper transfers using the mechanical lift and clarified full body lift as indicated on the Kardex meant a mechanical lift. She explained the in-service was provided via phone to staff, but all nursing staff were required to provide transfer demonstrations by 5/19/19. She stated all in services and transfer demonstrations were completed by 100% of the nursing staff by 5/19/19. On 6/10/19 at 5:10pm, an interview occurred with the physician who stated if the mechanical lift had been used as directed on Resident #2's care plan and Kardex the fracture might not have occurred. He felt the accident was avoidable. Interview with the Administrator and DON on 06/10/2019 at 12:45 PM revealed the facility developed a corrective action plan to prevent reoccurrence and provided a copy of the facility's plan. The following is the facility's corrective action plan: Facility compliance date of corrective action 5/19/19. Corrective Action for the resident involved: The physician was notified of the incident on 5/16/19 and ordered the resident to be transported to the ED for evaluation and treatment of [REDACTED]. Resident #2 returned to the facility in the evening of 5/16/19 with an order of [MEDICATION NAME] 5-325 milligrams 1 tab by mouth every six hours as needed for pain and her left leg immobilized. An orthopedic follow up was scheduled for 5/24/19. Identification of potentially affected residents and corrective actions taken: All current residents had their Kardex's and care plans audited by the Director of Nursing and Unit Managers for the correct mode of transfer assistance on 5/16/19. Beginning 5/16/19 random observations were made weekly of staff providing transfers to residents requiring assistance. The random transfer observations were made by the unit managers for 8 to 10 residents on each of the 2 wings for the 7am to 3pm and 3pm to 11pm shifts. Audits were completed weekly for 2 weeks and then will be monthly for 3 months. Systemic Changes: Education On 5/16/19 the Staff Development Coordinator began education of all the full time, part time and as needed licensed nurses and nurse aides on the following topics: abuse and neglect protocol, safe transfers, clarification of meaning of full body lift per the Kardex and use of gait belts. All staff were provided verbal in-service to include phone calls to the staff that were not working. From 5/16/19 to 5/19/19 all nursing staff were required to come to the facility and participate with demonstration of proper transfers. The Director of Nursing will ensure that any of the above identified staff who did not complete the in-service training by 5/19/19 would not be allowed to work until the training was completed. Per the SDC, the in-service materials to include demonstration of transfers would be incorporated into the new employee facility orientation as well as the annual evaluation for the above identified staff. Quality Assurance Plan: The Director of Nursing and Unit Managers will monitor the issue using the transfer audit tool for monitoring. The monitoring will include random transfer observations of 8 to 10 residents on each wing. This will be completed weekly times 2 weeks then monthly times 3 months. Reports will be presented to the weekly Quality Assurance (QA) meeting by the Director of Nursing or Unit Managers to ensure corrective action initiated as appropriate and compliance has been followed. The weekly QA meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Unit Managers, Therapy and Dietary Manager. Review of the facility Plan of Correction on 6/10/19 revealed an Inservice record for Safe Transfers dated 5/16/19 to 5/19/19, which included a sign in sheet with signatures of nursing and nurse aide staff. Review of the Transfer Audit form revealed the facility utilized this audit form for 8 to 10 residents on each of the 2 wings during the 7:00am to 3:00pm and 3:00pm and 11:00pm shifts. The review sheets were dated 5/16/19 and 5/23/19 and included the following: - The resident's name - Transfer assistance need - Shift/Date - Was the transfer carried out per the Kardex/care plan - Follow up actions Additionally, staff interviews, and observations were conducted during the survey which showed staff were knowledge on how to safely transfer residents and were transferring residents as specified on the resident's care plans. The facility's date of compliance was validated as 5/19/19.

Based on record review, observation, resident interview, and staff interview, the facility failed to treat Resident #67 in a dignified manner causing the resident to feel worthless and also failed to provide a privacy cover for a urinary catheter drainage bag to promote Resident #135 ' s dignity for 2 of 4 residents reviewed for dignity and respect. The findings included: 1. Resident #67 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 ' s cognition was fully intact. She was assessed with [REDACTED]. Resident #67 required the extensive assistance of 2 or more for bed mobility, dressing, toileting, and personal hygiene. She was dependent on 2 or more for transfers. Resident #67 had impairment on both sides of her lower extremities and she utilized a wheelchair. An interview was conducted with Resident #67 on 12/17/18 at 9:29 AM. Resident #67 stated that during the most recent weekend (12/15/18 or 12/16/18) she had asked a staff member to pull out one of the drawers on her dresser and place it on her bed, so she could look for one of her belongings. Resident #67 was unable to recall the name of the staff member who assisted her. She stated the staff member removed her drawer and placed it on her bed. She indicated that when she was finished with the drawer she asked her assigned second shift Nursing Assistant (NA), NA #6, to put her drawer back into dresser as she was unable to complete this task independently. Resident #67 stated that NA #6 told her, you got it out, you put it back. Resident #67 stated that this made me feel like I was worthless. She indicated that she spoke to Nurse #6 about the incident and she gave permission for Nurse #6 to report the incident to the Director of Nursing (DON). A phone interview was conducted with Nurse #6 on 12/18/18 at 4:15 PM. Nurse #6 confirmed that she was working this past weekend at the facility as the weekend Nurse Supervisor. She stated that over the past weekend (12/15/18 or 12/16/18) Nurse #7 reported to her that she overheard Resident #67 ask NA #6 to put her drawer back into her dresser. She indicated Nurse #7 informed her that NA #6 said something like it ' s your drawer you put it back to Resident #67. NA #6 then reportedly told the resident she was going on break. Nurse #6 reported that Resident #67 was not able to put the drawer back without assistance. She indicated that after the incident was reported to her by Nurse #7, she spoke to Resident #67. She stated that Resident #67 was tearful during this conversation and that she confirmed Nurse #7 ' s report of the incident with NA #6. She indicated that after speaking with the resident she reported the incident to the DON by phone. Nurse #6 stated that she also spoke with NA #6 and provided re-education on assisting residents timely and treating residents with dignity and respect. She additionally stated she instructed NA #6 not to return to Resident #67 ' s room during that shift. A phone interview was conducted with Nurse #7 on 12/18/18 at 4:30 PM. Nurse #7 confirmed she was working this past weekend and she was assigned to Resident #67. She stated that her medication cart was positioned in the hallway near Resident #67 ' s door when she observed Resident #67 ' s call light go off. She indicated she observed NA #6 enter Resident #67 ' s room and the resident asked her to put her drawer back into her dresser. She stated she overheard NA #6 say to Resident #67 something like you made this mess .I ' m not cleaning it up .I ' m going on break. NA #6 then left Resident #67 ' s room and slammed the door. Nurse #7 indicated she then entered Resident #67 ' s room and observed the resident crying and visibly upset. She stated she reported the incident to Nurse #6 as she was the weekend Nurse Supervisor. Nurse #7 reported that Resident #67 was not able to put the drawer back without assistance. A phone interview was conducted with NA #6 on 12/18/18 at 4:25 PM. NA #6 confirmed she was working this past weekend and she was assigned to Resident #67. She stated she was getting ready to go on her 30-minute break when Resident #67 asked her to assist her back into bed. NA #6 indicated she told Resident #67 she was clocking out for her break and was not putting her back to bed until after her break. She denied that Resident #67 asked her to put her drawer away. NA #6 reported that after her break Nurse #6 spoke with her and told her she needed to assist the residents with whatever they needed assistance with timely and instructed her not to re-enter Resident #67 ' s room that shift. An interview was conducted with the DON on 12/18/18 at 4:40 PM. She stated that Nurse #6 phoned her over the past weekend and informed her of the incident with Resident #67 and NA #6. The DON indicated that this was the first instance of any complaints or concerns reported about NA #67 ' s interaction with residents. She stated that her expectation was for all residents to be treated with dignity and respect. 2) Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated 12/7/18 revealed an indwelling urinary catheter was placed secondary to bladder outlet obstruction and distal urethral stricture. An admission MDS (Minimum Data Set) was in progress. The baseline care plan dated 12/7/18, specified the resident was alert and cognitively intact with confusion at times. On 12/17/18 at 12:35 PM, an observation was made of Resident #135 in his room. He was noted to have an indwelling urinary catheter with the drainage bag attached to the side of the bed. The urinary catheter drainage bag did not have a privacy cover and could be seen from the hallway. On 12/18/18 at 1:55 PM a second observation was made of Resident #135 in his room. The urinary catheter drainage bag did not have a privacy cover and could be seen from the hallway. During an interview on 12/19/18 at 9:30 AM with Resident #135, he stated that he felt better now that a cover was present on the urinary catheter drainage bag. An interview was completed with the Director of Nursing (DON) on 12/20/18 at 10:15 AM, the DON stated it was her expectation that nursing staff use a privacy cover for urinary catheter drain bags.

Based on observations, staff and Physician interviews, the facility failed to notify the Physician of continued unintended, significant (27%) weight loss for 1 (Resident #10) of 3 residents reviewed to nutrition. The findings included: Resident #10 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. His weight on admission was 172 pounds. Review of Resident #10's admission orders [REDACTED]. Review of Resident #10's care plan dated 3/16/18 read he was at risk for dehydration and weight fluctuations due to his nothing by mouth (NPO) status. Interventions include monitoring his labs, weights, tube feedings and a dietician per policy. Review of a dietary note dated 3/23/18 read Resident #10's admission weight was 172 pounds. The note read a referral was made to the Registered Dietician(RD) and recommendations were given to the nurse supervisor. The note Resident #10 would continue to be monitored and referral would be made to the RD and Physician as needed. This note was documented by the Dietary Manager (DM). Review of Resident #10's electronic medical record revealed his weight for (MONTH) (YEAR) remained at 172 pounds. Review of a dietary note dated 5/9/18 read Resident #10's current weight was 172 pounds. The note read to continue the current tube feeding orders and Resident #10 would continue to be monitored and referral would be made to the Rd and Physician as needed. This note was documented by the DM. Review of Resident #10's electronic medical record revealed his weight for (MONTH) (YEAR) remained at 172 pounds. Review of a dietary note dated 5/22/18 read Resident #10'sPhysican desired his tube feeding orders were to be changed from bolus feedings to continuous feedings. The note read Resident #10's weight would be monitored, and tube feeding would be adjusted as necessary. This note was documented by the RD. Review of a Physician order [REDACTED].#10's tube feeding was changed from bolus feedings to continuous feedings of [MEDICATION NAME] 1.5 at 65 ccs per hour with 50 ccs of water per hour due to abdominal discomfort. Review of Resident #10's electronic medical record revealed no documented weight for the month of (MONTH) . Review of a dietary note dated 6/7/18 read Resident #10's weights was stable at 172 pounds and no changes to his continuous tube feeding orders. The note read Resident #10 was tolerating his tube feeding well, his weight would be monitored, and he would be referred to the RD as needed. This note was documented by the DM. Review of a nursing note and Physician order [REDACTED].#10's tube feeding back to bolus of [MEDICATION NAME] 1.5 one can every four hours with 200 ccs of water with each feeding. Review of a Physician history and physical examination [REDACTED]. Review of a Physician history and physical examination [REDACTED]. Review of a dietary note dated 7/18/18 read as a late entry for 7/10/18 read Resident #10's weight was stable at 172 pounds. Resident #10's was changed to bolus feeding and Resident #10 would be referred to the RD on his next visit related to recent weight loss. The note read Resident #10 would continue to be monitored for weights and lab work. This note was documented by the RD. Review of the electronic medical record revealed Resident #10's readmission weight on 7/20/18 was weight was 142 pounds. Review of the Physician order [REDACTED].#10 readmitted from the hospital with tube feeding orders for [MEDICATION NAME] 1.5 one can every four hours with 200 ccs of water with each feeding. Review of a Physician history and physical examination [REDACTED]. Review of a dietary note dated 7/30/18 read Resident #10's weight was 142 pounds. The note read Resident #10 had several visits to the hospital since his admission. The note read Resident continued his bolus tube feedings and he would be referred to the RD on his next visit related to recent weight loss. There was no documentation that the Physician was notified of Resident #10's recent weight loss. The note read Resident #10 would continue to be monitored for weight loss and lab work. This note was documented by the DM. Review of a dietary note dated 8/21/18 read Resident #10's weight was 141.6 pounds and that his weights had remained stable for the past four weeks. The note read Resident #10 had a history of [REDACTED]. The note read Resident continued his bolus tube feedings. There was no documentation that the Physician was notified of Resident #10's recent weight loss. The note read Resident #10 would continue to be monitor weekly weights. This note was documented by the DM. Review of a Physician history and physical examination [REDACTED]. Review of a Physician history and physical examination [REDACTED]. Review of Resident #10's quarterly Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and total assistance with all of his activities of daily living. He was coded with known weight loss, a feeding tube and weight of 135 pounds. Review of a dietary note dated 9/26/18 read Resident #10's weight was 134.5 pounds. The note read Resident #10 had experienced weight loss since the last dietary note. The note read Resident #10 had a recent hospitalization and he would be referred to the RD on his next visit. The note read Resident #10 had a history of [REDACTED]. The note read Resident continued his bolus tube feedings and his weight would continue to be monitored. There was no documentation that the Physician was notified of Resident #10's recent weight loss. This note was documented by the DM. Review of a dietary note dated 10/12/18 read Resident #10's weight was still trending down at 133.8 pounds. New orders to stop the bolus feeding and begin [MEDICATION NAME] 1.5 at 60ccs per hour continuous with 35 ccs of water per hour. The note read this should provide a healthy weight goal and Resident #10's ideal body weight was 133-163 pounds. The note read Resident #10's tube feeding would be monitored for tolerance and adjusted as needed. There was no documentation that the Physician was notified of Resident #10's recent weight loss. This note was documented by the RD. Review of a dietary note dated 11/9/18 read Resident #10's weight was 130 pounds on 11/8/18. The note read Resident #10's weight remained stable for four weeks. There was no change in his tube feeding orders. The note read to continue the plan since Resident #10 was stable with current interventions. He would remain on weekly weights. There was no documentation that the Physician was notified of Resident #10's recent weight loss. This note was documented by the RD. Review of a Physician history and physical examination [REDACTED]. In an observation on 12/18/18 at 11:10 AM, Resident #10 was lying in bed with the head of his bed elevated 30 degrees. He was able to move his arms and legs on request and able to answer yes/no questions. His tube feeding was connected and running [MEDICATION NAME] 1.5 at 60 ccs per hour continuous with 35 ccs of water per hour. In an interview on 12/18/18 at 3:10 PM, Nurse #4 stated Resident #10 had been very sick on and off since admission. She stated he was living at home with his wife prior to admission to the facility in (MONTH) (YEAR). Nurse #4 stated Resident #10 frequently removed his feeding tube and required frequent hospitalization s. In an interview on 12/18/18 at 3:26 PM, the Dietary Manager (DM) stated the Registered Dietician (RD) comes to the facility on ce a month and as needed. She stated Resident #10 was on weekly weights due to his known weight loss associated with his multiple hospitalization s due to illness with multiple incidents of removing his feeding tube. The DM stated Resident #10 was discussed at the Patients at Risk meetings and she contacted the RD for direction about Resident #10's weight loss. The DM stated the RD could make visits as needed but that she consulted with the RD for recommendations regarding Resident #10's weight loss. The DM stated she did not inform the Physician. In a telephone interview on 12/18/18 at 5:15 PM, the RD stated Resident #10's weights were stable at 172 pounds up until sometime in (MONTH) (YEAR) when he hospitalized several times. The RD stated bolus tube feedings were implemented at one time because it was felt he would be less likely to remove his feeding tube but when his weights continued to decline, the Physician changed Resident #10 back to continuous feedings. The RD stated he was at the facility monthly and as needed. He stated the DM contacted him about Resident #10's weight loss and he thought the Physician was aware of Resident #10's weight loss but he did not notify the Physician. Review of a dietary note dated 12/19/18 read Resident #10's weight continues to trend downward due to multiple hospitalization s and a history of removing his feeding tube. His current weight on readmission was 125 pounds and continued to trend downward despite adjustment to address his weight loss. New orders dated 12/19/18 for [MEDICATION NAME] 1.5 at 65 ccs per hour continuous with 35 ccs of water per hour. There was no documentation that the Physician was notified of Resident #10's recent weight loss. This note was documented by the DM. In an observation on 12/19/18 at 8:20 AM, Resident #10 was lying in bed with his tube feeding running continuously as the ordered rate. He was observed to be alert and able to answer yes/no questions without difficulty. He was not observed attempting to removing his feeding tube but rather moving his arms in a continuous upward motion. In an interview on 12/19/18 at 11:02 AM, Unit Manager #1 stated the DM was in contact with the RD about Resident #10's weight loss. She stated she contacted the Physician about changing Resident #10's tube feedings to bolus feedings back in (MONTH) (YEAR) to keep Resident #10 from removing his feeding tube. The Unit Manager stated Resident #10 was being followed in the Patients at Risk meetings and it was her impression that the Physician was aware of Resident #10's weight loss. In an interview on 12/20/18 at 9:10 AM, the Medical Director stated he was aware of at least nine hospitalization s since being admitted to the facility and multiple incidences of Resident #10 removing his feeding tube. The Medical Director stated some weight loss was to be expected but he was not notified of the continued unintended, significant weight loss. The MD stated it was his expectation that the facility would have notified him of Resident #10 continued unintended significant weight loss. He stated Resident #10 may require a higher calorie tube feeding to prevent further weight loss and he would follow up with the facility RD. In an interview on 12/20/18 at 10:15 AM, the Director of Nursing stated it was her expectation that the Physician of continued weight loss by the Unit Manager or the RD so that other interventions could have been considered to prevent continued unintended, significant weight loss.

Based on observations, staff and Physician interviews, the facility failed to adequately address continued unintended, significant (27%) weight loss and implement effective interventions to prevent the self-removal of a feeding tube for 1 (Resident #10) of 3 residents reviewed to nutrition. The findings included: Resident #10 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #10's admission orders [REDACTED]. Review of Resident #10's care plan dated 3/16/18 read he was at risk for dehydration and weight fluctuations due to his nothing by mouth (NPO) status. Interventions include monitoring his labs, weights, tube feedings and a dietician per policy. Review of a Physician order [REDACTED].#10's tube feeding was changed from bolus feedings to continuous feedings of [MEDICATION NAME] 1.5 at 65 ccs per hour with 50 ccs of water per hour due to abdominal discomfort. Review of a nursing note dated 5/22/18 read Resident #10 disconnected his tube feeding and the tube feeding was draining into his bed. The tubing was reconnected. Review of a nursing note dated 5/24/18 read Resident #10 removed his feeding tube and was sent to the hospital due to bleeding from the feeding tube site. Review of a nursing note dated 6/8/18 read Resident #10 removed his feeding tube and orders received to replace the feeding tube. The feeding tube was replaced without difficulty. Review of a nursing note and Physician order [REDACTED].#10's tube feeding back to bolus of [MEDICATION NAME] 1.5 one can every four hours with 200 ccs of water with each feeding. Review of a nursing note dated 6/13/18 read Resident #10 removed his feeding tube and was sent to the hospital after failed attempts to replace it at the facility. He was hospitalized for [REDACTED]. Resident #10 was readmitted to the facility 6/15/18. Review of a nursing note dated 6/26/18 read Resident #10 was sent to the hospital due to increased respiratory secretions and a drop in his oxygen saturation level. He was readmitted to the facility on [DATE]. Review of a nursing note dated 7/16/18 read Resident #10 was sent to the hospital for [MEDICAL CONDITION]. He was readmitted to the facility on [DATE] with tube feeding orders for [MEDICATION NAME] 1.5 one can every four hours with 200 ccs of water with each feeding. Review of Resident #10's weights remained stable at 172 pounds for the month of March, (MONTH) and (MONTH) (YEAR) at 172 with no documentation of a weight obtained in (MONTH) (YEAR). On readmission from the hospital on [DATE] when his weight was 142 pounds on return from the hospital. Review of a nursing note dated 8/5/18 read Resident #10 removed his feeding and was sent to the hospital after failed attempts to replace it at the facility. He was admitted to the hospital for a urinary tract infection and returned to the facility on [DATE]. There was no change in his tube feeding orders. Review of a nursing note dated 8/28/18 read Resident #10 removed his feeding tube and orders received to replace the feeding tube. The feeding tube was replaced without difficulty. Review of a nursing note dated 9/5/18 read Resident #10 was sent to the hospital for increased respiratory secretions and a drop in his oxygen saturation level. He was readmitted to the facility on [DATE] with no change in his tube feeding orders. Review of a nursing note dated 9/23/18 read Resident #10 removed his feeding tube with orders received to replace the feeding tube with a larger size. The tube was replaced without difficulty. Review of Resident #10's quarterly Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and total assistance with all of his activities of daily living. He was coded with known weight loss, a feeding tube and weight of 135 pounds. Review of a dietary note dated 9/26/18 read Resident #10 had a history of [REDACTED]. His weight was 135 pounds and there was no change in his tube feeding orders. Review of a dietary note dated 10/12/18 read Resident #10's weight was still trending down at 134 pounds. New orders to stop the bolus feeding and begin [MEDICATION NAME] 1.5 at 60ccs per hour continuous with 35 ccs of water per hour. Review of a nursing note dated 10/30/18 read Resident #10 removed his feeding tube with unsuccessful attempts to reinsert the tube. He was sent to the hospital to have his feeding tube reinserted. Review of a dietary note dated 11/9/18 read Resident #10's weight was 130 pounds. There was no change in his tube feeding orders. Review of a nursing note dated 11/14/18 read Resident #10 removed his feeding tube and orders were received to replace the tube. The feeding tube was replaced without difficulty. Review of a nursing note dated 12/11/18 read Resident #10 was sent to the hospital due to blood in his stool. He returned to the facility on [DATE] with no change in his tube feeding orders. In an observation on 12/18/18 at 11:10 AM, Resident #10 was lying in bed with the head of his bed elevated 30 degrees. He was able to move his arms and legs on request and able to answer yes/no questions. His tube feeding was connected and running [MEDICATION NAME] 1.5 at 60 ccs per hour continuous with 35 ccs of water per hour. In an interview on 12/18/18 at 3:10 PM, Nurse #4 stated Resident #10 had been very sick on and off since admission. She stated he was living at home with his wife prior to admission to the facility in (MONTH) (YEAR). Nurse #4 stated Resident #10 was having a difficult time adjusting to the facility and that there were a lot of family dynamics involved. She stated Resident #10 frequently removed his feeding tube and required frequent hospitalization s. Nurse #4 stated the facility tried using an abdominal binder to prevent him from pulling out his feeding tube, but he started to develop skin issues, so it had to be discontinued. Nurse #4 stated the only other intervention attempted to prevent Resident #10 from removing his feeding tube was to change his feedings from continuous to bolus. She stated that was not effective at preventing him from removing his feeding tube. She stated psychiatric services were involved in Resident #10's care. In an interview on 12/18/18 at 3:26 PM, the Dietary Manager (DM) stated the Registered Dietician (RD) comes to the facility on ce a month and as needed. She stated Resident #10 was on weekly weights due to his known weight loss associated with his multiple hospitalization s due to illness and multiple incidents of removing his feeding tube. In a telephone interview on 12/18/18 at 5:15 PM, the RD stated Resident #10's weights were stable at 172 pounds up until sometime in (MONTH) (YEAR) when he hospitalized several times [MEDICAL CONDITIONS] and respiratory issues. The RD stated Resident #10 was receiving plenty of calories to support weight gain. The RD stated bolus tube feedings were implemented at one time because it was felt he would be less likely to remove his feeding tube but when his weights continued to decline, the Physician changed Resident #10 back to continuous feedings. Review of a dietary note dated 12/19/18 read Resident #10's weight continues to trend downward due to multiple hospitalization s and a history of removing his feeding tube. His current weight on readmission was 125 pounds. New orders dated 12/19/18 for [MEDICATION NAME] 1.5 at 65 ccs per hour continuous with 35 ccs of water per hour. In an observation on 12/19/18 at 8:20 AM, Resident #10 was lying in bed with his tube feeding running continuously as the ordered rate. He was observed to be alert and able to answer yes/no questions without difficulty. He was not observed attempting to removing his feeding tube but rather moving his arms in a continuous upward motion. In an interview on 12/20/18 at 9:00 AM, Nurse #3 stated Resident #10 was known to remove his feeding tube and required frequent hospitalization s. She stated he often acted out after visits from his family. In an interview on 12/20/18 at 9:10 AM, the Medical Director stated he was aware of at least nine hospitalization s since being admitted to the facility and multiple incidences of Resident #10 removing his feeding tube. The Medical Director stated some weight loss was to be expected but he was not notified of the continued unintended, significant weight loss. The MD stated the facility tried an abdominal binder at one time, but he started to develop skin issues, so it was discontinued. He stated he also changed his feedings from continuous to bolus on few instances in hopes that it would deter Resident #10 from removing his feeding tube. The MD stated it was also his expectation that the facility attempts other interventions to prevent Resident #10 from removing his feeding tube. He stated Resident #10 may require a higher calorie tube feeding to prevent further weight loss and he would follow up with the facility RD. In an interview on 12/20/18 at 10:15 AM, the Director of Nursing stated it was her expectation that facility staff would have notified the Physician of continued weight loss so that other interventions could have been considered to prevent continued unintended, significant weight loss.

Based on observations, staff and Physician interviews, the facility failed to provide dental services for a resident with expressed tooth pain for 1 (Resident #10) of 1 residents reviewed to dental care. The findings included: Resident #10 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of a nursing note dated 5/1/18 read Resident #10 was experiencing tooth pain. He was seen by the Medical Director with new orders given for [MEDICATION NAME] (oral topical pain reliever), and antibiotic and for Resident #10 to see the dentist when he completed the antibiotics. The note read the Responsible Party (RP) preferred Resident #10 to see the in-house dentist. Review of a history and physical examination [REDACTED]. An antibiotic was prescribed for 10 days for a possible periodontal abscess, the application of [MEDICATION NAME] to his tooth and for him to be put on the list to be seen by the dentist as soon as possible. Review of the medical record revealed Physician orders [REDACTED]. Review of a care plan dated 5/2/18 read Resident #10 was experiencing tooth pain. Interventions included medications as ordered, antibiotics as ordered, dental services as ordered and for the application of an ice pack as ordered. The care plan was documented as resolved on 11/28/18. Review of the medical record revealed Resident #10 was in the hospital from 5/9/18 through 5/14/18. Review of the Dental Notes-Summary revealed the facility Dentist visited the facility on 5/14/18. Resident#10 was not of the list of residents to be seen by the in-house Dentist on the Dental Notes-Summary dated 5/14/18. Review of the Dental Notes-Summary revealed the facility Dental Hygienist visited the facility on 6/4/18. Resident#10 was not of the list of residents to be seen by the Dental Hygienist on the Dental Notes-Summary dated 6/4/18 and he was not in the hospital at the time of the Dental Hygienist visit. Review of the medical record revealed Resident #10 was in the hospital from 6/26/18 through 6/29/18. Review of the Dental Notes-Summary revealed the facility Dentist visited the facility on 6/27/18. Resident#10 was not of the list of residents to be seen by the in-house Dentist on the Dental Notes-Summary dated 6/27/18 but would have been unavailable due to hospitalization . Review of a nursing note dated 7/13/18 read Resident #10 continues to have dental pain. An order already in place for [MEDICATION NAME]. New order for ice packs as needed. Review of the medical record revealed a Physician order [REDACTED]. Review of the medical record revealed no documentation related to tooth pain after 7/13/18 to present. Review of the Dental Notes-Summary revealed the facility Dentist visited the facility on 8/20/18. Resident#10 was not of the list of residents to be seen by the in-house Dentist on the Dental Notes-Summary dated 8/20/18 and he was not in the hospital at the time of the in-house Dentist visited the facility. Review of the Dental Notes-Summary revealed the facility Dentist visited the facility on 9/5/18. Resident#10 was not of the list of residents to be seen by the in-house Dentist on the Dental Notes-Summary dated 9/5/18 and he was not in the hospital at the time of the in-house Dentist visited the facility. Review of Resident #10's quarterly Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and total assistance with all of his activities of daily living. He was coded with for experiencing mouth pain. Review of the Dental Notes-Summary revealed the facility Dental Hygienist visited the facility on 10/22/18. Resident#10 was not of the list of residents to be seen by the in-house Dental Hygienist on the Dental Notes-Summary dated 10/22/18 and he was not in the hospital at the time of the in-house Dental Hygienist visited the facility. Review of the Dental Notes-Summary revealed the facility Dentist visited the facility on 11/19/18. Resident#10 was not of the list of residents to be seen by the in-house Dentist on the Dental Notes-Summary dated 11/19/18 and he was not in the hospital at the time of the in-house Dentist visited the facility. Review of the Dental Notes-Summary revealed the facility Dentist visited the facility on 11/30/18. Resident#10 was not of the list of residents to be seen by the in-house Dentist on the Dental Notes-Summary dated 11/30/18 and he was not in the hospital at the time of the in-house Dentist visited the facility. In an interview on 12/18/18 at 3:10 PM, Nurse #4 stated Resident #10 had expressed any tooth ache that she could recall. She confirmed the facility had in-house dental services. In an interview on 12/19/18 at 8:25 AM, the Social Worker (SW) stated it was her understanding that the in-house dentist came to the facility every 6 months and there had been a change in dental providers. The SW confirmed she was responsible to updating the list of residents to be seen by the in-house dentist on each visit to the facility. She stated Resident #10 was likely in the hospital when the dentist came to the facility in May. The SW stated she did not recall anyone informing her to place Resident #10 on the list to be seen by the in-house Dentist. In an interview on 12/19/18 at 11:02 AM, Unit Manager #1 stated she wrote the orders in (MONTH) (YEAR) when she was made aware that Resident #10 was experiencing tooth pain. She stated at that time, she contacted Resident #10's Responsible Party (RP) and informed him that to see the emergency Dentist, he would have to go out of the facility. The RP refused to send Resident #10 out to the emergency Dentist but rather opted to have Resident #10 seem on the next scheduled visit of the in-house Dentist. Unit Manager #1 stated it was at the time, she thought she spoke with the SW and asked her to add Resident #10 to the dental list to be seen at the next scheduled visit in (MONTH) (YEAR) and if he was in the hospital at the time of the Dentist visit in (MONTH) (YEAR), he would have been added to the next Dental visit in (MONTH) (YEAR). In an observation on 12/19/18 at 8:20 AM, Resident #10 was lying in bed. He confirmed he was not experiencing any tooth pain at present but refused visualization. There was no noted mouth odor detected. In an interview on 12/19/18 at 3:00 PM, Nursing Assistant (NA) #4 stated Resident #10 was not always cooperative with his oral care. In an interview on 12/20/18 at 9:00 AM, Nurse #3 stated she was not aware that Resident #10 was experiencing tooth pain but if he was, she would report it to Unit Manager #1. In an interview on 12/20/18 at 8:24 AM, The MDS Nurse stated she resolved the tooth pain care plan on 11/28/18 because she was not aware of any recent complaints of tooth pain and that the [MEDICATION NAME] order was discontinued on 11/23/18. She stated she spoke to Resident #10 in (MONTH) (YEAR) and he expressed no tooth pain and he had not required the use of any ice packs since (MONTH) (YEAR). In an interview on 12/20/18 at 9:10 AM, the Medical Director stated it was his expectation that Resident #10's tooth pain would have been addressed as soon as possible and he was not aware that his order for Dental Consult was not followed. The MD stated he would follow up with the facility to expediate a Dental Consult. In an interview on 12/20/18 at 10:15 AM, the Director of Nursing stated it was her expectation the Resident #10 receive a timely Dental Evaluation for reported tooth pain. She stated if Resident #10 was in the hospital in (MONTH) (YEAR), it was her expectation that he would have been seen on the next scheduled in-house Dentist visit in (MONTH) (YEAR).

Based on record review, and Physician, Speech Therapist (ST) and staff interviews, the facility neglected to provide necessary care and services for resident with dysphagia for 1 of 3 sampled residents reviewed (Resident #1). Immediate jeopardy began on [DATE], when Resident #1 was found unresponsive and was transferred to the hospital and died . The cause of death was [MEDICAL CONDITION] secondary to acute respiratory arrest with [MEDICAL CONDITION] and aspiration. Immediate jeopardy was removed on [DATE]. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident # 1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status Minimum data Set (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact and he had no swallowing disorder. The assessment further indicated that Resident #1 needed supervision/set up help with eating and he was not on mechanically altered diet. Review of Resident #1's hospital records revealed that he was discharged to the hospital on [DATE] due to cough. The hospital discharge summary dated [DATE] was reviewed. The notes revealed that on [DATE], Resident #1 was near respiratory arrest secondary to choking on chicken during dinner. [MEDICATION NAME] maneuver was performed by vigilant nursing staff resulted in expelling of food bolus. The diet discharge instruction was cardiac dysphagia diet with chopped meats and thickened liquids. Resident #1 was readmitted back to facility on [DATE] with new [DIAGNOSES REDACTED]. Resident #1's care plan was last updated on [DATE]. There was no care plan developed to address care to prevent choking/aspiration after readmission on [DATE]. Resident #1's kardex (resident care guide) was reviewed. The kardex indicated that Resident #1 was on mechanical soft diet with nectar thick liquids and he was independent with eating. The kardex did not indicate that Resident #1 needed supervision during meals or was on restorative dining program. The dietary notes were reviewed. The last dietary note was dated [DATE] indicating Resident #1's diet was regular with thin liquids. There were no notes after his readmission on [DATE]. The diet spreadsheet was reviewed. The menu for [DATE] dinner was beef tips with mushroom gravy for regular diet and ground beef with mushroom gravy for mechanical soft diet. The speech therapist notes were reviewed. The notes revealed that Resident #1 was evaluated on [DATE] and was treated for [REDACTED]. The resident was a high risk for choking/aspiration related complications due to his impulsiveness and history of choking. Resident #1 was referred to nursing for restorative dining and/or staff supervision during meals. The recommended diet was mechanical soft diet with honey thick liquids. The ST progress and discharge summary dated [DATE] was reviewed. The notes revealed that Resident #1 safely consumed mechanical soft exhibiting severe impairment, primarily non oral nutrition, high risk of aspiration, required supervision with oral intake due to aspiration risk and significant weight loss, and trial oral intake via therapeutic feedings due to impulsivity. He was at risk of aspiration of both consistencies due to impulsivity of intake. He was discharged as long term care resident with restorative dining. The nurse's notes dated [DATE] at 7:11 PM revealed resident was sitting in room and staff took meal tray in and sat while resident ate. Staff walked out of room when finished with meal and then went back in and found resident slumped over and came for writer. His eyes opened, not breathing or had no pulse. Placed resident on the bed and writer started cardiopulmonary resuscitation (CPR) and crash cart brought in and started using ambu bag and oxygen at 6:10 PM. Back board was placed under resident. West side nurse helped. Emergency Medical Service (EMS) arrived and started working with resident and 30 minutes later obtain blood pressure and heart beating. Transported to hospital. The hospital history and physical for Resident #1 dated [DATE] were reviewed. The records revealed that Resident #1 presented to the emergency room due to [MEDICAL CONDITION]. Pt. supposedly was witnessed drinking cologne and subsequently had some sort of arrest. High quality cardio [MEDICAL CONDITION] resuscitation (CPR) was immediately initiated. Pt. had a return of spontaneous circulation (ROSC) in the field but subsequently had another episode of arrest. He was intubated and brought to the emergency department where ROSC was once again achieved. The physical examination revealed he has rales in the right upper field, the right middle field, left upper field and the left middle field. The chest x-ray showed subtle bibasilar infiltrates are present and may be due to aspiration. The chest x-ray final result dated [DATE] revealed bilateral infiltrates are noted and appear stable. Findings are worrisome for pneumonia. The [MEDICATION NAME] consult dated [DATE] revealed attempted to place nasogastric tube (NGT) but unable to pass. Went back of throat and ok to push but kept curling up. Recommended esophagogastroduodenoscopy (EGD, a procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum) at bedside in the morning if stable and to try to place NGT. The EGD result dated [DATE] revealed food was found in the upper third of the esophagus. The hospital discharge summary dated [DATE] revealed that when EGD was performed on [DATE], large food bolus was found impacted in the proximal esophagus. The computerized tomography (CT) scan of head performed on [DATE] revealed findings consistent with severe diffuse cerebral [MEDICAL CONDITION] consistent with [MEDICAL CONDITIONS]. A decision was made to extubate Resident #1. He passed away on [DATE] at 4:51 PM. On [DATE] at 1:51 PM, a family member was interviewed. The family member stated that he/she went back to the facility to pick up Resident #1's belongings. She/he was informed by Nurse #1 that NA #1 stepped out of the room while the resident was eating and when she came back few minutes later to pick up the tray, she found the resident slumped over. On [DATE] at 2:30 PM, the ST was interviewed. She stated that she started treating Resident #1 for dysphagia upon his readmission on [DATE]. She indicated that resident choked on a piece of chicken at the hospital and was discharged to the facility on soft diet with thickened liquids. His behavior and his mental status had changed during his readmission of [DATE]. He was very impulsive and no desire to learn. She treated him once a day during lunch meal. He needed supervision during meals because he had no safety awareness. On [DATE] at 3:45 PM, Restorative Aide (RA) #1 was interviewed. She stated that she was the head of the restorative program. She indicated that Resident #1 refused to go to restorative dining, he was on 1:1 with the staff during meals. RA #1 did not have documentation that Resident #1 was refusing to go to restorative dining. On [DATE] at 3:50 PM, Nurse Aide (NA) #1 was interviewed. She was assigned to Resident #1 on [DATE], second shift. She stated that she was assigned to Resident #1 on [DATE] for the first time after his readmission from the hospital. She indicated that Nurse #1 informed her that Resident #1 needed 1:1 during meals. She served the dinner tray around 6 PM in the resident's room and stayed with him until he was finished eating. She indicated that the resident was able to feed himself. He had chunks of beef (not ground beef) on his tray about ¾ to an inch thick and thickened liquids. He consumed about 80% of his food and 50% of his liquids. He did not cough during the meal observation. NA #1 left the room with the resident's tray and proceeded to feed another resident. She stated that after 15 minutes she went back to the resident's room to remove the empty cups from his drawer and she found him slumped over to his right side and not breathing. She went to get Nurse #1. On [DATE] at 5:45 PM, the Dietary Manager (DM) was interviewed. She stated that Resident #1 was on mechanical soft diet and honey thick liquids. She verified the menu on [DATE] as beef tips (,[DATE] to ¾ inches in size) for regular diet and ground beef for the mechanical soft diet. She stated that staff used the food processor to grind the meat for the soft diet. The DM was not able to find dietary notes after the resident's readmission to the facility on [DATE]. On [DATE] at 5:27 PM, Nurse #3 was interviewed. She stated that she had been working at the facility for almost 3 months and had known Resident #1. He was independent with eating and he did not need any supervision during meals. On [DATE] at 5:29 PM, Nurse #4 was interviewed. She stated that she had been working at the facility for 4 months and he remembered Resident #1. He was independent with eating with set up help only and he didn't need any supervision. On [DATE] at 5:32 PM, NA #2 was interviewed. NA #2 had been working at the facility for 2 years on second shift. She used the kardex to care for the resident. She indicated that she remembered Resident #1 and he was independent with eating with set up help only and he didn't need any supervision during meals. On [DATE] at 8:30 AM, the ST was again interviewed. She stated that she had referred Resident #1 to restorative dining. The ST was unable to remember the date of the referral and she could not find her referral form to nursing. She had talked to the Restorative Aide who indicated that the resident refused restorative dining. The ST indicated that she expected the staff to sit and to watch him while he eats when he refused to go to restorative dining. She attended the morning meetings with the department heads and she had shared with them her concerns with Resident #1 the need for supervision during meals. The ST stated that she discharged Resident #1 from therapy on [DATE] and she recommended to continue restorative dining. On [DATE] at 8:40 AM, MDS Nurse #1 was interviewed. The MDS Nurse indicated that she attended the morning meetings and the ST had discussed the need for supervision and restorative dining for Resident #1 due to his risk for choking/aspiration. The MDS Nurse indicated that she didn't get the chance to update his care plan and his kardex to address risk for choking /aspiration. The MDS Nurse indicated that Resident #1 was on restorative dining after his readmission on [DATE] but he refused to go at times so a staff member has to sit and watch him while he ate in his room. On [DATE] at 8:50 AM, the Physician of Resident #1 was interviewed. He stated that he expected the facility to follow the recommendations of the ST regarding supervision with eating and to serve diet as ordered. The Physician stated that he didn't know if the food in his esophagus had caused the resident's death. On [DATE] at 9:01 AM, NA # 3 was interviewed. She was assigned to Resident #1 on first shift. She stated that Resident #1 was on restorative dining and he never refused to go to restorative dining. She brought him to restorative dining every breakfast and lunch when she was assigned to him. On [DATE] at 9:04 AM, Restorative Aide #2 was interviewed. She stated that she worked Monday through Friday on ,[DATE] shift. She was in the restorative dining room during breakfast and lunch. She indicated that Resident #1 had been to restorative dining once (didn't remember the date) and the ST was working with him. She indicated that she didn't have any documentation regarding restorative dining for Resident #1. On [DATE] at 10:10 AM, the Director of Nursing (DON) was interviewed. She stated that the ST attended the morning meetings every morning with the department heads. She discussed Resident #1 being high risk for choking/aspiration due to his impulsiveness/compulsiveness and he needed to be in restorative dining or needed supervision with meals, but these (restorative dining and supervision during meals) had not been formally implemented or ordered. It was on [DATE] when she informed Nurse #1 and the NAs that Resident #1 had to be supervised during meals but she could not remember the time. The DON verified that Resident #1 was not on restorative dining nor was on 1:1 with staff during meals prior to [DATE]. On [DATE] at 1:30 PM, Nurse # 1 was interviewed. Nurse #1 stated that she was assigned to Resident #1 on [DATE]. She stated that she was busy passing medications (little after 6 PM) when NA #1 called her to the resident's room. She found the resident slumped over, not breathing and no pulse. She called the code and cardio [MEDICAL CONDITION] resuscitation (CPR) was initiated. Emergency Medical Services (EMS) was called and when they arrived they took over the CPR. Nurse #1 stated that NA #1 informed her that she sat with the resident during supper and when he finished eating she took the tray out. Nurse #1 indicated that the resident refused restorative dining and the Director of Nursing (DON) informed them that Resident #1 needed 1:1 during meals, but she could not remember the date and time. On [DATE] at 12:34 PM, the DM was again interviewed. She stated that before she left on [DATE], she checked to make sure the dietary staff has everything they needed and they had enough food for soft diet and pureed diet. She also stated that she normally observed the tray line but she did not observe the whole process. On [DATE] at 5:02 PM, NA #1 was again interviewed. NA #1 stated that Resident #1 received beef tips on [DATE], ½ to ¾ in size solid meat during dinner. She indicated that she had received an in-service on the 2 way system on [DATE] by checking the dietary card against the food consistency served on the tray. She indicated that she didn't know the 2 way system prior to the in-service. On [DATE] at 2:32 PM, the Administrator and the Director of Nursing were informed of the Immediate jeopardy. On [DATE] at 7:00 PM, the facility provided the following credible allegation of Immediate jeopardy removal: Resident number 1 was hospitalized from [DATE] to [DATE]. During the resident ' s hospital stay, the resident had an episode of choking and was identified as being at risk for aspiration. Resident number 1 was readmitted to Pinehurst Healthcare and Rehabilitation Center on [DATE] with a [DIAGNOSES REDACTED]. Speech therapy reported that resident has impulsive behaviors and placed a whole dinner roll in the oral cavity at one time. Speech Therapy began to work with him on [DATE] for oropharyngeal dysphagia. Speech Therapy completed a bedside dysphagia evaluation on [DATE]. The bedside dysphagia evaluation showed that the resident needed speech therapy due to him being at risk for aspiration, aspiration-related complications, choking, and re-hospitalization due to his impulsive behavior of placing large amount of food(such as a whole roll) in his mouth at one time . Resident received speech therapy until [DATE] when he was discharged from therapy. Speech therapy recommended restorative dining continues in a note on [DATE] when he is discharged from therapy on [DATE] due to the need of constant supervision. There is no documentation to show that resident number 1 received constant supervision during his meals from [DATE] through [DATE]. Resident ' s care plan failed to identify him being at risk for aspiration and choking. Resident ' s Kardex listed him as independent in his ability to eat when he needed supervision during eating. Resident ' s current diet order on [DATE] was mechanical soft with honey thick liquids, magic cup, cut all rolls, Danish, bread, sandwiches into fourths or ,[DATE] inch pieces, and no peanut butter. On [DATE] the dietary department provided Resident Number 1 with his current diet of mechanical soft with honey thick liquids, magic cup, cut all rolls, Danish, bread, sandwiches into fourths or ,[DATE] inch pieces, and no peanut butter. The dietary department utilizes the standard practice of a two-system check which requires the cook to prepare the plate and the aide will make sure that the plate matches the food listed on the tray card prior to placing it in the serving cart. When the tray cart arrives on the hall the person passing the trays will make sure that the food matches the diet order on the tray card before giving it to the resident. If the tray card does not match the tray the person serving the plate will take the plate back to the kitchen to be corrected. The Administrator interviewed the certified nursing assistant on [DATE] who states that on [DATE] she did not know about the 2 system check. On [DATE] the Director of Nursing, the Assistant Director of Nursing, and the MDS Nurses re-educated 100% of staff on the two system check for meal trays. The interdisciplinary team made a verbal recommendation for restorative and supervision during meals during morning meeting after resident number 1 was readmitted on [DATE]. The recommendation for restorative for resident number 1 was not done in writing and was not implemented consistently. A Restorative care referral was not completed for resident number 1 on his discharge by the speech therapist and given to the Director of Nursing which contributed the lack of implementation of restorative for resident number 1. The Restorative Program did not have resident number 1 ' s information for restorative dining and supervised meals in written form. On [DATE] Resident was noted to be unresponsive and C.P.R. was initiated. Resident was discharged to the hospital on [DATE] due to an episode on non-responsiveness. The hospital records show that Resident number 1 had a large bolus of food impacted in the proximal esophagus. The Resident was intubated. The CT of the head showed the resident had diffuse cerebral [MEDICAL CONDITION] and diffuse infarct from diffuse [MEDICAL CONDITION] injury, on [DATE], the resident died after being extubated per family request. 1. On [DATE] there were no other concerns with mechanical soft diets being served and there is no reason to believe he would be the only one on that day to receive the wrong diet and the Dietary Manager reports she monitored the meal prior to the end of her shift and there was adequate amounts of chopped meat and pureed meat. The Dietary Manager ' s standard practice is to monitor the tray line to ensure that the food form is correct. The Dietary Manager monitored the consistency and the amount of food available to ensure there is enough for the residents at that meal, there were 2 aides and a cook serving the meal on [DATE] to ensure that all diets were served appropriately. An audit was completed by the Administrator on supervised residents and 2 residents in restorative to make sure diets matched their tray. All residents had their trays match their tray card on [DATE]. 2. There were no other residents on supervised meals. An Audit was completed by the Administrator on [DATE] on the residents that have been referred to restorative dining from therapy and there were no concerns with their recommendations being followed. Restorative dining has 2 residents that attend the restorative dining program 2 meals a day and the certified nursing assistants will feed the 3rd meal each day. Any resident that is identified as needing supervision during meals will have a care plan written addressing their needs by the MDS Nurses, the Director of Nursing, and / or the Assistant Director of Nursing, a Kardex placed in their closet by the MDS Nurses, the Director of Nursing, and /or the Assistant Director of Nursing. The MDS Nurses completed a 100% in-service with nursing staff on Kardex being updated anytime there is a change in a residents needs and placed in the resident ' s closet. The Kardex must be checked prior to care for changes on [DATE]. The Business Office Manager will bring all intent to discharge forms to morning meeting to review therapy recommendations. The Speech therapist will bring all written referrals for restorative care or supervision during meal time to the morning meeting for review. The Clinical Nurses will receive a copy of the referrals so a care plan may be written and the Kardex updated. Any referral for restorative or supervision during meal time will be addressed in the care plan by the clinical team after morning meeting. The Director of Nursing will notify the Restorative Manager/Nursing staff of new referrals by giving the restorative manager the care plan to add the resident to the restorative program and the Clinical Nurses will update the Kardex and place it in the resident ' s closet for the nursing staff. The week-end manager will review all hospital information on week-end admissions to determine the need for supervised dining and implement supervised dining for those that require it. 3. The MDS Nurses and the Assistant Director of Nursing reviewed and revised 100% of care plans for all residents on [DATE]. There were changes in at least one area for each resident ' s care plan. The Director of Nursing in-serviced the MDS Nurses and the Assistant Director of Nursing on Care plans addressing the residents current condition in all areas and if there is an acute change in condition the care plan must be reviewed and revised at that time and any time a care plan is reviewed and revised the Kardex for the resident will be updated and the new copy placed in the resident ' s room by the MDS Nurses on [DATE]. 4. A 100 % in-service was completed with all staff on making sure that food served to resident ' s matches what is on the tray card prior to serving the food to the resident by the MDS Nurses, the Activity Director, and the Social Worker on [DATE]. The Dietary Manager in-serviced 100% of dietary staff on special diets with return demonstration on [DATE]. A 100% in-service was completed [DATE] by Director of Nursing, The Administrator, The Social Worker, The Activity Director, The Housekeeping Supervisor, the Dietary Manager, and the Therapy Manager on neglect/abuse. The Director of Nursing, the Assistant Director of Nursing, and the MDS Nurses in -serviced all Nursing Staff on providing supervision during meals, cuing residents during the meal, the signs and symptoms of choking, and all staff were in-serviced on what to do if you see a resident eating or drinking a non-food item to include notification and assessment by the nurse on [DATE]. The credible allegation was validated on [DATE] at 11:35 AM as evidenced by nursing staff interviews and review of the in-service records regarding providing supervision during meals, cuing residents during meals, observing signs and symptoms of choking and what to do if you see a resident eating or drinking a non-food item to include notification and assessment by the nurse and the 2 way system (checking the dietary card and food serve are matching) and abuse/neglect. In-service records and interview with dietary staff were conducted and they had received in-service on special diet and tray line. In-service records and interview with non-licensed staff revealed they received in-service on abuse and neglect. An observation was conducted on [DATE] at 12:35 PM, during lunch and residents who needed supervision during meals were supervised, residents on mechanically soft diet received ground meat and the food served matched with their dietary cards.

Based on record review, observation and staff interviews, the facility failed to develop a care plan to address care to prevent choking/aspiration related complications for 1 of 3 sampled residents reviewed with dysphagia (Resident #1). Resident #1 was found unresponsive right after dinner and was sent to the hospital and died . The cause of death was [MEDICAL CONDITION] secondary to acute respiratory arrest with [MEDICAL CONDITION] and aspiration. Immediate jeopardy began on [DATE], when Resident #1 was found unresponsive and was transferred to the hospital. Immediate jeopardy was removed on [DATE]. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident # 1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status Minimum data Set (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact and he had no swallowing disorder. The assessment further indicated that Resident #1 needed supervision/set up help with eating and he was not on mechanically altered diet. Review of Resident #1's hospital records revealed that he was discharged to the hospital on [DATE] due to cough. The hospital discharge summary dated [DATE] was reviewed. The notes revealed that on [DATE], Resident #1 was near respiratory arrest secondary to choking on chicken during dinner. [MEDICATION NAME] maneuver was performed by vigilant nursing staff resulted in expelling of food bolus. The diet discharge instruction was cardiac dysphagia diet with chopped meats and thickened liquids. Resident #1 was readmitted back to facility on [DATE] with new [DIAGNOSES REDACTED]. Resident #1's care plan was last updated on [DATE]. There was no care plan developed after his readmission on [DATE] to address care to prevent choking/aspiration related complications. The nurse's notes dated [DATE] at 7:11 PM revealed that Resident #1 was found slumped over. Emergency Medical Service (EMS) was called and he was transported to the hospital. The hospital history and physical for Resident #1 dated [DATE] was reviewed. The records revealed that Resident #1 presented to the emergency room due to [MEDICAL CONDITION]. The physical examination revealed he has rales in the right upper field, the right middle field, left upper field and the left middle field. The chest x-ray showed subtle bibasilar infiltrates are present and may be due to aspiration. The EGD (Esophagogastroduodenoscopy - a procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum) result dated [DATE] revealed food was found in the upper third of the esophagus. On [DATE] at 8:01 AM, MDS Nurse #2 was interviewed. She stated that she was updating all the resident's care plans and she didn't get the chance to update Resident #1's care plan to address care to prevent choking/aspiration. On [DATE] at 8:40 AM, MDS Nurse #1 was interviewed. The MDS Nurse indicated that she attended the morning meetings every morning Monday through Friday and the ST (Speech Therapist) had discussed the need for supervision and restorative dining for Resident #1 due to his risk for choking/aspiration. The MDS Nurse indicated that she didn't get the chance to update his care plan and his kardex to address care to prevent choking/aspiration. On [DATE] at 10:10 AM, the Director of Nursing (DON) was interviewed. She stated that she expected the MDS Nurses to develop a care plan to address care to prevent choking/aspiration related complication when a resident was admitted /readmitted from the hospital with history of choking. On [DATE] at 2:32 PM, the Administrator and the Director of Nursing were informed of the Immediate jeopardy. On [DATE] at 7:00 PM, the facility provided the following credible allegation of Immediate jeopardy removal: Resident number 1 was hospitalized from [DATE] to [DATE]. During the resident's hospital stay the resident had an episode of choking and was identified as being at risk for aspiration. Resident number 1 was readmitted to Pinehurst Healthcare and Rehabilitation Center on [DATE]. He was admitted with a [DIAGNOSES REDACTED]. He was admitted with being at risk for aspiration and choking from the hospital. Speech Therapy began to work with him on [DATE] for oropharyngeal dysphagia. Speech Therapy completed a bedside dysphagia evaluation on [DATE]. The bedside dysphagia evaluations showed that the resident needed speech therapy due to him being at risk for aspiration, aspiration-related complications, choking and re-hospitalization . Resident received speech therapy until [DATE] when he was discharged from therapy. Speech therapy recommended restorative dining continues on [DATE] when he is discharged on [DATE]. The Director of Nursing educated the Nurses that Resident number 1 should be supervised when eating using the restorative dining program and certified nursing aides in the evening as a nursing intervention. On [DATE] the Restorative aide states resident number 1 refused to attend restorative dining and continued to do so throughout his stay. Resident ' s care plan failed to identify him being at risk for aspiration, choking, and needing supervised dining as directed by the Director of Nursing and the Interdisciplinary team. Resident's Kardex listed him as independent in his ability to eat when he needed supervision during eating. On [DATE] Resident was noted to be unresponsive after eating dinner and C.P.R. was initiated. Resident was discharged to the hospital on [DATE] due to an episode of non-responsiveness. The hospital records shows that Resident Number 1 had a large bolus of food impacted in the proximal esophagus. The Resident was intubated. The CT of the head showed the resident had diffuse cerebral [MEDICAL CONDITION] and diffuse infarct from diffuse [MEDICAL CONDITION] injury, on [DATE], the resident died after being extubated per the family request. Resident number 1 did not have his care plan revised due to Pinehurst Healthcare and Rehab Center standing practice that once a resident is discharged for any reason we do not document in their chart until they return. On [DATE], Pinehurst Healthcare and Rehabilitation Center's QAPI Committee reviewed the existing care plans to identify if the care plans reflected the current condition of the resident. The QAPI team identified that there were concerns with the care plans due to care plans not being reviewed and revised. The care plans were not being reviewed and revised by the MDS nurses. 100% of care plans were reviewed by the MDS Nurses and the Director of Nursing beginning on [DATE] until [DATE]. 1. There was no audit completed from [DATE] to [DATE] due to the 100% review and revision of all care plans for all residents being completed by the MDS Nurses and the Assistant Director of Nursing from [DATE] to [DATE]. There was at least one area in every care plan that required a correction. Recent changes in the MDS Nurse position helped cause the breakdown of the Care Planning process. The MDS Nurses will review and revise each care plan every time an MDS is completed. At each resident ' s annual care plan the MDS Nurses will purge the care plan and write a new care plan. Every time a care plan is updated the Kardex will be updated and placed in the resident ' s closet by the MDS Nurses. 2. The MDS Nurses and the Assistant Director of Nursing reviewed and revised 100% of care plans for all residents on [DATE]. There were changes in at least one area for each resident ' s care plan. The Director of Nursing in-serviced the MDS Nurses and the Assistant Director of Nursing on Care plans addressing the residents current condition in all areas and if there is an acute change in condition the care plan must be reviewed and revised at that time and any time a care plan is reviewed and revised the Kardex for the resident will be updated and the new copy placed in the resident ' s room by the MDS Nurses on [DATE]. A 100 % in-service was completed with all staff on making sure that food served to resident ' s matches what is on the tray card prior to serving the food to the resident by the MDS Nurses, the Activity Director, and the Social Worker on [DATE]. The Dietary Manager in-serviced 100% of dietary staff on special diets with return demonstration on [DATE]. A 100% in-service was completed [DATE] by Director of Nursing, The Administrator, The Social Worker, The Activity Director, The Housekeeping Supervisor, the Dietary Manager, and the Therapy Manager on neglect/abuse. The credible allegation was validated on [DATE] at 11:35 AM as evidenced by MDS Nurses interviews and review of the in-service records regarding revising and updating of care plans and Kardex. Kardex and care plan were reviewed and reflected resident's current condition.

Based on record review, observation and Physician, Speech Therapist (ST) and staff interviews, the facility failed to supervise a resident every meals as recommended by the Speech Therapist (ST) for 1 of 3 sampled residents reviewed with dysphagia (Resident #1). Resident #1 was found unresponsive right after dinner and was sent to the hospital and died . The cause of death was [MEDICAL CONDITION] secondary to acute respiratory arrest with [MEDICAL CONDITION] and aspiration. Immediate jeopardy began on [DATE], when Resident #1 was found unresponsive and was transferred to the hospital. Immediate jeopardy was removed on [DATE]. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident # 1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status Minimum data Set (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact and he had no swallowing disorder. The assessment further indicated that Resident #1 needed supervision/set up help only with eating and he was not on mechanically altered diet. Review of Resident #1's hospital records revealed that he was discharged to the hospital on [DATE] due to cough. The hospital discharge summary dated [DATE] was reviewed. The notes revealed that on [DATE], Resident #1 was near respiratory arrest secondary to choking on chicken during dinner. [MEDICATION NAME] maneuver was performed by vigilant nursing staff resulted in expelling of food bolus. The diet discharge instruction was cardiac dysphagia diet with chopped meats and thickened liquids. Resident #1 was readmitted back to facility on [DATE] with new [DIAGNOSES REDACTED]. Resident #1's care plan was last updated on [DATE]. There was no care plan developed after his readmission on [DATE] to address care to prevent choking and aspiration related complication. Resident #1's kardex (resident care guide) was reviewed for his readmission to the facility on [DATE]. The kardex indicated that Resident #1 was independent/set up help only with eating. The kardex did not indicate that Resident #1 needed supervision during meals. The speech therapist notes were reviewed. The notes dated: [DATE] at 4:16 PM - treatment of [REDACTED]. Patient (Pt) completed dysphagia therapy session during lunch meal of mechanical soft solid and nectar thick liquids (NTL). ST asked Pt several questions re: hospitalization and change of diet, patient did not respond to ST's questions, appears psychological in nature. Pt did not actively participate in any type of communication. ST observed Pt on multiple trials of soft solids and NTL. Pt completed MBS (modified [MEDICATION NAME] swallow) during hospital stay, with overt aspiration on thin liquids, transient penetration of NTL. Further therapy to address potential strengthening of airway closure to increase safety of intake of thin liquids. [DATE] at 5:40 PM -ST completed meal tray set up and verbal cues to utilize small bites, masticate thoroughly and take small sips. Pt does not respond or acknowledge ST in any way. Pt quickly consumed multiple bites of mechanical soft solid and ground meats in succession, not utilizing safe swallow strategies. Patient then consumed NTL via straw in rapid succession without adequately swallowing the entire bolus. Pt audibly penetrating /aspiration as there are rattles in respiration during and after the swallow. ST attempted to provide maximum verbal and physical cues to remove straw from patient ' s cup/mouth during the event however he quickly pulled away. Pt agitated, wheeled away from ST. [DATE] at 9:55 pm - (activity date [DATE]) Pt seen for dysphagia therapy during late afternoon snack of NTL and mechanical soft solid. Pt initially states he will not consume NTL due to consistency preferences. Pt eventually obliged, demonstrates mild need to throat clear following 50% of trials. Pt does not fully clear audible residue. Pt consumed soft solid snacks with deficits of oral or pharyngeal phase, however consistency is very soft and moist. [DATE] at 9:50 PM - (activity date [DATE]) Pt completed dysphagia therapy session during lunch meal of mechanical soft solid and NTL. On this date, Pt demonstrated no significant deficits of oral or pharyngeal phase for intake of solid. Pt observed to consume NTL in rapid manner via straw resulting in immediate throat clear and wet respirations. Pt unable /does not attempt to clear airway with throat clear or cough as directed by ST. Nursing made aware due to increased risk of aspiration-related complications. [DATE] at 9:26 PM - Pt completed dysphagia therapy session during lunch meal of mechanical soft solid and NTL. Prior to set up and consumption of meal, ST educated patient on deficits observed during prior sessions severely impacting safety of intake and ability to be upgraded to premorbid diet. Pt. does not acknowledge these deficits. Similar to previous session, Pt observed to consume entirely of meal in rapid, consecutive, large bites. Pt consumed a roll in a single bite. ST provided maximum cues to remove but Pt did not. Pt consumed a cup of NTL via cup rim without taking a break from consumption. Pt observed to have significant wet aspiration following intake. ST asked Pt multiple questions about feeding habits, Pt does not respond. ST educated dietary department of need to maintain strict restrictions and limit Pt ability to take leftover food from dirty trays in the dining room. Further assessment of solids and liquids for safest intake is necessary. [DATE] at 8:22 PM -Pt completed dysphagia therapy session during lunch meal of mechanical soft and NTL. On this date, Pt continue to demonstrate significantly impulsive behavior for all intake. ST retrieved honey thick liquids (HTL) to assess improve safety of intake as Pt does not respond to verbal or physical cues to cease rapid impulsive intake of NTL. NTL intake consistently results in throat clear, cough, and wet aspirations, to which Pt does not make attempts to clear material effectively. Pt consumed 6 ounce (oz.) cup of HTL in similar fashion at NTL but unable to do so as rapidly due to consistency. Pt demonstrates no s/s (signs/symptoms) of aspiration. ST spoke with psychiatry services extensively to collaborate on best treatment approach. ST downgraded Pt to HTL due to ongoing signs/symptoms of aspiration and psychiatry recommendation that Pt will likely to continue significantly impulsive behavior due to high ammonia levels and history of severe alcoholism. [DATE] at 9:21 PM -Pt seen on this date for dysphagia therapy session in Pt private room with sister present. ST educated sister on purpose of ST to minimize risk of aspiration/choking episodes while maintaining optimal desire to consume solid/liquids. ST educated family on cause of choking episodes secondary to impulsivity and poor awareness of risk and consequences of choking. Family verbalized agreement and good understanding of education received. Family able to verbalize Pt typical performance, impulsively consuming an entire glass of HTL without taking breath or using dry swallows to clear potential residue. ST attempted to physically remove Pt cup of HTL. Pt demonstrated need to clear throat and produce strong cough for approximately 45 seconds following intake of liquids. Pt demonstrated mostly functional intake of soft solid, cooked vegetable, mashed potatoes and sugar cookie, however family states they would pursue further diet downgrade versus a feeding tube if necessary. [DATE] at 9:42 PM - (activity date [DATE]) Pt seen on this date for dysphagia therapy session in Pt room for lunch meal. ST arrived with Pt meal, provided set up. Pt sitting in wheelchair at bedside table. Pt observed to consume bowl of vegetable with the bowl at Pt lips, scooping vegetable into mouth in very large bites. Pt continued to scoop vegetable without fully masticating and swallowing trials. ST attempted to remove the bowl but Pt would not cooperate and consumed all vegetable into the oral cavity. Pt required an extended period of time to complete mastication and bolus prep due to large amount of food placed in the oral cavity. Typical of previous sessions, Pt consumed all of the HTL in one drinking attempt, taking large consecutive gulps until the cup was empty. Pt with audible wet respirations immediately following intake. Pt does not produce cough or throat clear as directed by ST [DATE] at 9:32 PM - Pt seen for dysphagia therapy session during lunch meal of mechanical soft solids and HTL. Pt consumed HTL glass of apple juice impulsively despite ST verbal cues and tactile cue to lower the glass. Pt pulled away from ST aggressively. PT transferred self to the wheelchair, wheeled self to the bathroom and retrieved a half glass of water from the sink. Pt consumed it immediately and in an impulsive manner. Pt cough immediately and continued to throat clear with obvious wet respirations. Pt returned to room and consumed solids from lunch tray. Further therapy to address improving Pt attendance to restorative dining to improve safety if he chokes during meal. [DATE] at 8:48 PM - Pt seen for dysphagia therapy session during afternoon snack of mechanical soft solids (2 packs of Sugar free cookies), pudding and HTL. Pt lying in bed on entry. Pt originally states he will not sit on edge of bed to eat snack and want ST to give all trials in bed. ST educated Pt on risk of consumption in bed. ST assisted Pt into upright sitting position. Once in safe sitting position Pt given 3 small lemon cookies on table, separated by several inches to attempt to dissuade him from impulsively consuming cookies. Pt picked up all cookies and shoved them into his mouth despite ST attempting to physically remove the cookies. ST cued Pt to spit out excess cookies while attempting to masticate such a large bolus. Pt would not. Once he began drinking TL, he did not stop. Pt throat cleared for ,[DATE] minutes following intake. ST provided cup of pudding, which Pt consumed in 4 bites. ST educated restorative dining aide on strategies to reduce risk of aspiration on both solids and liquids. Restorative aide reports Pt refuses to attend restorative dining. [DATE] at 8:52 PM - (activity date [DATE]) Pt completed dysphagia session in Pt private room during lunch meal of mechanical soft solid and HTL. On this date, Pt significantly impulsive in all areas including transfer to wheelchair, use of utensils and condiments on lunch tray as well intake of solids and liquids. ST attempted to provide education re: choking and aspiration risks. Pt did not respond to ST or appear to comprehend any education given. Pt consumed HTL in large, consecutive gulps resulting in cough following the straw. Pt does not appear to acknowledge education if he is safer in impulsive intake, he could be downgraded back to NTL. Further therapy indicated to improve behavioral safety. [DATE] at 9:23 PM - Pt completed dysphagia therapy session on [DATE] in Pt ' s private room during lunch meal of mechanical soft solid and HTL. [DATE] at 9:14 PM -Pt completed lunch meal in Pt private room for lunch meal of mechanical soft solid and HTL. Pt observed to search for straw in bedside table for several minutes prior to intake. ST educated Pt on likely inability to consume liquids through the straw as well as history of unsafe intake from the straw. Pt conceded and proceeded to pick up the cup and consume entire contents in several large consecutive gulps. Pt began throat clearing during intake and swallow but did not stop taking consecutive gulps. Following swallow of final large gulp, Pt required hard throat clear and cough to clear material from the airway/pharynx. ST attempted to provide education re: safety of swallowing however Pt demonstrated no understanding or desire to learn information. Pt observed to consume solids in mostly safe and functional manner to given food selection. Pt did not retrieve water from the faucet of the bathroom on this date. [DATE] at 4:57 PM - Pt completed dysphagia therapy session during lunch meal of mechanical soft solid and HTL in restorative dining room. On this date, Pt demonstrate considerably improved impulsivity, taking appropriate size bites and drinks at an appropriate rate. Pt appears to be less concerned with rapid rate of intake and seeking out next step of daily sequence. ST educated Pt on improved overall behavior significantly improving safety of by mouth (po) intake. ST recommends ongoing attendance in restorative dining to improve overall safety of po intake. [DATE] at 5:00 PM - Pt completed dysphagia therapy session in restorative dining room for intake of mechanical soft solids and HTL. On this date, Pt demonstrate good improvement in safety of po intake, demonstrating no impulsive intake of solids, however Pt observed to take multiple large drinks of HTL. There is no overt signs/symptoms of aspiration. Pt does not respond to ST throughout therapy session. The ST progress and discharge summary dated [DATE] was reviewed. The notes revealed that the end of goal status was not met as Pt safely consumes mechanical soft exhibiting severe impairment, primarily non oral nutrition, high risk of aspiration, requires supervision with oral intake due to aspiration risk and significant weight loss, and trial oral intake via therapeutic feedings due to impulsivity. Pt is at risk of aspiration of both consistencies due to impulsivity of intake. Pt discharged as long term care resident with restorative dining. The nurse's notes dated [DATE] at 7:11 PM revealed resident was sitting in room and staff took meal tray in and sat while resident ate. Staff walked out of room when finished with meal and then went back in and found resident slumped over and came for writer. His eyes opened, not breathing or had no pulse. Placed resident on the bed and writer started cardiopulmonary resuscitation (CPR) and crash cart brought in and started using ambu bag and oxygen at 6:10 PM. Back board was placed under resident. West side nurse helped. Emergency Medical Service (EMS) arrived and started working with resident and 30 minutes later obtain blood pressure and heart beating. Transported to hospital. The hospital history and physical records for Resident #1 dated [DATE] were reviewed. The records revealed that Resident #1 presented to the emergency room due to [MEDICAL CONDITION]. Pt. supposedly was witnessed drinking cologne and subsequently had some sort of arrest. High quality CPR was immediately initiated. Pt. had a return of spontaneous circulation (ROSC) in the field but subsequently had another episode of arrest. He was intubated and brought to the emergency department where ROSC was once again achieved. The physical examination revealed he has rales in the right upper field, the right middle field, left upper field and the left middle field. The chest x-ray showed subtle bibasilar infiltrates are present and may be due to aspiration. The chest x-ray final result dated [DATE] revealed bilateral infiltrates are noted and appear stable. Findings are worrisome for pneumonia. The [MEDICATION NAME] consult dated [DATE] revealed attempted to place nasogastric tube (NGT) but unable to pass. Went back of throat and ok to push but kept curling up. Recommended Esophagogastroduodenoscopy (EGD, a procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum, at bedside in the morning if stable and to try to place NGT. The EGD result dated [DATE] revealed food was found in the upper third of the esophagus. The hospital discharge summary dated [DATE] revealed that when EGD was performed on [DATE], large food bolus was found impacted in the proximal esophagus. The computerized tomography (CT) scan of head performed on [DATE] revealed findings consistent with severe diffuse cerebral [MEDICAL CONDITION] consistent with [MEDICAL CONDITIONS]. Decision was made to [MEDICATION NAME] extubate patient. He was extubated and failed to take any spontaneous breaths. Patient passed peacefully at 4:51 PM on [DATE]. On [DATE] at 12:35 PM, a lunch meal observation was conducted in the restorative dining room. There were two residents with doctor's orders for mechanically altered diet with thickened liquids. The dietary cards matched with the consistency of food on their trays. Residents with orders for mechanical soft diet received ground meat on their tray. On [DATE] at 1:51 PM, a family member was interviewed. The family member stated that he/she went back to the facility to pick up Resident #1's belongings. She/he was informed by Nurse #1 that NA #1 stepped out of the room while the resident was eating and when she came back few minutes later to pick up the tray, she found the resident slumped over. On [DATE] at 2:30 PM, the ST was interviewed. She stated that she started treating Resident #1 for dysphagia upon his readmission on [DATE]. She indicated that resident choked on a piece of chicken at the hospital and was discharged to the facility on soft diet with thickened liquids. His behavior and mental status had changed during his readmission of [DATE]. He was very impulsive and no desire to learn. Treated him once a day during lunch meal. He needed supervision during meals because he had no safety awareness. On [DATE] at 3:45 PM, Restorative Aide (RA) #1 was interviewed. She stated that she was the head of the restorative program. She indicated that Resident #1 refused to go to restorative dining, he was on 1:1 with the staff during meals. RA #1 did not have documentation that Resident #1 was refusing to go to restorative dining. On [DATE] at 3:50 PM, Nurse Aide (NA) #1 was interviewed. She was assigned to Resident #1 on [DATE], second shift. She stated that she was assigned to Resident #1 on [DATE] for the first time after his readmission from the hospital. She indicated that Nurse #1 informed her that Resident #1 needed 1:1 during meals. She served the dinner tray around 6 PM in the resident's room and stayed with him the whole meal. She indicated that the resident was able to feed himself. He had chunks of beef (not ground beef) on his tray about ¾ to an inch thick and thickened liquids. He consumed about 80% of his food and 50% of his liquids. He did not cough during the meal observation. After he finished eating, he turned around and opened his bedside drawer, took a bottle of cologne and drank from it. She noticed empty cups inside his drawer and he would not allow her to take them out. She indicated that she thought she informed Nurse #2 that she observed the resident drinking from the cologne bottle. NA #1 left the room with the resident's tray and proceeded to feed another resident. She stated that after 15 minutes she went back to the resident's room to remove the empty cups from his drawer and she found him slumped over to his right side and not breathing. She went to get Nurse #1. On [DATE] at 5:27 PM, Nurse #3 was interviewed. She stated that she had been working at the facility for almost 3 months and had known Resident #1. He was independent with eating and he did not need any supervision during meals. On [DATE] at 5:29 PM, Nurse #4 was interviewed. She stated that she had been working at the facility for 4 months and he remembered Resident #1. He was independent with eating with set up help only and he didn't need any supervision during meals. On [DATE] at 5:32 PM, NA #2 was interviewed. NA #2 had been working at the facility for 2 years on second shift. She used the kardex to care for the resident. She indicated that she remembered Resident #1 and he was independent with eating with set up help only and he didn't need any supervision during meals. On [DATE] at 8:01 AM, MDS Nurse #2 was interviewed. She stated that she was updating all the resident's care plans and she didn't get the chance to update Resident #1's care plan and kardex to address his risk for choking/aspiration following his readmission to the facility on [DATE]. On [DATE] at 8:30 AM, the ST was again interviewed. She stated that she had referred Resident #1 to restorative dining. The ST was unable to remember the date of the referral and she could not find her referral form to nursing. She had talked to the Restorative Aide who indicated that the resident refused restorative dining. The ST indicated that she expected the staff to sit and to watch him while he eats in his room when he refused to go to restorative dining. She attended the morning meetings with the department heads and she had shared with them her concerns with Resident #1 the need for supervision during meals. The ST stated that she discharged Resident #1 from therapy on [DATE] and she recommended to continue restorative dining. On [DATE] at 8:40 AM, MDS Nurse #1 was interviewed. The MDS Nurse indicated that she attended the morning meetings and the ST had discussed the need for supervision and restorative dining for Resident #1 due to his risk for choking/aspiration. The MDS Nurse indicated that she didn't get the chance to update his care plan and his kardex to address risk for choking/aspiration. The MDS Nurse indicated that Resident #1 was on restorative dining after his readmission on [DATE] but he refused to go at times so a staff member had to sit and watch him while he ate in his room. On [DATE] at 8:50 AM, the Physician of Resident #1 was interviewed. He stated that he expected the facility to follow the recommendations of the ST regarding supervision with eating. The Physician stated that he didn't know if the food in his esophagus had caused the resident's death. On [DATE] at 9:01 AM, NA # 3 was interviewed. She was assigned to Resident #1 on first shift. She stated that Resident #1 was on restorative dining and he never refused to go to restorative dining. She brought him to restorative dining every breakfast and lunch when she was assigned to him. On [DATE] at 9:04 AM, Restorative Aide #2 was interviewed. She stated that she worked Monday through Friday on ,[DATE] shift. She was in the restorative dining room during breakfast and lunch. She indicated that Resident #1 had been to restorative dining once (didn't remember the date) and the ST was working with him. She indicated that she didn't have any documentation regarding restorative dining for Resident #1. On [DATE] at 10:10 AM, the Director of Nursing (DON) was interviewed. She stated that the ST attended the morning meetings with the department heads. She discussed Resident #1 being high risk for choking/aspiration due to his impulsiveness/compulsiveness and he needed to be in restorative dining or needed supervision with meals, but these (restorative dining and supervision during meals) had not been formally implemented or ordered. It was on [DATE] when she informed Nurse #1 and the NAs that Resident #1 had to be supervised during meals but she could not remember the time. The DON verified that Resident #1 was not on restorative dining nor was on 1:1 with staff during meals prior to [DATE]. On [DATE] at 1:30 PM, Nurse # 1 was interviewed. Nurse #1 stated that she was assigned to Resident #1 on [DATE]. She stated that she was busy passing medications (little after 6 PM) when NA #1 called her to the resident's room. She found the resident slumped over, not breathing and no pulse. She called the code and cardio [MEDICAL CONDITION] resuscitation (CPR) was initiated. EMS (Emergency Medical Services)was called and when they arrived they took over the CPR. Nurse #1 stated that NA #1 informed her that she sat with the resident during supper and when he finished eating she took the tray out. Nurse #1 indicated that the resident refused restorative dining and the DON informed them that Resident #1 needed 1:1 during meals, but she could not remember the date and time. On [DATE] at 2:32 PM, the Administrator and the Director of Nursing were informed of the immediate jeopardy. On [DATE] at 7:00 PM, the facility provided the following credible allegation of immediate jeopardy removal: Resident number 1 was hospitalized from [DATE] to [DATE]. During the resident's hospital stay, the resident had an episode of choking and was identified as being at risk for aspiration. Resident number 1 was readmitted to Pinehurst Healthcare and Rehabilitation Center on [DATE] with a [DIAGNOSES REDACTED]. Speech therapy reported that resident has impulsive behaviors and placed a whole dinner roll in the oral cavity at one time. Speech Therapy began to work with him on [DATE] for oropharyngeal dysphagia. Speech Therapy completed a bedside dysphagia evaluation on [DATE]. The bedside dysphagia evaluation showed that the resident needed speech therapy due to him being at risk for aspiration, aspiration-related complications, choking, and re-hospitalization due to his impulsive behavior of placing large amount of food(such as a whole roll) in his mouth at one time . Resident received speech therapy until [DATE] when he was discharged from therapy. Speech therapy recommended restorative dining continues in a note on [DATE] when he is discharged from therapy on [DATE] due to the need of constant supervision. There is no documentation to show that resident number 1 received constant supervision during his meals from [DATE] through [DATE]. Resident number 1 was supervised by a certified nursing assistant during his dinner meal on [DATE]. The certified nursing assistant states she remained in the room throughout the meal and there were no signs of distress, complications, or universal signs of choking. The Director of Nurses educated the hall nurses that Resident number 1 should be supervised when he is eating using the restorative dining program for 2 meals a day and certified nursing aides in the evening as a nursing intervention. The Director of Nursing did not complete the education on an in-service form and does not remember the date. On [DATE] the speech therapist documented in her note that the restorative aides reported that resident refused to participate in the restorative dining program. The interdisciplinary team made a verbal recommendation for restorative and supervision during meals during morning meeting after resident number 1 was readmitted on [DATE]. The recommendation for restorative for resident number 1 was not done in writing and was not implemented consistently. A Restorative care referral was not completed for resident number 1 on his discharge by the speech therapist and given to the Director of Nursing which contributed the lack of implementation of restorative for resident number 1. The Restorative Program did not have resident number 1 ' s information for restorative dining and supervised meals in written form. On [DATE] Resident was noted to be unresponsive and C.P.R. was initiated. Resident was discharged to the hospital on [DATE] due to an episode of non-responsiveness. The hospital records show that Resident number 1 had a large bolus of food impacted in the proximal esophagus. The Resident was intubated. The CT of the head showed the resident had diffuse cerebral [MEDICAL CONDITION] and diffuse infarct from diffuse [MEDICAL CONDITION] injury, on [DATE], the resident died after being extubated per family request. 1. There were no other residents on supervised meals. An Audit was completed by the Administrator on [DATE] on the residents that have been referred to restorative dining from therapy and there were no concerns with their recommendations being followed. Restorative dining has 2 residents that attend the restorative dining program 2 meals a day and the certified nursing assistants will feed the 3rd meal each day. Any resident that is identified as needing supervision during meals will have a care plan written addressing their needs by the MDS Nurses, the Director of Nursing, and / or the Assistant Director of Nursing, a Kardex placed in their closet by the MDS Nurses, the Director of Nursing, and /or the Assistant Director of Nursing. The MDS Nurses completed a 100% in-service with nursing staff on Kardex being updated anytime there is a change in a residents needs and placed in the resident's closet. The Kardex must be checked prior to care for changes on [DATE]. The Business Office Manager will bring all intent to discharge forms to morning meeting to review therapy recommendations. The Speech therapist will bring all written referrals for restorative care or supervision during meal time to the morning meeting for review. The Clinical Nurses will receive a copy of the referrals so a care plan may be written and the Kardex updated. Any referral for restorative or supervision during meal time will be addressed in the care plan by the clinical team after morning meeting. The Director of Nursing will notify the Restorative Manager/Nursing staff of new referrals by giving the restorative manager the care plan to add the resident to the restorative program and the Clinical Nurses will update the Kardex and place it in the resident's closet for the nursing staff. The week-end manager will review all hospital information on week-end admissions to determine the need for supervised dining and implement supervised dining for those that require it. 2. The MDS Nurses and the Assistant Director of Nursing revised and reviewed 100% of care plans and Kardex's for all residents on [DATE]. There were changes in at least one area for each resident's care plan and Kardex. The Director of Nursing in-serviced the MDS Nurses and the Assistant Director of Nursing on [DATE] on reviewing and revising the care plan to reflect the residents current condition in all areas, if there is an acute change in condition the care plan must be reviewed and revised at that time. The Director of Nursing in-serviced the MDS Nurses and the Assistant Director of Nursing that anytime the care plan is revised the Kardex must be revised and a new Kardex hung in the resident's room by the MDS Nurses on [DATE]. A 100% in-service was completed with all staff on making sure that food served to the resident matches what is on the tray card prior to serving the food to the resident by the MDS Nurses, the Activity Director, and the Social Worker on [DATE]. The Dietary Manager in-serviced 100% of dietary staff on special diets with return demonstration on [DATE]. A 100% in-service was completed on [DATE] by the Director of Nursing, the Administrator, the Social Worker, the Activity Director, the Housekeeping Supervisor, the Dietary Manager, and the Therapy Manager on Neglect/Abuse on [DATE]. The Director of Nursing, the Assistant Director of Nursing, and the MDS Nurses in-serviced all Nursing Staff on providing supervision during meals, cuing residents during the meal, the signs and symptoms of choking, and what to do if you see a resident eating or drinking a non-food item to include notification and assessment by the nurse on [DATE]. The credible allegation was validated on [DATE] at 11:35 AM as evidenced by nursing staff interviews and review of the in-service records regarding providing supervision during meals, cuing residents during meals, observing signs and symptoms of choking and what to do if you see a resident eating or drinking a non-food item to include notification and assessment by the nurse. An observation was conducted in the restorative dining room and main dining room on [DATE] at 12:35 PM, during lunch and residents who needed supervision during meals were supervised.

Based on record review, observation and Physician, Speech Therapist (ST)and staff interviews, the facility failed to serve food in a form ordered by the physician for 1 of 3 sampled residents reviewed with dysphagia (Resident #1). Resident #1 was found unresponsive right after dinner and was sent to the hospital and died . The cause of death was [MEDICAL CONDITION] secondary to acute respiratory arrest with [MEDICAL CONDITION] and aspiration. Immediate jeopardy began on [DATE], when Resident #1 was served food in regular consistency instead of mechanical soft as ordered. Immediate jeopardy was removed on [DATE]. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident # 1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status Minimum data Set (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact and he had no swallowing disorder. The assessment further indicated that Resident #1 needed supervision/set up help with eating and he was not on mechanically altered diet. Review of Resident #1's hospital records revealed that he was discharged to the hospital on [DATE] due to cough. The hospital discharge summary dated [DATE] was reviewed. The notes revealed that on [DATE], Resident #1 was near respiratory arrest secondary to choking on chicken during dinner. [MEDICATION NAME] maneuver was performed by vigilant nursing staff resulted in expelling of food bolus. The diet discharge instruction was cardiac dysphagia diet with chopped meats and thickened liquids. Resident #1 was readmitted back to facility on [DATE] with new [DIAGNOSES REDACTED]. Resident #1's care plan was last updated on [DATE]. There was no care plan developed after his readmission on [DATE] to address care to prevent choking and aspiration related complication. Resident #1's kardex (resident care guide) was reviewed. The kardex indicated that Resident #1 was on mechanical soft diet with nectar thick liquids. The dietary notes were reviewed. The last dietary note was dated [DATE] indicating the resident's diet was regular with thin liquids. There were no notes after his readmission on [DATE]. The diet spreadsheet was reviewed. The menu for [DATE] dinner was beef tips with mushroom gravy for regular diet and ground beef with mushroom gravy for mechanical soft diet. The Speech Therapist (ST) progress and discharge summary dated [DATE] was reviewed. The notes revealed that patient (Pt) safely consumes mechanical soft exhibiting severe impairment, primarily non oral nutrition, high risk of aspiration, requires supervision with oral intake due to aspiration risk and significant weight loss, and trial oral intake via therapeutic feedings due to impulsivity. Pt is at risk of aspiration of both consistencies due to impulsivity of intake. Pt discharged as long term care resident with restorative dining. The nurse's notes dated [DATE] at 7:11 PM revealed that Resident #1 was found slumped over right after dinner in his room. Cardio [MEDICAL CONDITION] resuscitation (CPR) was initiated and he was sent to the hospital. The hospital history and physical dated [DATE] revealed that Resident #1 was presented to the Emergency Department (ED) due to [MEDICAL CONDITION]. The physical examination revealed that Resident #1 had rales in the right and left upper and middle fields. The chest x-ray result showed subtle bibasilar infiltrates which might be due to aspiration. The hospital discharge summary dated [DATE] revealed that when esophagogastroduodenoscopy (EGD), a procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum) was performed on [DATE], a large food bolus was found in the proximal esophagus. The computerized tomography (CT) scan of the head performed on [DATE] revealed findings consistent with severe diffuse cerebral [MEDICAL CONDITION] consistent with [MEDICAL CONDITIONS]. A decision was made to extubate Resident #1. He was extubated and passed away on [DATE]. On [DATE] at 12:35 PM, a lunch meal observation was conducted in the restorative dining room. There were two residents with doctor's orders for mechanically altered diet with thickened liquids. The tray cards matched with the consistency of food on their trays. Residents with orders for mechanical soft diet received ground meat on their tray. On [DATE] at 2:30 PM, the ST was interviewed. She stated that she started treating Resident #1 for dysphagia upon his readmission on [DATE]. She indicated that resident choked on a piece of chicken at the hospital and was discharged to the facility on soft diet with thickened liquids and she expected the facility to serve diet as ordered. On [DATE] at 3:50 PM, Nurse Aide (NA) #1 was interviewed. She was assigned to Resident #1 on [DATE], second shift. She stated that on [DATE] was her first time assigned to the resident after his readmission from the hospital. She served the dinner tray around 6 PM in the resident's room. He had chunks of beef (not ground beef) on his tray about ¾ to an inch thick and thickened liquids. He consumed about 80% of his food and 50% of his liquids. He did not cough during the meal observation. After he finished eating, he turned around and opened his bedside drawer, took a bottle of cologne and drank from it. On [DATE] at 5:45 PM, the Dietary Manager (DM) was interviewed. She stated that Resident #1 was on mechanical soft diet and honey thick liquids. She verified the menu on [DATE] as beef tips (,[DATE] to ¾ inch in size) for regular diet and ground beef for the mechanical soft diet. She stated that staff used the food processor to grind the meat for the soft diet. On [DATE] at 8:50 AM, the Physician of Resident #1 was interviewed. He stated that he expected the facility to follow the diet as ordered. The Physician stated that he didn't know if the food in his esophagus had caused the resident's death. On [DATE] at 10:10 AM, the Director of Nursing (DON) was interviewed. She stated that the ST attended the morning meetings every morning with the department heads. She discussed Resident #1 being high risk for choking/aspiration due to his impulsiveness. His diet order was mechanical soft diet and she expected the dietary department to serve the diet as ordered. On [DATE] at 12:34 PM, the DM was again interviewed. She stated that before she left on [DATE], she checked to make sure the dietary staff has everything they needed and they had enough food for soft and pureed diet. She also stated that she normally observed the tray line but she did not observe the whole process. On [DATE] at 5:02 PM, NA #1 was again interviewed. NA #1 stated that Resident #1 received beef tips on [DATE], ½ to ¾ inch in size solid meat during dinner. She indicated that she had received an in-service on the 2 way system (kitchen staff and the cook prepare the tray according to the tray/dietary card and nursing staff check the tray against the tray/dietary card before serving and if there was a concern, the nursing staff would bring the tray back to the kitchen to be corrected) on [DATE]. She indicated that she didn't know the 2 way system prior to the in-service that she had to check the tray and to compare the food served with the dietary card before serving the tray to the resident. On [DATE] at 2:32 PM, the Administrator and the Director of Nursing were informed of the immediate jeopardy. On [DATE] at 7:00 PM, the facility provided the following credible allegation of immediate jeopardy removal: Resident number #1 was hospitalized from [DATE] to [DATE]. During the resident's hospital stay, the resident had an episode of choking and was identified as being at risk for aspiration. Resident number 1 was readmitted to Pinehurst Healthcare and Rehabilitation Center on [DATE] with a [DIAGNOSES REDACTED]. He was admitted with being at risk for aspiration and choking from the hospital. Speech Therapy began to work with him on [DATE] for oropharyngeal dysphagia. Speech Therapy completed a bedside dysphagia evaluation on [DATE]. The bedside dysphagia evaluations showed that the resident needed speech therapy due to him being at risk for aspiration, aspiration-related complications, choking and re-hospitalization due to his behavior of putting a whole roll in his mouth or large amounts of food. Resident received speech therapy until [DATE] when he was discharged from therapy. Speech therapy recommended restorative dining continues in a note on [DATE] when he is discharged from therapy due to his impulsive behaviors and placing a whole roll in his mouth at one time. The Director of Nursing educated the hall nurses that resident number 1 should be supervised when he is eating using the restorative dining program and certified nursing assistants for the evening meal as a nursing intervention. The Director of Nursing did not complete the education on an in-service form and does not remember the date. The Certified Nursing Assistant stated to the Administrator that she was instructed to monitor resident for eating on [DATE] by the hall nurse. The Hall Nurse stated to the Administrator that she told the Certified Nursing Assistant to monitor resident for eating during his meal on [DATE]. Resident number 1's chart contains a note that the Certified Nursing Assistant monitored resident during his meal on [DATE]. Resident's care plan failed to identify him being at risk for aspiration and choking. Resident's Kardex listed him as independent in his ability to eat when he should have been listed as supervised due to behaviors. Resident's current diet order on [DATE] was mechanical soft with honey thick liquids, magic cup, cut all rolls, Danish, bread, sandwiches cut into fourths or ,[DATE] inch pieces, and no peanut butter. The Dietary Cook states that on [DATE] the dietary department provided a mechanical soft tray to resident number 1. The dietary department utilizes the standard practice of a two-system check which requires the cook to prepare the plate and the aide will make sure that the plate matches the food listed on the tray card prior to placing it in the serving cart. When the tray cart arrives on the hall the person passing the trays will make sure that the food matches the diet order on the tray card before giving it to the resident. If the tray card does not match the plate the person serving the plate will take the plate back to the kitchen to be corrected. The Dietary Manager monitored the tray line for the consistency and the amount of available food for special diets prior to her shift ending on [DATE]. The dietary department was able to provide the appropriate diet to all residents without any other concerns. There is no reason to believe that resident number 1 was received the wrong diet. The Certified Nursing Assistant states she remembered that his beef tips on his tray were about ,[DATE] to ¾ inch in size on [DATE] to the Administrator but she cannot remember anything else that he had. This is a change from what she reported earlier so it is possible she is unable to remember correctly. The Dietary Manager stated on [DATE] that she made sure there was enough ground for all the mechanical soft diets. There is no reason to believe that resident number 1 did not receive his correct diet. She stayed in his room until he had finished eating and took his tray out of the room with her when he finished eating. Certified Nursing Assistant states there were no complications, distress, and no universal signs of choking when she exited the room. Prior to exiting the room the Certified Nursing Assistant states that Resident Number 1 was going through his drawers and actually attempted to close her hand in the drawer. The Certified Nursing Assistant stated to the hall nurse on [DATE] that she saw Resident Number 1 take a sip of something out of his drawer and thought it was cologne. The Hall Nurse was involved in doing C.P.R. and did not go check to see if the resident had cologne in his drawer. The Hall Nurse asked her if she saw him drink it and the Certified Nursing Assistant told her she thought she did. The Hall Nurse reported to EMS that it was possible that Resident Number 1 drank cologne on [DATE]. The Certified Nursing Assistant proceeded to feed another resident and then returned to Resident Number 1's room to find him slumped over. The Hall Nurse states that from the time she told the Certified Nursing Assistant to supervise Resident Number 1 during his meal to the time the Certified Nursing Assistant came to ask her to look at him was around 20 to 30 minutes. The Certified Nursing Assistant stated the Hall Nurse told her to supervise resident number 1 during his evening meal. The Hall Nurse reports that she told the Certified Nursing Assistant to supervise Resident Number 1 during his meal on [DATE] because the Director of Nursing had told the Nurses to supervise him during meals for a nursing intervention. The Hall Nurse states she can't remember when she was told to supervise Resident Number 1 by the Director of Nursing. On [DATE] Resident was noted to be unresponsive and C.P.R. was initiated. Resident was discharged to the hospital on [DATE]. The resident was intubated. The CT of the head showed the resident had diffuse cerebral [MEDICAL CONDITION] and diffuse infarct from diffuse [MEDICAL CONDITION] injury. On [DATE] the resident died after being extubated per family request. 1. A 100% audit was completed on [DATE] by the Hall Nurses to ensure that all tray cards matched the trays being served to the residents. The result showed that all tray cards matched the resident ' s trays being served on [DATE]. The Dietary Manager and the Cook state that resident was given the diet that is on his tray card. Dietary Manager re-educated dietary staff on the tray line on [DATE] and The Director of Nursing, the MDS Nurses, and the Assistant Director of Nursing re-educated the nursing staff on the tray line process on [DATE]. 100% in-service was completed with nursing staff on the 2system tray line process on [DATE]. 2. The MDS Nurses and the Assistant Director of Nursing reviewed and revised 100% of care plans for all residents on [DATE]. There were changes in at least one area for each resident's care plan. The Director of Nursing in-serviced the MDS Nurses and the Assistant Director of Nursing on Care plans addressing the residents current condition in all areas and if there is an acute change in condition the care plan must be reviewed and revised at that time and any time a care plan is reviewed and revised the Kardex for the resident will be updated and the new copy placed in the resident ' s room by the MDS Nurses on [DATE]. 3 A 100 % in-service was completed with all staff on making sure that food served to resident's matches what is on the tray card prior to serving the food to the resident by the MDS Nurses, the Activity Director, and the Social Worker on [DATE]. The Dietary Manager in-serviced 100% of dietary staff on special diets with return demonstration on [DATE]. A 100% in-service was completed [DATE] by Director of Nursing, The Administrator, The Social Worker, The Activity Director, The Housekeeping Supervisor, the Dietary Manager, and the Therapy Manager on neglect/abuse. The credible allegation was validated on [DATE] at 11:35 AM as evidenced by review of in-service records and nursing staff interviews regarding in-service on 2 way system (checking dietary card and the food serve on their tray match) and dietary staff interview regarding special diets and tray line. An observation was conducted on [DATE] at 12:35 PM, during lunch and food consistency matched with their dietary cards.

Based on record review, observation and staff interview, the facility failed to use a sling specifically designed for the lift for 3 (Residents #1, #3 & #4) of 3 sampled residents who used a lift for transfer resulting in injury to Resident #1. The facility failed to ensure that slings did not show signs of damage or wear for 1 (Resident #1) of 3 sampled residents who used a lift for transfer. Findings included: Review of the electronic records of Resident #1 revealed that Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had memory and decision making problems and needed extensive assistance with 2 plus person assist with transfer. The facility's policy on the lift procedure dated 11/2015 was reviewed. The policy indicated that the lift would be used when determined appropriate to provide safe transfer for the non-ambulatory resident. The procedures instructed staff to: explain the lift process to the resident; to utilize two or more staff to use the lift; request instruction on the equipment use, if necessary, and provide lifting and transfer training upon hire, annually and as needed. The Food and Drug Administration (FDA) safety guide for patient lifts used by the facility to educate the staff was reviewed. The safety guide indicated only use a sling specifically designed for your lift, using the wrong sling may cause serious injury, most lifts require two or more caregivers to safely operate lift and handle patient and examine sling and attachment areas for tears, holes and frayed seams. Do not use sling with any signs of wear. The care plan dated 12/15/15 was reviewed. One of the care plan problems was (name of resident) is immobile due to quadriplegia, has contracture right and left hands. The goal was (name of resident) will remain passive range of motion of bilateral upper extremities and hands through range of motion, splinting and positioning through next review. The approaches included, lift transfer with assist of two. The incident reports were reviewed. The report dated 1/18/16 at 5:40 PM indicated, Resident was transferred from chair to bed using a motorized lift (lift #1), and after resident was placed in the bed she began to jerk uncontrollably and caused the metal bar on the lift to strike her in the face below her right eye. The report also indicated that redness was noted but no apparent signs of swelling or bruising. The statements from the two nurse's aides who assisted with the transfer were reviewed. The statement from NA #1 dated 1/18/16 indicated that she was assigned to Resident #1 on 1/18/16. At 11:45 AM, Resident #1 was transferred from bed to the Geri chair by NA #1. Around 4:30 PM, NA #1 with the help of NA #2 had transferred Resident #1 back to bed using a lift. After the resident was back in bed, NA #2 left the room leaving NA #1 by herself. The resident started to have a spasm really bad and the lift bar began to shake and fell off hitting the resident's face. The statement from NA #2 dated 1/19/16 indicated that she was helping NA #1 put Resident #1 back to bed. She was operating the lift when the resident started to jerk. NA #2 further indicated that she did not observe the bar hit the resident because she was looking at the lift and operating the lift. On 1/19/16 there was a doctor's order for x-ray of the facial bones and the report revealed no fracture. The nurse's notes were reviewed. The notes dated 1/19/16 at 1:27 PM indicated that Nurse #1 was called to the room of Resident #1 on 1/18/16 by Nurse Aide (NA) #1. NA #1 informed Nurse #1 that while transferring Resident #1 from the chair to the bed using the lift, the resident began to jerk and the metal bar on the lift struck the resident underneath her right eye. Nurse #1 immediately assessed the resident and observed some redness underneath the right eye. There was no swelling or apparent bruising noted at that time. There was a red line approximately 1.5 inches underneath the right eye. Ice pack was applied to prevent swelling. The attending physician and the family were notified of the incident. On 1/19/16 at 2:40 PM, the notes indicated that a new bruise was noted to the right side of face/eye area. The notes dated 1/22/16 at 2:58 AM indicated that the resident continued to have dark ecchymosis on her right cheek just below her right eye. The skin assessment dated [DATE] at 12:30 PM indicated that Resident #1 had bruises on her right eye and face. On 1/26/16 at 9:16 AM, Resident #1 was observed in bed. She was nonverbal, both hands were contracted and both feet had foot drop. Small bruises were noted around her right eye and a fifty cent size yellowish discoloration under the right eye. On 1/26/16 at 9:20 AM, Resident #1 was observed during transfer from bed to chair using lift #1. Two NAs (NA #3 & NA #4) were assisting with the transfer. A blue mesh sling was used during the transfer. On 1/26/16 at 9:30 AM, the lifts at the facility were observed. There were 2 different brand of lifts in use at the facility. There were two lifts (battery operated (lift #1) and a manual (lift #2)) on station 1. There were also two additional lifts (battery operated (lift #3) and a manual (lift #4)) on station 2. Lifts #1 and #2 were of one brand and lifts #3 & #4 were of another brand. On 1/26/16 at 11:20 AM, administrative staff #1 was interviewed. The administrative staff indicated that the two NAs (NA #1 and NA #2) involved during the transfer were interviewed and statements were obtained. The administrative staff indicated that he was not informed that NA #2 left the room before the resident was off the lift. His expectation was that two aides always assisted with the transfer when using the lift, from the start to finish and to hold the bars because the bars had a tendency to swing. He also revealed that there was an incident in the past where the bar fell off, but the resident did not have an injury from it. On 1/26/16 at 10:56 AM, NA #1 was interviewed via phone. NA #1 indicated that she was assigned to Resident #1 on 1/18/16. She asked NA #2 to help her transfer Resident #1 to bed using lift #1. NA#2 operated the lift while she guided the resident to the bed. When the resident was laid in bed, NA #2 left the room to take care of her residents. She started to unhook the straps of the sling on the left side and went around the bed to unhook the bottom strap on the right side when the resident started to jerk. When she unhooked the bottom strap, the bar came off and hit the resident's face. She added that their practice was for two NAs always assisted with the transfer but after the resident was in bed, the other NA can leave the room. On 1/26/16 at 10:59 AM, NA #2 was interviewed. She stated that she was asked by NA #1 to help her transfer Resident #1 back to bed. They were using lift #1 during the transfer. She was operating the lift. When the resident was in bed she left the room to attend to her residents. She further indicated that she was not in the room when the bar fell off. She also stated that she was assigned to Resident #1 in the past and the resident had never jerk on her. On 1/26/16 at 12:40 PM, administrative staff #2 was interviewed. She stated that the expectation was for 2 staff members to assist in transferring a resident using a lift, from the start of the transfer until the lift was not in use. On 1/26/16 at 3:12 PM, Nurse #1 was interviewed. He was assigned to Resident #1 during the incident. NA #1 informed him that Resident #1 jerked and the bar on the lift hit the resident on the face. Nurse #1 stated that Resident #1 barely moves and she was in a vegetative state. On 1/27/16 at 8:40 AM, NA #1 was interviewed. She stated that she was not informed in the past that two NAs had to stay in the room during transfer using the lift until the lift was out of the room. She further stated that to prevent the incident from happening again, two staff members had to stay until the resident was not hooked to the lift, one person to hold the bar on each side. On 1/27/16 at 9:50 AM, NA #1 demonstrated how the bar fell off the lift. She stated that she had unhooked the straps of the sling on the left side and when she was removing the bottom strap of the sling on the right side, the resident started to jerk and the bar came off with the top strap on and landed on the resident's face. NA #1 also showed the type of sling used to transfer Resident #1. It was a comfort glide sheet made by (brand name). This sheet was intended for positioning resident only and not for transferring a resident using a lift. NA #1 stated that she always used this sheet in transferring Resident #1 from bed to chair and vice versa. On 1/27/16 at 10:10 AM, NA #1 was observed transferring Resident # 3 from bed to chair using lift #1. A solid blue sling was used during the transfer. NA #1 indicated that almost all the residents had their own sling in their rooms. NA #1 did not know the brand of the sling. On 1/27/16 at 10:15 AM, the slings in each rooms were observed. There were solid blue cotton slings and blue mesh slings observed. The slings had either no tags in them or the tags were unreadable. In the room of Resident #1, there were 2 slings observed, one comfort glide sheet and a blue mesh sling. The blue mesh sling had a 2 inch tear beside the strap. On 1/27/16 at 10:14 AM, NA #3 was interviewed. She stated that she used the blue mesh sling for Resident #1. NA #3 did not know the brand of the sling. She also stated that she did not notice the tear on the sling. On 1/27/16 at 10:20 AM, administrative staff #3 observed the comfort glide sheet and the blue mesh sling that had a tear on it. At 10:30 AM, she acknowledged that the comfort glide sheet was intended for positioning only and not for transfer using a lift. She also indicated that the solid blue sling and the blue mesh sling were intended for use for lifts #3 and lifts #4 only and not for lifts #1 and #2. She also indicated that lifts #1 and #2 were taken out and not to be used at all starting today (1/27/16) because they have only 2 slings available for those lifts. She also indicated that the management staff were going around checking the slings for any damage or wear. Administrative staff #3 stated that nobody from the staff was aware that they have to use a sling designed for the specific lift. On 1/27/16 at 11:30 AM, administrative staff #1 was interviewed. He indicated that there were 21 residents who were using a lift for transfer. He indicated that after checking all the slings, he had tossed 7 blue mesh slings and 13 solid blue slings out due to wear and tear. There were 6 blue mesh slings and 2 solid blue slings left at the facility for use at the present time.

Based on medical record review, staff and resident interviews the facility failed to protect a resident ' s right to be free from physical abuse for 1 of 1 Residents (#1). Immediate jeopardy began on 12/27/15 when Resident # 1 was slapped by two nursing assistants. Immediate jeopardy was removed on 1/7/16 when an acceptable credible allegation was provided. The facility remains out 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 ensure monitoring systems put into place are effective related to resident rights to be free from abuse. Findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment 10/22/15 revealed that the resident was understood and understood others. The resident was coded as having a score of 3 on the Brief Interview of Mental Status (BIMS). BIMS is a brief snapshot of how well a resident is functioning cognitively at the moment. A BIMS score of three indicates that the resident had problems with memory and recall of events. The resident was coded as not displaying physical behavioral symptoms. He was coded as displaying verbal behavior such as threatening or screaming during the past 1-3 days. Medical record review revealed a care plan goal 12/17/15 which stated will have 1 or less combative/verbal abuse behavior through next review. Interventions included, approach resident warmly and positively, talk with resident in calm voice when behavior is disruptive. Review of the statement written on 12/27/15 by nursing assistant (NA) #1 revealed, I (NA #1), went into (Resident #1 ' s) room around 9:30am-10 am. (Resident #1) was already fussy this morning before proceeding into his room. I went into his room to perform ADL (activity of daily living) care. (Resident #1) started to fuss at me. As I went to go get him dressed, Resident #1 was still fussing calling me pathetic and all other names. He then raised his hand and slapped me across the face. I then proceeded to go get my nurse but she was on break. The statement revealed that she requested that 2 other nursing assistants help her get the resident ready. The statement continued, Once inside the room, (Resident #1) continued to be combative. I was in the room but did not proceed getting him ready. NA #3 dressed him since he was more calmer at the moment. NA #2 helped but morely observed. Once finished, he was pushed down to activities and I did report to (nurse supervisor) about the situation that had occurred. During interview with (NA) #1 at 4:20 pm on 12/31/15 she stated, Resident #1 was agitated during breakfast. As I was getting ready to do activity of daily living care, he hit me in my face. NA #1 reported that she went to get the nurse and asked two other NAs to come help her. NA #1 reported that Resident #1 was basically given care by NA #3 when they returned to the room. She said, No one touched him but NA #3 when we went back to the room. NA #1 further stated that the resident had calmed down and that there was no abuse. NA #1 reported that Resident #1 hit her when she first attempted to give him morning care. She stated, It wasn't even a purposeful hit. He was already in a rant, his hand came up and I left the room. Interview with NA#2 at 3:25 pm on 12/31/15 revealed that she saw NA #1 coming down the hall. NA #1 was upset about (Resident #1). I said what's wrong? She said (Resident #1) is getting on my damn nerves. NA #2 said she told NA #1 that she would help and went down the hall with her. NA #2 reported that (Resident #1) was sitting on the side of the bed with NA #1 on one side and NA #3 on the other side. NA #2 said she saw NA #1 swing and hit (Resident #1) in the face. Then NA #3 swung on the other side. She stated that she helped (Resident #1) stand up and put on his shoes and went out of the room. NA #2 reported that NA#1 and #3 were saying a bunch of curse words. NA #2 said that she did not know the other two nursing assistants outside of the facility. Review of the written statement by NA #2 revealed the following, NA #1 was coming down from 200 Hall towards nursing station saying she was gonna clock out and go home. I asked her what was wrong. She said that (Resident #1) was getting on her damn nerves. We was at nursing station then NA#3 came up and we all went to (Resident #1)'s room. He was very agitated sitting on the side of the bed. NA #1 and #3 were antagonizing him (Resident #1) verbally. NA#1 was on the right side of (Resident #1) jerking his arm as she was putting his shirt on and NA#3 was on the left side. (Resident #1) was swinging his arms towards both of them saying they were mean girls. NA #1 hit (Resident #1) in the face on his right side, then he swung again and NA #3 hit him in the face on his left side. I helped put his pants and shoes on and made sure he was in his chair then I left the room. During follow up telephone interview with NA #2 on 1/5/16 at 8:45 pm she stated that she was standing right in front of (Resident #1) in the room. She said NA #1 was on her left side and NA #3 was on her right side. She stated that NA #1 hit (Resident #1) in the face and NA#3 was in a boxing stance when she hit the resident. NA #2 reported that (Resident #1) was swinging but she did not see him hit either NA #1 or #3. NA #2 said that she told NA #1 and #2 to stop. NA #2 said that she reported the incident to the nurse #1 about an hour later. Review of written statement written by nurse aide # 3 revealed: At or around 8:30, 9:00am another CNA (certified nursing assistant) came to me which was (NA#1) and asked for help. (NA #2) was standing in the hallway and followed NA #1 and into (Resident #1 ' s) room. Upon entering (Resident #1 ' s) room (Resident #1) already was being loud and combative. (Resident #1) was swearing, swinging and kicking at (NA #1), so she stepped back. NA #2 was just standing at the door. I stepped in and started talking to (Resident #1). At first he started swinging and kicking again. I put my hands up and told (Resident #1) that that kind of behavior would not be tolerated. And told him he wouldn ' t lie for anyone to hit him. (Resident #1) looked at me and said yes. I then told (Resident #1 to let ' s finish getting his clothes on and he said okay. I began to put his pants on, (NA #1) was still in the room, but just standing there. (NA#2) then tried to help once I had gotten (Resident #1) calm and putting his clothes on. Once (Resident #1) was dressed, I took him out of the room and to church (activities) and reported to the nurse that he was being combative. During interview on 12/31/15 at 3:36 pm with NA #3, she reported that on Sunday 12/27/15 around 9/9:30 NA #1 said to her you better come down and stated that (Resident #1) was being combative. Soon as we walked to the door he was already combative. He was waving his hands. I took his hands in mine and said you need to calm down. I told him that he needed to put his clothes on and get dressed for the day. I said will you do that for me? He calmed down, I put his clothes on. NA #3 reported that no one helped her dress him. I told them (NA#1 and #2) to just let me do it. The NA stated that when the resident was agitated she put her hands up and called his name several times. She said she has worked with (Resident #1) before and he can get a little rowdy. NA #3 reported that NA #1 was standing behind her, NA #2 was at the door and (Resident #1) was sitting on the side of the bed when they were all in the room. She reported that the resident was upset for no reason. During telephone interview at 4:52 pm on 1/5/16 with the Nurse #1 (nurse assigned to the resident ' s hall at the time of the incident) she reported that she did not know about the incident when she went in to give Resident #1 his morning medication. She said that his face was a little red at that time but was not red at all when she went in with the nurse supervisor. Nurse #1 reported that Resident # 1 was a very confused resident. She said she saw Resident #1 up in his wheelchair in the hallway when she asked him if someone hit him. Nurse #1 reported that Resident #1 said Yeah, there were two of them but she helped me and pointed to NA #2. The nurse further stated that when she went to talk to the resident with the nurse supervisor he was mumbling and a little out of it. Review of the statement written by Nurse #1 (nurse assigned to the resident ' s hall on 12/27/15) revealed the following, CNA #2 reported to me (Nurse #1) that this morning around 9:45-10:15 am another CNA (certified nursing assistant) asked her to help with (Resident #1). NA #2 stated while she was in (Resident #1) room with (NA #1 and NA #3), the two cna's listed above stood on either side of the resident as she was assisting place his pants on him, one CNA (NA#1) slapped resident in his face, then immediately after (NA#3) slapped him as well. NA #2 also stated both CNA's were causing resident to become more agitated and combative. I spoke with resident and he said two women were in his room and they hit him, but that he hit them back, then he pointed to NA #2 saying she was there, but she was the one that helped me. Resident did not have any marks at that time. During telephone interview with the nursing supervisor on 1/6/16 at 2:32 pm she stated that she saw the resident around 3:30 pm on Sunday 12/27/15. She said that when she went to the room he was kind of asleep and she had to wake him up. She asked Resident #1 if anyone hit him and he said no. The supervisor said that the girl who witnessed it reported the incident at shift change. The supervisor said that she has not known the resident to have any lucid moments and that he talks stuff that doesn't make sense. The nurse supervisor reported that she has worked with the nursing assistant who reported the abuse (NA #2) for 8 years and only know her to be outstanding. During interview with Resident #1 on 12/31/15 at 2:50 pm the resident said that someone hit him on the hand 2-3 times and that he hit them back. The resident stated she (the resident was unclear regarding who she was) doesn't belong here or anywhere, she went away. He stated, I was so angry. Resident #1 said this happened a couple days ago. Review of the Director of Nurses (DON) statement revealed, It was reported to me on Sunday December 27, 2015 at around 3pm that 2 CNA's (Certified Nursing Assistant) slapped a resident during morning ADL (activity of daily living care). When I arrived at facility on Monday December 28, 2015 I went and did a skin assessment on resident at 9:30 am. There was no evidence of any bruising or red marks noted on resident. I also asked the resident if he remembered at any time anyone being mean to him or hitting him and he stated no. Interview with the Director of Nurses (DON) on 12/31/15 at 3:09 pm revealed that she went down to see the resident on Monday and the resident did not have any redness or bruising. The DON said that she asked the resident, Did anything happen yesterday that you need to tell me about? The resident said no. The DON reported that NA #2 worked every other weekend and that she had no complaints from residents regarding the nursing assistant. Telephone interview with the Director of Nurses on 1/6/16 at 10:51 am revealed that the resident was alert and oriented to person. The DON further stated that sometimes in the mornings the resident is more alert. The administrator was notified of immediate jeopardy on 1/6/16 at 4:45 pm. Credible Allegation: To insure the safety of the identified resident, The Charge Nurse was informed of an abuse allegation on 12-27-15 around 9:45am to 10:15am. The Charge Nurse went to the identified resident ' s room and completed a skin assessment on 12-27-15 at 12:32pm. This skin assessment showed some redness but no markings or bruising on the face area identified in the abuse allegation. The Charge Nurse notified the RN supervisor around 3:00pm of the abuse allegation at that time the RN Supervisor removed the CNAs (NA # 1 and NA # 3) from the building and suspended them until investigation was completed. The RN supervisor went to the room at 3 pm to perform an interview and skin assessment on the identified resident, during the interview the RN supervisor ask the identified resident if anyone had slapped him, his comment was NO. The RN supervisor performed another skin assessment on identified resident ' s facial area and was unable to identified any markings or bruising. At this time the RN supervisor contacted the Director of Nursing. The Director of Nursing contacted the Administrator at 3:05 pm on 12-27-15. The Director of Nursing submitted a 24 hour report on 12-28-15 at 11:12 am. The Director of Nursing performed an interview and a skin assessment to the facial area identified in the abuse allegation at 9:45 am on 12-28-2015. During this interview the identified resident denied any abuse and were no noted bruising or marks on the facial area in the abuse allegation. The Responsible Party for the identified resident was notified by the Director of Nursing on 12-29-15 at 4 pm concerning the abuse allegation. The Medical Director was notified on 12-31-15 at 7:30 am that identified resident needed a physical examination. The Medical Director performed the evaluation that morning around 9 am. The Medical Director noted old skin tears but did not note anything about bruising or markings to the facial area. The Responsible Party for the identified resident requested that the resident be sent out to the emergency room for complaints of left shoulder pain. The Responsible Party signed the resident out and arrived at the emergency room at 3:59 pm on 1-1-16. The Responsible Party explained to the physician on duty that the resident was assaulted by some of the staff at the facility about a week ago. The physician ordered x-rays and notified Department of Social Services. There were no acute fractures noted. The physician will send all x-rays to Department of Social Services by 1-6-16. Resident returned to the facility at 7:45 pm on 1-1-16 with no acute changes. CNA 1 (NA # 1) that was involved in abuse allegation was terminated on 12-30-15 for accepting money from a family member to wash the resident 's clothes and she never returned to work. CNA 2 (NA # 2) returned to work on 12-30-15, she was not assigned to the identified resident and was forbidden by the Director of Nursing to be in contact with the identified resident. CNA 2 (NA # 2) was terminated on 1-6-16 due to the abuse allegation substantiated. A police report was filed on 1-6-16 in regards to this abuse allegation, Police interviewed identified resident and will be interviewing all parties involved. The Police Report number is . The Police officer hand delivered his findings on 1/7/16 of his investigation that concluded there was not enough evidence to prove that an assault did occur and he closed the case. The 5 day investigation was completed and submitted by Director of Nursing on 12-30-15 at 3:37 pm. 100% of full time, part time and PRN staff were in serviced on combative and agitated residents from 1-1-16 to 1-7-16. The identified resident was seen by Nurse Psychiatrist on 1-7-16 to see if there are any interventions to help with the identified resident ' s behaviors. The interventions that she recommended were to redirect resident if agitated and be careful when touching resident around the wrist, when resident is touched around the wrist area it can cause him to be more agitated. The resident will always have two people in the room when care is being performed. These interventions have been added to the resident ' s Kardex and care plan on 1-7-16. All CNAs (NAs) must go to the Kardex before each shift to see how to perform care on residents. The identified resident will be continued to be monitored by the Nurse Psychiatrist. Both CNAs (NA # 1 and # 3) that were involved in this abuse allegation have been terminated and are banned from coming on the facility grounds. For those residents having the potential to the affected by the same alleged deficient practice: · Resident still resides in facility, all alleged employees involved in abuse allegation have been terminated or have been disciplined. Resident has been interviewed by psychiatry for any emotional distress from the incident and none has been noted. Resident continues to have behaviors but all staff and new hires have and will be educated on how to deal with behavior issues. With all interventions in place the identified resident is comfortable and safe at the facility. · The NH performs background checks on all potential employees before hiring them. The Administrator reviews all backgrounds to insure there is no abuse or criminal charge that could lead to abuse. If the background check reports any criminal items that could be consider abusive, the individual is never hired. The abuse policy covers what types of abuse, who to report abuse to, to report abuse immediately when notified or when you see abuse, notify family immediately, notify physician immediately and remove the alleged persons from the facility immediately. · 100% active, part time and as needed staff were educated from 1-1-16 thru 1-6-16 on how to deal with combative and agitated residents. 1st step is try to figure out what is making the resident agitated, 2nd see if you can redirect the resident away from what is making them combative or agitated. 3rd if you are unable to calm the person, go get someone else and let them try to calm the resident, 4th always take your time and speak clearly and slowly to the resident, and 5th always be kind and respectful . Resident ' s rights were included in the in service on 1-6-16 that included the resident always has the right to refuse service. The two CNAs (NA # 1 and # 3) that were involved in this abuse allegation were terminated. The terminations were completed by 1-6-16. · All employees are educated on the company abuse policy on hire date, at each alleged incident of abuse or neglect and annually. · The Social Worker contacted all responsible parties of residents that cannot speak for themselves to inquire of any concerns or changes in resident ' s behavior that could indicate possible abuse on 1-6-15. These interviews included those residents that the two accused CNAs (NAs) were assigned & performed care on. There were no concerns voiced by responsible parties, no report of any behaviors or physical signs reported by any of the responsible parties. · The Nursing staff completed skin audits for injuries of unknown origin for 100% of residents, this includes 100% of residents that the two accused CNAs (NA # 1 and # 3) were assigned and performed care on. These skin audits were completed from 1-1-16 to 1-7-16. No injuries of unknown origin were found. · The Social Worker, Admissions Coordinator, Director of Nursing and Clinical Supervisors asked all residents capable of being interviewed if they had ever felt mistreated by a staff member of the facility, this included all residents including the ones that were cared for by accused CNA ' s (NA # 1 and # 3) that were named in the abuse allegation. All residents interviewed denied feeling mistreated by any member of the staff. All interviews were completed on 1-6-16 at 8pm. The credible allegation was verified on 1/13/16 at 3:00 PM as evidenced by staff interviews on abuse policy and procedures, different types of abuse, what to do if a resident displayed aggressive behaviors and actions to be taken if abuse was observed and/or suspected. Review of in-service records revealed 100% of facility staff (licensed nursing staff, unlicensed nursing staff, housekeeping, dietary, maintenance, transportation, administrative staff, activities, social worker) had been in-serviced by 1/7/16 on the abuse policy and procedures to be initiated if abuse was observed/suspected.

Based on staff interviews, resident interview and record review it was determined that the facility failed to operationalize abuse policies and procedures in the areas of intervening when physical abuse was witnessed, immediately reporting physical abuse so that protection could be implemented, identification (immediately assessing a resident, immediately assessing if other residents could have been affected, reporting (notifying law enforcement). The abuse policy did not empower any staff person to notify law enforcement for 1 of 1 residents (#1). Immediate jeopardy began on 12/27/15 when Resident # 1 was slapped by two nursing assistants and staff witness did not intervene or immediately report. Immediate jeopardy was removed on 1/7/16 when an acceptable credible allegation was provided. The facility remains out 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 ensure monitoring systems put into place are effective related to resident rights to be free from abuse and abuse policies are operationalized. Findings included: Review of the facility guidelines for investigating allegations of resident abuse, neglect or misappropriation of property included the following instructions (undated), Notify the appropriate State agencies as required, Call Director of Operations, in regards to the notification of the department of social services/adult protective services. The policy stated, Notification of Law Enforcement Agencies requires the approval of the Director of Operations. Review of the facility abuse policy revealed: Allegations of abuse, neglect or misappropriation of property or injuries of unknown origin must be investigated thoroughly and timely. The investigation phase of the policy includes the following, · Notify the Administrator and Director of Nursing immediately. · Call Director of Ops. (Operations), in regards to the notification of DSS/APS (Department of Social Service/Adult Protective Services). · Notification of Law Enforcement Agencies requires the approval of the Director of Ops. The facility policy included miscellaneous points to remember. This portion of the policy stated, if abuse or potential abuse has not been reported timely to the facility: · Take steps to assess if abuse could have occurred in the building elsewhere · Review, conduct, and document resident physical assessments as necessary (one hall, or entire facility), as appropriate. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment 10/22/15 revealed that the resident was understood and understood others. The resident was coded as having a score of 3 on the Brief Interview of Mental Status (BIMS). BIMS is a brief snapshot of how well a resident is functioning cognitively at the moment. A BIMS score of three indicates that the resident had problems with memory and recall of events. The resident was coded as not displaying physical behavioral symptoms. He was coded as displaying verbal behavior such as threatening or screaming during the past 1-3 days. Medical record review revealed a care plan goal 12/17/15 which stated will have 1 or less combative/verbal abuse behavior through next review. Interventions included, approach resident warmly and positively, talk with resident in calm voice when behavior is disruptive. Review of the statement written on 12/27/15 by nursing assistant (NA) #1 revealed, I (NA #1), went into (Resident #1 ' s) room around 9:30am-10 am. (Resident #1) was already fussy this morning before proceeding into his room. I went into his room to perform ADL (activity of daily living) care. (Resident #1) started to fuss at me. As I went to go get him dressed, Resident #1 was still fussing calling me pathetic and all other names. He then raised his hand and slapped me across the face. I then proceeded to go get my nurse but she was on break. The statement revealed that she requested that 2 other nursing assistants help her get the resident ready. The statement continued, Once inside the room, (Resident #1) continued to be combative. I was in the room but did not proceed getting him ready. NA #3 dressed him since he was more calmer at the moment. NA #2 helped but morely observed. Once finished, he was pushed down to activities and I did report to (nurse supervisor) about the situation that had occurred. During interview with (NA) #1 at 4:20 pm on 12/31/15 she stated, Resident #1 was agitated during breakfast. As I was getting ready to do activity of daily living care, he hit me in my face. NA #1 reported that she went to get the nurse and asked two other NAs to come help her. NA #1 reported that Resident #1 was basically given care by NA #3 when they returned to the room. She said, No one touched him but NA #3 when we went back to the room. NA #1 further stated that the resident had calmed down and that there was no abuse. NA #1 reported that Resident #1 hit her when she first attempted to give him morning care. She stated, It wasn't even a purposeful hit. He was already in a rant, his hand came up and I left the room. Review of the written statement by NA #2 revealed the following, NA #1 was coming down from 200 Hall towards nursing station saying she was gonna clock out and go home. I asked her what was wrong. She said that (Resident #1) was getting on her damn nerves. We was at nursing station then NA#3 came up and we all went to (Resident #1)'s room. He was very agitated sitting on the side of the bed. NA #1 and #3 were antagonizing him (Resident #1) verbally. NA#1 was on the right side of (Resident #1) jerking his arm as she was putting his shirt on and NA#3 was on the left side. (Resident #1) was swinging his arms towards both of them saying they were mean girls. NA #1 hit (Resident #1) in the face on his right side, then he swung again and NA #3 hit him in the face on his left side. I helped put his pants and shoes on and made sure he was in his chair then I left the room. Interview with NA #2 at 3:25 pm on 12/31/15 revealed that she saw NA #1 coming down the hall. NA #1 was upset about (Resident #1). I said what's wrong? She said (Resident #1) is getting on my damn nerves. NA #2 said she told NA #1 that she would help and went down the hall with her. NA #2 reported that (Resident #1) was sitting on the side of the bed with NA #1 on one side and NA #3 on the other side. NA #2 said she saw NA #1 swing and hit (Resident #1) in the face. Then NA #3 swung on the other side. She stated that she helped (Resident #1) stand up and put on his shoes and went out of the room. NA #2 reported that NA#1 and #3 were saying a bunch of curse words. NA #2 said that she did not know the other two nursing assistants outside of the facility. During follow up telephone interview with NA #2 on 1/5/16 at 8:45 pm she stated that she was standing right in front of (Resident #1) in the room. She said NA #1 was on her left side and NA #3 was on her right side. She stated that NA #1 hit (Resident #1) in the face and NA#3 was in a boxing stance when she hit the resident. NA #2 reported that (Resident #1) was swinging but she did not see him hit either NA #1 or #3. NA #2 said that she told NA #1 and #2 to stop. NA #2 said that she reported the incident to the nurse #1 about an hour later. Review of written statement written by nurse aide # 3 revealed: At or around 8:30, 9:00am another CNA (certified nursing assistant) (NA) came to me which was (NA#1) and asked for help. (NA #2) was standing in the hallway and followed NA #1 and into (Resident #1 ' s) room. Upon entering (Resident #1 ' s) room (Resident #1) already was being loud and combative. (Resident #1) was swearing, swinging and kicking at (NA #1), so she stepped back. NA #2 was just standing at the door. I stepped in and started talking to (Resident #1). At first he started swinging and kicking again. I put my hands up and told (Resident #1) that that kind of behavior would not be tolerated. And told him he wouldn ' t lie for anyone to hit him. (Resident #1) looked at me and said yes. I then told (Resident #1 to let ' s finish getting his clothes on and he said okay. I began to put his pants on, (NA #1) was still in the room, but just standing there. (NA#2) then tried to help once I had gotten (Resident #1) calm and putting his clothes on. Once (Resident #1) was dressed, I took him out of the room and to church (activities) and reported to the nurse that he was being combative. During interview on 12/31/15 at 3:36 pm with NA #3, she reported that on Sunday 12/27/15 around 9/9:30 NA #1 said to her you better come down and stated that (Resident #1) was being combative. Soon as we walked to the door he was already combative. He was waving his hands. I took his hands in mine and said you need to calm down. I told him that he needed to put his clothes on and get dressed for the day. I said will you do that for me? He calmed down, I put his clothes on. NA #3 reported that no one helped her dress him. I told them (NA#1 and #2) to just let me do it. The NA stated that when the resident was agitated she put her hands up and called his name several times. She said she has worked with (Resident #1) before and he can get a little rowdy. NA #3 reported that NA #1 was standing behind her, NA #2 was at the door and (Resident #1) was sitting on the side of the bed when they were all in the room. She reported that the resident was upset for no reason. Review of the statement written by Nurse #1 (nurse assigned to the resident's hall on 12/27/15) revealed the following, CNA #2 reported to me (Nurse #1) that this morning around 9:45-10:15 am another CNA (certified nursing assistant) asked her to help with (Resident #1). NA #2 stated while she was in (Resident #1) room with (NA #1 and NA #3), the two cna's listed above stood on either side of the resident as she was assisting place his pants on him, one CNA (NA#1) slapped resident in his face, then immediately after (NA#3) slapped him as well. NA #2 also stated both CNA's were causing resident to become more agitated and combative. I spoke with resident and he said two women were in his room and they hit him, but that he hit them back, then he pointed to NA #2 saying she was there, but she was the one that helped me. Resident did not have any marks at that time. During telephone interview at 4:52 pm on 1/5/16 with the Nurse #1 (nurse assigned to the resident ' s hall at the time of the incident) she reported that she did not know about the incident when she went in to give Resident #1 his morning medication. She said that his face was a little red at that time but was not red at all when she went in with the nurse supervisor. Nurse #1 reported that Resident # 1 was a very confused resident. She said she saw Resident #1 up in his wheelchair in the hallway when she asked him if someone hit him. Nurse #1 reported that Resident #1 said Yeah, there were two of them but she helped me and pointed to NA #2. The nurse further stated that when she went to talk to the resident with the nurse supervisor he was mumbling and a little out of it. During telephone interview with the nursing supervisor on 1/6/16 at 2:32 pm she stated that she saw the resident around 3:30 pm on Sunday 12/27/15. She said that when she went to the room he was kind of asleep and she had to wake him up. She asked Resident #1 if anyone hit him and he said no. The supervisor said that the girl who witnessed it reported the incident at shift change. The supervisor said that she has not known the resident to have any lucid moments and that he talks stuff that doesn't make sense. The nurse supervisor reported that she has worked with the NA who reported the abuse (NA #2) for 8 years and only know her to be outstanding. Review of the Director of Nurses (DON) statement revealed, It was reported to me on Sunday December 27, 2015 at around 3pm that 2 CNA's (Certified Nursing Assistant) slapped a resident during morning ADL (activity of daily living care). When I arrived at facility on Monday December 28, 2015 I went and did a skin assessment on resident at 9:30 am. There was no evidence of any bruising or red marks noted on resident. I also asked the resident if he remembered at any time anyone being mean to him or hitting him and he stated no. Interview with the Director of Nurses (DON) on 12/31/15 at 3:09 pm revealed that she went down to see the resident on Monday and the resident did not have any redness or bruising. The DON said that she asked the resident, Did anything happen yesterday that you need to tell me about? The resident said no. Interview with the DON revealed that NA #1 and #3 were taken off the schedule during the investigation. Per the DON, NA #1 was terminated due to an unrelated incident. (NA # 3 was observed working on 12/31/15 at 2:30 pm). The DON reported that no other residents had been interviewed regarding mistreatment during the abuse investigation. Telephone interview with the Director of Nurses on 1/6/16 at 10:51 am revealed that the resident was alert and oriented to person. The DON further stated that sometimes in the mornings the resident is more alert. The DON said that that the police were not notified of the allegation of abuse after discussion with the administrator. During interview with Resident #1 on 12/31/15 at 2:50 pm the resident said that someone hit him on the hand 2-3 times and that he hit them back. The resident stated she (the resident was unclear regarding who she was) doesn't belong here or anywhere, she went away. He stated, I was so angry. Resident #1 said this happened a couple days ago. During telephone interview with the facility administrator on 1/6/16 at 10:55 am the administrator reported that he was in contact with the DON and the registered nurse (RN) supervisor. The RN supervisor could not find any markings on the resident ' s face. Two nurses observed the resident with no markings and he did not notify the police because there was no physical evidence or bruising. Review of a statement written by the facility administrator (undated) revealed, (Resident #1 is a long term resident at (facility). (Resident #1) was admitted to our facility on 7/7/15. (Resident #1) suffers from multiple [DIAGNOSES REDACTED]. Resident is alert and oriented X 1. Resident is able to make his needs know (known). A CNA (Certified Nursing Assistant) on the east wing brought an incident to the charge nurse on 12-27-15 around 10am. This incident was accusing two CNAs of slapping a resident in the face. Due to the severity of this incident, the charge nurse went down and performed a skin assessment on the resident. Per this skin assessment and nurse statement, no bruising or red marks were noted to the area addressed in the incident. The charge nurse had the RN supervisor to perform a skin assessment on (Resident #1) and she was unable to find any bruising or red marks to the areas noted in the incident report. The RN Supervisor interviewed the resident and she asked resident if anyone had hit him today and (Resident #1) stated no. The two accused CNAs were asked to write a statement before they left and both CNAs denied hitting (Resident #1). They did state that (Resident #1) was combative and he hit them but they got help from another CNA to perform care on (Resident #1). The DON performed a skin assessment on 12-28-2015 at 9:30 am and was unable to locate any bruising or red areas to the locations noted in the incident report. She performed an interview with the resident and the resident did not remember anyone being mean to him or hitting him. Based on the information provided by the accuser, the accused and the investigation that followed, the administrator and DON concluded that there is not enough evidence to substantiate this allegation. The administrator was notified of immediate jeopardy on 1/6/16 at 4:45 pm. Credible Allegation To insure the safety of the identified resident, The Charge Nurse was informed of an abuse allegation on 12-27-15 around 9:45 am to 10:15 am. The Charge Nurse went to the identified resident ' s room and completed a skin assessment on 12-27-15 at 12:32 pm. This skin assessment showed some redness but no markings or bruising on the face area identified in the abuse allegation. The Charge Nurse notified the RN supervisor around 3:00 pm of the abuse allegation at that time the RN Supervisor removed the CNAs (NA # 1 and NA # 3) from the building and suspended them until investigation was completed. The RN supervisor went to the room at 3 pm to perform an interview and skin assessment on the identified resident, during the interview the RN supervisor ask the identified resident if anyone had slapped him, his comment was NO. The RN supervisor performed another skin assessment on identified resident's facial area and was unable to identified any markings or bruising. At this time the RN supervisor contacted the Director of Nursing. The Director of Nursing contacted the Administrator at 3:05 pm on 12-27-15. The Director of Nursing submitted a 24 hour report on 12-28-15 at 11:12 am. The Director of Nursing performed an interview and a skin assessment to the facial area identified in the abuse allegation at 9:45 am on 12-28-2015. During this interview the identified resident denied any abuse and were no noted bruising or marks on the facial area in the abuse allegation. The Responsible Party for the identified resident was notified by the Director of Nursing on 12-29-15 at 4 pm concerning the abuse allegation. The Medical Director was notified on 12-31-15 at 7:30 am that identified resident needed a physical examination. The Medical Director performed the evaluation that morning around 9 am. The Medical Director noted old skin tears but did not note anything about bruising or markings to the facial area. The Responsible Party for the identified resident requested that the resident be sent out to the emergency room for complaints of left shoulder pain. The Responsible Party signed the resident out and arrived at the emergency room at 3:59 pm on 1-1-16. The Responsible Party explained to the physician on duty that the resident was assaulted by some of the staff at the facility about a week ago. The physician ordered x-rays and notified Department of Social Services. There were no acute fractures noted. The physician will send all x-rays to Department of Social Services by 1-6-16. Resident returned to the facility at 7:45 pm on 1-1-16 with no acute changes. CNA 1 (NA # 1) that was involved in abuse allegation was terminated on 12-30-15 for accepting money from a family member to wash the resident's clothes and she never returned to work. CNA 2 (NA # 2) returned to work on 12-30-15, she was not assigned to the identified resident and was forbidden by the Director of Nursing to be in contact with the identified resident. CNA 2 ( NA # 2) was terminated on 1-6-16 due to the abuse allegation being substantiated. A police report was filed on 1-6-16 in regards to this abuse allegation, a police officer interviewed identified resident and will be interviewing all parties involved. The Police Report number is . The police officer hand delivered his findings on 1/7/16 of his investigation that concluded there was not enough evidence to prove that an assault did occur and he closed the case. The 5 day investigation was completed and submitted by Director of Nursing on 12-30-15 at 3:37 pm. 100% of full time, part time and as needed staff were in serviced on combative and agitated residents from 1-1-16 to 1-7-16. The identified resident was seen by Nurse Psychiatrist on 1-7-16 to see if there are any interventions to help with the identified resident ' s behaviors. The interventions that she recommended were to redirect resident if agitated and be careful when touching resident around the wrist, when resident is touched around the wrist area it can cause him to be more agitated. The resident will always have two people in the room when care is being performed. These interventions have been added to the resident's Kardex and care plan. All CNAs must go to the Kardex before each shift to see how to perform care on residents. The identified resident will be continued to be monitored by the Nurse Psychiatrist. Both CNAs (NA # 1 and # 3) that were involved in this abuse allegation have been terminated and are banned from coming on the facility grounds. For those residents having the potential to the affected by the same alleged deficient practice: · The Abuse Policy: states all residents also have the right to be free from verbal or physical abuse or other mistreatment by other residents and staff. Incidents of aggressive, sexual, or abusive behavior by one resident toward another resident or staff member toward a resident. This must be reported immediately to the supervisor and the resident must be protected from harm. · The NH performs background checks on all potential employees before hiring them. The Administrator reviews all backgrounds to insure there is no abuse or criminal charge that could lead to abuse. If the background check reports any criminal items that could be consider abusive, the individual is never hired. · The Director of Nursing and Administrator were educated on 1-6-16 by the Nursing Consultant on the company abuse policy, the Elder Justice Act and reporting abuse to the state agency and police immediately when notified. · 100% active, part time and as needed staff were educated from 1-1-16 thru 1-6-16 by the Director of Nursing, Clinical Supervisors and Administrator. The in-service covered the company's abuse policy, what types of abuse, who to report the abuse to and to report the abuse immediately when told or seen and how to identify signs and symptoms of abuse to nonverbal resident. The steps that we take to report, protect and prevent abuse in the facility. The in-service included that the medical director, responsible party and Administrator of the building must be informed immediately when abuse is reported. 100% full time, part time and as needed staff were educated on the elder justice act and received a copy to review and keep on 1-6-16 by Administrator, Director of Nursing, Social Worker and Clinical Supervisors. · 100% active, part time and as needed staff were educated from 1-1-16 thru 1-6-16 on how to deal with combative and agitated residents. 1st step is try to figure out what is making the resident agitated, 2nd see if you can redirect the resident away from what is making them combative or agitated. 3rd if you are unable to calm the person, go get someone else and let them try to calm the resident, 4th always take your time and speak clearly and slowly to the resident, and 5th always be kind and respectful . Resident's rights were included in the in-service on 1-6-16 that included the resident always has the right to refuse service. · The Social Worker, Admissions Coordinator, Director of Nursing and Clinical Supervisors asked all residents capable of being interviewed if they had ever felt mistreated by a staff member of the facility, this included all residents including the ones that were cared for by accused CNA's ( NA # 1 and # 3) that were named in the abuse allegation All residents interviewed denied feeling mistreated by any member of the staff. All interviews were completed on 1-6-16 at 8pm. · A Resident Council Meeting was conducted Thursday, January 7, 2016. The residents will be reminded of their rights to be free from abuse, different types of abuse and how and who to report it to. · The Social Worker contacted all responsible parties of residents that cannot speak for themselves to inquire of any concerns or changes in resident ' s behavior that could indicate possible abuse on 1-6-15. These interviews included those residents that the two accused CNAs (NA # 1 and # 3) were assigned & performed care on. There were no concerns voiced by responsible parties, no report of any behaviors or physical signs reported by any of the responsible parties · The Nursing staff completed skin audits for injuries of unknown origin for 100% of residents, this includes 100% of residents that the two accused CNAs (NA # 1 and # 3) were assigned and performed care on. These skin audits were completed from 1-1-16 to 1-7-16. No injuries of unknown origin were found · All employees are educated on the company abuse policy on hire date, at each alleged incident of abuse or neglect and annually. · The CNA that reported the abuse (NA # 2) was in serviced on 1-1-16, she admitted there was an hour delay in telling her supervisor. She was disciplined on 1-7-16. · The Charge Nurse involved in the abuse allegation was terminated due to breaking company abuse policy and endangering the life of a resident on 1-7-16. · The CNA (NA # 2) that reported the abuse was in serviced on 1-1-16, she admitted there was an hour delay in telling her supervisor. She was disciplined on 1-7-16. The credible allegation was verified on 1/13/16 at 3:00PM as evidenced by staff interviews on abuse policy and procedures, different types of abuse, what to do if a resident displayed aggressive behaviors and actions to be taken if abuse was observed and/or suspected. 100% of facility staff had been in-serviced by 1/7/16 on the abuse policy and protocol which included notification of law enforcement in cases of alleged abuse.

Based on staff interviews, physician interviews, family interview, medical record review, and observation, the facility failed to identify and implement interventions for one (1) of six (6) residents (Resident # 6) reviewed who developed pressure ulcers. The facility also failed to provide an air mattress and timely Wound Care Clinic referral for one (1) of (6) residents (Resident # 179) to prevent worsening of a pressure ulcer. The immediate jeopardy (IJ) for Resident # 6 in Example #1 began on May 27, 2012. The administrator was notified of the immediate jeopardy (IJ) on July 10, 2012 at 8:40am. The IJ was removed on July 12, 2012 at 4:30pm when the facility demonstrated they had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with the potential for more than minimal harm that is not IJ (D) to allow ongoing in-servicing and monitoring to be accomplished. Example #2 (Resident #179) was cited at a scope and severity of (D) which constituted no actual harm with the potential for more than minimal harm that is not IJ. Findings Include: 1. Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. On 2/15/12, a Pressure Ulcer Risk Evaluation Form rated the resident at high risk for the development of a pressure ulcer. On 4/10/12, a Renal Function Panel was done and revealed all labs within normal limits except for the Resident calcium was 8.2 (normal is between 8.9 and 10.3). His [MEDICATION NAME] was 3.0 with normal ranges 3.5 to 5.0. On 5/10/12, Resident #6 was evaluated to be at high risk for the development of a pressure ulcer on his Pressure Ulcer Risk Evaluation Form. The Annual Minimum Data Set ((MDS) dated [DATE] for Resident #6 stated he was cognitively intact. This MDS further revealed the following: Resident #6 had unclear speech, but could make himself understood and understood others. He required extensive to total staff assistance with care except for eating in which he was coded as independent. He was coded as being able to move from a seated to a standing position with staff help and to move from one surface to another with staff help. There was no coding regarding any shortness or breath or [MEDICAL CONDITION]. The annual MDS also indicated that the resident did not have 6 months or less to live as of 5/14/12. His skin assessment on the annual MDS dated [DATE] coded him at risk for pressure ulcers but there were no pressure ulcers noted and there was no documented history of healed pressure ulcers. The resident was not coded for the use of a Geri-chair. Resident #6 did trigger for weight loss and for pressure ulcers at this time. Resident #6 had a Care Area Assessment for pressure ulcers related to impaired mobility, incontinence and weight loss. His nutritional status Care Assessment Area triggered. It was noted that Resident #6 has had some weight loss due to illness, but was expected to return to previous level. On 5/22/12, the physician ordered Resident #[MEDICATION NAME](antibiotic) for suspected [MEDICAL CONDITION] to the right lower extremity with 4+ [MEDICAL CONDITION]. A review of nursing notes stated, Resident #6 was encouraged to stay in bed or to sit in a Geri-chair in order to elevate his lower extremities due to [MEDICAL CONDITION]. In addition, a physician progress notes [REDACTED]. On 5/27/12, a nursing note stated Resident #6 was up in a wheelchair self propelling around with the right foot up on a foot rest. The first documentation of an area to the right buttock was in a weekly skin assessment dated [DATE] and it was described as a red area. There was no documentation in the medical record of any treatment initiated for the red area. On 5/29/12, a nursing note stated that the resident was up in a wheelchair and staff was unable to put him in the Geri-chair because the Responsible Party did not want him to be in it. It was noted that the Responsible Party stated several times the day before that she wanted the resident to move about. The first physician orders for wound care were dated 6/1/12 which stated "cleanse right buttocks near rectum with normal saline (NS) to open area, apply Triple Antibiotic Ointment (TAO) and Flexicol (a bordered foam dressing) until resolved daily." A wound clinic note dated 6/5/12 read that the gluteus ulcer measured 1.5 centimeters (cm) x 2.0 cm x 0.1 cm and was characterized as an improving stage 2 (partial thickness skin loss involving the epidermis, dermis or both). There were new wound care orders for [MEDICATION NAME] AG and foam dressing. It was to be changed daily with follow up again on 6/19/12. The doctor also ordered an alternating pressure mattress for bed on 6/5/12 by writing a prescription for the facility to order it. On 6/6/12 a nursing note stated Resident #6 sat in a Geri-chair today and that both legs and feet were swollen. On 6/6/12 resident #6 had a General Chemistry Profile done which revealed all his lab results were within normal limits except his calcium was 8.5 (normal ranges between 8.9 to 10.3).The resident was started on Calcium 600mg with vitamin D by mouth twice daily. His [MEDICATION NAME] was 3.0 with normal ranges between 3.5 to 5.0. Also his Alkaline [MEDICATION NAME], which is a measure of liver function, was low at 49 with normal ranges between 65 to 126. His Alkaline Aminotransferase, which is also a measure of the liver's function, was 13 with normal ranges between 17 to 63. A review of the invoice from the durable medical equipment supplier revealed the alternating air mattress was ordered on [DATE] and was delivered on 6/8/12. On 6/9/12, a review of the weekly skin assessment sheet stated the right gluteus measured 3.0 cm x 1.8 cm x 0.1 cm and was absent of odor. There was yellowish brown drainage and the tissue appeared pink to yellow. Resident #6's care plan, dated 6/9/12, included a problem related to the resident's impaired skin integrity with stasis ulcers and pressure ulcer. Interventions included to reposition frequently, measure wound weekly, report any decline to the doctor, administer treatments, assess for pain during dressing change and administer pain medication as needed. On 6/20/12, a new intervention was added to the care plan to use the alternating air pressure mattress to bed and check for inflation every shift. On 6/10/12, a nursing note stated Resident #6 was placed in a Geri-chair yesterday and today. He refused to lean back so legs could be elevated. The Responsible Party was made aware of concerns regarding swelling. On 6/11/12 a nursing note stated Resident #6 wanted to get in the wheelchair but he was encouraged to get in the Geri-chair with legs elevated. He agreed to do so. On 6/15/11 a care plan was added regarding the resident risk for pressure ulcers related to his immobility, history of right sided weakness and incontinence. Interventions included weekly skin checks, to report rashes, redness, open areas or irritation. Further interventions were to initiate treatment per facility protocol, monitor lower legs for swelling, compression stockings on during the day and to be removed at night, prompt incontinence care with barrier cream, frequent reposition and a cushion in place to his wheel chair with date of 6/5/12. On 6/15/12, a nursing note stated resident #6 had an order for [REDACTED]. It was removed from bed and sent back to get a replacement. Resident #6's previous pressure guard mattress was put back on his bed until new alternating mattress arrived. The company manufacturing the pressure guard mattress indicated the use was for the prevention and treatment of [REDACTED]. On 6/17/12 a review of the weekly skin assessment sheet stated the right gluteus measured 3.5 cm x 2.5 cm x 0.1 cm with mild odor noted and the drainage was yellowish brown. The tissue appeared pink and reddish brown around the outside circle and a blackened area fell off with the dressing change. On 6/18/12, the Registered Dietician (RD) recommended Resident #6 have the following for wound healing: Med Pass (nutritional supplement) 2 ounces four times daily and Prostat Advanced Wound Care (protein supplement) 1 ounce three times daily until wounds were healed. On 6/19/12, a nursing note stated alternating air mattress to bed and functioning properly. It was used to off load the gluteal area and a message was left for his responsible party. A review of the durable medical equipment provider's invoice revealed the replacement alternating air mattress was reordered on [DATE] and arrived on 6/19/12. A wound clinic noted dated 6/19/12 stated that an alternating pressure mattress was ordered for Resident #6. The RP stated that the facility sent it back because "it was not working". The treatment order to the right gluteal ulcer was [MEDICATION NAME] AG and foam dressing daily. The area measured 4.5 cm x 4.0 cm x 0.1 cm and was described as having areas of induration and fluctuance. When palpated, the physician was able to express brownish purulent material. The area was cultured and physician attempted to debride but did not continue, but noted the sacral area appeared to track backwards but not all the way to the rectum. At the visit, the ulcer was named a gluteal ischial decubitus ulcer with a complicating abscess and described as non-stagable. A Computed Tomography Scan (CT) was ordered by the wound clinic physician for the resident on 6/22/12 at 8:30am. (This test produces a 3 dimensional image to reveal a far more detailed test result). On 6/20/12, a review of the weekly skin assessment sheet stated the right gluteus ulcer measured 4.4 cm x 3.2 cm x 0.8 cm with large amount of yellow brown drainage and small odor. The tissue color was yellow to tan and there was tan adherent slough. A physician's order, by the medical director, dated 6/22/12 stated to clean the right gluteal fold with NS (normal saline), apply Santyl/Collaganase to wound bed, pack moist gauze and cover with foam and dry dressing daily and as needed. This was done at request of the wound nurse to debride the eschar from the area. On 6/25/12, a nursing note stated the right gluteal fold measured 4.4 cm x 3.2 cm x 4.1 cm with an open area. There was moderate amount of brownish yellow drainage noted. The color was described as pink and black with adherent black/tan slough. The notes from the wound clinic visit on 6/26/12 stated the CT scan looked "worrisome" for osteo[DIAGNOSES REDACTED]. The wound clinic doctor stated in his notes that the right gluteal wound was unclear whether it started out as an ulcer or abscess. He cultured the wound and it was positive for [MEDICATION NAME] faecalis, Proteus Mirabilis and E-Coli. There was also an ultrasound ordered that was negative for [MEDICAL CONDITION] (blood clot) to the right ankle brachial indices. The resident was then sent to the hospital for admission. On 6/28/12 at 3:15pm, in an interview with the clinical coordinator (CC), she stated that the alternating air mattress was ordered and received on 6/8/12 The CC stated that before the alternating air mattress could be ordered, it had to be approved because the resident was a private pay resident. On or approximately 6/15/12, it "sprung a leak around the hose." The CC stated that the maintenance director called the company to get a technician to look at it. The CC said the staff removed the defective alternating air mattress and put Resident #6's regular pressure guard mattress back on the bed until the replacement arrived. On 6/28/12 at 3:20pm a phone call was made to the sales representative for the durable medical equipment supplier regarding the defective mattress. He stated that on June 15, he was made aware about a problem with the air mattress and the alarm kept sounding. He said the company sent a technician out and repaired the mattress. On 6/28/12 at 3:40pm, a phone call from the sales representative for the durable medical equipment supplier was received. He stated he was mistaken and that a service technician did not make an onsite visit but "tried to troubleshoot" with the maintenance director over the phone but they were unable to fix it. He stated another mattress was ordered that following Monday and resident #6's old mattress was put back on the bed until the new one arrived. On 6/29/12 at 8:40am, in an interview with the wound nurse she stated she began her job last Thursday (6/21/12), and up until that time, a treatment aide was doing treatments. The wound nurse stated, prior to her taking over as a wound nurse, the weekend nurses were the doing measurements and treatments every weekend while the treatment aide did the treatments during the week. The wound nurse said that on Monday (6/25/12) there was a small area that opened up and large amount of yellow brown tissue came out of Resident #6's right gluteus wound. She said she was able to see the wound bed. She said it was pink in some areas but at the right of base at 2pm to 6pm, there was necrotic tissue noted. She stated no odor was noted at this time. On 6/29/12 at 8:45am, in an interview with the treatment aide, she said she was told about the area to his right buttock sometime the end of May. The treatment aide said when she looked at it, it looked like an area about the size of a 50 cent piece with yellow slough. The treatment aide stated she told nurse #2 and she (nurse #2) told her to put a [MEDICATION NAME] on it. A review of the record revealed no orders for the [MEDICATION NAME]. However, in a physician progress notes [REDACTED]. Nursing has been instructed to place a [MEDICATION NAME] over it." On 6/29/12 at 9:00am in an interview with nurse #2, she stated she first noticed a red spot on Resident #6's buttock sometime the end of May and told the staff to put extra fanny cream to the area. She said she was assisting the treatment aide in the Resident's wound care one day when she removed the old dressing, it looked like a hole with an opening about a 50 cent piece, had some slough but no drainage and no odor. Nurse #2 said the treatment aide went and got the CC and DON (director of nursing) and they looked at the area on 6/1/12 and the medical director gave them orders to cleanse the right buttocks with normal saline, apply Triple Antibiotic Ointment daily until resolved. Nurse #2 said the resident was going to the wound clinic and that the doctor there would look at the area on 6/5/12. Nurse #2 stated the first air mattress that was sent had a problem with the tubing. The old mattress remained on the bed until the new one arrived. It may have taken 3 days to get new air mattress but when it did come, the old mattress was removed and the new one was put on the bed. On 6/29/12 at 9:40am in an interview with the CC, she said that when the wound on Resident 6's buttock was brought to her attention, she and the DON both looked at it that day. The CC stated she called the medical director and there were no new orders for care except to go to the wound clinic on 6/5/12. The CC stated it took 3 days (6/8/12) to get the alternating air mattress on the bed but the alternating air mattress was alarming frequently so they called to see if a technician could come to the facility to repair it. Resident #6's regular mattress was placed on the bed until the replacement alternating air mattress was delivered. The CC stated she did not look at the wound again except for what she thought was 6/1/12. On 6/29/12 at 10:55am, in an interview with the MDS nurse, she stated she felt the backside breakdown on Resident #6's buttock was a result of putting him the Geri-chair to elevate his feet due to the [MEDICAL CONDITION]. She stated there was a cushion in the Geri-chair. On 6/29/12 at 11:50am, in an interview with the RD, she stated she left a printed list of recommendations with the Administrator, the DON and the DM. She stated it was the facility's responsibility to contact the physician regarding her recommendations. On 6/29/12 at 2:05pm, in an interview with the DON, she stated she first was involved regarding Resident #6's leg wounds. The DON stated several weeks later, she went in to check on him and the nurse told her about the place on the Resident #6's backside. The DON stated it didn't look bad and was a small area. The DON stated the resident had swelling in the lower extremities, and to get the swelling down, they put him in the Geri-chair. The DON stated she thought there was a cushion in the Geri-chair. The DON stated she performed rounds to assess pressure areas but did not know how often. She further indicated rounds were done on random residents and she did not have any documentation of the wound rounds. The DON stated there were no orders ever written for the supplements recommended by the RD. She stated she did not realize that the CC did not have a copy of the Dietary Recommendations Report and that she was used to having the CC talking with the doctor and getting the orders for any recommended dietary supplements. She stated the dietary recommendations for that week "fell through the cracks." Resident #'6 was hospitalized from [DATE] to 7/3/12 and on 7/3/12, Resident #6 was admitted to the hospice house with his primary [DIAGNOSES REDACTED]. Resident #6 was readmitted to the facility on [DATE]. On 7/10/12 at 9:20am, a phone interview with the physician at the wound clinic was conducted. He stated that on first observation, the area appeared at a stage 2 but on 6/19/12 he stated the area was consistent with pressure sore but did appear to tract like an abscess would have. The physician stated he would have assumed that any kind of deterioration would have resulted in a call to him. Regarding the CT results from 6/22/12, the physician stated that the nurse case manager would have reviewed the results and notified him or another doctor about the results. On 7/10/12 at 10:50 am, an observation of the right ischial wound care for Resident #6 revealed the area appeared light pink with a soft area of what appeared to be old necrotic tissue. The area was moist and clinging the left of the wound's interior. The wound measured 4.5.x 3.5.[MEDICAL CONDITION]. There was no odor noted, moderate amount of yellowish drainage and no pain indicated by the resident. On 7/10/12 at 11:00am in an interview with Resident #'6 RP, she stated that she was told in the hospital and at the hospice house that the resident was likely left in the same position too long and not repositioned. On 7/11/12 at 11:00am, in an interview with the treatment aide, she stated she would report any redness, opening areas, warmth, rashes or skin tears to the charge nurse. On 7/11/12 at 11:30am, the Medical Director stated that Resident #6 "suddenly tanked" and that he felt Resident #6's right gluteus ulcer happened because he was "decompensating and his time has finally come." When questioned as to when he would expect to be notified by nurses regarding any changes in a wound, he stated within 24-48 hours but further stated he was in the building 5 days a week, and his nurse practitioner was in the building one or two days each week. He also said his nurse was in the facility every week as well. The administrator provided a credible allegation of compliance on July 12, 2012 at 4:30 pm. The identified resident has recently returned from a hospitalization . Upon re-admission, the identified resident's wound was a Stage IV. Upon readmission, the resident had treatment orders for cleanse wound to right gluteal crease with normal saline apply [MEDICATION NAME] to necrotic tissue in wound bed. Pack wound with calcium alginate and cover with bordered foam every day and as needed. The resident currently has interventions in place to prevent the worsening of the gluteal wound, which is the only pressure sore the resident has. Interventions include, consultation(s), with First Health Moore Regional Wound Clinic on July 20, 2012. The resident is scheduled for assessment by his attending physician on July 11, 2012 and currently has treatment orders performed in accordance with the attending/consulting wound physician's orders. The identified resident receives PROStat 64-30cc via peg bid, Zinc, Vitamin C, and Multivitamin once daily starting on July 9, 2012. Additionally, resident is currently receiving [MEDICATION NAME] 66 cc/hr with 200 cc water qid. The resident has a properly functioning alternating pressure air mattress which is functioning according to the manufacturer's specifications. Additionally, the identified resident is turned and repositioned every two hours, side to side. The resident was reviewed by the consulting dietician on June 18th, 2012 and the resident shall be evaluated no less than monthly by the consultant dietician to ensure appropriate nutritional interventions are in place to prevent further worsening of the wound and promote wound healing as may be practicable. Upon evaluation by the consulting dietician, the recommendations shall be communicated to the Director of Nursing. The Director of Nursing shall ensure the attending physician is consulted regarding the orders by either telephone and/or fax and shall ensure the orders are carried out timely (e.g. within 48 hours of the recommendation's being made). The Clinical Coordinator shall audit all the consulting dietician's recommendations to ensure they have been carried out timely. The resident shall be evaluated by Physical and/or Occupational Therapy to ensure the resident is properly positioned while in and out of bed on July 11, 2012. Upon identification of the proper positioning, using the appropriate device and/or chair, the licensed therapists shall instruct the nursing staff, inclusive of licensed and certified nursing staff on the proper devices and/or devices to be used for proper positioning. In addition, all nursing staff will be in-serviced on proper positioning to prevent, identify, and care for Pressure Ulcers on July 11, 2012. The resident's attending physician is aware of the resident's pressure area(s) and shall examine the resident weekly. Following the attending and/or consulting physician's rounds/visit/consultation, the Clinical Coordinator shall ensure all orders are communicated to the applicable nursing staff (i.e. licensed/certified nursing staff, dietary, etc.). The Director of Nursing and/or her designee shall audit all orders daily for 1 week, weekly for 8 weeks, and monthly thereafter to ensure orders are properly communicated to the appropriate personnel and implemented timely. The family is aware of the resident's clinical condition. While out of bed, the resident shall use a pressure relieving device deemed clinically appropriate by the care plan team and/or licensed therapy staff which may include but not necessarily limited to: pressure relieving cushions and/or chairs specifically designed to reduce and/or eliminate pressure to the affected site. While in bed, in addition to the alternating air mattress, the staff shall turn and reposition the identified resident at least every two hours and may use other devices which may include but shall not be limited to: pillows, positioning wedges, etc. The identified resident's wound was reassessed upon the resident's readmission to the facility on [DATE], and has been reassessed as of July 10, 2012. The identified resident's care plan has been updated on July 11, 2012 to include information related to the resident's having a pressure sore and the interventions currently in place to treat the pressure sore and other interventions being utilized to prevent the area from worsening. The resident's current treatment was ordered by the treating physician in the hospital. For those residents having the potential to be affected by the same alleged deficient practice, all residents' skin has been assessed/re-assessed by a Corporate Nurse Consultant on July 11, 2012. Residents were assessed/re-assessed using a visual assessment process whereby each resident's skin (from head to toe) was assessed individually, using the facility's Wound Care Policy, the guidance found at F314, and the Weekly Skin Assessment Form. Assessments/Re-assessments were completed to ensure 1) the current condition of the residents' skin and to ensure appropriate measures (e.g. pressure relieving devices, air overlays, etc.) are in place to prevent pressure sores (if resident is assessed as being high-risk) and 2) the current condition of any existing wounds or pressure related areas to ensure accurate assessment and documentation. The admission skin assessment and risk assessment is done on every admission and re-admission. In addition, the Pressure Ulcer Risk evaluation is to be done quarterly thereafter. Additionally, the facility made changes to its wound care personnel on June 20, 2012 and has begun training a new Wound Care Nurse using outside consultant(s) as the trainer. The training is multi-faceted and includes, but is not limited to, assessing the wound(s), measuring/monitoring for signs/symptoms of healing or further deterioration; family and physician notification; staging, relevant types of treatments for particular types of wounds, preventative measures, and potential pressure relieving dressings and/or devices, etc. In addition to her more than [AGE] years of nursing experience, the Wound Care Nurse received the essential training, as determined by the Corporate Nurse Consultant, necessary to provide wound care in accordance with the facility's policy(ies) and the applicable rules and regulations (e.g. F314). Such training was completed on July 2, 2012. Access to the Wound Consultant(s) is available in-person, via telephone, and on a 24-hour call basis. The Wound Care Nurse shall have the primary responsibility for the assessment and re-assessment of all wounds. Additionally, the Wound Care Nurse shall ensure compliance with MD/Responsibility Party notification(s). In the event a wound does not show improvement; the Wound Nurse will consult with the residents' attending physician to determine any treatment regimen changes including outside consultations. In the event the Wound Care Nurse is out of the building, the Director of Nursing, Clinical Coordinator, and/or RN Supervisor shall ensure wound care is provided according to the facility's policy and procedure and according to facility practice. Currently, there are 8 residents with pressure sores with a total of 12 areas; of which 11 areas were acquired In-House. The Director of Nursing and/or RN Supervisor shall monitor the Wound Care Nurse to ensure timeliness of assessments. The Pressure Ulcer Critical Element shall serve as a check/balance to ensure assessments are completed as required or as necessary. All 11 areas have been assessed by the Corporate Nursing Consultant and, based on her clinical judgment, she believes the treatment methodologies and treatment regimens are current with acceptable standards of practice for the type of wound(s) being treated. The care plans have been reviewed to ensure that they reflect the needs of the resident. All residents have been reassessed to determine their risk for pressure sore development as of July 11, 2012. Those residents identified as being "high risk" based on the "Risk Assessment for Pressure Sores" shall have their skin integrity assessed weekly by the Wound Care Nurse. Similarly, residents risk for development of pressure sores shall be assessed upon admission and/re-admission according to the facility's Pressure Sore Risk Assessment Policy. The credible allegation was verified 7/12/12 at 4:30pm. Staff interviews across various shifts were conducted. Staff demonstrated verbally knowledge about the contents of the in-services on assessing the wound(s), measuring/monitoring for signs/symptoms of healing or further deterioration; family and physician notification; staging, relevant types of treatments for particular types of wounds, preventative measures, and potential pressure relieving dressings and/or devices, etc. A review of the in-servicing records verified education and those employees not having attended in-servicing as of 7/12/12 at 4:30pm were removed from scheduling until such time, in-servicing was completed. A review of skin assessment documentation for all residents was completed. It was found to provide evidence of all resident's skin assessment were completed as of 7/12/12. A review of the care plans, treatment orders and skin assessments was conducted for the 8 identified residents who had documented pressure areas developed in house. 2. Resident # 179 was admitted to the facility 1/5/11 and discharged [DATE]. Cumulative [DIAGNOSES REDACTED]. Pressure ulcer risk assessment dated [DATE] revealed a score of 19. A score of 22 or less indicated Resident # 179 was at risk for pressure ulcers. An Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 179 was cognitively intact. She required extensive assistance of two people for bed mobility and extensive assistance of one person for transfers. Resident # 179 was frequently incontinent of bladder and bowel. The assessment stated she was at risk for pressure ulcers. No unhealed pressure ulcers were documented during the assessment period. Pressure ulcer device for bed was checked on the assessment. A Care Area Assessment (CAA) for pressure ulcers dated 3/11/2011 revealed Resident # 179 needed a special mattress/ seat cushion to reduce/ relieve pressure. She required staff assistance to move sufficiently to relieve pressure over any one site. The CAA indicated a pressure guard mattress was on the bed. Skin was documented as intact at the time of the assessment. A Skin assessment form dated 4/29/11 noted all skin was intact. A nursing note dated 4/30/11 indicated Resident # 179's buttocks was checked per family request. Redness was noted. Area cleansed and skin protectant cream applied. Family was notified and made aware of redness of buttocks. A Nursing note dated 5/1/11 at 1 PM. stated Resident # 179 had an open area on her sacrum that measured 2 centimeters (cm.) wide x 0.6 cm. length. Skin was pink around the area with several small pin size areas around a larger area. On 5/1/11, a physician's order stated to cleanse the sacral wound with normal saline once daily. Apply moist collagen and dry dressing until healed. A Care plan dated 5/2/11 indicated Resident # 179 had a pressure ulcer to the sacrum. Approaches included: place resident on a turning and repositioning program: assess for pain during dressing changes; if appropriate, administer pain medicine thirty (30) minutes prior to dressing change. Measure wound weekly. Record measurements of wound, appearance, amount and odor of any drainage. Report any decline in wound status to physician. Turn and position resident frequently to relieve pressure and maintain proper body alignment. Weekly skin condition reports, skin assessment forms and physician orders for May 2011 revealed the following: A physician's order dated 5/2/11 noted to cleanse the wound to the left side of buttocks with normal saline, apply moist collagen and dry dressing until healed. A skin assessment dated [DATE] noted Resident # 179 had a yeast-like rash to the sacrum. A physician's order dated 5/4/11 was received for [MEDICATION NAME] II to be applied twice daily for one week. The skin condition report dated 5/4/2011 noted a six centimeter(6) red area on the buttocks as rashy, unable to define as a wound. The Physician and family were notified. The skin condition report dated 5/10/11 noted the rash had cleared and a Stage 3 wound 2.3cm x 0.5cm x 0.2cm depth and red in color was on the sacrum. The physician and family were notified. The skin assessment form dated 5/13/11 noted a stage 3 decubitus to sacrum and area was being treated with Santyl( a product used to help heal skin ulcers) daily. The skin condition report dated 5/18/11 noted Resident # 179 with a stage 3 sacrum wound measuring 2.1cm x 0.5 cm x 0.2 cm depth with minimal exudate and red in color. The skin condition repo