Every finding on record at PruittHealth-Union Pointe

Based on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 25 opportunities, resulting in a medication error rate of 12% for 1 of 3 residents observed for medication administration (Resident #307). The findings included: Resident #307 was admitted to the facility on [DATE] with diagnoses that included type II diabetes with diabetic autonomic neuropathy (a complication of diabetes where high blood sugar damages the nerves that control involuntary bodily functions), vascular dementia, epilepsy, and other depressive episodes. A review of Resident #307's active physician orders revealed the following: An order dated 4/30/26 for carbidopa-levodopa tablet extended release; 50-200 milligrams (mg). Give 1 tablet by mouth 3 times daily. This medication is used to manage severe movement disorders such as tremors, stiffness, and slowness. An order dated 4/30/26 for duloxetine capsule, delayed release;30 mg. Take 30 mg by mouth two times daily. This medication is an antidepressant primarily used to treat depression, anxiety, fibromyalgia, and chronic nerve or musculoskeletal pain. An order dated 5/1/26 for metoprolol succinate tablet extended release 24 hour; 25 milligrams (mg); amount 0.5 tablet by mouth once a day. This medication is a once-daily, extended-release medication used to treat high blood pressure. It slows the heart rate and relaxes blood vessels to reduce strain on the heart. An observation and interview were conducted with Nurse #1 on 6/24/26 at 9:51 AM during medication administration for Resident #307. Nurse #1 explained she had received verbal report during shift change that morning that Resident #307 was supposed to take her medications crushed in applesauce and showed the surveyor a printed list of 300-hall residents with the initials CAS (Nurse #1 explained this meant crushed in applesauce) next to Resident #307's name. Nurse #1 then crushed the carbidopa-levodopa and metoprolol succinate tablets and mixed them into applesauce then opened the duloxetine capsule and sprinkled the contents over the applesauce and administered the medications to Resident #307. A follow-up interview was conducted with Nurse #1 on 6/24/26 at 11:10 AM. Nurse #1 stated she should have recognized extended-release medications should not have been crushed before administration and should have clarified with the Nurse Practitioner before crushing. An interview was conducted with the Nurse Practitioner (NP) on 6/24/26 at 11:16 AM. The NP stated extended-release medication being crushed would cause the medication to break down faster, but she did not anticipate Resident #307 would have an adverse reaction to receiving carbidopa-levodopa crushed or duloxetine capsules being opened. The NP stated by administering metoprolol succinate in crushed form, side effects might present as a faster heart rate and lower blood pressure. The NP stated due to the potential side effects, she felt crushing the metoprolol succinate posed a potential for Resident #307 to experience more significant side effects. On 6/24/26 at 1:33 PM Pharmacist #1 was interviewed and stated carbidopa-levodopa should not be crushed because it would cause Resident #307 to receive the full dosage of the medication at once and not be spread out for the extended-release timeframe the medication would have been effective for if taken whole. Although the pharmacist indicated the resident would receive a more concentrated level of the medication at once, she did not perceive any adverse effects from crushing carbidopa-levodopa. The pharmacist explained she did not perceive any ill effects from opening the capsule of duloxetine if it was sprinkled in the applesauce and not crushed even though it would cause the resident to receive a more concentrated dose all at once. The pharmacist further stated metoprolol succinate was designed for once daily administration due to its time delayed release that would last 24 hours. The pharmacist stated Resident #307 was taking a very small dose of metoprolol succinate at only 12.5 mg which would be unlikely to cause any adverse effects. An interview was conducted with the Director of Nursing (DON) on 6/25/26 at 11:10 AM who stated to prevent the medication errors, Nurse #1 should not have relied on the shift change verbal report or relied on the shift change paper but should have followed proper procedure and read Resident #307's orders in the chart and compared them to the medication administration record.

Based on observation, record review, and interviews with the Nurse Practitioner, pharmacist, and staff, the facility failed to administer scheduled medications in the correct form when the nurse crushed 2 tablets and opened 1 capsule of extended-release and delayed-release medications for 1 of 3 residents reviewed for significant medication errors (Resident #307). The findings included: Resident #307 was admitted to the facility on [DATE] with diagnoses that included type II diabetes with diabetic autonomic neuropathy (a complication of diabetes where high blood sugar damages the nerves that control involuntary bodily functions), vascular dementia, epilepsy, and other depressive episodes. Resident #307 had a physician's order dated 5/1/26 for metoprolol succinate tablet extended release 24 hour; 25 milligrams (mg); amount 0.5 tablet by mouth once a day. Metoprolol succinate is a once-daily, extended-release medication used to treat high blood pressure. It slows the heart rate and relaxes blood vessels to reduce strain on the heart. Resident #307 also had a physician order dated 4/30/26 for carbidopa-levodopa tablet extended release; 50-200 milligrams (mg). Give 1 tablet by mouth 3 times daily. This medication is used to manage severe movement disorders such as tremors, stiffness, and slowness. Resident #307 also had a physician's order dated 4/30/26 for duloxetine capsule, delayed release;30 mg. Take 30 mg by mouth two times daily. This medication is an antidepressant primarily used to treat depression, anxiety, fibromyalgia, and chronic nerve or musculoskeletal pain. An observation and interview were conducted with Nurse #1 on 6/24/26 at 9:51 AM during medication administration for Resident #307. Nurse #1 explained she had received verbal report during shift change that morning that Resident #307 was supposed to take her medications crushed in applesauce and showed the surveyor a printed list of 300-hall residents with the initials CAS (Nurse #1 explained this meant crushed in applesauce) next to Resident #307's name. Nurse #1 then crushed the metoprolol succinate as well as the carbidopa-levodopa tablets then opened the duloxetine capsule, without crushing, and added all medications into applesauce then administered the medication to Resident #307. A record review and medication reconciliation for Resident #307 was completed after the medication administration and revealed an order dated 4/30/26 that read: May use alternate dosage form of ordered drug if necessary and appropriate. An order dated 6/6/26 read: Resident takes medication whole and takes them orally. A follow-up interview was conducted with Nurse #1 on 6/24/26 at 11:10 AM. She stated she typically worked on a different hall but had been assigned to the 300-hall that day. Nurse #1 indicated she was not familiar with the residents on the 300-hall and relied on the verbal shift change report instead of reading Resident #307's orders. Nurse #1 stated she overlooked Resident #307's order to take medication whole. Nurse #1 also stated she should have recognized extended-release medications should not have been crushed, and the capsule should not have been opened before administration. Nurse #1 stated she should have clarified with the Nurse Practitioner before crushing and opening the medications. An interview was conducted with the Nurse Practitioner (NP) on 6/24/26 at 11:16 AM who stated she was not overly concerned that Resident #307 received her medication crushed in applesauce that morning. According to the NP, Resident #307 had a difficult time taking her medications due to her advanced dementia and level of alertness. The NP stated extended-release medication being crushed or opened would cause the medication to break down faster. The NP stated by administering metoprolol succinate in crushed form, side effects might present as a faster heart rate and lower blood pressure. The NP stated due to the potential side effects, she felt crushing the metoprolol succinate posed a potential for Resident #307 to experience more significant side effects. According to the NP, the carbidopa-levodopa being crushed and the duloxetine being opened would result in a more concentrated dosage at once instead of spreading throughout the extended-release period if the medications had not been crushed or opened. The Nurse Practitioner stated she was unaware any nurses were crushing Resident #307's medications and would have ordered a different form of the medication or changed the order if she had known Resident #307 could not take the medication whole. The Nurse Practitioner followed up her interview on 6/24/26 at 12:25 PM and explained she had assessed Resident #307 who had not exhibited any adverse reactions to her medication that morning. She stated Resident #307's blood pressure remained at 121/60 (within normal limits), and her heart rate remained at 90 beats per minute which were her typical readings. On 6/24/26 at 1:33 PM Pharmacist #1 was interviewed by phone, and stated metoprolol succinate was designed for once daily administration due to its time delayed release that would last 24 hours. According to Pharmacist #1, metoprolol succinate had the potential to cause more significant side effects by being crushed for administration. The pharmacist further stated Resident #307 was taking a very small dose of metoprolol succinate at only 12.5 mg which would be unlikely to cause any adverse effects. The pharmacist explained that the carbidopa-levodopa being crushed and the duloxetine capsule being opened, without crushing, would result in the resident receiving the full dosage of the medications at once instead of being spread out for the delayed-release period. The pharmacist stated she did not expect Resident #307 would experience significant side effects from the carbidopa-levodopa being crushed or the duloxetine being opened and added to applesauce. An interview was conducted with the Director of Nursing (DON) on 6/25/26 at 11:10 AM who stated Nurse #1 should not have relied on the shift change verbal report or relied on the shift change paper but should have followed proper procedure and read Resident #307's orders in the chart and compared them to the medication administration record.

Based on record review, staff and Medical Director interviews the facility failed to administer scheduled medication as ordered by the physician for 7 of 24 residents on the 500 hall reviewed for medication administration (Resident #339, Resident #335, Resident #20, Resident #13, Resident #43, Resident #8, Resident #11). The findings included: A. Resident #339 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder and generalized anxiety Physician order dated 10/17/2024 revealed an order to administer Resident #339 Lorazepam (antidepressant and anxiety) 2 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #339 did not receive Lorazepam 2 mg at 9:00 PM on 12/7/2024. B. Resident #335 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder and anxiety disorder. Physician order dated 3/17/2023 revealed an order to administer Resident #335 Mirtazapine (antidepressant and anxiety) 7.5 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #335 did not receive Mirtazapine 7.5 mg at 8:00 PM on 12/7/2024. C. Resident #20 was admitted to the facility on [DATE] with a diagnosis that included pain in right knee and major depressive disorder. Physician order dated 9/24/2021 revealed an order to administer Resident #20 Mirtazapine (depression) 15 mg at bedtime. Physician order dated 10/31/2024 revealed an order to administer Resident #20 Gabapentin (pain) 100 mg two times a day. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #20 did not receive Gabapentin 100 mg at 8:00 PM and Mirtazapine 15 mg at 8:00 PM on 12/7/2024. D. Resident #13 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder. Physician order dated 10/15/2024 revealed an order to administer Resident #13 Zoloft (antidepressant) 100 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #13 did not receive Zoloft 100 mg at 9:00 PM on 12/7/2024. E. Resident #43 was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's disease. Physician order dated 3/25/2024 revealed an order to administer Resident #43 Donepezil (Alzheimer's disease) 10 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #43 did not receive Donepezil 10 mg at 8:00 PM on 12/7/2024. F. Resident #8 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder. Physician order dated 2/23/2024 revealed an order to administer Resident #8 Trazodone (antidepressant) 25 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #8 did not receive Trazodone 25 mg at 8:00 PM on 12/7/2024. G. Resident #11 was admitted to the facility on [DATE] with a diagnosis that included generalized anxiety disorder and major depressive disorder. Physician order dated 6/7/2024 revealed an order to administer Resident #11 Mirtazapine (antidepressant, anxiety) 7.5 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #11 did not receive Mirtazapine 7.5 mg at 8:00 PM on 12/7/2024. A telephone interview was conducted with Nurse #4 on 5/8/25 at 8:46 AM. Nurse #4 stated on 12/7/2024 she was assigned a shift of 7:00 PM to 7:00 AM. She indicated after 10:30 PM there were only two nurses (Nurse #5 and herself) in the facility to administer medications. Nurse #4 nor Nurse #5 wanted to take responsibility for taking an additional assignment when Nurse #6 left at 11:00 PM. Due to only having two Nurses on 3rd shift, she contacted the Administrator to communicate she did not feel safe taking the medication cart keys for the 500 hall because she would be responsible for administering medications to the entire unit (400 and 500 halls). Nurse #4 stated she nor Nurse #5 administered medication to the 500 hall resulting in the residents not receiving medications as ordered. An interview was attempted with Nurse #6 on 5/8/2025 at 11:26 AM. The phone call was not returned. An interview was attempted with Nurse #5 on 5/8/2025 at 11:28 AM, her mailbox was full and a message could not be left. Another call was attempted with Nurse #5 on 5/8/2025 at 1:14 PM, after the surveyor introduced herself the call was disconnected. At 1:15 PM a final attempt was made to call Nurse #5 back with no answer and her mailbox was full and no message could be left. The Infection Preventionist was interviewed on 5/8/25 at 1:23 PM. She revealed on 12/7/24 she was acting as the interim DON. The Infection Preventionist stated she did not recall being contacted by the Administrator or nursing staff regarding there not being a nurse assigned to administer medications. Had she been contacted about the staffing concern she would have come into the facility to cover the shift to ensure medications were administered according to the physician orders. An interview was conducted on 5/9/2025 at 9:43 AM via telephone with the Medical Director. During the interview the Medical Director stated he did recall the incident when residents did not receive medication but did not recall the exact date or time. He recalled there was no delay in his notification and implementation of interventions which included assessment of all affected residents to ensure there was no significant change in resident status due to missed doses of medication. He conducted a general sweep of the affected hall (500) to review any high-risk medications. He stated in general missing a single dose or two of medication in many chronic conditions would not result in decompensation or adverse outcomes. An interview was conducted on 5/8/2025 at 7:49 AM with the Administrator. During the interview he revealed on 12/7/2024 (time unknown) he was informed by Nurse #4 the facility was short nursing staff on the 7:00 PM to 7:00 AM shift. He stated he asked the dayshift Nurse #6 to stay until 11:00 PM leaving the facility with two nurses Nurse #4 and Nurse #5 after 11:00 PM. After being notified by Nurse #4 she was not going to administer medications on the 500 hall, he attempted to contact other nurses to cover the unit. He further stated when he arrived at the facility, he felt as though there was sufficient staff. The Administrator contacted the Medical Director and notified him that medications had not been administered to residents on the 500 hall due to not having a nurse. The Administrator stated the Medical Director adjusted medication times and residents were assessed with no negative outcomes. An additional interview with the Administrator was conducted on 5/9/2025 at 10:43 AM. He stated the expectation of the nurses was to ensure all residents received their medication. He further stated if the unit was short staffed the expectation was for the nurse on the unit to get report from the off going nurse and take the medication cart keys to administer medication to the residents.

Based on record review, Medical Director and staff interviews, the facility failed to have sufficient staff in the facility to administer medications as ordered to the 500 hall/unit for 17 of 24 residents reviewed for medication administration (Resident #339, Resident #335, Resident #20, Resident #56, Resident #338, Resident #38, Resident #63, Resident #19, Resident #336, Resident #333, Resident #11, Resident #13, Resident #45, Resident #26, Resident #29, Resident #337, Resident #8). Finding included: This tag is crossed referenced to: F658: Based on record review, staff and Medical Director interviews the facility failed to administer scheduled medication as ordered by the physician for 7 of 24 residents (Resident #339, Resident #335, Resident #20, Resident #13, Resident #43, Resident #8, Resident #11) on the 500 hall reviewed for medication administration. This tag is cross referenced to: F760: Based on record review, staff and Medical Director interviews the facility failed to administer scheduled medication as ordered by the physician for 17 of 24 residents (Resident #339, Resident #335, Resident #20, Resident #56, Resident #338, Resident #38, Resident #63, Resident #19, Resident #336, Resident #333, Resident #11, Resident #13, Resident #45, Resident #26, Resident #29, Resident #337, Resident #8) on the 500 hall when there was no nurse assigned to administer medication. This practice resulted in significant medication errors. Nurse Supervisor #1 was interviewed on 5/8/2025 at 6:14 AM. She revealed when nurses called out the procedure was to call the Staffing Coordinator or the Administrator. An interview was conducted with Unit Manager #1 on 5/8/2025 at 6:18 AM. She revealed when the facility was short staffed, she was able to adjust the schedule. She would call off duty nursing staff to come in or notify the Staffing Coordinator, Administrator or DON when she was unable to get additional staff to come in. She further revealed if the facility was short staffed the Unit Manager or Supervisor should take a cart to pass medication. An interview was conducted with the Staffing Coordinator on 5/8/2025 at 8:33 AM. She stated on 12/7/2024 she was notified there was a call out and attempted to call off duty nurses to come in to work. She further stated she informed the Administrator and Infection Preventionist who was acting as the interim DON the facility was short nursing staff. She further stated she did not recall if she was able to get additional nurses to come in to work.

Based on record review, staff and Medical Director interviews the facility failed to administer scheduled medication as ordered by the physician for 17 of 24 residents (Resident #339, Resident #335, Resident #20, Resident #56, Resident #338, Resident #38, Resident #63, Resident #19, Resident #336, Resident #333, Resident #11, Resident #13, Resident #45, Resident #26, Resident #29, Resident #337, Resident #8) on the 500 hall when there was no nurse assigned to administer medication. This practice resulted in significant medication errors. The findings included: A. Resident #339 was admitted to the facility on [DATE] with a diagnosis that included atrial fibrillation (irregular, rapid heart rate), congestive heart failure and hypertension. Physician order dated 10/17/2024 revealed an order to administer Resident #339 Eliquis (anticoagulant) 2.5 milligrams (mg) two times a day. Physician order dated 10/29/2024 revealed an order to administer Resident #339 Metoprolol Tartrate (used to treat chest pain and hypertension) 50 mg two times a day. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #339 did not receive Eliquis 2.5 mg at 9:00 PM and Metoprolol Tartrate 50 mg at 9:00 PM on 12/7/2024. B. Resident #335 was admitted to the facility on [DATE] with a diagnosis that included essential tremors. Physician order dated 5/22/2024 revealed an order to administer Resident #335 Carbidopa-Levodopa (combination drug to treat symptoms of Parkinson's disease) 25-100 mg two times a day. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #335 did not receive Carbidopa-Levodopa 25-100 mg at 8:00 PM. C. Resident #20 was admitted to the facility on [DATE] with a diagnosis that included hypertension. Physician order dated 10/31/2024 revealed an order to administer Resident #20 Coreg 6.25 mg (used to treat hypertension and congestive heart failure) twice a day. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #20 did not receive Coreg 6.25 mg at 8:00 PM on 12/7/2024. D. Resident #56 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes mellitus. Physician order dated 10/24/2024 revealed an order to administer Resident #56 Lantus Insulin (long-acting insulin) 25 units once a morning. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #56 did not receive Lantus Insulin 25 units at 6:00 AM on 12/8/2024. Per the MAR on 12/7/2024 the medication was not initialed as given. E. Resident #338 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes mellitus with diabetic nephropathy (nerve pain) and restless legs syndrome. Physician order dated 11/4/2024 revealed an order to administer Resident #338 Gabapentin (used to treat neuropathy and restless legs syndrome) 300 mg two times a day. Physician order dated 11/22/2024 revealed an order to administer Resident #338 Ropinirole (used to treat restless legs syndrome)1.5 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #338 did not receive Gabapentin 300 mg at 9:00 PM and Ropinirole 1.5 mg at 9:00 PM on 12/7/2024. F. Resident #38 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes mellitus and bipolar disorder. Physician order dated 11/7/2024 revealed an order to administer Resident #38 Depakote (anticonvulsant drug used to treat bipolar disorder) 1500 mg at bedtime. Physician order dated 11/2/2024 revealed an order to administer Resident #38 Novolog Insulin (rapid-acting insulin) per sliding scale before meals and at bedtime. Physician order dated 11/7/2024 revealed an order to administer Resident #38 Seroquel (antipsychotic medication used to treat bipolar disorder) 50 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #38 did not receive Depakote 1500 mg at 9:00 PM, Novolog Insulin per sliding scale at 9:00 PM and Seroquel 50 mg at 9:00 PM on 12/7/2024. G. Resident #63 was admitted to the facility on [DATE] with a diagnosis that included hypertension, diabetes mellitus with diabetic neuropathy and chronic pain syndrome. Physician order dated 11/9/2023 revealed an order to administer Resident #63 Carvedilol (used to treat hypertension) 25 mg two times a day. Physician order dated 4/11/2024 revealed an order to administer Resident #63 Gabapentin 100 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #63 did not receive Carvedilol 25 mg at 9:00 PM and Gabapentin 100 mg at 9:00 PM on 12/7/2024. H. Resident #19 was admitted to the facility on [DATE] with a diagnosis that included hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, peripheral vascular disease, venous thrombosis (blood clot) and embolism (blood vessel blockage)-apical thrombus. Physician order dated 8/14/2023 revealed an order to administer Resident #19 Eliquis 2.5 mg two times a day. Physician order dated 8/14/2023 revealed an order to administer Resident #19 Entresto 24-26 (lowers blood pressure and treats heart failure) mg two times a day. Physician order dated 11/23/2023 revealed an order to administer Resident #19 Levemir Insulin (long-acting insulin) 16 units every 12 hours. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #336 did not receive Eliquis 2.5 mg at 8:00 PM, Entresto 24-26 mg at 8:00 PM on 12/7/2024 and Levemir Insulin 16 units at 6:00 AM on 12/8/2024. I. Resident #336 was admitted to the facility on [DATE] with a diagnosis that included hypertension, type 2 diabetes mellitus with diabetic neuropathy and atrial fibrillation. Physician order dated 11/15/2024 revealed an order to administer Resident #336 Lantus Insulin 13 units at bedtime. Physician order dated 11/15/2024 revealed an order to administer Resident #336 Metoprolol 12.5 mg two times a day. Physician order dated 11/15/2024 revealed an order to administer Resident #336 Novolog Insulin per sliding scale before meals and at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #336 did not receive Lantus Insulin 13 units at 9:00 PM, Metoprolol 12.5 mg at 9:00 PM, Novolog Insulin per sliding scale at 9:00 PM on 12/7/2024 and Novolog Insulin per sliding scale at 6:30 AM on 12/8/2024. There was no documented Blood Sugar (BS) on the MAR at 9:00 PM on 12/7/2025, the 6:30 AM, 11:30 AM and 4:30 PM doses were not given per sliding scale parameters. J. Resident #333 was admitted to the facility on [DATE] with a diagnosis that included hypertension, type 2 diabetes mellitus, schizophrenia and dementia. Physician order dated 12/3/2024 revealed an order to administer Resident #333 Basaglar Insulin (long-acting insulin) 4 units at bedtime. Physician order dated 9/21/2024 revealed an order to administer Resident #333 Metoprolol 50 mg two times a day. Physician order dated 12/5/2024 revealed an order to administer Resident #333 Risperidone (antipsychotic medication used to treat schizophrenia) 0.25 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #333 did not receive Basaglar Insulin 4 units at 9:00 PM, Metoprolol 50 mg at 9:00 PM and Risperidone 0.25 mg at 9:00 PM on 12/7/2024. K. Resident #11 was admitted to the facility on [DATE] with a diagnosis that included generalized anxiety disorder, major depressive disorder, factitial dermatitis (intentional self-inflicted skin injury), rheumatoid arthritis, chronic pain, pain in right hip, pain in left ankle and joints of left foot. Physician order dated 11/8/2024 revealed an order to administer Resident #11 Divalproex (prescribed for factitial dermatitis) 125 mg two times a day. Physician order dated 4/9/2024 revealed an order to administer Resident #11 Hydrocodone-Acetaminophen (narcotic pain reliever) 5-325 mg two times a day. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #11 did not receive Divalproex 125 mg at 8:00 PM and Hydrocodone-Acetaminophen 5-325 mg at 8:00 PM on 12/7/2024. L. Resident #13 was admitted to the facility on [DATE] with a diagnosis that included pain in left knee, pain in left hand and seizures. Physician order dated 10/15/2024 revealed an order to administer Resident #13 Gabapentin (anticonvulsant) 300 mg two times a day. Physician order dated 10/15/2024 revealed an order to administer Resident #13 Primidone (anticonvulsant)250 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #13 did not receive Gabapentin 300 mg at 9:00 PM and Primidone 250 mg at 9:00 PM. M. Resident #45 was admitted to the facility on [DATE] with a diagnosis that included schizophrenia, epilepsy and anxiety disorder. Physician order dated 8/15/2024 revealed an order to administer Resident #45 Lorazepam (used to treat anxiety, insomnia and epilepsy) 0.5 mg three times a day. Physician order dated 8/15/2024 revealed an order to administer Resident #45 Risperidone 3 mg two times a day. Physician order dated 12/6/2024 revealed an order to administer Resident #45 Tegretol (anticonvulsant and mood stabilizer) 100 mg two times a day. Physician order dated 8/15/2024 revealed an order to administer Resident #45 Trazodone (antidepressant sometimes prescribed as a sleep aid) 50 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #45 did not receive Lorazepam 0.5 mg at 9:00 PM, Risperidone 3 mg at 9:00 PM, Tegretol 100 mg at 9:00 PM and Trazodone 50 mg at 9:00 PM on 12/7/2024. N. Resident #26 was admitted to the facility on [DATE] with a diagnosis that included unspecified convulsions, extrapyramidal and movement disorder (involuntary movement often caused by medication), bipolar disorder and unspecified psychosis. Physician order dated 11/11/2024 revealed an order to administer Resident #26 Benztropine (used to treat extrapyramidal and movement disorder) 2 mg two times a day. Physician order dated 11/11/2024 revealed an order to administer Resident #26 Divalproex (anticonvulsant also used to treat bipolar disorder)) 500 mg two times a day. Physician order dated 11/11/2024 revealed an order to administer Resident #26 Risperidone (antipsychotic medication used to treat bipolar disorder) 1 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #26 did not receive Benztropine 2 mg at 9:00 PM, Divalproex 500 mg at 9:00 PM and Risperidone 1 mg at 9:00 PM on 12/7/2024. O. Resident #29 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder, Parkinson's disease with dyskinesia (involuntary movements of the face, arms, legs and trunk), essential tremor, anxiety disorder, chronic pain, delusional disorder, auditory hallucinations, restlessness and agitation. Physician order dated 8/12/2024 revealed an order to administer Resident #29 Buspirone (antianxiety medication) 15 mg three times a day. Physician order dated 8/12/2024 revealed an order to administer Resident #29 Gabapentin 100 mg three times a day. Physician order dated 10/18/2024 revealed an order to administer Resident #29 Lorazepam (antianxiety medication) 0.5 mg at bedtime. Physician order dated 8/12/2024 revealed an order to administer Resident #29 Pramipexole (used to treat symptoms of Parkinson's disease) 0.25 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #29 did not receive Buspirone 15 mg at 9:00 PM, Gabapentin 100 mg at 9:00 PM, Lorazepam 0.5 mg at 9:00 PM and Pramipexole 0.25 mg at 9:00 PM on 12/7/2024. P. Resident #337 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes mellitus with diabetic polyneuropathy (damage to multiple peripheral nerves), generalized anxiety disorder, dementia, depression, restlessness and agitation. Physician order dated 12/2/2024 revealed an order to administer Resident #337 Divalproex mg every 8 hours (atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder). Physician order dated 11/26/2024 revealed an order to administer Resident #337 Humalog Insulin (fast-acting insulin) per sliding scale before meals and at bedtime. Physician order dated 11/22/2024 revealed an order to administer Resident #337 Quetiapine (atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depressive disorder) 100 mg at bedtime. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #337 did not receive Humalog Insulin per sliding scale at 9:00 PM, Quetiapine 100 mg at 9:00 PM, Divalproex 250 mg at 10:00 PM on 12/7/2024 and Divalproex 250 mg at 6:00 AM on 12/8/2024. According to the MAR there was no documentation on 12/7/2024 of the 6:30 AM or 9:00 PM blood sugars. Q. Resident #8 was admitted to the facility on [DATE] with a diagnosis that included hypertension, chronic pain, neuralgia (nerve pain) and neuritis (pain causing inflammation of the peripheral nerves). Physician order dated 12/4/2024 revealed an order to administer Resident #8 Doxazosin (used to treat hypertension) 4 mg at bedtime. Physician order dated 10/15/2024 revealed an order to administer Resident #8 Gabapentin 100 mg every 8 hours. Physician order dated 2 /3/2024 revealed an order to administer Resident #8 Hydralazine (used to treat hypertension) 50 mg every 8 hours. Physician order dated 10/26/2024 revealed an order to administer Resident #8 Oxycodone (narcotic pain reliever)10 mg two times a day. Review of the Medication Administration Record (MAR) for the month of December 2024 indicated Resident #8 did not receive Doxazosin 4 mg at 8:00 PM, Gabapentin 100 mg at 10:00 PM, Hydralazine 50 mg at 10:00 PM and Oxycodone 10 mg at 8:00 PM on 12/7/2024. A telephone interview was conducted with Nurse #4 on 5/8/25 at 8:46 AM. Nurse #4 stated on 12/7/2024 she was assigned a shift of 7:00 PM to 7:00 AM. She indicated after 10:30 PM there were only two nurses (Nurse #5 and herself) in the facility to administer medications. Nurse #4 nor Nurse #5 wanted to take responsibility for taking an additional assignment when Nurse #6 left at 11:00 PM. Due to only having two Nurses on 3rd shift, she contacted the Administrator to communicate she did not feel safe taking the medication cart keys for the 500 hall because she would be responsible for administering medications to the entire unit (400 and 500 halls). Nurse #4 stated she nor Nurse #5 administered medication to the 500 hall resulting in the residents not receiving medications as ordered. An interview was attempted with Nurse #6 on 5/8/2025 at 11:26 AM. The phone call was not returned. An interview was attempted with Nurse #5 on 5/8/2025 at 11:28 AM, her mailbox was full and a message could not be left. Another call was attempted with Nurse #5 on 5/8/2025 at 1:14 PM, after the surveyor introduced herself the call was disconnected. At 1:15 PM on 5/8/2025 a final attempt was made to call Nurse #5 back with no answer and her mailbox was full and no message could be left. The infection Preventionist was interviewed on 5/8/25 at 1:23 PM. She revealed on 12/7/24 she was acting as the interim DON. The Infection Preventionist stated she did not recall being contacted by the Administrator or nursing staff regarding there not being a nurse assigned to administer medications. Had she been contacted about the staffing concern she would have come into the facility to cover the shift to ensure medications were administered according to the physician orders. An interview was conducted on 5/9/2025 at 9:43 AM via telephone with the Medical Director. During the interview the Medical Director stated he did recall the incident when residents did not receive medication but did not recall the exact date or time. He recalled there was no delay in his notification and implementation of interventions which included assessment of all affected residents to ensure there was no significant change in resident status due to missed doses of medication. He conducted a general sweep of the affected hall (500) to review any high-risk medications. He stated in general missing a single dose or two of medication in many chronic conditions would not result in decompensation or adverse outcomes. An interview was conducted on 5/8/2025 at 7:49 AM with the Administrator. During the interview he revealed on 12/7/2024 (time unknown) he was informed by Nurse #4 the facility was short nursing staff on the 7:00 PM to 7:00 AM shift. He stated he asked the day shift Nurse #6 to stay until 11:00 PM leaving the facility with two nurses Nurse #4 and Nurse #5 after 11:00 PM. After being notified by Nurse #4 she was not going to administer medications on the 500 hall, he attempted to contact other nurses to cover the unit. He further stated when he arrived at the facility, he felt as though there was sufficient staff. The Administrator contacted the Medical Director and notified him that medications had not been administered to residents on the 500 hall due to not having a nurse. The Administrator stated the Medical Director adjusted medication times and residents were assessed with no negative outcomes. An additional interview with the Administrator was conducted on 5/9/2025 at 10:43 AM. He stated the expectation of the nurses was to ensure all residents received their medication. He further stated if the unit was short staff the expectation was for the nurse on the unit to get report from the off going nurse and take the medication cart keys to administer medication to the residents.

Based on record review, resident, Resident Representative, and staff interviews, the facility failed to conduct quarterly care conferences with residents and their families for 3 of 3 residents reviewed for care conferences (Resident #25, Resident #12, and Resident #41). The findings included: A. Resident #25 was admitted to the facility 6/11/24. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #25 to be cognitively intact. Review of Resident #25's medical record revealed a care conference conducted on 1/6/25. The medical record indicated the next care conference date was 4/6/25. Review of the medical record revealed no care conference had been conducted on 4/6/25. Resident #25 was interviewed on 5/6/25 at 8:59 AM. When asked if she had participated in quarterly care conferences, Resident #25 reported she had, but it had been months since the last one. B. Resident #12 was admitted to the facility 11/12/24. The quarterly MDS assessment dated [DATE] assessed Resident #12 to be cognitively intact. The medical record for Resident #12 was reviewed and a care conference was documented on 11/19/24. The medical record indicated the next care conference date was 2/17/25. Review of the medical record revealed no care conference had been conducted on 2/17/25. Resident #12 was interviewed on 5/8/25 at 12:51 PM and he reported he participated in a care conference in November 2024 when he was admitted to the facility but had not had another since then. C. Resident #41 was admitted to the facility 12/23/24. The quarterly MDS documented Resident #41 was severely cognitively impaired. Review of Resident #41's medical record revealed no care conferences documented. Resident #41's Representative was interviewed by phone on 5/5/25 at 5:40 PM. The Representative reported she had not received an invitation to a care conference. The Representative explained she was Resident #41's Power of Attorney and she expected to be invited to care conferences. The former SW was interviewed by phone on 5/7/25 at 4:37 PM. The SW explained that she was not aware the care conferences were her responsibility and thought it was another staff member's responsibility. The SW explained when she was told it was her responsibility, she was so behind, she was unable to get caught up. The Nurse Consultant and Administrator were interviewed on 5/7/25 at 2:01 PM. The Administrator reported the Social Worker (SW) had been responsible for the care conferences. The SW had been terminated from her position and when the facility consultant reviewed charts, the Nurse Consultant discovered that the care conferences had not been completed. The Administrator reported he expected the care conferences to be completed quarterly, and the residents and representatives to be invited. The Nurse Consultant explained that she had conducted a 100% audit of all residents, and the facility had distributed the work between departments to complete the care conferences. The facility provided the following corrective action plan with a completion date of 5/3/25: How corrective action will be accomplished for those residents found to have been affected by the deficient practice On April 4.16.2025 the Social Worker was suspended from her position due to job performance. Ultimately, this would also be her last day working for the Organization. In efforts to identify issues needing to be addressed within the Social Services Department, the facility began to conduct internal audits to address areas within her job duties. On 5.2.2025 it was discovered that several residents had not had either had care plans scheduled, or there was no documentation to validate care plans had been held. Resident #25's care conference was scheduled for 5/15/25; Resident #12's care conference was scheduled for 5/5/25; Resident #41's care conference was scheduled for 5/12/25. Address how the facility will identify other residents having the potential to be affected by the same deficient. All residents have the potential to be affected by this deficient practice. On 5.2.2025, the Nurse Consultant conducted an audit on 100% of resident charts to identify residents who were missing documented care plan meetings. Forty-five of 82 residents were identified as not having documented quarterly care plan meetings. Care Plan meetings for the identified residents will be scheduled were scheduled and held beginning 5.5.2025. Care Plan meetings will be held by 5.16.25, unless families and/or responsible parties have conflicts and cannot attend. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur. On 5.2.2025, an abbreviated Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting was held to discuss the findings related to care plan meeting audit. Due to the nature of the audit's findings and urgency to resolve the deficient practice, the abbreviated Ad Hoc committee assigned the facility Infection Preventionist to contact families telephonically to schedule meetings. To ensure the deficient practice does not reoccur, on 5.2.2025, the Administrator re-educated the designated facility interdisciplinary team members on the policy and procedure for the right of residents to participate in the person-centered care planning process. Meeting attendees included the Administrator, Clinical Competency Coordinator, Director of Health Services, Assistant Director of Health Services. Dietary Manager, Case Mix Director, and Activities Director. This education has also been added to the facility's General Orientation for all newly hired interdisciplinary team members. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Assistant Director of Health Services will audit 10 records weekly to ensure care plan meeting notification to residents, families and/or responsible parties has been made and scheduled. The Assistant Director of Health Services will also audit the previous week's care plan meetings to ensure there is documentation of the meeting. This audit will be conducted weekly for 4weeks. Thereafter, audits will be conducted twice monthly for two months, and then monthly for three months. The Assistant Director of Health Services will present audit findings and analysis to the Administrator weekly and with the Quality Assurance and Performance Improvement Committee monthly for three months and until compliance is maintained. The Assistant Director of Health Services is responsible for implementing and maintaining the acceptable plan of correction. The decision to monitor and include in QAPI was made 5/2/2025. Date of compliance: 5.3.2025 The facility's corrective action was reviewed on-site and validated on 5/8/25. Initial audits were reviewed and 100% of residents in house on 5/2/25 were reviewed and 45 of the 82 residents were identified as not having care conference meetings. Staff were interviewed regarding calling resident representatives to schedule care conferences. Resident Representative for Resident #41 reported she had received an invitation to a care conference to be conducted the week of 5/12/25. The ad-hoc QAPI meeting minute notes for 5/2/25 were reviewed and the team discussed the missed care conferences and developed a plan for correction. Education provided to the interdisciplinary staff and general orientation for interdisciplinary staff was reviewed and included review of the facility policy Care Plans. The facility compliance date of 5/3/25 was validated on 5/8/25.

Based on record review, and Nurse Practitioner (NP) and staff interviews, the facility failed to notify the physician of an unsuccessful attempt to insert a midline intravenous (IV) line (long, thin, flexible tube that is inserted into a large vein in the upper arm) for 1 of 3 residents reviewed for notification (Resident #80). The findings included: Resident #80 was admitted to the facility 11/17/20 with diagnoses including stroke and dementia. The quarterly Minimum Data Set assessment dated [DATE] did not conduct an interview for cognition because Resident #80 was rarely or never understood. A NP note dated 2/27/25 documented a positive urine culture and potential pneumonia for Resident #80 and ordered cefepime (an antibiotic) to be administered by IV due to Resident #80's refusal to take oral medications. Physician orders for Resident #80 were reviewed and revealed an order dated 2/27/25 to insert a midline IV to be inserted. An order dated 2/27/25 specified cefepime 1 Gram to be administered in 50 milliliters of dextrose intravenously every 12 hours starting on 2/28/25. A nursing note dated 2/27/25 written by Nurse #3 documented the midline IV was not inserted because Resident #80 was pulling and jerking her arm away. The note documented the Resident Representative was notified. An interview was conducted with Nurse #3 on 5/8/25 at 11:39 AM. Nurse #3 reported she was assigned to Resident #80 on 2/27/25 when the infusion company attempted to insert the midline IV, but Resident #80 was combative and would not allow them to insert the IV. Nurse #3 reported she told the Resident Representative the IV could not be inserted. When asked if Nurse #3 called the on-call NP to notify the physician, Nurse #3 reported she had told the Unit Manger (UM) that the midline IV could not be inserted and she assumed the UM would call the on-call NP. The UM was interviewed by phone on 5/12/25 at 4:37 PM. The UM reported she was working on 2/27/25 and was told by Nurse #3 that Resident #80 did not have the midline IV inserted because she was combative. The UM explained she did not call the on-call NP to notify the physician because that would have been Nurse #3's responsibility. The NP was interviewed by phone on 5/12/25 at 9:55 AM. The NP reported that Resident #80 had been refusing oral medications and the Resident Representative agreed to trying IV medications for the urinary tract infection and possible pneumonia. The NP explained that neither her nor the on-call NP received a notification that the midline IV was not inserted on Resident #80 due to her combativeness on 2/27/25. The NP reported the UM notified her the midline was not inserted the morning of 2/28/25. The NP reported that she would not have ordered anything to be done for Resident #80 after the failed attempt to start the midline IV on 2/27/25, however, she expected to be notified immediately of any refusals or changes for residents. The NP explained that not receiving the antibiotic on 2/28/25 did not adversely affect Resident #80's outcome and she would not have ordered a different antibiotic on 2/27/25 until she was able to consult with a pharmacist. The Director of Nursing (DON) was interviewed by phone on 5/12/25 at 4:54 PM. The DON explained that during the morning meeting on 2/28/25, the interdisciplinary team reviewed nursing notes from the previous date and noted that the on-call NP had not been notified that Resident #80 was combative and the midline IV was not inserted. The DON reported they recognized the staff nurses required education about notifying the NP, but because this was an isolated incident, they did not start a plan of correction with monitoring and only provided education to the nursing staff. The DON reported he expected the nursing staff to report resident changes and refusals to the on-call NP.

Based on record review, observations, and staff and Nurse Practitioner interviews the facility failed to protect Resident #1's and Resident #2's right to be free from sexual abuse. On 6/16/24 staff (Nurse Aide #1, Nurse Aide #2, and Nurse #1) observed Resident #1 (female) in Resident #2's (male) room. Resident #2 was lying on his back on the bed naked from the waist down and Resident #1 was on top of him with her brief and pants down at her ankles. Resident #2 had one hand on his erect penis and was trying to insert his penis in Resident #1, and he was touching her private parts with his other hand. Approximately 30 minutes after the residents were separated, Nurse Aide #2 observed Resident #1 back in Resident #2's room with her hands on the front of his pants and was attempting to remove them. Resident #1 and Resident #2 had severe cognitive impairment and did not have the capacity to consent. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause trauma and fear. This deficient practice affected 2 of 4 residents reviewed for abuse. Immediate Jeopardy began on 6/16/2024 when the facility failed to protect Resident #1's and Resident #2's right to be free from sexual abuse. Immediate Jeopardy was removed on 6/29/2024 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] and her diagnoses included dementia with psychosis and a cognitive communication deficit. A quaterly Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and required moderate assistance with transfers, used a wheelchair for mobility in the facility, and had not had behaviors. Resident #1's care plan was reviewed and a care planned problem dated 2/10/2024 and updated on 6/11/2024 indicated Resdient #1 required various degrees of assistance with activities of daily living and should be allowed to attempt activities of daily living before being assisted and required incontience care as needed and during care rounds. A care plan problem dated 8/1/2023 indicated Resident #1 had physical and verbal behaviors of attempting to touch others (residents and visitors), yelling out, resisting care, and not being easily redirected during behaviors. The care plan problem indicated staff would assess whether the behavior endangers the resident or others and intervene if necessary. Resident #2 was admitted to the facility on [DATE] and his diagnoses included a history of stroke and schizophrenia. A quarterly MDS assessment dated [DATE] which indicated he was severely cognitively impaired; was independent with transfers, walking, and toileting; and he had not behaviors. Resident #2's care plan was reviewed and a care plan for 1/6/2024 stated he was independent with transfers, walking, and toileting and had verbal behaviors of theatening others, screaming at and cursing others, and episodes of fighting others. The interventions for Resident #2's care plan indicated staff would avoid overstimulation and maintain a calm environment. Review of Resident #1's medical record revealed a Nurse's Progress Note written by the Director of Health Services (DHS) on 6/16/2024 at 5:30 pm which stated Resident #1 exhibited behaviors. A Nurse's Progress Note written by the DHS on 6/16/2024 at 5:35 pm in Resident #2's electronic record dated 6/16/2024 at 5:35 pm indicated Resident #2 exhibited behaviors. A Witness Statement written on 6/16/2024 at 1:30 pm by Nurse Aide #2 revealed the following: She entered Resident #2's room and found Resident #2 lying on his back with his body perpendicular to the bed with his legs hanging over the side of the bed and Resident #1 was lying on top of Resident #2. Both residents were naked from the waist down and Resident #2 had one hand on his penis and was trying to put his penis in Resident #1, and he was touching her private parts with his other hand. Nurse Aide #2 called out to Nurse Aide #1 and Nurse Aide #1 called out to Nurse #1. When Nurse #1 arrived at the room they assisted Resident #1 off Resident #2, dressed her, and removed her from the room. Nurse Aide #2 was interviewed on 6/26/2024 at 10:00 am by phone and she stated she worked on 6/16/2024 and found Resident #1 in Resident #2's room. She stated Resident #2 was lying on his back on his bed with his legs perpendicular to his bed and his legs hanging over the side of the bed with Resident #1 lying on top of him. Nurse Aide #2 stated Resident #2 had an erection and he had one hand on his penis and was trying to penetrate Resident #1's vagina but was not successful. She stated she was just inside the doorway to the room when she saw what was happening she called out to Nurse Aide #1 who came to the room. Nurse Aide #2 stated they did not separate Resident #1 and Resident #2 before they called for Nurse #1. She indicated then Nurse Aide #1 called out to Nurse #1 to come to the room. Nurse Aide #2 stated Nurse Aide #1 left the room to get Nurse #1 and it was only a few minutes before Nurse #1 came to the room. She indicated she remained standing inside the doorway to the room until Nurse #1 got to the room. Nurse Aide #2 stated she did not think about seperating Resident #1 and Resident #2 before calling Nurse #1 to the room because everything happened so fast. Nurse Aide #2 stated she and Nurse #1 dressed Resident #1, put her in her wheelchair, and removed her from the room. She revealed about thirty minutes later she (Nurse Aide #2) found Resident #1 in Resident #2's room again in her wheelchair beside his bed with her hand on the front of his pants and was attempting to remove them. Nurse Aide #2 stated Resident #2 was lying on the bed on his back. Nurse Aide #2 stated one-to-one monitoring was put into place for Resident #2 at 6:00 pm that evening. Nurse Aide #2 stated Resident #2 was able to dress and undress, transfer, and walk without assistance and Resident #1 could transfer herself to the commode and back to her wheelchair without assistance at times and could pull her pants and brief down herself. Nurse Aide #2 stated Resident #1 had a history of behaviors of making sexual comments to other residents. A Witness Statement written on 6/16/2024 at 1:30 pm by Nurse Aide #1 revealed the following: Nurse Aide #1 saw Resident #1 and Resident #2 in the hallway and Resident #2 whispered to Resident #1 come in my room. The statement indicated Nurse Aide #1 redirected Resident #1 and told her she should not go in Resident #2's room and then she began passing lunch meal trays. Nurse Aide #2 called her to Resident #2's room and Resident #2 was lying on his bed and Resident #1 was lying on top of him. Resident #2 was naked from the waist down and Resident #1's brief and pants were down. Resident #1 was humping Resident #2 and Resident #2 was rubbing Resident #1's private parts and was also trying to penetrate Resident #1 with his penis, but was not able to. Nurse Aide called out to the Nurse #1 and she came to the room. During an interview on 6/25/2024 at 1:14 pm with Nurse Aide #1 she stated on 6/16/2024 she was passing lunch meal trays when she was called to Resident #2's room by Nurse Aide #2. She stated when she came to the door to Resident #2's room he was lying on the bed perpendicular to the bed with his legs over the side edge of the bed and Resident #1 was on top of him. Nurse Aide #1 stated she stayed just inside the doorway to Resident #2's room. She stated Resident #2 had an erection and he was trying to insert his penis in Resident #1. Nurse Aide #1 stated she yelled at Nurse #1 to come to the room but she had to leave the room to get Nurse #1 because she (Nurse #1) could not hear her. She stated when she returned to the room with Nurse #1 a few minutes later and they assisted Resident #1 off of Resident #2, dressed Resident #1 and removed her from the room. Nurse Aide #1 stated she was so shocked she did not think about seperating Resident #1 and Resident #2 immediately when called to the room by Nurse Aide #2. An interview was conducted with Nurse #1 on 6/25/2024 at 12:49 pm and she stated she was not assigned to Resident #1 or Resident #2 on 6/16/2024. She stated she was called to Resident #2's room by Nurse Aide #1. She stated she was on the 400-hall when Nurse Aide #1 called out to her but she could not understand what Nurse Aide #1 was saying to her so Nurse Aide #1 came down the hall and asked her to come to Resident #2's room. Nurse #1 stated she entered the room and Resident #2 was on his back perpendicular to the bed and Resident #1 was lying on top of him. Nurse #1 stated Resident #2 was naked from the waist down and Resident #1's brief and pants were pulled down to her ankles and Resident #2 was attempting to penetrate Resident #1's vagina. Nurse #1 stated they assisted Resident #1 off of Resident #2 and removed her from the room. Nurse #1 stated Resident #1 was found in Resident #2's room again about 30 minutes later by Nurse Aide #2. Nurse #1 stated Resident #1 was put on one-to-one observation after the second time she was found in Resident #2's room. Nurse #1 stated Resident #1 was able to transfer herself to the toilet and could pull down her brief and pants and Resident #2 was independent for dressing and undressing. Attempts were made during the survey to reach Nurse #2 who was assigned to Resident #1 and Resident #2 during the 7:00 am to 7:00 pm shift on 6/16/2024. Nurse #2 no longer worked for the facility and did not return messages left for a return call. On 6/25/2024 at 2:35 pm an attempt was made to interview Resident #2 and due to his cognition he was not able to answer any questions. Resident #1 was observed in her room on 6/26/2024 at 10:00 am and an attempt was made to interview her regarding the incident on 6/16/204. Resident #1 did not remember the incident. During an interview on 6/25/2024 at 4:45 pm the Director of Health Services (DHS) was interviewed by phone and stated on Sunday, 6/16/2024 at 1:10 pm she received a call from Nurse #2 who reported the incident that occurred at 1:00 pm. The DHS stated Resident #1 was found approximately 30 minutes later in Resident #2's room, by Nurse Aide #2, and Resident #1 had her hand on the front of Resident #2's pants like she was trying to take his pants off. The DHS stated Resident #1 was not put on one-to-one observation until after she was found in Resident #2's room a second time. The DHS also stated both Resident #1 and Resident #2 were very confused, but neither of them had behaviors of inappropriate touching before the incident. She stated she tried to interview Resident #1 after the incident but she denied the incident happened. The Nurse Practitioner (NP) was interviewed on 6/25/2024 at 1:58 pm and she stated both Resident #1 and Resident #2 were cognitively impaired and did nto have the capacity to consent to sexual contact. During an interview with the Administrator on 6/25/2024 at 12:24 pm he stated he was aware of allegation of sexual touching between Resident #1 and Resident #2 that occurred on 6/16/2024 at approximately 1:00 pm. He stated he was not aware of the second incident between Resident #1 and Resident #2 and one-to-one observation should have been put into place after the first incident between the two residents. The Administrator was notified of immediate jeopardy on 6/26/2024 at 10:36 am. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to protect Resident #1's and Resident #2's right to be free of sexual abuse. Both Resident #1 and Resident #2 had severe cognitive impairment and were not capable of consenting to sexual acts. On 6/16/2024 at 1:00 PM Nurse Aide #1 entered Resident #2's room. Resident #2 (a male resident) was lying on his bed with Resident #1 (a female resident) lying on top of him. Resident #2 was undressed from the waist down and Resident #1's brief and pants were down around her ankles. According to the written statements of Nurse Aide #1 and Nurse Aide #2, Resident #1 was humping Resident #2 and Resident #2 had an erection and was trying to penetrate Resident #1 but was not able to. Nurse #1 stated Nurse Aide #1 called out to her (she was in the hall), Nurse Aide #1 left the room to get her (Nurse #1) and she entered the room (approximately 5 minutes after she was notified) and observed Resident #1 lying on top of Resident #2 and Resident #2 had his hand on his penis which was erect and was trying to place his penis in Resident #1. Nurse #1 stated Resident #2 had not penetrated Resident #1. Nurse #1 stated she instructed Nurse Aide #1 and Nurse Aide #2 to Resident #1 off Resident #2, and they dressed her and wheeled her from the room. After removing Resident #1 from Resident #2's room, they wheeled her down the hallway for monitoring. According to the staff, monitoring Resident #1 was a collective effort. Approximately 30 minutes later, Resident #1 was again found in Resident #2's room with her hand on the front of Resident #2's pants and when asked what she was doing she stated she was fixing his pants. It was at this time a dedicated staff member was assigned one to one to Resident #1. On 6/19/2024, Resident #1's skin was assessed by a facility staff nurse to help ensure there was no skin impairment because of the incident. Resident #2's skin assessment was done by the charge nurse on 6/26/2024. The assessment revealed no skin impairments. Resident #1 had a room change on 6/25/2024 to remove her from proximity to Resident #2. On 6/16/2024 Resident #1 was placed on dedicated 1:1 monitoring until the psychiatrist deems her change in medication has stabilized her behaviors. On 6/20/2024 Resident #1 and Resident #2 were evaluated by their psychiatrist. Resident #1's medication, paroxetine, a psychotherapeutic medication, was evaluated and increased. Resident #1's care plan and resident profile were reviewed and identified touching other residents and was reviewed and revised on 6/27/2024 to reflect the medication changes and 1:1 monitoring. On 6/27/2024, Resident #2 did not have required any changes to his medication regimen, Resident #2's care plan was reviewed and revised on 6/27/2024 to include sexual inappropriate behaviors towards others to include attempted sexual encounter with another resident. The Administrator directed the Nurse Managers and Licensed Nurses on 6/26/2024 to complete the skin observations of all residents with a Brief Interview for Mental Status (BIMS) of 9 or below to identify any skin impairments of unknown origin (bruises, skin tears). Residents with a BIMS score of 10 or above will be interviewed by a Department Manager (Administrator, Social Worker, Clinical Competency Coordinator, Case Mix Director, Director of Health Services, Nurse Navigator) on 6/27/2024 regarding any concerns related to abuse, nonconsensual sexual abuse, and mistreatment. The facility will initiate abuse prevention, identification and reporting policy if any concerns are identified from skin assessments and resident interviews. This includes notification to the State agencies, police and local adult protective services. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed. On 6/26/2024, during an Ad Hoc Quality Assurance Meeting, the Administrator and Clinical Competency Coordinator educated the Department Managers (Director of Health Services, Social Worker, Environmental Services, Dietary Manager, Case Mix Director, Cas Mix Coordinator, Financial Counselor, Nurse Navigator, Admissions Director) on the facility's Prevention of Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation Policy and Procedures that includes sexual abuse is non-consensual sexual contact of any type with a resident and staff's heightened awareness of sexually inappropriate actions between residents. In the event of a resident-to-resident nonconsensual sexual behavior, the residents will be provided a one-to-one staff member until review is made by the provider (Nurse Practitioner, Physician, Psychiatrist) to determine a removal plan for the one-to-one. One-to-one is a dedicated staff member assigned to the resident to prevent further occurrences of a specific behavior. The Director of Health Services and/or Nurse Managers assign the designated staff members by identification on the Certified Nursing assignment sheet. On 6/26/2024 the Clinical Competency Coordinator and Department Managers began educating their respective department related to the facility Prevention of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Policy and Procedures that includes sexual abuse is non-consensual sexual contact of any type with a resident and staff's heightened awareness of sexually inappropriate actions between residents. Any resident voicing desire to have a sexual relationship with another resident will be evaluated by the provider (physician) and/or social worker to ensure both residents have the cognitive compacity to make an informed decision. In the event of a resident-to-resident nonconsensual sexual behavior, or an observed sexual act without the staff's prior knowledge of consent of both residents with BIMS score of 10 or greater with cognitive capacity to consent to the sexual act, the staff members report the behavior to the Licensed Nurse, who reports to the Nurse Manager and Administrator. The residents will be provided a one-to-one staff member until review is made by the provider (Nurse Practitioner, Physician, Psychiatrist) to determine the removal plan for the one-to-one. One-to-one is a dedicated staff member assigned to the resident to prevent further occurrences of specific behavior. Staff members not educated by 6/27/2024 will be educated prior to their next scheduled shift. The Administrator and/or Clinical Competency Coordinator are responsible for ensuring all staff are educated by 6/27/2024. Facility Staff who are scheduled to work will receive the in-person education; Facility Staff who are not scheduled to work will receive verbal education over the phone with review of education by their Department Manager and/or Administrator upon next scheduled shift. This education has been added to the general orientation for all newly hired staff provided by the Clinical Competency Coordinator. The Administrator and/or Clinical Competency Coordinator maintains the employee roster of those who have been educated and who require review. Alleged date of immediate jeopardy removal: 6/29/2024. Validation of the facility's Credible Allegation of Immediate Jeopardy removal was completed on 7/1/2024. Interviews were conducted with the Administrator, Director of Health Services, Nurse Aides, Nurses, Social Worker, Dietary Staff, Environmental Staff, Maintenance Director, Clinical Competency Coordinator, and Assistant Director of Nursing and staff were able to identify the different types of abuse, and that sexual abuse is non-consensual sexual contact of any type. Staff also indicated residents should be removed from abusive situations and monitored to ensure no further abuse occurs. The facility provided a skin assessment completed on 6/26/2024 for Resident #1 and she did not have any skin impairments. Resident #1's room was changed on 6/25/2024 to remove her from the immediate vicinity of Resident #2. Resident #1 was placed on one-to-one observations and was observed during the validation on one-to-one observation. A review of Resident #1's medical record revealed she was seen by the Nurse Practitioner on 6/17/2024 and was seen by Psychiatric Services on 6/20/2024 and her psychotherapeutic medication, paroxetine was evaluated and increased. Resident #1's Care Plan was reviewed and updated on 6/27/2024 to reflect she had one-to-one monitoring and a change to her psychotherapeutic medication. Resident #2's care plan was reviewed and verified to be updated on 6/27/24. The facility provided Skin Assessment forms for residents with a BIMS of 10 or lower and documentation of interviews with residents with a BIMS higher than 10 to show that all other residents were assessed for abuse that were completed on 6/28/204. The facility also provided a copy of the minute notes for their 6/26/2024 Quality Assurance Meeting which indicated the Quality Assurance Team discussed the facility's progress with their credible allegation and plan of correction. The facility's Immediate Jeopardy's removal date of 6/29/2024 was validated.

Based on record review, observations, and staff interviews the facility failed to implement their abuse policy by failing to immediately implement protective measures when Nurse Aide #1 and Nurse Aide #2 observed two residents with severe cognitive impairment (Resident #1 and Resident #2) engaged in sexual activity that they did not have the capacity to consent to and the staff did not immediately separate the residents to provide protection from further abuse. The residents remained engaged in the sexual act until Nurse #1 arrived at the room and instructed Nurse Aide #1 and Nurse Aide #2 to separate the residents. Approximately 30 minutes after the residents were separated, Nurse Aide #2 observed Resident #1 back in Resident #2's room with her hands on the front of his pants and she was attempting to remove them. Additionally, the facility failed to implement their abuse policy for reporting and investigating the sexual abuse for 2 of 4 residents (Resident #1 and Resident #2) reviewed for allegations of abuse. Immediate Jeopardy began on 6/16/2024 when the facility failed to immediately implement protective measures when Resident #1 and Resident #2 were observed engaging in sexual activity that they did not have the cognitive capacity to consent to. Immediate Jeopardy was removed on 6/29/2024 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, last revised on 1/11/2024, included the following: Sexual abuse is non-consensual sexual contact of any type with a resident. Any person observing or identifying any signs or symptoms of abuse was to report it to the Administrator as soon as possible. The Administrator was to inform and designate other staff members to assist in the investigation as needed. If there was an occurrence or an allegation involving resident abuse, the facility would ensure that precautions were taken to protect the health and safety of the resident during the course of and following the investigation. The Administrator or their designee should notify the state agency and other agencies in accordance with the regulations and state law. The initial report to the state agency should include the nature and extent of any injuries. The investigation report was to be submitted to per state requirements. Resident #1 was admitted to the facility on [DATE] and her diagnoses included dementia with psychosis and a cognitive communication deficit. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired. Resident #2 was admitted to the facility on [DATE] and his diagnoses included a history of stroke and schizophrenia. A quarterly MDS assessment dated [DATE] indicated Resident #2 was severely cognitively impaired. A Witness Statement dated 6/16/2024 at 1:30 pm completed by Nurse Aide #2 included the following information: She entered Resident #2's room and found Resident #2 lying on his back with his body perpendicular to the bed with his legs hanging over the side of the bed and Resident #1 was lying on top of Resident #2. Both residents were naked from the waist down and Resident #2 had one hand on his penis and was trying to put his penis in Resident #1, and he was touching her private parts with his other hand. Nurse Aide #2 called out to Nurse Aide #1 and Nurse Aide #1 called out to Nurse #1. When Nurse #1 arrived at the room they assisted Resident #1 off Resident #2, dressed her, and removed her from the room. During an interview by phone with Nurse Aide #2 on 6/26/2024 at 10:00 am she stated she was assigned to Resident #1 and Resident #2 on 6/16/2024 on the 7:00 am to 7:00 pm shift. She stated she found Resident #1 in Resident #2's room. Nurse Aide #2 stated Resident #2 was lying on his back on his bed with his legs perpendicular to his bed and his legs hanging over the side of the bed with Resident #1 lying on top of him. Nurse Aide #2 stated Resident #2 had an erection and he had one hand on his penis and was trying to penetrate Resident #1's vagina but was not successful. She stated she was just inside the doorway of Resident #2's room when she saw Resident #1 and Resident #2 and she called out to Nurse Aide #1 who came to the room. She indicated Nurse Aide #1 then called out to Nurse #1 to come to the room. Nurse Aide #2 stated Nurse Aide #1 left the room to get Nurse #1 and was only gone a few minutes before Nurse #1 came to the room. Nurse Aide #2 stated she did not separate the residents prior to getting assistance from Nurse Aide #1 and they (Nurse Aide #2 and Nurse Aide #1) did not separate Resident #1 and Resident #2 before they called for Nurse #1. When asked why, she stated she did not think about separating the residents because everything happened so fast. Nurse Aide #2 stated Nurse #1 instructed her to help remove Resident #1 from the bed, get her dressed and remove her from the room. Nurse Aide #2 stated no interventions or monitoring was implemented for Resident #1 or Resident #2 after this incident. She indicated about thirty minutes later she found Resident #1 back in Resident #2's room. Resident #1 was in her wheelchair beside Resident #2's bed and Resident #2 was lying on his back in bed. Resident #1 had her hand on the front of his pants and was attempting to remove them. Nurse Aide #2 stated she notified Nurse #1 of Resident #1 coming back into Resident #2's room and she (Resident #1) was removed from the room again. Nurse Aide #2 stated between 6:30 pm and 7:00 pm on 6/16/2024 Resident #1 was put on one-to-one observation, and she did not know why Resident #1 was not put on one-to-one observation sooner. Nurse Aide #2 indicated no additional interventions or monitoring were implemented for either resident prior to the one-to-one observation of Resident #1. A Witness Statement written on 6/16/2024 at 1:30 pm by Nurse Aide #1 revealed the following: Nurse Aide #2 called her to Resident #2's room and Resident #2 was lying on his bed and Resident #1 was lying on top of him. Resident #2 was naked from the waist down and Resident #1's brief and pants were down. Resident #1 was humping Resident #2 and Resident #2 was rubbing Resident #1's private parts and was also trying to penetrate Resident #1 with his penis, but was not able to. Nurse Aide called out to the Nurse #1 and she came to the room. During an interview with Nurse Aide #1 on 6/25/2024 at 1:14 pm she stated she was called to Resident #2's room Nurse Aide #2 on 6/16/2024. She stated when she arrived at Resident #2's room he was lying on his back on the bed perpendicular to the bed with his legs hanging off the bed and Resident #1 was lying on top of him. Nurse Aide #1 stated Resident #2 was trying to put his penis in Resident #1, but he was not able to. She stated she called out to Nurse #1, but Nurse #1 did not hear her, so she walked up the hallway from the 500-hall to the 400-hall and got Nurse #1. She stated when they returned to the room Resident #1 was still on top of Resident #2 and Resident #2 had his penis in his hand and was still attempting to penetrate Resident #1. Nurse #1 instructed them to get Resident #1 off Resident #2 and get her removed from the room. Nurse Aide #1 stated she felt they were shocked and neither she nor Nurse Aide #2 thought about removing Resident #1 from the room before calling Nurse #1 to the room. Nurse Aide #1 stated approximately 30 to 45 minutes after the first incident, Resident #2 was found in Resident #1's room again with her hand on the front of his pants and she was messing with his zipper. Nurse Aide #1 stated after the second incident Resident #1 was put on one-to-one observation. An interview was conducted with Nurse #1 on 6/25/2024 at 12:49 pm and she stated she was not assigned to Resident #1 or Resident #2 on 6/16/2024. She stated she was called to Resident #2's room by Nurse Aide #1. She stated Nurse Aide #1 had called to her but she did not hear her and then Nurse Aide #1 came down to 400-hall (Resident #2's room was on 500-hall) and told her she needed to come to Resident #2's room. Nurse #1 stated it was approximately 5 minutes from the time Nurse Aide #1 came to get her until she arrived at Resident #2's room. Nurse #1 stated she entered Resident #2's room and observed Resident #2 naked from the waist down on his bed, lying on his back, with his legs perpendicular to the bed and his legs hanging off the bed; and Resident #2 was naked from the waist down and Resident #1's brief and pants were down to her ankles. Nurse #1 stated Resident #1 was lying on top of Resident #2, and Resident #2 had his hand on his penis, and he was trying to penetrate Resident #1. Nurse #1 stated Resident #2 had an erection, but she did not observe him penetrate Resident #1's vagina. She stated she instructed Nurse Aide #1 and Nurse Aide #2 to get Resident #1 off Resident #2, they dressed her and removed her from the room. Nurse #1 stated she did not assess either Resident #1 or Resident #2 for any injuries She stated approximately thirty minutes after they removed Resident #1 from Resident #2's room she was found again by Nurse Aide #2 in Resident #2's room with her hand on the front of Resident #2's pants. Nurse #1 stated Resident #1 was put on one-to-one observation after she was found in Resident #2's room the second time, but she did not remember what time the one-to-one observation began. Attempts were made during the survey to reach Nurse #2 who was assigned to Resident #1 and Resident #2 during the 7:00 am to 7:00 pm shift on 6/16/2024. Nurse #2 no longer worked for the facility and did not return messages left for a return call. There was no evidence in Resident #1 or Resident #2's record that they were immediately assessed and there was no evidence the facility reported the sexual abuse to the state agency, Adult Protective Services, and law enforcement. The Director of Health Services (DHS) was interviewed on 6/25/2024 at 4:45 pm and she stated she received a call from Nurse #2 at 1:10 pm on Sunday, 6/16/2024, and was told Resident #1 was found in Resident #2's room, Resident #1 was lying on top of Resident #2 in his bed, and both residents were unclothed from the waist down. She stated she immediately called the Administrator and reported Resident #1 and Resident #2 were attempting to have sex and told him she was on her way to the facility to get witness statements and would keep him updated. The DHS did not indicate the Administrator gave her any instructions regarding the investigation and monitoring. The DHS stated she interviewed Nurse Aide #1, Nurse Aide #2, and Resident #1. The DHS stated she was not aware Resident #1 and Resident #2 were not separated immediately and was not aware Resident #1 was not put on one-to-one observation immediately. The DHS also stated the staff should have separated them immediately and put Resident #1 on one-to-one observation immediately to protect both residents. The DHS stated approximately 30 minutes after the initial incident Nurse Aide #2 found Resident #1 in Resident #2's room again. She stated Nurse Aide #2 told her, she [Resident #1] had her hands on the front of his [Resident #2] pants like she was trying to take them off. The DHS stated Resident #1 was put on one-to-one observation after the second incident. The DHS stated Resident #1 did not have a skin assessment after the incident, but she took her to the bathroom between 6:00 pm and 8:00 pm that evening and she did not have any bleeding when wiped and she did not complain of pain or grimace when she was wiped. The DHS stated she did not do any interviews or assessments of any other residents to ensure no one else was sexually abused; she did not do education with the staff regarding the facility's sexual abuse policy, and she did not report the incident to the state agency, Adult Protective Services, or the authorities. The DHS stated the Administrator was responsible for reporting abuse to the state agency, Adult Protective Services, and the authorities and she did not know why it was not reported. The Administrator was interviewed on 6/26/2024 at 1:15 pm and he stated he should have reported the allegation of sexual abuse to the state agency, Adult Protective Services, and the local law enforcement authorities and he should have asked more questions of the staff when the incident was reported to him on 6/16/2024. The Administrator stated since both residents were severely confused and were not aware they were doing anything wrong, he had not considered the incident to be sexual abuse. He revealed he realized now he should have reported the incident since neither resident was able to consent to the sexual activity. The Administrator stated staff had not made him aware there was a second incident with Resident #1 returning to Resident #2's room or that they had not separated Resident #1 and Resident #2 immediately after the first incident. The Administrator stated he should have made sure Resident #1 and Resident #2 were separated immediately and one-to-one observation was put into place after the first incident when Resident #1 was found in Resident #2's room the first time to ensure both residents were safe. He stated he should have also ensured there were no other residents that may have been involved by having the other residents interviewed and assessed for any signs of abuse and he should have ensured education was completed with all the staff regarding reporting, investigating, and protecting residents from sexual abuse. The Administrator was notified of immediate jeopardy on 6/26/2024 at 10:36 am. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 6/16/2024 at 1:00 pm Nurse Aide #1 entered Resident #2's room and identified Resident #1 and Resident #2, who both lacked capacity to consent in a sexual compromising position and did not immediately separate them. Nurse Aide #1 called out for help to Nurse #1 (Nurse #1 was down the hall), Nurse Aide #1 left the room to get Nurse #1. When Nurse #1 and Nurse Aide #1 entered the room, they observed Resident #1 lying on top of Resident #2 and Resident #2 had his hand on his penis which was erect and was trying to place his penis in Resident #1. Nurse #1 stated Resident #2 had not penetrated Resident #1. Nurse #1 stated she instructed Nurse Aide #1 and Nurse Aide #2 to assist Resident #1 off of Resident #2 and they dressed her and wheeled her from the room. After removing Resident #1 from Resident #2's room, they wheeled her down the hallway for monitoring. According to the staff, monitoring Resident #1 was a collective effort. Approximately 30 minutes later, Resident #1 was again found in Resident #2's room with her hand on the front of Resident #2's pants and when asked what she was doing she stated she was fixing his pants. It was at this this time a dedicated staff member was assigned to Resident #1. The issues leading to the facility not implementing its abuse policy for reporting, protecting, and investigating the allegation of resident-to-resident sexual abuse was due to a lapse in education. The facility should have treated this incident as abuse and reported to local and state agencies as outlined in its policy. Resident #1 and Resident #2 do not have the capacity to make rational decisions as it relates to sexual intercourse; therefore, their inability to make this decision could have resulted in injury or harm. The decision to monitor Resident #1 by different staff members observation versus a dedicated assigned staff member was not appropriate as it did not protect Residents #1 and #2 from each other and other facility residents. To help ensure the immediate protection of residents to prevent further occurrences, Resident #1 was placed on 1:1 observation on 6/16/2024. Direct monitoring will remain in place until deemed safe by Resident #1's physician. As a result of the facility not implementing its abuse policy, local and state agencies were not notified, which compromised the protection of residents and thorough investigation of the event. The lack of reporting and following the facility policy compromises all residents and their protection against abuse. An initial investigation report regarding this incident has been submitted to NC Department of Health and Human Services Regulation department on 6/26/24. The incident has also been reported to the County Adult Protective Services and the local Police department on 6/26/24. On 6/27/24 the Facility Administrator conducted an audit of all other abuse allegations within the past six months to ensure interventions were immediately implemented to protect the residents and prevent further abuse, that the allegations were reported as required and were investigated thoroughly. Any identified discrepancies will be addressed according to the abuse protocol up to and including notification to Department of Health and Human Services, Adult protective services and local police department. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed. An Ad Hoc Quality Assessment and Performance Improvement meeting was held 6/26/24 to discuss and review its policies on abuse identification and abuse prevention and reporting. Attendees included the Administrator, Director of Nursing Services, Social Services, Case Mix Nurse, Nurse Navigator, Business Office, and Admissions Director. The Committee concluded the policy and procedure had not been followed. The committee reviewed the facility's policy on Abuse Identification as well as Abuse Prevention to ensure understanding of how to identify and address allegations of abuse. On 6/26/24 the Clinical Competency Coordinator educated facility Nurse Managers and Department Managers (Dietary, Housekeeping, and Environmental Services) on abuse identification and abuse prevention and reporting, to ensure they were prepared and able to disseminate information to their staff. Department Managers (Dietary, Housekeeping, and Environmental Services) educated their staff on Abuse Identification as well as Abuse Prevention to ensure understanding of how to identify and address allegations of abuse on 6/26/2024. The Clinical Competency Coordinator also began education to all Facility Staff members on 6/26/24 on the facility abuse identification and abuse prevention and reporting policies. Staff education included all clinical and non-clinical staff. Those who have not received education by 6/28/24 will be provided education prior to the beginning of their next scheduled shift. The Administrator and/or Clinical Competency Coordinator maintains the employee roster of those who have been educated and who requires education and ensure staff do not work until education has been completed. All new employees will be educated by the facility Clinical Competency Coordinator during the New Employee Orientation and will not be permitted to work on the units until this education has been completed. Alleged date of immediate jeopardy removal: 6/29/2024. On 7/1/2024 the facility's credible allegation of immediate jeopardy removal was validated. The facility provided documentation of education provided by the facility regarding implementing their abuse policy which included providing a thorough investigation, protection of the resident involved and all other residents, assessment of the resident involved and assessment and interview of all other resident, and reporting of all allegations of abuse to the state agency, adult protective services, and local police authorities which was completed on 6/26/2024. The facility provided the documentation of the sexual abuse allegation report sent to the state agency, adult protective services, and the local police department. The facility provided documentation of the one-to-one observation by staff of Resident #1 and observations of Resident #1 on one-to-one observations were completed during the survey. The facility's Administrator conducted an audit of all other abuse allegations within the past six months to ensure interventions were immediately put into place to protect residents from further abuse on 6/27/2024. An Ad Hoc Quality Assessment and Performance Improvement meeting was held on 6/26/2024 and the minutes indicated the facility reviewed their policies on abuse identification and abuse prevention and reporting. Facility staff were interviewed and were able to verbalize understanding of identification of abuse and how to prevent and report abuse. All the facility staff were knowledgeable about the types of abuse, who they should report abuse to, how they should protect the residents, and that residents should be assessed immediately if abuse is suspected. The facility's immediate jeopardy removal date of 6/29/2024 was validated.

Based on record reviews, resident, family member, and staff interviews, the facility failed to protect residents' dignity when residents were left soiled in feces and saturated in urine for 4 of 17 residents reviewed for dignity issues (Resident #192, Resident #34, Resident #48, and Resident #69), and failed to provide a dignity cover over a urinary catheter drainage bag for 1 of 4 residents reviewed for urinary catheters (Resident #390). Resident #192, Resident #34, Resident #48, and Resident #69 reported they felt upset, angry, mad, and like they did not matter at all when they were not provided incontinence care. Resident #390 felt upset that everyone could see my urine. The reasonable person concept was applied for Resident #48 due to her inability to express her feelings and a reasonable person would feel humiliated and degraded having to holler for assistance. The findings included: 1. Resident #192 was admitted to the facility on [DATE] with diagnoses including respiratory failure and hypertension. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #192 to be cognitively intact. The remainder of the MDS was in progress and incomplete. The admission nursing assessment dated [DATE] documented Resident #192 was incontinent of urine and feces. A care plan dated 2/1/2024 addressed Resident #192's potential for skin breakdown related to incontinence. The MDS vision assessment was not completed, however, Resident #192 read from her phone, and was able to read the name badge of the surveyor. Resident #192 was interviewed on 2/5/2024 at 11:17 AM. Resident #192 reported that on Sunday 2/4/2024 she was left saturated in urine, and she waited for care from 8:30 AM until 12:30 PM. Resident #192 described that her bed linens were wet with urine, her nightgown was wet with urine, and her incontinence brief was saturated with urine. Resident #192 explained that she had very little control of her bladder and she required an incontinence brief all the time. Resident #192 reported the incident made her feel sad and bad about herself, Like I didn't matter at all, and she was cold and uncomfortable. When asked how she knew she waited for 4 hours for incontinence care, Resident #192 explained she pressed her call light at 8:30 AM and the nurse told her he would be in to help her when he finished with his medication pass. Resident #192 reported she tracked the time on her cell phone. An interview was conducted with Nurse #10 on 2/6/2024 at 3:45 PM. Nurse #10 reported on Sunday 2/4/2024 the hall had one nursing assistant (NA) and him working. Nurse #10 reported that he had to administer medications before he was able to help the NA with incontinence care on residents. Nurse #10 reported Resident #192 was very wet when he provided her with incontinence care after he had administered medication, but she did not mention she was upset. NA #1 was interviewed on 2/8/2024 at 10:12 AM. NA #1 reported she was the only NA scheduled to work the short-term unit and it was her and Nurse #10 on the hall on 2/4/2024. NA reported she started at one side of the short-term hall and started providing care to residents one-by-one. NA #1 explained that several residents were soiled and saturated in urine, and she was not certain how long it took to provide care to all the residents. NA #1 reported she had provided care to Resident #192 on Saturday 2/3/2024 and she was aware that Resident #192 was incontinent of urine. NA#1 reported she did not know when Resident #192 received incontinence care on Sunday 2/4/2024 because Nurse #10 provided that care. The Director of Nursing (DON) #1 was interviewed on 2/8/2024 at 4:09 PM. DON #1 explained she was not certain why staffing was so low on 2/4/2024 and she would need to review the staffing sheets. DON #1 reported she expected incontinence care to be provided to residents in a timely manner. 2. Resident #34 was admitted to the facility on [DATE] with diagnoses to include stroke and diabetes. The admission MDS dated [DATE] assessed Resident #34 to be cognitively intact. The MDS documented Resident #192 was occasionally incontinent of urine and always continent of bowels. Resident #34 was interviewed on 2/5/2024 at 12:02 PM. Resident #34 reported during the past weekend (he was not certain if it was 2/3/2024 or 2/4/2024) he was left soiled in feces and his bed linens were wet with urine. Resident #34 reported he used the call bell for assistance, but it was a significant amount of time before he was provided incontinence care. Resident #34 reported he did not track the time; he only knew he was wet and soiled and upset. Resident #34 reported he felt horrible to be left wet and soiled and he was very upset. NA #1 was interviewed on 2/8/2024 at 10:12 AM. NA #1 reported she was the only NA scheduled to work the short-term unit and it was her and Nurse #10 on the hall on 2/4/2024. NA #1 explained that several residents were soiled and saturated in urine, and she was not certain how long it took to provide care to all the residents. NA recounted Resident #34 was soiled with feces and his bed linens and incontinence brief was saturated with urine. NA #1 reported Resident #34 was very angry and upset when she was able to provide care to him. The Director of Nursing (DON) #1 was interviewed on 2/8/2024 at 4:09 PM. DON #1 explained she was not certain why staffing was so low on 2/4/2024 and she would need to review the staffing sheets. DON #1 reported she expected incontinence care to be provided to residents in a timely manner. 28265 3. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic diastolic (congestive) heart failure, vascular dementia with behavioral disturbance, pulmonary hypertension, urinary incontinence, chronic pain syndrome, hemiplegia with hemiparesis following cerebral infarction affecting left non-dominant side, and erosive (osteo) arthritis. Review of Resident #48's quarterly Minimum Date Set (MDS) dated [DATE] revealed Resident #48 was moderately cognitively impaired. She was able to communicate her needs to staff and required extensive assistance to total dependence with all her activities of daily living. Resident #48 was always incontinent of bowel and bladder. During an observation on 02/08/24 at 8:15 am Resident #48 could be heard from the hallway hollering for help. Upon entry into Resident #48's room, a urine odor was present. A follow-up observation was conducted on 02/08/24 at 8:50 am of Resident #48, her call light was on and she was hollering for help. An interview was attempted with Resident #48 but was unsuccessful. On 02/08/24 at 9:00 am NA #8 was observed leaving Resident #48's room and the call light was turned off. NA #8 was interviewed at this time and reported Resident #48's brief was wet. The NA stated she was the scheduler/transportation person but was assisting on the floor that day as a nurse aide. NA #8 indicated that she would get NA #10 who was assigned to the Resident to provide incontinence care. On 02/08/24 at 10:10 am an observation was conducted of NA #8 providing incontinence care to Resident #48. Resident#48's brief was observed to be saturated in urine and a strong smell of urine was present. An interview with NA #10 on 02/08/24 at 10:30 am. NA #10 indicated she was the only NA on the hall to care for 26 Residents. NA #10 indicated Resident #48 had a behavior of hollering out from time to time when it took staff too long to provide care and when she was upset. NA #10 indicated she believed Resident #48 was upset and feeling bad because staff did not come in sooner to provide care she needed. NA #10 indicated that she tried to treat all her residents with dignity and respect. The Director of Nursing (DON) #1 was interviewed on 2/8/24 at 4:09 PM. DON #1 explained she was not certain why staffing was so low on 2/8/24 and she would need to review the staffing sheets. 46095 4. Resident #69 was admitted to the facility on [DATE], diagnosis included diabetic nephropathy, Cerebellar stroke syndrome, congestive heart failure (CHF), repeated falls, and lack of coordination. Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was moderately impaired and he displayed no rejection of care behaviors. He was coded to exhibit disorganized thinking behavior that was present and/or fluctuated. He required maximum assistance with personal hygiene, toileting hygiene, shower/bath, and dressing. He was frequently incontinent of bowel and bladder. Resident #69's active care plan, last revised on 01/04/2024, included the focus area of functional status activities of daily living (ADL) decline related to slurred speech and impaired mobility. The interventions included for staff to encourage Resident #69 to do as much as possible and to provide assistance as needed or requested. A focus area of bladder incontinence which included the intervention to provide Resident #69 incontinence care after each incontinent episode. He also had a focus that he was at risk for skin breakdown related to decline in mobility and medical diagnosis. The interventions included to keep skin clean and dry as possible and minimizing skin exposure to moisture and providing incontinence care. An interview was conducted on 02/07/24 at 1:43 PM with Resident #69's family member. She stated she was active in Resident #69's care. She explained there have been multiple times when Resident #69 was saturated with urine through his pants and his bed would be wet. She indicated she comes to the facility daily for breakfast and dinner to ensure he eats and was changed. She also stated she had to come into the facility to make sure he was cared for. She stated she was very unhappy with the care provided. An interview was conducted on 02/08/24 at 9:03 AM with Resident #69. He stated there had been many times where he was saturated with urine so much that his clothes and/or his bed would be soaked. He then pointed at his mattress and stated, look at my mattress, it happened this morning, they even had to change my sheets, indicated his sheets and his incontinence brief was saturated with urine. Observation of the mattress revealed a circular area in center of mattress extending out to approximately 2 inches from each side of the mattress. The center of the large area was slightly damp, and the edges of the circular area were whitish in color. No sheets were observed on the mattress. He stated he did not receive a shower, but the Nursing Assistant wiped him up. He further commented that there was no call for it, and he hoped that he didn't get sores from the urine on him like that. He then stated it made him frustrated and mad when staff don't change him often enough to prevent him from soaking through his clothes and bedding. An interview was conducted on 02/08/24 at 9:15 AM with Nursing Assistant (NA) #11. She stated Resident #69 was out of bed and dressed sitting in his wheelchair when she came on shift at 7:00 AM. The night shift NA had gotten him up. She verified there were no sheets on the bed when she entered the room. She stated normally sheets are changed if they were wet, soiled, or it was the residents shower day. She verified circular discoloration to the mattress. An interview was conducted on 02/08/24 at 9:20 AM with Nursing Assistant (NA) #4. She verified the circular discoloration area on the mattress was present. She indicated she did not know what was on the mattress, but it appeared to be urine. She further stated she cleaned the area prior to applying the clean sheets. An interview was conducted on 02/07/24 at 10:05 AM with Director of Nursing (DON) #1. She stated Resident #69 was to receive incontinence as needed and should be checked for incontinence needs often. No residents' clothing or bed linens should be wet with urine. Multiple phone calls were made to the Nursing Assistant (NA) #12 from 02/07/24 through 02/08/24 with no answer. She was assigned to Resident #69 on 02/07/24 from 7:00 PM-7:00 AM. 40197 5. Resident #390 was admitted to the facility on [DATE] with diagnoses that included retention of urine. A care plan, dated 1/29/24, was in place for a urinary catheter related to diagnosis of urinary retention. On 2/5/24 at 10:50 AM, Resident #390 was observed walking in the hallway with Physical Therapy (PT). He was noted to have an indwelling urinary catheter with the drainage bag attached to the walker. The drainage bag did not have a privacy cover and contained yellow urine which was visible to other residents and staff in the hallway. On 2/5/24 at 12:00 PM, Resident #390 was observed walking in the therapy gym. He was noted to have a urinary catheter with the drainage bag attached to the walker. The drainage bag did not have a privacy cover and urine was visible to the other residents and staff in the gym. An interview and observation occurred with Resident #390 on 2/6/24 at 9:18 AM. He was observed to be sitting on the side of the bed with the urinary drainage bag attached to a walker. The drainage bag did not have a privacy cover, had yellow urine in the drainage bag and could be seen from the hallway. Resident #390 commented, I don't think everyone should see my urine. An interview occurred with Nurse #13 on 2/6/24 at 9:20 AM and she stated all residents with urinary catheters should have a privacy cover on the drainage bags and indicated she would make sure one was provided for Resident #390. On 2/6/24 at 2:18 PM, Resident #390 was observed sitting up in a recliner chair watching TV. The urinary drainage bag was hanging to the left side of the chair, yellow urine in the drainage bag and was visible from the hallway. There was no privacy cover in place. Another interview occurred with Nurse #13 on 2/6/24 at 4:13 PM and she stated she spoke with the Central Supply Clerk and was told there were no dignity covers available. Nurse #13 added she instructed the nurse aides to cover the drainage bag with a pillowcase. On 2/7/24 at 11:08 AM, Resident #390 was observed sitting up in a chair in his room with a walker in front of him. The urinary drainage bag was attached to the walker with a pillowcase partially wrapped around it. Yellow urine was still visible from the hallway and there was no dignity cover in place. The Central Supply Clerk was interviewed on 2/7/24 at 11:45 AM. She explained the facility had urinary drainage bags with a dignity cover in place. The Central Supply Clerk was able to show that multiple urinary drainage bags with a dignity cover were present in the supply closet on the hallway where Resident #390 resided. She added the nurses were responsible for making sure the residents with urinary catheters had a urinary drainage bag with a dignity cover. Director of Nursing #1 was interviewed on 2/8/24 at 9:54 AM and stated it was her expectation for the nursing staff to use a privacy cover for urinary drainage bags to protect the resident's dignity and was unable to state why Resident #390's drainage bag was not covered.

Based on observations, record reviews, and staff, resident, Nurse Practitioner, and Medical Director interviews, the facility failed to provide sufficient nursing staff which resulted in residents being treated in an undignified manner when left incontinent of urine or stool (Resident #192, #34, #48, and #69) and when a urinary catheter bag was left uncovered (Resident #390). These residents reported feeling upset, angry, mad and unimportant. The facility failed to provide sufficient nursing staff to assist with activities of daily living (ADL) care for dependent residents (Resident #192, #34, #69, #48, and #339). The facility failed to supervise a resident who was at high-risk for falls which resulted in acute cervical 6, cervical 7 and 1 thoracic fractures due to a fall (Resident #16). This affected 9 of 86 residents reviewed for sufficient nursing staff. The findings include: This tag is crossed referenced to F 550: Based on record reviews and staff interviews, the facility failed to protect residents' dignity when residents were left soiled in stool and saturated in urine for 4 of 17 residents reviewed for dignity issues (Resident #192, Resident #34, Resident #48, and Resident #69), and failed to provide a dignity cover over a urinary catheter drainage bag for 1 of 4 residents reviewed for urinary catheters (Resident #390). Resident #192, Resident #34, Resident #48, and Resident #69 reported they felt upset, angry, mad, and like they did not matter at all when they were not provided incontinence care. Resident #390 felt upset that everyone could see my urine. The reasonable person concept was applied for Resident #48 due to her inability to express her feelings and a reasonable person would feel humiliated and degraded having to holler for assistance. This tag is crossed referenced to F 677: Based on observations, record reviews and interviews of residents, family member, and staff, the facility failed to provide incontinence care for dependent residents (Resident #192, Resident #34, Resident #69, Resident #48, and Resident #339), and failed to provide bathing for a dependent resident (Resident #339) for 5 of 16 residents reviewed for activities of daily living. This tag is crossed referenced to F689: Based on staff, Nurse Practitioner, (NP) #1 and Medical Director (MD) interviews, observations and record review, the facility failed to supervise Resident #16 who was cognitively impaired and impulsive. The resident was eating in a dining room without any staff present in the room and with the back of her wheelchair positioned in front of a stone hearth. While passing trays on the 300 hall, NA #8 observed Resident #16 aggressively bounce her wheelchair and suddenly flip her wheelchair backwards hitting her head on the stone fireplace. This accident resulted in acute cervical 6, cervical 7 and thoracic 1 fractures. The fall on 12/23/23 resulted in pain at a level of 6 out of 10 and the use of a hard cervical collar. This was for 1 of 6 residents reviewed for accidents (Resident #16). On 2/7/24 at 2:03 pm an interview was conducted with Nursing Assistant (NA) #8. NA #8 stated, this past Saturday (2/4/24), she worked on the long-term care hall (Halls 400 and 500) with 1 other NA and 48 residents on day shift. NA #8 stated, yesterday (2/6/24), from 3:00 pm to 5:30 pm I was the only NA on the long-term care hall with 87 residents. NA #8 stated she texted the Director of Nursing (DON) #1 multiple times and informed her. The residents residing on Hall 500 had not received any care or had call lights answered by me during this time. NA #8 stated she had spoken with the Corporate Floating DON and informed her the care was not completed and showed her that Resident #339 was soaked through to the bed flooded with urine and had not received care for hours. NA #8 stated the Corporate Float DON informed her to do her best and answer call lights. NA #8 stated some resident call lights were answered after 30 minutes. NA #8 stated she had not observed licensed nursing staff provide incontinence or personal care to the residents during this time. NA #8 stated that the staffing problem had become unsafe for staff and residents and currently the staffing was the worst she had seen in the 5 years she had been employed at the facility. A review of the nursing staffing for 2/6/24 revealed there was 1 NA scheduled from 3:00 to 7:00 pm on the long-term care Hall (400 and 500) due to call outs. The census for the facility (4 halls 100 - 400) was 78. On 2/7/24 at 2:03 pm an interview was conducted with NA #8. She stated on 2/3/24 and 2/6/24 there were approximately 40 residents to care for on Halls 400 and 500. The Infection Preventionist Nurse (IP) was interviewed on 2/7/24 at 11:55 am. The IP stated she was frequently pulled to cover licensed nursing call outs for a hall assignment to pass medication. The IP stated she was on the floor assignment during the 3:00 pm to 7:00 pm block of time when there were few NAs. She was aware that there were only 3 NAs during this time for 80 to 90 residents. The prior Administration had 8 hours shifts for NAs and the facility was moving to 12 hours shifts for the NAs which caused the occasional low staff gap from 3:00 pm to 7:00 pm NA schedule. On 2/8/24 at 4:10 pm an interview was conducted with the Director of Nursing #1 (DON). The DON stated she was scheduling nursing staff and not aware of a NA staffing shortage/coverage and she would need to review the staffing sheets. The DON had no further comments.

Based on staff, Nurse Practitioner, (NP) #1 and Medical Director (MD) interviews, observations and record review, the facility failed to supervise Resident #16 who was cognitively impaired and impulsive. The resident was eating in a dining room without any staff present in the room and with the back of her wheelchair positioned in front of a stone hearth. While passing trays on the 300 hall, NA #8 observed Resident #16 aggressively bounce her wheelchair and suddenly flip her wheelchair backwards hitting her head on the stone fireplace. This accident resulted in acute cervical 6, cervical 7 and thoracic 1 fractures. The fall on 12/23/23 resulted in pain at a level of 6 out of 10 and the use of a hard cervical collar. This was for 1 of 6 residents reviewed for accidents (Resident #16). The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of metabolic encephalopathy, peripheral vascular disease with a left above the knee amputation (AKA) and a history of falls. Resident #16 was care planned on 5/13/23 for cognitive loss and a memory recall problem. An intervention read to provide verbal and visual reminders. An Interdisciplinary Team note (IDT) evaluation note following a 7/20/23 fall determined Resident #16 was impulsive, poor safety awareness and attempted to transfer without assistance. The intervention added to the care plan was to remind her to call for assistance with transferring. A care plan intervention initiated on 7/27/23 was for increased supervision. Resident #16's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #16 had severe cognitive impairment, impairment to one lower extremity and substantial/maximum assistance with transfers from sit to stand and transfers from bed to wheelchair and wheelchair to bed. She was coded for one fall with minor injury. Review of a nursing note dated 12/23/23 at 5:36 PM read Resident #16 was sitting in her wheelchair in the dining room. She had eaten her evening meal and apparently had locked her wheelchair brakes. As she attempted to push her wheelchair back away from the table, her wheelchair tipped backwards resulting in Resident #16 striking her head on the hearth of the stone fireplace behind where she was seated. There was bleeding noted with an open area to the back of her head. She was sent to the emergency room for an evaluation. This note was written by Nurse #18. Review of an event report completed by Nurse #18 dated 12/23/23 at 5:41 PM read Resident #16 was eating her dinner in the dining room. The report did not include any further details. There were no IDT evaluation notes and the report read not applicable (NA)-event still open: An interview was completed on 2/7/24 at 2:19 PM with Nurse #18. She stated she was assigned Resident #16 on the 500 hall on 12/23/23 when she fell and hit her head on the stone fireplace hearth. Nurse #18 stated she was down the hall passing medications. Resident #16 was in the dining room eating dinner. She was not aware if any staff were in the dining room at the time of the fall but the aides yelled and she went to the dining room to assess Resident #16. She stated there was a lot of blood from a laceration on the back of her head and she complained of neck pain. Nurse #18 stated she immediately called the previous Director of Nursing (DON) and emergency medical services (EMS) for a hospital transfer. She stated that was all she knew about it until the next day when she learned about the cervical and thoracic fractures. An interview was completed on 2/7/24 at 3:00 PM with NA #9 who worked 12/23/23 7:00 AM to 7:00 PM and was assigned Resident #16. She recalled assisting Resident #16 to the dining room but did not recall locking her brakes and Resident #16 was known to do that herself. She stated she was passing trays on the hall because Resident #16 could feed herself. NA #9 stated it was Christmas weekend and they were working short. She stated normally one person was assigned to observe and assist in the dining room, but she did not think there was an aide in the dining room when Resident #16's fall happened because her peers were also passing trays and feeding residents in their rooms. NA #9 stated the dining room was right across from the nurses station and anyone could observe the residents while passing the dining room. A telephone interview was completed on 2/8/24 at 10:13 AM with NA #8. She recalled working on 12/23/23 at the time of Resident #16's fall in the dining room. She stated she was passing trays on the 300 hall which was across from the dining room, and she saw Resident #16 aggressively bouncing her wheelchair but NA #8 stated she did not notice that Resident #16's wheelchair brakes were locked when she suddenly flipped her wheelchair backwards and hit her head on the stone fireplace. A telephone interview was completed on 2/8/24 at 10:39 AM with NA #10. She recalled Resident #16's fall on 12/23/23. She stated there were only three aides working at the time of the fall. She stated she and her peers were either passing trays or feeding residents in their rooms. NA #10 stated there was no staff normally assigned to the dining room and there was approximately 8-10 residents eating there. She stated the residents she observed in the dining room on 12/23/23 were independent or set up assistance only. NA #10 stated she was walking by the dining room when she saw Resident #16's wheelchair in midair and before she could react, she fell backwards striking her head on the stone fireplace. NA #10 stated apparently Resident #16's wheelchair brakes were locked and she complained of pain immediately. An interview was completed on 2/8/24 at 10:20 AM with Nurse #11. She stated she was working on 12/23/23 but she was assigned the 300 and 400 halls. She stated Resident #16 had a lot of falls from her wheelchair and thought Resident #16 overestimated her abilities. Nurse #11 stated she had seen Resident #16 eating in the dining room at a table with her back to the stone fireplace. She stated apparently Resident #16 was attempting to leave her table when she flipped her wheelchair striking her head on the fireplace hearth. She stated there were no anti-tippers on her wheelchair at the time of the fall. Review of a nursing note dated 12/24/23 at 11:55 AM read Resident #16 arrived back to the facility with multiple fractures throughout her spine and her thoracic spine. The noted read there was no surgical intervention recommended and orders were for her to wear a hard collar neck brace for 4-6 weeks until she could follow up with a neurologist. The note also read that it was recommended she be prescribed opiates, muscle relaxers and nonsteroidal anti-inflammatory (NSAIDS) medication as needed for pain control. This note was written by Nurse #6. Review of the December Physician orders read a new order dated 12/25/23 for hydrocodone-a acetaminophen 5mg-325mg every 6 hours as needed. She received the pain medication once on 12/25/23 and 12/26/23. She received Ibuprofen once on 12/28/23. New orders were given on 12/28/23 for scheduled hydrophone-acetaminophen four times daily which she received as ordered. An observation was completed on 2/5/24 at 11:00 AM. Resident #16 sitting up in her wheelchair with her brakes unlocked. There was a padded cushion to the seat of the wheelchair. A telephone call was completed on 2/8/24 at 11:59 AM with former NP. She stated up until about 2 weeks ago, she was working at the facility and recalled Resident #16's fall on 12/23/23. NP #1 stated she was familiar with Resident #16. She stated she was impulsive and required close supervision. An interview was completed on 2/8/24 at 2:40 PM with the MD. He stated Resident#16 was known to be impulsive. He stated there should be closer supervision of the residents eating in the dining room and it sounded like a plan should be implemented to prevent additional unsupervised falls.

Based on observations, record reviews and interviews of residents, family member, and staff, the facility failed to provide incontinence care for dependent residents (Resident #192, Resident #34, Resident #69, Resident #48, and Resident #339), and failed to provide bathing for a dependent resident (Resident #339) for 5 of 16 residents reviewed for activities of daily living. The findings included: 1. Resident #192 was admitted to the facility on [DATE] with diagnoses including respiratory failure and hypertension. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #192 to be cognitively intact. The remainder of the MDS was in progress and incomplete. The MDS vision assessment was not completed, however, Resident #192 read from her phone, and was able to read the name badge of the surveyor. The admission nursing assessment dated [DATE] documented Resident #192 was incontinent of urine and feces. A care plan dated [DATE] addressed Resident #192's potential for skin breakdown related to incontinence. Resident #192 was interviewed on [DATE] at 11:17 AM. Resident #192 reported that on Sunday [DATE] she was left saturated in urine, and she waited for care from 8:30 AM until 12:30 PM. Resident #192 described that her bed linens were wet with urine, her nightgown was wet with urine, and her incontinence brief was saturated with urine. Resident #192 explained that she had very little control of her bladder and she required an incontinence brief all the time. When asked how she knew she waited for 4 hours for incontinence care, Resident #192 explained she pressed her call light at 8:30 AM and the nurse told her he would be in to help her when he finished with his medication pass. Resident #192 reported she tracked the time on her cell phone. An interview was conducted with Nurse #10 on [DATE] at 3:45 PM. Nurse #10 reported on Sunday [DATE] the hall had one nursing assistant (NA) and him working. Nurse #10 reported that he had to administer medications before he was able to help the NA with incontinence care on residents. Nurse #10 reported Resident #192 was very wet when he provided her with incontinence care after he had administered medication. NA #1 was interviewed on [DATE] at 10:12 AM. NA #1 reported she was the only NA scheduled to work the short-term unit and it was her and Nurse #10 on the hall on [DATE]. NA reported she started at one side of the short-term hall and started providing care to residents one-by-one. NA #1 explained that several residents were soiled and saturated in urine, and she was not certain how long it took to provide care to all the residents. NA #1 reported she had provided care to Resident #192 on Saturday [DATE] and she was aware that Resident #192 was incontinent of urine. NA#1 reported she did not know when Resident #192 received incontinence care on Sunday [DATE] because Nurse #10 provided that care. The Director of Nursing (DON) was interviewed on [DATE] at 4:09 PM. The DON explained she was not certain why staffing was so low on [DATE] and she would need to review the staffing sheets. The DON reported she expected incontinence care to be provided to residents in a timely manner. 2. Resident #34 was admitted to the facility on [DATE] with diagnoses to include stroke and diabetes. The admission MDS dated [DATE] assessed Resident #34 to be cognitively intact. The MDS documented Resident #192 was occasionally incontinent of urine and always continent of bowels. Resident #34 was interviewed on [DATE] at 12:02 PM. Resident #34 reported during the past weekend (he was not certain if it was ,d+[DATE] or [DATE]) he was left soiled in feces and his bed linens were wet with urine. Resident #34 reported he used the call bell for assistance, but it was a significant amount of time before he was provided incontinence care. Resident #34 reported he did not track the time; he only knew he was wet and soiled. NA #1 was interviewed on [DATE] at 10:12 AM. NA #1 reported she was the only NA scheduled to work the short-term unit and it was her and Nurse #10 on the hall on [DATE]. NA #1 explained that several residents were soiled and saturated in urine, and she was not certain how long it took to provide care to all the residents. NA recounted when she provided incontinence care to Resident #34, he was soiled with feces and his bed linens and incontinence brief were saturated with urine. The Director of Nursing (DON) was interviewed on [DATE] at 4:09 PM. The DON explained she was not certain why staffing was so low on [DATE] and she would need to review the staffing sheets. The DON reported she expected incontinence care to be provided to residents in a timely manner. 46095 3. Resident #69 was admitted to the facility on [DATE], diagnosis included diabetic nephropathy, Cerebellar stroke syndrome, congestive heart failure (CHF), repeated falls, and lack of coordination. Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was moderately impaired and he displayed no rejection of care behaviors. He was coded to exhibit disorganized thinking behavior that was present and/or fluctuated. He required maximum assistance with eating, personal hygiene, toileting hygiene, shower/bath, dressing, and bed mobility. He was frequently incontinent of bowel and bladder. Resident #69's active care plan, last revised on [DATE], included the focus area of functional status activities of daily living (ADL) decline related to slurred speech and impaired mobility. The interventions included for staff to encourage Resident #69 to do as much as possible and to provide assistance as needed or requested. A focus area of bladder incontinence which included the intervention to provide Resident #69 incontinence care after each incontinent episode. He also had a focus that he was at risk for skin breakdown related to decline in mobility and medical diagnosis. The interventions included to keep skin clean and dry as possible and minimizing skin exposure to moisture and providing incontinence care. Nursing notes reviewed from [DATE] through [DATE] no refusals of incontinence care were noted. An interview was conducted on [DATE] at 1:43 PM with Resident #69's family member. She stated she was active in Resident #69's care. She explained there have been multiple times when Resident #69 was saturated with urine through his pants and his bed would be wet. She indicated she comes to the facility daily for breakfast and dinner to ensure he eats and was changed. She also stated she had to come into the facility to make sure they are cared for. She stated she was very unhappy with the care provided. An interview was conducted on [DATE] at 9:03 AM with Resident #69. He stated there had been many times where he was saturated with urine so much that his clothes and/or his bed would be soaked. He then pointed at his mattress and stated, look at my mattress, it happened this morning, they even had to change my sheets. Observation of the mattress revealed a circular area in center of mattress extending out to approximately 2 inches from each side of the mattress. The center of the large area was slightly damp, and the edges of the circular area were whitish in color. No sheets were observed on the mattress. He stated he did not receive a shower, but the Nursing Assistant wiped him up. He further commented that there was no call for it, and he hoped that he didn't get sores from the urine on him like that. He then stated it made him frustrated and mad when staff don't change him often enough to prevent him from soaking through his clothes and bedding. An interview was conducted on [DATE] at 9:15 AM with Nursing Assistant (NA) #11. She stated Resident #69 was out of bed and dressed sitting in his wheelchair when she came on shift at 7:00 AM. The night shift NA had gotten him up. She verified there were no sheets on the bed when she entered the room. She stated normally sheets are changed if they were wet, soiled, or it was the residents shower day. She verified circular discoloration to the mattress. An interview was conducted on [DATE] at 9:20 AM with Nursing Assistant (NA) #4. She verified the circular discoloration area on the mattress was present. She stated the only time sheets are normally changed is if they were wet, soiled, or it was the residents shower day. She indicated she did not know what was on the mattress, but it appeared to be urine. She further stated she cleaned the area prior to applying the clean sheets. The shower schedule on [DATE] at 10:43 AM revealed Resident #69's shower days were Tuesdays and Fridays on day shift. An interview was conducted on [DATE] at 10:05 AM with the Director of Nursing (DON). She stated Resident #69 was to receive incontinence as needed and should be checked for incontinence needs often. No residents' clothing or bed linens should be wet with urine. Multiple phone calls were made to the Nursing Assistant (NA) #12 from [DATE] through [DATE] with no answer. She was assigned to Resident #69 on [DATE] from 7:00 PM-7:00 AM. 28265 4. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic diastolic (congestive) heart failure, vascular dementia with behavioral disturbance, pulmonary hypertension, urinary incontinence, chronic pain syndrome, hemiplegia with hemiparesis following cerebral infarction affecting left non-dominant side, and erosive (osteo) arthritis. Review of Resident #48's quarterly Minimum Date Set (MDS) dated [DATE] revealed Resident #48 was moderately cognitively impaired. She was able to communicate her needs to staff and required extensive assistance to total dependence with all her activities of daily living. Resident #48 was always incontinent of bowel and bladder. A review of Resident #48's care plan revised on [DATE] indicated that Resident was resistive to care due to dementia and she would refuse activities of daily living (ADL) care. Resident #48 was also care plan that she needed extensive to total care of one to two plus staff for most of her ADL care. During an observation on [DATE] at 8:15 am Resident #48 could be heard from the hallway hollering for help. The Resident's call light was not on. Upon entry into Resident #48 room, a urine odor was present in the room. On [DATE] a continuous observation of the hall where Resident #48 resided was conducted starting at 8:15 am until 8:47 am and no nurse aide (NA) was observed on the hall during this timeframe. Resident #48 continued to holler for help during the continuous observation. On [DATE] at 8:50 am NA#8 and another unidentified person were observed in the sitting area on the unit. Resident #48 continued to holler out for help. Resident #48's call light was on. On [DATE] at 8:55 am Resident #48 continued to holler out. NA #8 asked Resident #48 what she wanted, and Resident #48 was observed moving her hands up and down in front of her brief. On [DATE] at 9:05 am an interview was conducted with NA #8, and she indicated that she was the scheduler/transporter but was assisting on the floor today as a nurse aide. NA #8 indicated that she would get NA #10 who was assigned to this Resident. NA #8 confirmed that Resident #48 was wet. NA #8 explained that Resident #48 used her hands to communicate she was wet by moving them up and down. An observation was conducted on [DATE] at 10:10 am of NA #8 performing incontinence care on Resident #48. NA#8 removed the old brief, and it was observed to be saturated with urine and noted to have a strong urine smell. The resident's skin was intact. NA #8 confirmed she smelled the urine smell. NA #8 applied a new brief on Resident #48 after applying barrier cream. An interview was conducted with NA #10 on [DATE] at 10:30 am. The NA revealed she performed her round after breakfast, and she had to help with feeding on another hall. She stated that Resident #48 did not communicate at 8:00 am that she was wet and incontinence care was not provided. NA #10 indicated that she was the only NA on the hall to care for 26 residents on [DATE] until 7pm. NA #22 was identified by DON #1 as the nurse aide assigned to Resident #48 on [DATE] during third shift (11:00 pm until 7:00 am). On [DATE] at 12:45 pm NA #22 was interviewed and stated she had not worked in the facility since Monday, [DATE] and did not recall working with Resident #48. Attempts were made to contact Resident #48's nurse on duty for the evening of [DATE] but the nurse was unable to be reached for an interview. The Director of Nursing (DON) #1 was interviewed on [DATE] at 4:09 PM. DON #1 explained she was not certain why staffing was so low on [DATE] and she would need to review the staffing sheets. DON #1 reported she expected incontinence care to be provided to residents in a timely manner. During an interview with the DON and Administrator on [DATE] at 4:50 pm the Administrator indicated that his start date with the facility was [DATE] and the DON indicated she had been in the facility for two weeks. 38129 5. Resident #339 was admitted to the facility on [DATE] with the diagnosis of a stroke and dementia. Resident #339's quarterly Minimum Data Set, dated dated dated [DATE] documented he had a severe cognitive deficient. The resident was dependent for bathing and an extensive assist of 2 staff for personal hygiene. The resident was always incontinent of bowel and had a urinary catheter. Active diagnoses were neurogenic bladder and stroke. Resident #339 had a care plan dated [DATE] for activities of daily living (ADL) deficit set up with assistance as needed. The resident was no longer at the facility a. On [DATE] at 11:16 am an interview was conducted with Resident #339's family member. The family member stated the resident was dependent on staff for all his care. The family member visited frequently and found the resident had stool that dried to his buttocks and there was a concern the resident was not cleaned for hours. The family member stated she had brought her concerns to the attention of the Director of Nursing and the care had not improved. The family member stated the care concerns continued from February 2023 until [DATE] when the resident expired. A review of Resident #339's activity of daily living record for February 2023 documented he was incontinent of stool almost every day, 1 to 3 times a day. Personal hygiene for incontinence care was not documented as being completed during February 2023 on dates [DATE], [DATE], [DATE], [DATE], [DATE]. There was no documentation in the system for any type of care on [DATE]. Nursing Assistant (NA) #8 was assigned to the resident frequently during February 2023. On [DATE] at 2:03 pm an interview was conducted with NA #8. NA #8 stated she had worked at the facility for 5 years. She had worked in January, February, and [DATE] when there were only 3 NAs on the 3:00 pm to 7:00 pm schedule responsible for 90 residents until staff arrived at 7:00 pm and other day shifts she had 20 residents (8 hours). NA #8 stated resident care could not be completed and when care was completed it was delayed. The residents would be very soiled when staff was able to provide care. The resident's ADL documentation was not completed because the care was not provided. b. On [DATE] at 11:16 am an interview was conducted with Resident #339's family member. The family member stated the resident was dependent on staff for all his care. The family member visited frequently and found the resident had body odor and dirty looking hair. The family member stated she had brought her concerns to the attention of the Director of Nursing and the resident received a bath that day, but it was not consistent. The family member stated the care concerns continued from February 2023 until [DATE] when the resident expired. A review of Resident #339's ADL bathing records for February 2023 documented the resident received 7 baths out of 28 days in the month. The 4 times bathing was completed, 2 were partial bed baths and 1 bath was documented as other. The resident was incontinent of stool almost every day, 1 to 3 times a day. On [DATE] at 2:03 pm an interview was conducted with Nursing Assistant (NA) #8. NA #8 stated she had worked at the facility for 5 years. She had worked in January, February, and [DATE] when there were only 3 NAs on the 3:00 pm to 7:00 pm schedule responsible for 90 residents until staff arrived at 7:00 pm and other day shifts she had 20 residents (8 hours). NA #8 stated resident care bathing could not be completed. The resident's ADL documentation was not completed because the care was not provided. On [DATE] at 4:10 pm an interview was conducted with the Director of Nursing. The DON stated she was not aware resident care was not being completed and had no further comments.

Based on record review, observation and interview of facility staff, the facility failed to label/date an opened vial of tuberculin (injectable solution to test for tuberculosis) and failed to discard an opened expired vial of tuberculin for 2 of 2 medication storage refrigerators observed on the short-term hall and long-term hall respectively. Findings included: The manufacturer's instructions for tuberculin read initial and date the tuberculin vial when opened and to discard the tuberculin vial 30 days after opening. On [DATE] at 11:04 am the short-term hall medication storage refrigerator observation revealed that a tuberculin vial was opened and not dated. The Infection Preventionist (IP) was present for observation and stated the tuberculin should have been dated when opened and discarded the vial. On [DATE] at 11:04 am an interview was conducted with the IP during medication storage observation. The IP stated that nursing staff was required to date all medication when opened and to check for expired medication during their shift to discard. On [DATE] at 11:29 am the long-term hall medication storage refrigerator observation revealed that a tuberculin vial had a date tag which was written opened on [DATE]. The vial had expired 30 days after opening, [DATE]. The vial was discarded by Nurse #15. Concurrent interview with Nurse #15 stated she did not know how long an open Tuberculin vial could be used before expiring. She further commented that she worked on the short-term hall and the vials were used before they expired. On [DATE] at 4:10 pm an interview was conducted with the Director of Nursing (DON). The DON was not aware of the findings for the medication storage of tuberculin. The DON had no further comments.

Based on record review, and resident, family and staff interviews, the facility failed to have an effective system to ensure there was sufficient and competent dietary staff available on 12/31/23 to serve breakfast. This failure had the potential to impact all residents who received meals from the kitchen. The findings included: The facility's meal delivery times were recorded as follows: Breakfast - 7:00 AM - 8:30 AM Lunch - 12:00 AM - 1:30 PM Dinner - 5:00 PM - 6:30 PM An interview was conducted on 02/07/24 at 12:25 PM with the Infection Preventionist Nurse. She stated a group email was sent out by Administrator #2 on 12/30/23 at approximately 10:00 PM requesting anyone that was available to come in and help cook in the kitchen on 12/31/23 due to no dietary staff. She responded saying she would be able to help. She arrived at 6:00 AM and upon arriving, Dietary Staff #1 was already cooking breakfast. She stated Dietary Staff #1 instructed her to set the breakfast trays up which she done. She also indicated she read the meal tickets and made sure the correct diet was provided. Pureed diets were blended to a smooth consistency. She stated that her husband came in and assisted in the kitchen as well. She verified her husband was not an employee at the facility but had some previous work experience in a kitchen. She explained she had helped in the past but had not been trained to cook in the kitchen. She did not recall what time breakfast was served on 12/31/23 but it was served late. An interview was conducted on 02/08/24 at 11:25 AM with Dietary Aide #1. She stated she was scheduled to work on 12/31/23 but she had called out due to back pain. She could not remember who took the callout. She indicated there have been mornings in the past that Nursing Assistants (NAs) have had to assist her with cooking. Breakfast on those mornings was served late but it was always served. Dietary Aide #1 stated she did not work on 12/31/23. Review of the dietary staff schedule and time clock detail report for 12/31/23 revealed Dietary Aide #1 did not work. A phone interview was conducted on 02/08/24 at 2:07 PM with Administrator #2. She indicated that she received a call on 12/30/23 from the facility stating they had a call out for the kitchen for 12/31/23 which would leave them with no staff for breakfast shift. She did not recall who notified her of the call out. She explained that she sent a group email out to the administrative staff to inquire if anyone could assist with preparing breakfast on 12/31/23. She received a response from the Infection Preventionist that she would assist and that there were extra staff scheduled and she would pull someone from the nursing area for additional help if needed. She also indicated it was her understanding the shift was covered. She further explained that she did call the Interim Dietary Manager (DM) #1 on 12/31/23 to have him come in as well to assist. An interview was conducted on 02/07/24 at 2:18 PM with Dietary Manager (DM) #1. He stated he was called by Administrator #2 on 12/31/23 at approximately 9:00 AM and was told no dietary staff showed up for the early shift and he needed to come in to work. He arrived at the facility at 11:00 AM. He explained at that time he was the interim DM and was working at two different buildings. He indicated a nurse, and a Nursing Assistant (NA) were asked to work in the kitchen to assist in getting breakfast out to the residents. He also stated he did not recall what time breakfast was served to the residents, but it was served later than the regularly scheduled time. He verified the nurse and NAs had not had training on working in the kitchen. He further stated additional staff were hired and this has not occurred since 01/01/24. He then indicated that now they have 2 cooks, 2 aides, 2 managers, and a supervisor during day shift. An interview was conducted on 02/07/24 at 1:43 PM with a family member for Resident #69. She stated she comes to the facility every day for breakfast and dinner. She indicated breakfast had been late on many mornings in December. She also stated that she arrived between 7:30 AM and 8:00 AM on the morning of 12/31/23 but breakfast was not served until after 10:00 AM and that was unacceptable. She further explained her family member had a diagnosis of type 2 diabetes mellitus and although his blood sugar remained stable, he needed to eat his breakfast at approximately the same time each day. She further indicated it had been an ongoing problem but had improved lately. An interview was conducted on 02/08/24 at 9:03 AM with Resident # 69. He stated breakfast had been late on many days in December, with the latest being at approximately 10:15 AM. He explained he had a diagnosis for type 2 diabetes mellitus and takes diabetic medications by mouth twice a day and insulin at bedtime. He indicated his blood sugar has been good, but it makes him nervous when he doesn't eat by 9:00 AM. He stated he was very disappointed and frustrated with the facility. An interview was conducted on 02/07/24 at 1:07 PM with Resident # 57. She stated breakfast was late on many days in December. She indicated it made her feel as if the facility did not care enough for the residents to make sure they get their meals on time. An interview was conducted on 02/07/24 at 12:05 PM with Director of Nursing (DON) #3. She indicated she received a complaint on 01/02/24 from a family member that breakfast had been served late on 12/31/23. She explained that when she investigated the concern, she found that on 12/31/23 no dietary staff showed up to the facility to work. She indicated that the Infection Preventionist came in to cook breakfast and that Nurse # 3 was pulled from the floor to assist. She verified breakfast was late but could not recall the exact time it was served.

Based on observations, record review, resident, family member, physician, nurse practitioner, and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor the interventions that the committee put into place in following the complaint investigation of 3/12/2021 and 10/22/2021, and the recertification and complaint investigation of 6/30/2022. This was for 4 deficiencies in the areas of F677 Activities of Daily Living (ADLs), F842 Accuracy of Records, F684 Quality of Care/Professional Standards, and F883 Influenza and Pneumococcal Immunizations. These deficiencies were recited on the current recertification and complaint investigation survey of 2/16/2024. The continued failure of the facility during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This tag is cross referred to: F677: Based on observations, record reviews and interviews of residents, family member, and staff, the facility failed to provide incontinence care for dependent residents (Resident #192, Resident #34, Resident #69, Resident #48, and Resident #339), and failed to provide bathing for a dependent resident (Resident #339) for 5 of 16 residents reviewed for activities of daily living. During the complaint investigation of 3/12/2021 the facility failed to provide a dependent resident with shaving assistance for 1 of 4 residents reviewed for activities of daily living (ADL). F842: Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of surgical wound care (Resident #70) for 1 of 1 resident record reviewed for surgical wound care. During the complaint survey dated 10/22/2021, the facility failed to document the correct medication dosage on the electronic medication administration record (eMAR) for Fentanyl patch for 1 of 1 resident reviewed for accurate medical record. F684: Based on record review, staff and medical director interviews, the facility failed to obtain daily weights as ordered for a resident with heart failure on a diuretic (Resident #70). This was for 1 of 8 residents reviewed for nutrition. During the recertification and complaint survey dated 6/30/2022, the facility failed to assess, document, and treat skin tears, resulting in the resident receiving antibiotic treatment, for one of three sampled residents reviewed for wound care. F883: Based on record reviews and staff interviews, the facility failed to administer an influenza vaccine for a resident who signed a consent form to receive an influenza vaccine or document an influenza vaccine was received for 1 of 5 residents reviewed for infection control (Resident #58). During the recertification and complaint survey dated 6/30/2022, the facility failed to offer the pneumococcal vaccine and include documentation in the resident's medical record of education or vaccination status for the pneumococcal vaccination for two of five residents reviewed for the pneumococcal vaccinations. An interview was conducted with the Regional Nurse Consultant and the Clinical Reimbursement Consultant RN on 2/8/2024 at 11:19 AM and they revealed a mock survey had been conducted in December 2023 and multiple areas of concern were identified. The Clinical Reimbursement Consultant RN reported several plans of correction were in place as well as several performance improvement plans. The Regional Nurse Consultant explained that during the follow-up a couple weeks ago, the team found that the facility was not meeting metrics and the plans of correction were modified. The Administrator was interviewed on 2/8/2024 at 4:32 PM. The Administrator explained his first day at the facility was 2/5/2024. The Administrator reported the QAPI committee met monthly and reviewed risks and monitored areas of concern by following standard monitoring guidelines. The Administrator explained that to maintain compliance, the QAPI committee would review areas of concern and track the audit results for up to 6 months if necessary.

Based on observations, record review, resident, and staff interview the facility failed to assess a resident's ability to self-administer medications for 2 of 2 residents reviewed for medications at bedside (Resident #440 and Resident #194). The findings included: 1. Resident #440 was admitted to the facility on [DATE] with diagnoses that included chronic congestive heart failure, chronic kidney disease, type 2 diabetes mellitus, anxiety disorder, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #440 was cognitively intact. Review of Resident #440's medical record revealed no documentation that Resident #440 had been assessed to self-administer medications at bedside. Further review of Resident #440's medical record revealed no care plan for self-administration of medications. An observation and interview were conducted with Resident #440 on 02/06/24 at 9:13 AM. Resident #440 was sitting in his wheelchair beside his bedside table. He was noted to have over-the-counter medications, fluticasone propionate nasal spray (used for sneezing and a runny nose) and refresh tear eye drops (relief of eye irritation), on his bedside table. A further observation revealed a table in the corner of his room that contained personal items which included over-the-counter medications, a bottle of MiraLAX (for constipation) and AREDS 2 eye vitamins (a supplement). Review of Resident #440's physician orders sheet dated January 2024 revealed no physician orders for the refresh tear eye drops, MiraLAX, and AREDS 2, however it was noted an order dated 01/23/24 for Flonase Allergy Relief (fluticasone propionate) spray, suspension; 50 micrograms (mcg)/actuation: 2 sprays; nasal once a day. An interview was conducted with Resident #440 on 02/06/24 at 9:20 am and he indicated the medications observed were his medications and he had used the medications on his bedside table that morning. Nurse #13 was interviewed on 02/06/24 at 9:32 AM. She indicated she had administered Resident #440's morning medications this morning. She stated, he took his medicines from me, and I don't give any of these medications. Nurse #13 indicated she was not aware of the medications in Resident's room as he was sitting close to the door in his wheelchair, and she did not see the medications when she administered his medications. She stated she had talked to Resident's family members before because they had brought medications in before. Nurse #13 indicated Resident #440 had not been assessed for self-administration and did not have an order for self-administration of medications. Director of Nursing (DON) #1 was interviewed on 02/06/24 at 4:09 PM and she indicated sometimes family members would bring in medications and would not tell the nursing staff. She indicated they needed to be better at checking and educating residents/families. 37281 2. Resident #194 was admitted to the facility 2/1/2024 with diagnoses to include dry eye syndrome and ocular hypertension. The admissionMinimum Data Set (MDS) assessment dated [DATE] assessed Resident #194 to be cognitively intact. The remainder of the MDS was in progress and not completed. Resident #194's medical records were reviewed and there was no order for Resident #194 to self-administer his medications. There was no care plan developed for self-administering medications for Resident #194, and no assessment of his ability to self-administer medications. Orders for Resident #194 included an order dated 2/1/2024 for brimonidine/timolol eye drops to be administered every 12 hours. Review of the medication administration record indicated Resident #194 received this medication as evidenced by nursing initials. An order dated 2/5/2024 for dorzolamide eye drops to be administered every 8 hours. The medication administration record indicated this was administered on 2/6/2024. During an interview with Resident #194 on 2/5/2023 at 2:30 PM, he mentioned his wife brought in the eye drops for him to administer until the facility was able to get his prescription eye drops. Resident #194 opened his nightstand drawer to reveal the 2 bottles of eye drops, brimonidine/timolol and dorzolamide. When asked if the nursing staff knew that he had the eye drops in his room, Resident #194 reported he had told a nurse (he was uncertain who) he had his own eye drops. Resident #194 was interviewed again on 2/6/2023 and he reported the facility had obtained both of his prescription eye drops and his wife took his bottles home. Nurse #13 was interviewed on 2/6/2024 at 3:37 PM. Nurse #13 reported she was not aware Resident #194 had eye drops in his room. Nurse #13 reported she asked about home medications when she completed the admission assessment but did not complete Resident #194's admission assessment. Nurse #10 was interviewed on 2/6/2024 at 3:45 PM. Nurse #10 reported that he was not aware Resident #194 had eye drops in his nightstand drawer and was self-administering the eye drops. The facility physician was interviewed on 2/8/2024 at 3:03 PM. The physician reported that eye drops in a closed nightstand drawer would not pose a danger to other residents, but an assessment for self-administration of medications should have been completed for Resident #194. The Director of Nursing (DON) #1 was interviewed on 2/8/2024 at 4:09 PM. DON #1 explained that sometimes residents will bring in medications and not tell staff. DON #1 reported she would expect if a resident brought in medication from home, a medication self-administration assessment was completed.

Based on observation, staff interviews and record review, the facility failed to revise a care plan for falls to include a new intervention on 12/27/23 for anti-tippers to a wheelchair. This was for 1 of 6 residents reviewed for accidents (Resident #16). The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of metabolic encephalopathy, peripheral vascular disease with a left above the knee amputation (AKA). Resident #16's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #16 had severe cognitive impairment, impairment to one lower extremity and substantial/maximum assistant with transfers from sit to stand and transfers from bed to wheelchair and wheelchair to bed. She was coded for one fall with minor injury. Review of a nursing note dated 12/23/23 at 5:36 PM read Resident #16 was sitting in her wheelchair in the dining room. She had eaten her evening meal and apparently had locked her wheelchair brakes. As she attempted to push her wheelchair back away from the table, her wheelchair tipped backwards resulting in Resident #16 striking her head on the hearth of the stone fireplace behind where she was seated. There was bleeding noted with an open area to the back of her head. She was sent to the emergency room for an evaluation. Review of a physical therapy note dated 12/27/23 read anti-tippers were added to her wheelchair. Review of Resident #16's fall risk care plan dated initiated on 12/19/23 last revised on 12/29/23 included a new intervention dated 12/23/23 for staff to give her verbal reminder not to ambulate/transfer without assistance, staff to visually monitor frequently and to observe Resident #16 frequently and place her in a supervised area when she was out of the bed. There was another new intervention dated 12/28/23 which read to analyze her falls to determine a pattern/trend and the last new intervention was dated 12/29/23 read for Resident #16 to wear a new brace due to spinal fractures. There was not any documentation on the care plan regarding the new intervention of anti-tippers added to her wheelchair on 12/27/23. An interview was completed on 2/8/24 at 1:30 PM with the Clinical Reimbursement Consultant. She stated she had oversight of the regional MDS departments. She stated the two MDS Coordinators started six months ago, and they were still learning. She also said there was one part-time MDS person also assisting. She stated she had discussed care plans with the previous Administrator and she was to write up a formal performance improvement plan but she apparently did not do so. She stated she had a spread sheet of all the residents whose care plan was revised and that Resident #16's fall care plan was revised on 12/29/23. The Clinical Reimbursement Coordinator stated the new intervention of the wheelchair anti-tippers must have been an oversight and it should have been added to her care plan when it was last revised.

Based on record review, staff and medical director interviews, the facility failed to obtain daily weights as ordered for a resident with heart failure and prescribed a diuretic (Resident #70). This was for 1 of 8 residents reviewed for nutrition. The findings included: Resident #70 was admitted to the facility on [DATE] with diagnoses that included heart failure. He was discharged to the hospital on 10/18/23 and did not return to the facility. A review of Resident #70's physician orders included the following: - An order dated 10/16/23 for Torsemide (a diuretic medication) 20 milligrams (mg) one tablet by mouth once a day. - An order dated 10/17/23 to obtain daily weights and to notify the provider if weight gain of greater than three pounds was present. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 was cognitively intact. A review of the October 2023 Medication Administration Record (MAR) revealed daily weights were not documented as obtained or refused by Resident #70 on 10/20/23. A review of the November 2023 MAR revealed the daily weight was not documented as obtained or refused by Resident #70 on 11/3/23, and 11/17/23. A review of the December 2023 MAR revealed the daily weight was not documented as obtained or refused by Resident #70 on 12/1/23, 12/2/23, 12/3/23, 12/9/23 and 12/10/23. A phone interview was completed with Nurse #1 on 2/7/24 at 2:36 PM. She was assigned to Resident #70 on the 7:00 PM to 7:00 AM shift on 10/20/23. She could not recall Resident #70 or explain why the daily weight was documented as obtained or refused. Nurse #1 stated a list of was provided to the Nurse Aides for weights to be obtained at 6:00 AM. She stated if the weight wasn't documented then it must not have been obtained. On 2/7/24 at 3:30 PM, a phone interview occurred with Nurse #5. She was assigned to Resident #70 on the 7:00 PM to 7:00 AM shift on 12/2/23 and could not recall Resident #70 or why there was no daily weight value. She added if the weight wasn't documented then it most likely wasn't obtained. Nurse #9 was interviewed by phone on 2/7/24 at 3:38 PM. She was assigned to Resident #70 on the 7:00 PM to 7:00 AM shift on 12/10/23 and could not recall why the daily weight was not documented with a value or as refused and most likely wasn't obtained. A phone interview occurred with Nurse #8 on 2/7/24 at 4:23 PM. She was assigned to Resident #70 on the 7:00 PM to 7:00 AM shift on 12/9/23 and could not recall why the daily weight was documented with a value or as refused. She added if the weight wasn't documented then it wasn't obtained on that day. An interview was completed with Director of Nursing #1 on 2/8/24 at 9:54 AM and stated that she expected daily weights to be obtained as ordered and documented with the value or if the resident refused. An interview occurred with the Medical Director on 2/8/24 at 2:49 PM and explained that when a resident had a diagnosis of heart failure and was on a diuretic, daily weights were important in order to monitor and adjust the medications as needed. Multiple phone calls were made to Nurse #2 from 2/6/24 to 2/8/24 without an answer. She was assigned to Resident #70 on 11/3/23, 11/17/23 and 12/1/23.

Based on record review and interview of facility staff, the facility failed to follow the physician's order to obtain a urine sample for urinalysis and culture and sensitivity (to evaluate for a urinary tract infection) for 1 of 5 residents reviewed for urinary catheter/urinary tract infection (Resident #343). Findings included: Resident #343 was admitted to the facility on [DATE] with the diagnosis of urinary retention. Resident #343's admission Minimum Data Set (MDS) dated [DATE] documented the resident was admitted with a urinary catheter and had the diagnosis of urinary retention. Physician order dated 1/29/24 documented Resident #343 had her urinary catheter removed for a voiding trial. Resident #343's nurses' note dated 2/2/24 documented the resident had delusions. Resident was noted sitting in her wheelchair at the bedside talking incoherently to herself. The resident's abdomen was distended, and the resident complained of discomfort. The physician was notified, and a bladder scan was completed which revealed 867 milliliters of urine in the resident's bladder. The physician was notified of urine retention and an order was received to insert a urinary catheter and to obtain urine for a urinalysis and culture & sensitivity, documented by Nurse #12. A physician order dated 2/2/24 for Resident #343 was to place a urinary catheter and obtain urine for a urinalysis and culture and sensitivity. Physician note dated 2/2/24 documented nursing reported Resident #343 had urine retention and Flomax (medication to improve urine flow) was started, a urinary catheter was placed, and a urinalysis and culture & sensitivity was ordered. The resident was confused. Nurses' note documented on 2/5/24 at 12:14 pm documented the resident had a urinary catheter placed to collect a urine sample for confusion on 2/2/24. The diagnosis was repeat urinary retention and an order for urinalysis and culture and sensitivity was obtained, documented by Nurse #12. On 2/7/24 at 2:30 pm an interview was attempted with Nurse #12, but she was unable to be reached. The Director of Nursing was unavailable for information during the survey and information was obtained from the Corporate MDS Nurse as directed. On 2/6/24 at 3:30 pm an interview was conducted with the Corporate MDS Nurse (Director of Nursing was unavailable). She stated the urinalysis and culture & sensitivity ordered for Resident #343 was missed, not obtained on 2/2/24 and she would notify the physician. On 2/7/24 a new order for urinalysis and culture & sensitivity was obtained from the physician for Resident #343. On 2/8/24 at 4:10 pm an interview was conducted with the Director of Nursing (DON). The DON stated she was not aware the lab for Resident #343 was missed. The DON had no other comments.

Based on observation, staff, resident, family and nurse practitioner interviews, and record review, the facility failed to provide incontinent care in a safe manner to prevent a fall from the bed which resulted in a fractured leg for 1 of 3 sampled residents reviewed for falls (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set ((MDS) dated [DATE] revealed an assessment of moderately impaired cognition. The MDS indicated Resident #1 required the extensive assistance of 2 persons with bed mobility and toilet use. The MDS documented Resident #1 had no falls since the prior assessment. Review of Resident #1's care plan dated 07/29/19 revealed interventions to prevent falls included use of a mechanical lift with two persons for transfer. The care plan included direction to provide incontinent checks and provision of personal care. Review of a nursing note dated 10/07/19 by Nurse #1 revealed Nurse Aide (NA) #1 reported Resident #1 rolled out of bed during incontinence care. Nurse #1 documented Resident #1 complained of left knee and left hip pain after she fell from her bed. An x-ray of the left knee and hip was ordered. Resident #1 received Tylenol (a medication used to treat pain). Review of Resident #1's x-ray dated 10/07/19 revealed an acute [MEDICAL CONDITION] distal femur with no acute pathology. Resident #1 received an orthopedic consultation and placement of a leg immobilizer on 10/08/19. Review of Resident #1's fall safety event form dated 10/08/19 revealed Nurse #2 documented Resident #1 rolled off the bed during incontinence care with the result of a distal femur fracture. Resident #1 received a scoop mattress after the fall to prevent recurrence. The report documented interventions were effective and did not contain description of the interventions except for addition of a scoop mattress after the fall. Interview on 10/16/19 at 10:17 AM with NA #1 revealed she asked Resident #1 to roll on her left side for incontinence care. NA #1 explained she began incontinence care and needed Resident #1 to turn away from her to be more on the left side. NA #1 stated Resident #1 was on her left side in the middle of the bed. NA #1 reported Resident #1 lifted her right leg up and over which caused the fall. NA #1 did not remember if Resident #1 reached for the ¼ side rail. NA #1 added she lowered the bed as Resident #1 was falling in order to lessen the height of the fall and used the call light to summon assistance. NA #1 explained Resident #1 could use the right leg and not the left leg. NA #1 reported Resident #1 required one person for assistance with turning. NA #1 explained she had cared for Resident #1 since her admission to the facility. NA #1 noted Resident #1 had always required one person's assistance with incontinence care since Resident #1 could move her right leg. Interview with Nurse #1 on 10/16/19 at 10:27 AM revealed she responded to NA #1's request for assistance on 10/07/19. Nurse #1 reported she assessed Resident #1 who complained of left leg pain. The Nurse Practitioner and Resident #1's family member received notification and an x-ray was ordered. Nurse #1 reported Resident #1 required one to two persons for incontinence care, but one NA could safely reposition Resident #1. Interview with NA #2 on 10/16/19 at 10:37 AM revealed Resident #1 required two persons for incontinence care due to Resident #1's immobility. NA #2 explained Resident #1 could not move in bed independently and required two person assistance due to inability to use her left side prior to the fall. NA #2 reported she began employment approximately 6 weeks ago and occasionally cared for Resident #1. Observation on 10/16/19 at 10:50 AM revealed NA #2 and NA #3 used a mechanical lift to transfer Resident #1 onto a scoop mattress with ¼ side rails. NA #3 turned Resident #1 toward her and NA #2 provided incontinence care. Interview with NA #3 on 10/16/19 at 10:55 AM revealed Resident #1 required two-person physical assistance with turning prior to the fall from bed. NA #3 reported she always asked for another NAs assistance when assigned to Resident #1 for safety. NA #3 explained Resident #1's confusion and inability to move her left side required 2 persons. NA #3 reported she seldom cared for Resident #1 but always asked for assistance of another N[NAME] During an interview with Resident #1 and a family member on 10/16/19 at 8:48 AM, Resident #1 reported she broke her leg when she fell out of bed. Resident #1 did not remember the details of the fall from bed. Resident #1's family member explained Resident #1 could not remember the exact circumstances of the fall. The facility informed Resident #1's family member that the fall occurred during incontinence care. An interview was conducted on 10/16/19 at 12:13 PM with Nurse #2. Nurse #2 reported her job responsibilities included fall investigations. Upon receipt of report of Resident #1's fall from bed, Nurse #2 reported a scoop mattress was immediately implemented to prevent recurrence. Nurse #2 explained Resident #1's leg movement caused the fall so the number of persons required for bed mobility was not addressed. Nurse #2 reported a reenactment was not done but NA #1 reported Resident #1 turned away from her. Nurse #2 stated Resident #2's leg movement caused the fall. Interview with the Director of Nursing (DON) on 10/16/19 at 1:28 PM revealed NAs caring for Resident #1 determined the number of persons required for turning and repositioning. The DON explained Resident #1 usually required one person's assistance except for periods of illness. The DON stated Resident #1's fall was a result of Resident #1's right leg movement. The DON reported NA #1 requested Resident #1 to turn away from her which caused the fall. The DON reported NA #1 could safely request this of Resident #1 since Resident #1 had no history of sudden leg movement and falls. The DON considered the fall unavoidable. Telephone interview with Nurse Practitioner (NP) on 10/16/19 at 11:41 AM revealed Resident #1's fall from bed resulted in the leg fracture. The NP explained she relied on the facility to assess the number of persons required for turning and repositioning Resident #1. The NP reported best practice would be to turn a resident toward the staff member since Resident #1 had limited mobility.

Based on interviews with resident, family, facility staff, contracted van transportation driver and owner, and record review, the facility failed to ensure that a resident was assessed by medical professionals before he was lowered to the floor of the van after he slid forward in his wheelchair. The resident slid forward in the wheelchair and his knee hit the back of the driver seat. The resident experienced some lower back pain and right knee pain and needed pain medication. This was evident in 1 of 1 sampled resident (Resident # 264). Findings included: The contract between the transportation company and the facility dated 10/1/2016 was reviewed and it was noted there were no statements in the contract regarding emergency procedures for the transportation van staff to follow, no specifications of training for transportation van staff. Resident #264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s admission minimum data set (MDS) of 7/24/2017 revealed the resident was cognitively intact. The resident had no problem with short and long term memory and was independent in making decision of tasks of daily living. The resident required extensive, one-person assistance with bed mobility, ambulation, and extensive two-person assistance with transfers. The resident height was 77 inches and he weighed 300 pounds. The resident had no impairment of upper or lower body range of motion and required one person assistance to move from sitting position to standing. He was unable to ambulate without one person assistance. A review of the care plans for Resident #264 found a plan in place dated 8/3/2017 related to the fall risk due to impaired mobility, medication effects, history of falls and medical [DIAGNOSES REDACTED]. Interventions in place to include to remind resident to call for assistance and to maintain the environment free of clutter and safety hazards. A review of the resident ' s medical record revealed he was scheduled for [MEDICAL TREATMENT] treatments three times per week. Resident #264 was scheduled to be transported by the contracted transportation van company from the [MEDICAL TREATMENT] center to the facility on [DATE]. The Administrator for the facility was interviewed on 8/30/2017 at 2:13 PM. He reported the facility transported residents to appointments using its own transportation van. Also, the facility had a contract with a private van company to transport residents to appointments. Resident # 264 was interviewed on 9/7/2017 at 10:41 AM. He reported on 8/30/2017 at approximately 4:15 PM he was returning from [MEDICAL TREATMENT] to the facility. He reported the driver (Driver #1) of the contracted transportation van, did not secure his wheelchair wheels when she loaded him into the van. He reported the driver did not secure him with a lap belt or shoulder belt once he was in the van. The resident reported that while driving on Highway 74 West, the driver hit the brakes and he slid forward in the wheelchair and was bracing himself on the back of the passenger seat and the driver ' s seat. When this happened, driver #1 stopped the van in the middle of traffic on Highway 74 W to attempt to assist him back into the wheelchair, but was unable to scoot him back in the wheelchair and he was unable to assist due to weakness. Resident #264 instructed her to pull the van over out of traffic and she pulled into restaurant ' s parking lot. Resident #264 reported that bystanders in the parking lot of a restaurant assisted driver #1 to release the lock on the wheels of Resident #264 ' s wheelchair and he was lowered to the floor of the van by the bystanders and the driver called the owner of the van. Resident #264 stated he did not fall out of the wheelchair, he was lowered to the floor of the van because they couldn ' t lift him back into the wheelchair. The resident called his wife at 4:26 PM and the wife arrived on the scene at approximately 4:45 PM. The wife reported that the driver of the van had not called EMS and the wife called EMS. The resident reported that the EMS arrived approximately 5 minutes after his wife called them and they assisted him off the floor of the van to a stretcher and transported him to the hospital ' s emergency department. Resident #264 reported he was evaluated and no bones were fractured, but he had a contusion with abrasion to the right tibia, left knee laceration and left forearm laceration. The resident reported he returned to the facility from the emergency department on 8/30/2017 about 9:30 PM. The resident and his wife were interviewed on 9/7/2017 at 12:00 PM. The wife reported that when she arrived at the incident, Emergency Medical Services (EMS) had not been called. She placed the call to EMS and they arrived within five minutes. Driver #1, who was an employee of the contracted van company, was interviewed on 9/7/2017 at 4:18 PM via phone call. She reported, on 8/30/17, she picked Resident #264 up from his [MEDICAL TREATMENT] treatment and secured his wheelchair with the safety straps to the floor of the van. She reported the (black) seatbelt that was special made for restraining residents in the wheelchair and it was not operational. She used the factory installed seatbelt (tan seatbelt intended for restraining residents sitting in van seat) to secure Resident # 264 who was sitting in a wheelchair. Driver #1 reported she was heading west on Highway 74 and traffic was dense. She hit the brakes hard to avoid hitting a car in front of her and when she did, Resident #264 stated, I think I ' m coming out of my seat. She looked back and Resident #264 had slid forward in his wheelchair and was bracing himself with his hands on the back of the passenger and driver seats. Driver #1 reported she pulled into a restaurant parking lot and asked for help from two bystanders. The bystanders assisted her to release the straps on the wheelchair wheels and lower Resident #264 to the floor of the van. She reported that the factory installed seatbelt had come undone. She then reported she used her own cell phone to call the owner of her company to report the incident. She reported the owner had offered to come with a stretcher for transport back to the facility, but the resident did not want him to come. The resident wanted Driver #1 and the bystander to attempt to push him back into the wheelchair, but when they couldn ' t get him back into the wheelchair, Resident #264 requested to be lowered to the van floor and transported back to the facility. Driver #1 reported she could not drive back to the facility with the resident on the floor of the van and he called his wife from his phone. When Resident #264 ' s wife arrived at the restaurant parking lot, she called for an ambulance. EMS arrived and transported the resident to the hospital. Driver #1 was interviewed again on 9/8/2017 at 11:42 AM. She reported she did not call 911 because she had been instructed to call the owner for minor incidents and to call 911 only if the resident was injured or in distress, like a stroke or something. When asked about the training she had received, Driver #1 reported that she had ridden in the van with a trainer for several days and she took some notes, but did not receive written training materials or an employee handbook. She concluded by sharing she had handwritten a statement for the incident and the owner had a copy. An undated handwritten statement written by Driver #1 was reviewed. The statement described the series of event of the incident on 8/30/2017 that happened during Resident #264 transportation and included her name and the date of the incident. The statement described the series of events as they happened. The statement read, in part: . Traffic is heavy on Highway 74 so by the time I come through the light near (drug store), I ' m in the left lane and traffic is so congested and I hit my brakes and then (Resident #264) says ' I believe my chair is tilting. I feel like I ' m going to come out or something. ' So I then put my emergency lights on and get over to pull into (restaurant) parking lot. At this time I ' m asking (Resident #264) is he alright, ' I ' m going to pull here to check you out to make sure your (sic) ok. ' When I get out to open the side door to check him, I seen (Resident #264) hands on the back of the chairs of the van as if he was trying to push his weight back to the back of his chair. I called for help . Some guy in a truck came to assist me. I then called (owner of transportation van) to explain the situation. (Owner of transport van) asked if (Resident #264) would like him and his guys to come transport him with the stretcher. (Resident #264) said, ' If you are close then that ' s fine, but if not maybe EMS if they (Driver #1 and bystander) can ' t pull me back in the chair. ' (Owner of transportation van) said he would call (facility) and call (me) right back. So me and the (bystander) try our best to push him back. (Resident #264) then says ' No, I don ' t believe you guys are going to do it because I can ' t help you push back my weight is coming down more. ' I get his chair unbuckled to lower him onto the floor. At this same time (Resident #264) was saying he has too much pressure on his leg. I got the full chair undone and I pulled it out of the van. (Owner of transport van) was then calling me back asking how was everything and he was on his way. (Resident #264) then said ' No, we don ' t need (Owner) to come I feel ok like this, just take me to (facility) laying here. ' I told (Resident #264) I ' m sorry, but that ' s not safe I cannot take you like this. (Resident #264 then yelled ' Well tell him to call EMS or you call, well better yet give me my phone so I can call my wife. ' Resident #264 called his wife and then told Driver #1 he wanted EMS called to check out his leg. By then (Resident #264 ' s) wife had arrived and was yelling ' call EMS ' . I try telling the wife what ' s going on and she brushed me off saying ' I don ' t wanna (sic) hear it, why haven ' t EMS arrived. ' .I then said, ' I ' m so sorry I was following the guidelines and my boss was sending help our way. ' .EMS (arrived) there . load(ed) (Resident #264) into the (ambulance). The owner of the transportation company was interviewed on 9/7/2017 at 1:50 PM. He reported that he was called by the driver of the van after she had braked hard and Resident #264 slipped forward out of his wheelchair. The owner reported he offered to come to the van to assist the driver to put the resident back into the wheelchair, but the resident did not want him to come to the incident. He told the driver he would call the facility and would call her back with further instructions. He further reported he called the facility to report the incident to the administrator on 8/30/2017 at approximately 4:45 PM. He explained the procedure for drivers was to call the office/him to report minor incidents, and to call EMS if the resident is injured or in distress. The EMS record dated 8/30/2017 was reviewed. The time of the call received was 4:33 PM on 8/30/2017. The EMS was dispatched at 4:33 PM and was on the scene at 4:38 PM. The EMS record further noted transport of Resident #264 to the hospital emergency room at 5:03 PM on 8/30/2017. It was recorded Resident #264 had a fall and was found lying on his left side in the rear of a wheelchair van. Resident #264 was complaining of right knee pain and the EMS did not note deformities or swelling during the assessment. The hospital emergency department notes were reviewed dated 8/30/2017 at 5:13 PM. The physician notes indicated Resident #264 was experiencing pain in his left lower back and right knee. The resident was medicated and expressed some relief of the pain. The hospital record described his skin with multiple superficial abrasion on forearms (old), no head trauma, left lateral paraspinal tenderness to palpation, the right lower leg effusion noted and bilateral pedal [MEDICAL CONDITION], and no neurological deficit observed. The x-ray report dated 8/30/2017 at 6:16 PM from the hospital was reviewed and it revealed no acute fracture or dislocation of the right knee. A review of the facility nursing notes dated 8/30/2017 at 11:13 PM noted resident was alert and oriented and without signs or symptoms of pain. The resident reported during the interview that he was sore from the accident and did not receive a [MEDICAL TREATMENT] treatment on 9/6/2017 because he was too sore to travel to the [MEDICAL TREATMENT] center. The Administrator for the facility was interviewed on 8/30/2017 at 2:13 PM. He stated he was notified of the incident on 8/30/2017 at about 4:45 PM after the owner of the transportation company called the facility. He conveyed his knowledge of the incident, the resident had an injury and was desiring to go to the emergency room . On 9/9/2017 at 8:46 AM, the administrator provided the following corrective action with compliance date of 8/31/2017. On August 30 at approximately 4:45 PM, facility staff notified the administrator of an incident with the van. It was relayed by the caller, the passenger was involved in an incident and was desiring to go to the emergency department (ED). The administrator directed them to immediately call 911. The administrator texted the owner of the company and requested to get the details and to meet the following morning. In the meantime, using the said company was suspended. At 7:23 p.m. on 8/30/2017 the administrator called the spouse to see if he could gain any information regarding the incident. She passed the phone to the resident. The conversation offered the administrator a perspective from the resident ' s point of view. The resident stated he did not feel the back of his chair was strapped properly. He also stated the shoulder restraint was in poor repair for the past three weeks and the driver stated she has told (the owner) them to get it fixed. He stated no over the shoulder strap was used but a lap restraint was. In front of (a restaurant), he stated she slammed on brakes and the chair tipped over putting him on the floor. He hit his knee in the incident and wanted to go to the hospital. The administrator asked for screen shots of any calls placed so he could recreate the incident to the best of his ability but the wife was unable to do so. On 8/30/17 allegedly the wife contacted EMS to help transport the resident to the ED for evaluation and possible treatment. The resident was found to have no injuries and was transported back to the facility by EMS later in the day. On August 31, 2017 at 9:35 a.m., the administrator met with the owner and the driver. During the conversation, the administrator shared his desire to determine exactly what occurred in order to prevent such an occurrence in the future. The driver denied the resident came out of the chair rather the chair tipped up (similar to a 45 degree angle) and as he slid down, his knee(s) was pressed against the driver seat. She cannot recall if a seatbelt was used. She stated she turned her hazard lights on, pulled over in the (restaurant) parking lot and got a bystander to help. She then followed company protocol and phoned the owner of the company. Though our van driver was not involved, the van driver demonstrated proper securing of a wheelchair according to policy on the morning of 8/31/2017 and was retrained by the administrator on the aspects of safely transporting our residents. She has never had any incidents as a van driver. She was also reminded by the administrator it is the desire of the facility for her to call 911 regardless of the severity of any incident in which the van is involved in. She was also instructed not to move the resident unless they are clearly in a dangerous position or situation. If physical damage is present, regardless of extent, the van should not be moved until administrator is contacted and the van is assessed. To ensure ongoing compliance, the facility will not deviate from its regular inspection by the administrator or maintenance director of both its van, driver training and periodic and random assessments of passengers beings secured to our van by the administrator or maintenance director. This has proven to be highly effective and has assisted us in maintaining full compliance with state and federal regulations. The driver will be reminded during annual retraining by the administrator or maintenance director and informally of our on-going desire for 911 to be contacted as soon as any incident occurs regardless of the severity and not to move the resident unless they are clearly in a dangerous position or situation. Only the passenger can refuse treatment directly with 911 personnel. Though we have no immediate plans of utilizing outside transports, if this need were to change in the future, the facility will require proof of their training which must be equivalent to our own internal training, proof the vehicle is in proper working condition, immediate notification of 911 regardless of severity and this would supersede their own company policy, and proof of periodic training of the drivers and van assessments. The QA committee will monitor the on-going compliance of our driver and his/her training with respect to F309 as well as any future events monthly for the next 12 months and then as needed. The corrective action was validated on 9/9/2017 by reviewing the following: The facility administrator reported the contract with the transportation company had been terminated. The driver of the van had been suspended on 9/1/2017 and she would be terminated when the investigation was completed. The program worksheet dated 8/31/2017 with the signature of the facility driver and the Administrator was reviewed. The facility driver was instructed by Administrator on the procedures to follow after an incident. The Administrator documented 911 was to be contacted after any incident, regardless the severity, and the van was not to be driven until Administration had audited the van for safety.

Based on observation, interviews with resident, family, facility staff, contracted van transportation driver and owner, and record review, the facility failed to ensure a resident was transported from the dialysis center to the facility in a safe manner. The resident slid forward in the wheelchair and his knee hit the back of the driver seat. The resident experienced some lower back pain and right knee pain and needed pain medication. This was evident in 1 of 1 sampled resident (Resident # 264). Findings included: The Q ' straint manufacturer ' s user instructions for the transportation van were reviewed and the instructions stated, in part: A. Secure the wheelchair by placing wheelchair facing forward; attach tie-down hooks into floor anchorages and ensure they are locked in; attach the four tie-down hooks to solid frame members or weldments near seat level. Ensure tie-downs are fixed at approximately 45 degrees and are with angles shown in Figure 2; Do not attach hooks to wheels, plastic or removable parts of wheelchair; ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs to take up additional webbing slack. B. Secure passenger: attach lap belts: use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant; on the aisle side, attach belt with female buckle to rear tie-down pin connector ensuring buckle rests on passenger ' s hips; on the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle; attach shoulder belt: extend shoulder belt over passenger ' s shoulder and across upper torso and fasten pin connector onto lap belt; ensure belts are adjusted as firmly as possible, but consistent with user comfort. C. Warnings: lap and shoulder belt should not be held away from passenger ' s body by wheelchair components or parts such as the wheelchair ' s wheels, armrests, panels or frame; occupant belts should always bear upon the bony structure of the passenger ' s body and be worn low across the front of the pelvis with the junction between lap and shoulder belts located near passenger ' s hip. The contract between the transportation company and the facility dated 10/1/2016 was reviewed and it was noted there were no statements in the contract regarding emergency procedures for the transportation van staff to follow, no specifications of training for transportation van staff and no specifics regarding maintenance and upkeep of the van or transportation safety equipment. Resident #264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s admission minimum data set (MDS) of 7/24/2017 revealed the resident was cognitively intact. The resident had no problem with short and long term memory and was independent in making decision of tasks of daily living. The resident required extensive, one-person assistance with bed mobility, ambulation, and extensive two-person assistance with transfers. The resident height was 77 inches and he weighed 300 pounds. The resident had no impairment of upper or lower body range of motion and required one person assistance to move from sitting position to standing. He was unable to ambulate without one person assistance. A review of the care plans for Resident #264 found a plan in place dated 8/3/2017 related to the fall risk due to impaired mobility, medication effects, history of falls and medical [DIAGNOSES REDACTED]. Interventions in place to include to remind resident to call for assistance and to maintain the environment free of clutter and safety hazards. A review of the resident ' s medical record revealed he was scheduled for dialysis treatments three times per week. Resident #264 was scheduled to be transported by the contracted transportation van company from the dialysis center to the facility on [DATE]. The Administrator for the facility was interviewed on 8/30/2017 at 2:13 PM. He reported the facility transported residents to appointments using its own transportation van. Also, the facility had a contract with a private van company to transport residents to appointments. Resident # 264 was interviewed on 9/7/2017 at 10:41 AM. He reported on 8/30/2017 at approximately 4:15 PM he was returning from dialysis to the facility. He reported the driver (Driver #1) of the contracted transportation van, did not secure his wheelchair wheels when she loaded him into the van. He reported the driver did not secure him with a lap belt or shoulder belt once he was in the van. The resident reported that while driving on Highway 74 West, the driver hit the brakes and he slid forward in the wheelchair and was bracing himself on the back of the passenger seat and the driver ' s seat. When this happened, driver #1 stopped the van in the middle of traffic on Highway 74 W to attempt to assist him back into the wheelchair, but was unable to scoot him back in the wheelchair and he was unable to assist due to weakness. Resident #264 instructed her to pull the van over out of traffic and she pulled into restaurant ' s parking lot. Resident #264 reported that bystanders in the parking lot of a restaurant assisted driver #1 to release the lock on the wheels of Resident #264 ' s wheelchair and he was lowered to the floor of the van by the bystanders and the driver called the owner of the van. Resident #264 stated he did not fall out of the wheelchair, he was lowered to the floor of the van because they couldn ' t lift him back into the wheelchair. The resident called his wife at 4:26 PM and the wife arrived on the scene at approximately 4:45 PM. The wife reported that the driver of the van had not called Emergency Medical Services (EMS) and the wife called EMS. The resident reported that the EMS arrived approximately 5 minutes after his wife called them and they assisted him off the floor of the van to a stretcher and transported him to the hospital ' s emergency department. Resident #264 reported he was evaluated and no bones were fractured, but he had a contusion with abrasion to the right tibia, left knee laceration and left forearm laceration. The resident reported he returned to the facility from the emergency department on 8/30/2017 about 9:30 PM. The resident and his wife were interviewed on 9/7/2017 at 12:00 PM. The wife reported that when she arrived at the incident, EMS had not been called. She placed the call to EMS and they arrived within five minutes. An interview was conducted on 9/8/2017 at 4:20 PM with the resident and his wife. Resident #264 denied the van driver had applied any restraint to him and had only locked down the wheels of the wheelchair for transport. The resident had been told the black shoulder/lap restraint was broken by the driver and he recalled her stating . no use in me giving this to you, it ' s broke. Driver #1, who was an employee of the contracted van company, was interviewed on 9/7/2017 at 4:18 PM via phone call. She reported, on 8/30/17, she picked Resident #264 up from his dialysis treatment and secured his wheelchair with the safety straps to the floor of the van. She reported the (black) seatbelt that was special made for restraining residents in the wheelchair and it was not operational. She used the factory installed seatbelt (tan seatbelt intended for restraining residents sitting in van seat) to secure Resident # 264 who was sitting in a wheelchair. Driver #1 reported she was heading west on Highway 74 and traffic was dense. She hit the brakes hard to avoid hitting a car in front of her and when she did, Resident #264 stated, I think I ' m coming out of my seat. She looked back and Resident #264 had slid forward in his wheelchair and was bracing himself with his hands on the back of the passenger and driver seats. Driver #1 reported she pulled into a restaurant parking lot and asked for help from two bystanders. The bystanders assisted her to release the straps on the wheelchair wheels and lower Resident #264 to the floor of the van. She reported that the factory installed seatbelt had come undone. She then reported she used her own cell phone to call the owner of her company to report the incident. She reported the owner had offered to come with a stretcher for transport back to the facility, but the resident did not want him to come. The resident wanted Driver #1 and the bystander to attempt to push him back into the wheelchair, but when they couldn ' t get him back into the wheelchair, Resident #264 requested to be lowered to the van floor and transported back to the facility. Driver #1 reported she could not drive back to the facility with the resident on the floor of the van and he called his wife from his phone. When Resident #264 ' s wife arrived at the restaurant parking lot, she was very upset and called for an ambulance. Emergency Medical Services (EMS) arrived and transported the resident to the hospital. Driver #1 was interviewed again on 9/8/2017 at 11:42 AM. Driver #1 reported she had used the tan, factory installed seatbelt to secure Resident #264 by connecting the tan belt to the Q-straint and had not attempted to use the black wheelchair seatbelt because it was not working and I had told (the owner) it wasn ' t working. Driver #1 further stated she thought the tan belt disconnected from the Q-straint connection when she pressed the brakes during the 8/30/2017 incident. She reported she did not call 911 because she had been instructed to call the owner for minor incidents and to call 911 only if the resident was injured or in distress, like a stroke or something. When asked about the training she had received, Driver #1 reported that she had ridden in the van with a trainer for several days and she took some notes, but did not receive written training materials or an employee handbook. She was asked to demonstrate securing passengers in wheelchairs after watching the procedure. She concluded by sharing she had handwritten a statement for the incident and the owner had a copy. An undated handwritten statement written by Driver #1 was reviewed. The statement described the series of event of the incident on 8/30/2017 that happened during Resident #264 transportation and included her name and the date of the incident. The statement read, in part, First I lifted his two leg rest(s) before I pushed (him) up the ramp. I then pushed him up the ramp into the van and as I positioned him in the locking area, I then locked his wheelchair wheels on both sides. Next I straped (sic) his two back strapes (sic) to his chair to secure the back of his chair. Onced (sic) I finished the back I then went around to my side door and straped (sic) the two front strapes (sic) down to secure the front of the chair. When finished with that I straped (sic) his shoulder and waist belt. Traffic is heavy on Highway 74 so by the time I come through the light near (drug store), I ' m in the left lane and traffic is so congested and I hit my brakes and then (Resident #264) says ' I believe my chair is tilting. I feel like I ' m going to come out or something. ' So I then put my emergency lights on and get over to pull into (restaurant) parking lot. At this time I ' m asking (Resident #264) is he alright, ' I ' m going to pull here to check you out to make sure your (sic) ok. ' When I get out to open the side door to check him, I seen (Resident #264) hands on the back of the chairs of the van as if he was trying to push his weight back to the back of his chair. I called for help . Some guy in a truck came to assist me. I then called (owner of transportation van) to explain the situation. (Owner of transport van) asked if (Resident #264) would like him and his guys to come transport him with the stretcher. (Resident #264) said, ' If you are close then that ' s fine, but if not maybe EMS if they (Driver #1 and bystander) can ' t pull me back in the chair. ' (Owner of transportation van) said he would call (facility) and call (me) right back. So me and the (bystander) try our best to push him back. (Resident #264) then says ' No, I don ' t believe you guys are going to do it because I can ' t help you push back my weight is coming down more. ' I get his chair unbuckled to lower him onto the floor. At this same time (Resident #264) was saying he has too much pressure on his leg. I got the full chair undone and I pulled it out of the van. (Owner of transport van) was then calling me back asking how was everything and he was on his way. (Resident #264) then said ' No, we don ' t need (Owner) to come I feel ok like this, just take me to (facility) laying here. ' I told (Resident #264) I ' m sorry, but that ' s not safe I cannot take you like this. (Resident #264 then yelled ' Well tell him to call EMS or you call, well better yet give me my phone so I can call my wife. ' Resident #264 called his wife and then told Driver #1 he wanted EMS called to check out his leg.) By then (Resident #264 ' s) wife had arrived and was yelling ' call EMS ' . I try telling the wife what ' s going on and she brushed me off saying ' I don ' t wanna (sic) hear it, why haven ' t EMS arrived. ' .I then said, ' I ' m so sorry I was following the guidelines and my boss was sending help our way. ' .EMS (arrived) there . load(ed) (Resident #264) into the (ambulance). The owner of the transportation company was interviewed on 9/7/2017 at 1:50 PM. He reported that he was called by the driver of the van after she had braked hard and Resident #264 slipped forward out of his wheelchair. The owner reported he offered to come to the van to assist the driver to put the resident back into the wheelchair, but the resident did not want him to come to the incident. He told the driver he would call Pruitt and would call her back with further instructions. He further reported he called the facility to report the incident to the administrator on 8/30/2017 at approximately 4:45 PM. He explained the procedure for drivers was to call the office/him to report minor incidents, and to call EMS if the resident is injured or in distress. The owner concluded by reporting Driver #1 was suspended during the investigation and would be terminated. An observation of securing a wheelchair for transport in the contracted transportation van was completed at 10:41 AM on 9/8/17. The facility administrator, the owner of the transportation van and Driver #2 were present. Driver #2 was an employee of the contracted transportation van, but was not the driver of the resident during the incident on 8/30/2017; Driver #1 had been suspended by the contracted company and was not available to perform the demonstration. A standard 20 inch wheelchair was used for the observation. The administrator reported that the wheelchair Resident #264 used in the facility was a 22 inch wide wheelchair. Driver #2 demonstrated securing the Q-straps that hooked to the wheels and then locked into the floor of the van. It was noted there were three seatbelts in the rear of the van: a red lap belt, a black shoulder/lap belt and a factory installed tan seatbelt that the owner of the van reported was used for seated passengers and not for passengers in wheelchairs. The driver demonstrated applying the red waist belt across the wheelchair and fastening it into the Q-straps on the floor of the van and stated the straps would hold the resident in place. The driver then took the black waist and shoulder restraint that was attached at the same point as the tan seatbelt and she brought it across the wheelchair and through the wheels to hook into the Q-strap. The driver explained there were 8 points of safety to secure the resident in place. The owner of the van reported that he was not aware the black seatbelt was not functioning and had not been informed by Driver #1 about this fact. During the interview on 9/8/2017 at 11:42 AM, Driver #1 was asked if she had used the red lap belt that was observed in the demonstration described above. Driver #1 stated What red lap belt? The driver said that the only seatbelts on that van the day of the incident on 8/30/17 were the tan one that came with the van and the black seatbelt (shoulder and waist belt). She further stressed the black seatbelt was not functioning and she used the tan seatbelt only to secure the resident in his wheelchair. The EMS record dated 8/30/2017 was reviewed. The time of the call received was 4:33 PM on 8/30/2017. The EMS was dispatched at 4:33 PM and was on the scene at 4:38 PM. The EMS record further noted transport of Resident #264 to the hospital emergency room at 5:03 PM on 8/30/2017. It was recorded Resident #264 had a fall and was found lying on his left side in the rear of a wheelchair van. Resident #264 was complaining of right knee pain and the EMS did not note deformities or swelling during the assessment. The hospital emergency department notes were reviewed dated 8/30/2017 at 5:13 PM. The physician notes indicated Resident #264 was experiencing pain in his left lower back and right knee. The resident was medicated and expressed some relief of the pain. The hospital record described his skin with multiple superficial abrasion on forearms (old), no head trauma, left lateral paraspinal tenderness to palpation, the right lower leg effusion noted and bilateral pedal edema, and no neurological deficit observed. The x-ray report dated 8/30/2017 at 6:16 PM from the hospital was reviewed and it revealed no acute fracture or dislocation of the right knee. A review of the facility nursing notes dated 8/30/2017 at 11:13 PM noted resident was alert and oriented and without signs or symptoms of pain. The resident reported during the interview that he was sore from the accident and did not receive a dialysis treatment on 9/6/2017 because he was too sore to travel to the dialysis center. The Administrator for the facility was interviewed on 8/30/2017 at 2:13 PM. He was notified of the incident on 8/30/2017 at about 4:45 PM after the owner of the transportation company called the facility. He conveyed his knowledge of the incident, the resident had an injury and was desiring to go to the emergency room . The facility Administrator performed audits on the facility transportation vans on 8/30/2017 at 9:23 PM and found no issues with the safety of the facility van. Driver #1 met with the Administrator and the owner of the transportation van on 8/31/2017 at 9:35 AM. Driver #1 demonstrated securing a wheelchair into the van and took a statement from Driver #1. The statement the Administrator received from Driver #1 differed from the statement he received from Resident #264. He further reported he had inspected the contracted transportation van on 8/31/2017 and all seat belts appeared to be in working order. The Administrator provided a written account of the incident. A Quality Assurance document dated 8/30/2017 prepared by the Administrator was reviewed. The document reported the Administrator had been notified of an incident on 8/30/2017 at 4:45 PM by (unnamed) caller and the Administrator instructed the caller to call EMS immediately. A meeting was arranged with the owner of the transportation company and Driver #1 by the Administrator on 8/31/2017. The Administrator inspected the facility vans on 8/30/2017 at 9:21 PM and found it to be in good repair with no imperfections with the straps or other ancillary equipment that would be necessary for safe transport. Driver #1 provided a statement in which she shared the resident did not fall out of his chair, but rather tipped forward at a 45 degree angle and slid forward with his knees pressed to the back of the driver seat. Driver #1 proceeded to explain she had pulled the van over into a restaurant parking lot and enlisted the assistance of a bystander. The Administrator further documented that he reviewed the background checks, drug test, training records and driver credentials for Driver #1. The correct demonstration by Driver #1 to secure a wheelchair to the floor of the transportation van during the demonstration on 831/2017 was noted by the Administrator. The factory installed black seatbelt in place for wheelchair passengers locked when sudden pressure applied to it, as intended, per the documentation by the Administrator. It was also noted Driver #1 had reported the presence of an additional seatbelt, but that it was broken and she didn ' t use it, instead she used the tan seatbelt to secure the resident. On 9/9/2017 at8:46 AM, the administrator provided the following corrective action with compliance date of 8/31/2017. On August 30 at approximately 4:45 PM, a facility staff notified the administrator of an incident with the van. It was relayed by the caller, the passenger was involved in an incident and was desiring to go to the emergency department (ED). The administrator directed them to immediately call 911. The administrator texted the owner of the company and requested to get the details and to meet the following morning. In the meantime, using the said company was suspended. At 7:23 p.m. on 8/30/2017 the administrator called the spouse to see if he could gain any information regarding the incident. She passed the phone to the resident. The conversation offered the administrator a perspective from the resident ' s point of view. The resident stated he did not feel the back of his chair was strapped properly. He also stated the shoulder restraint was in poor repair for the past three weeks and the driver stated she has told (the owner) them to get it fixed. He stated no over the shoulder strap was used but a lap restraint was. In front of (a restaurant), he stated the driver slammed on brakes and the chair tipped over putting him on the floor. He hit his knee in the incident and wanted to go to the hospital. The administrator asked for screen shots of any calls placed so he could recreate the incident to the best of his ability but the wife was unable to do so. On 8/30/17 allegedly the wife contacted EMS to help transport the resident to the ED for evaluation and possible treatment. The resident was found to have no injuries and was transported back to the facility by EMS later in the day. At 9:21 p.m., on 8/30/2017 the administrator inspected his own van and found it to be in good repair with no imperfections with straps or other ancillary equipment that would be necessary for a safe transport. The document used for the administrator ' s review was a document developed and provided by his corporation to ensure a very thorough and detailed review of any automobile used to transport residents. On August 31, 2017 at 9:35 a.m., the administrator met with the owner and the driver. During the conversation, the administrator shared his desire to determine exactly what occurred in order to prevent such an occurrence in the future. The driver denied the resident came out of the chair rather the chair tipped up (similar to a 45 degree angle) and as he slid down, his knee(s) was pressed against the driver seat. She cannot recall if a seatbelt was used. She stated she turned her hazard lights on, pulled over in the (restaurant) parking lot and got a bystander to help. She then followed company protocol and phoned the owner of the company. During this meeting, the administrator reviewed the background checks, drug test, training records, driver credentials, etc. to ensure the driver had been properly vetted and trained in accordance with state and federal regulations that govern skilled nursing facilities. This review revealed compliance with all local, state and federal regulations. The administrator and both representatives from the company went outside for a demonstration of what occurred. The driver recalled the representative of the dialysis company stating how hard it was to push the resident ' s wheelchair - implying something was wrong with it. The administrator assessed the wheelchair and found it in good repair without any noted concerns including the wheels or anything that would make it difficult to maneuver. With the same wheelchair and van involved, the driver demonstrated through simulation pushing the chair onto the rear ramp and stated the resident was trying to help by scooting forward in a rocking motion with both feet on the leg rests. Upon pushing the chair to the front of the van, the driver demonstrated securing the rear of the chair first before coming around and securing the front of the chair on points located under the chair. After this, she (the driver) stated she would apply the seatbelt. During the observation, the administrator noted what appeared to be a factory installed, tan seatbelt in place. The driver provided a demonstration with a black seat belt that connected to the Q strap. The administrator pulled the tan seatbelt all the way out and verified it was in good working order and grabbed when sudden pressure was applied as it was intended. She stated they would use the black seatbelt for wheelchair bound residents but it was broken. During the demonstration, the administrator could not determine any aspect broken and she was unable to show it. The owner said they were in the process of replacing the van. According to the owner, the tan seatbelt is not designed for wheelchair transports thus the installation by the conversion company of the black seatbelt and attachments. After the observation and simulations, the administrator and owner discussed the situation and the variances between the stories. Beyond the investigation, the administrator performed quality assurance checks on the facility ' s only van and observed the transport driver securing a resident. The administrator observed 5 wheelchairs of those scheduled for transport and found them all in working order with no issues. These were standard wheelchairs issues to residents upon admission. Though our van driver was not involved, the van driver demonstrated proper securing of a wheelchair according to policy on the morning of 8/31/2017 and was retrained on the aspects of safely transporting our residents. She has never had any incidents as a van driver. Furthermore the administrator reviewed the weekly van checks since June 2017 and found them to be in compliance with regulations and company policy. He noted no issues in light of this event during her review of these documents. To ensure ongoing compliance, the facility will not deviate from its regular inspection of both its van, driver assessments of passengers beings secured to our van. These assessments of securing passengers will be at least annually but then as needed based upon a random sample and if any event occurs. These random assessment currently includes the administrator or maintenance director accessing the van without warning to ensure any passenger secured is done so in compliance with corporate standards as well with state and federal regulations. This has proven to be highly effective and has assisted us in maintaining full compliance with state and federal regulations. For the purpose of this plan for compliance, we will inspect 1 transfer a month for 3 months, and then PRN. As such, we do not plan to use this or any other transport company to assist with transports. If residents elect to utilize such services, it will be the policy of the facility to require the resident to sign out just as they would if they were being transported in their own car. The facility will no longer coordinate or contract with outside vendors. However, if this need were to arise in the future, the facility will require proof of their training which must be equivalent to our own internal training, proof the vehicle is in proper working condition, immediate notification of 911 regardless of severity and this would supersede their own company policy, and proof of periodic training of the drivers and van assessments. The facility currently holds monthly QA meetings and the QA committee will monitor our on-going compliance at each meeting for the next 12 months and then as needed. If any event occurs this oversight will be specific to that event as well as our on-going compliance with state and federal regulations. The corrective action was validated on 9/9/2017 by reviewing the following: A pre-trip checklist was reviewed dated 8/30/2017 at 6:41 PM and completed by the facility administrator for a facility owned van. The form noted the securement station was properly equipped with four securement straps. The lap belt and a shoulder belt, all straps and belts were in good working condition without defects. All floor anchorages were clear of dirt/debris and allowed for proper system fitting attachment. A clean, dry container in the vehicle was in place to allow for storage of the system when not in use. The vehicle was equipped with web/belt cutter for use in an emergency evacuation. A complete system operational instructions in either printed or decal form were located within the vehicle compartment to serve as a reference. A pre-trip checklist was reviewed dated 8/31/2017 at 10:06 AM and completed by the facility administrator for the contracted transportation van. The administrator noted the securement station was properly equipped with four securement straps. The lap belt and a shoulder belt, all straps and belts were in good working condition without defects. All floor anchorages were clear of dirt/debris and allowed for proper system fitting attachment. A clean, dry container in the vehicle was in place to allow for storage of the system when not in use. The vehicle was equipped with web/belt cutter for use in an emergency evacuation. A complete system operational instructions in either printed or decal form were located within the vehicle compartment to serve as a reference.