Every finding on record at Raleigh Rehabilitation Center

Based on record review and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for 1 of 39 residents reviewed for accurate medical records (Resident #139).The findings included:Resident #139 was admitted into the facility on 4/9/25.Resident #139 had a physician's order dated 4/9/25 for Lidocaine External Patch (topical anesthetic) 4% apply to bilateral shoulders topically in the morning for pain.Resident #139's September 2025 Medication Administration Record (MAR) indicated that the Lidocaine patches were not documented as administered on 9/1/25 and 9/9/25 by Nurse #1.Resident #139's October 2025 MAR indicated that the Lidocaine patches were not documented as administered on 10/6/25 and 10/20/25 by Nurse #1.An interview with the Unit Manager on 3/25/26 at 7:55 AM revealed that all nurses should ensure medications were documented at the end of their shift.A telephone interview on 3/25/26 at 4:00 PM with Nurse #1 revealed that she could not remember if she applied the Resident #139's Lidocaine patches or not. She further revealed that she could not remember why the Lidocaine patches were not documented as administered on 9/1/25, 9/9/25, 10/6/25, or 10/20/25. A telephone interview on 3/26/25 at 8:34 AM with the Director of Nursing indicated that the nursing staff should ensure all medication was documented accordingly at the end of their shift.A telephone interview on 3/26/25 at11:32 AM with the Administrator revealed that she expected the nursing staff to document medication administration when the medication was given.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of use of anticonvulsant medication for 1 of 39 residents whose MDS assessments were reviewed (Resident #128). The findings included: Resident #128 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, dementia with other behavioral disturbances, and anxiety disorder. Resident #128 had a physician order dated 6/03/25 for lamotrigine (an anticonvulsant medication) 25 milligram (mg) oral tablet; give one tablet by mouth two times a day for bipolar disorder. Review of the Medication Administration Record (MAR) for January 2026 revealed Resident #128 was administered the lamotrigine medication as ordered.The Minimum Data Set (MDS) quarterly assessment dated [DATE] and completed by MDS Nurse #2, revealed Resident #128 had severely impaired cognition. Resident #128 was not coded for anticonvulsant medication use during the 7-day lookback period.The Regional MDS Nurse was interviewed on 3/25/26 at 3:15 pm and revealed MDS Nurse #2 was a per diem staff member that assisted the facility with resident assessments when needed. The Regional MDS Nurse reviewed Resident #128's physician order and MAR and confirmed the quarterly MDS assessment should have been coded for the use of the anticonvulsant medication. A telephone interview was conducted with MDS Nurse #2 on 3/26/26 at 10:44 am. MDS Nurse #2 stated that not coding the anticonvulsant medication was an oversight when she completed Resident #128's MDS assessment. During an interview with the Administrator on 3/26/26 at 11:35 am she revealed MDS Nurse #2 should have coded Resident #128's MDS assessment correctly based on the documentation in the medical record within the look back period.

Based on record review, and Responsible Party (RP) and staff interviews, the facility failed to provide written grievance summaries for 4 grievances filed by Resident #136's responsible party. The deficient practice occurred for 1 of 1 resident reviewed for grievances (Resident #136).Findings included: Review of facility policy dated 08/2023 titled Resident Rights/Grievances read in part: The Administrator is responsible for overseeing the grievance process. The process includes receiving and tracking grievances, leading investigations while maintaining the confidentially of all information associated with grievance, reaching conclusion, and taking appropriate actions.The resident, or anyone acting on their behalf filing the grievance, will be communicated with regarding the conclusion of the investigation and the corrective actions that will be taken. The resident or anyone acting on their behalf has the right to obtain a copy of the written conclusion. The Administrator will validate the completion of the process in a timely manner upon receipt of the completed Grievance Report. Resident 136 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #136's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was severely cognitively impaired. A review of the facility's grievance log from January 2025 through March 2026 revealed four grievances from Resident #136's RP that revealed: A grievance dated 02/03/25 read in part, issues with activities of daily living (ADL) care, with Resident #136 found wet and soiled. Date the written decision was issued section, was left blank. Identify the method(s) used to notify the resident and/or anyone acting on their behalf section, was left blank. Delivery method of conclusion section was left blank. Was the grievance conclusion accepted or declined section, was left bank. Resident/Responsible Party offered conclusion section, was left blank. Date notification offered section, was left blank. Summary of pertinent findings of conclusions regarding the resident's concerns section, was left blank. Resident/Responsible Party signature section was left blank. A grievance dated 07/22/25 read in part, issues with missing washable pads and a listening ear microphone. Date the written decision was issued section, was left blank. Identify the method(s) used to notify the resident and/or anyone acting on their behalf section, was left blank. Delivery method of conclusion section was left blank. Was the grievance conclusion accepted or declined section, was left bank. Resident/Responsible Party offered conclusion section, was left blank. Date notification offered section, was left blank. Summary of pertinent findings of conclusions regarding the resident's concerns section, was left blank. Resident/Responsible Party signature section was left blank. A grievance dated 02/12/26 read in part, RP expressed concern with Resident #136's hair appearance. Identify the method(s) used to notify the resident and/or anyone acting on their behalf section, was left blank. Resident/Responsible Party offered conclusion section, was left blank. Date notification offered section, was left blank. Summary of pertinent findings of conclusions regarding the resident's concerns section, was not completed. Corrective actions taken or to be taken by the facility as a result of the grievance (be specific), was left blank. Summary statement of the grievance was left blank. Completed by (signature and title), was left bank. Resident/Responsible Party signature section was left blank. A grievance dated 03/09/26 read in part, issue with discoloration on Resident #136's right and left hand from a lab draw. Identify the method(s) used to notify the resident and/or anyone acting on their behalf section, was left blank. Resident/Responsible Party offered conclusion section, was left blank. Date notification offered section, was left blank. Resident/Responsible Party signature section was left blank. An interview was conducted on 03/25/26 at 3:02 PM with Resident #136's RP. She reported submitting multiple verbal grievances to the facility's administrative staff, including the Administrator. She stated that she was not asked whether she wanted a written grievance summary, did not receive any written summaries or follow-up communication, and was not provided with any verbal or written updates or follow up interviews regarding her grievances. An interview was conducted on 03/23/26 at 3:21 PM with the Administrator. The Administrator confirmed that Resident #136's RP did not receive written grievance summaries for any grievances filed. She acknowledged she was not fully aware that complainants or those filing a grievance on the resident's behalf must receive written summaries of grievance findings, even when issues were resolved verbally. The Administrator stated that Resident #136's RP also did not receive written grievance summaries because the administrative staff did not believe formal written documentation was required for the representative's four verbal grievances, which concerned activities of daily living (ADL) care, missing pads and a microphone, hair grooming, and right/left hand discoloration. The Administrator reported that she learned only today (03/23/26) that the facility was required to offer or provide written grievance summaries to complainants or those filing a grievance on the resident's behalf. Prior to this, staff communicated resolutions solely through phone calls or in person conversations, with no written documentation provided. The Administrator indicated that all four of Resident #136's grievances were resolved. The interview further revealed the Administrator investigated and resolved grievances and was responsible for overseeing the grievance process. On 03/26/26 at 8:05 AM, an interview was conducted with the [NAME] President of Operations. He stated that staff were expected to follow the facility's grievance policy, ensuring that individuals who filed a grievance were informed of the grievance summary and its conclusion. An interview was conducted on 03/26/26 at 9:08 AM with the Director of Clinical Services. She confirmed that Resident #136's RP did not receive a verbal or written grievance summary or any follow up notifications from the grievances she filed. She stated that, moving forward, all individuals submitting a grievance would receive a written grievance summary and decision.

Based on observations, record review and staff interviews, the facility failed to: discard expired zinc supplement tablets for 1 of 2 medication rooms (Unit 3 Medication Storage Room), discard an opened bottle of aspirin that had no expiration date for 1 of 3 medication carts (4 B Medication Cart), and dispose of loose and unidentified pills for 2 of 3 medication carts (Medication Cart 3A and Medication Cart 4B) reviewed for medication storage. The findings included: a. An observation of the Unit 3 medication storage room on [DATE] at 3:50 PM revealed an unopened bottle of Zinc 50mg (milligrams) 100 tablets with an expiration date of [DATE]. b. An observation of the 3A medication cart with Nurse #3 on [DATE] at 3:27 PM revealed 3 pills (one round white pill, one oblong shaped white pill, and one white capsule) were loose in the medication cart. Nurse #3 revealed she was not aware the loose pills were in the cart. Nurse #3 stated she could not identify the loose pills. Nurse #3 stated the loose medications were to be discarded. c. An observation of the 4B medication cart with Nurse #2 on [DATE] at 4:00 PM revealed an opened bottle of Aspirin 81 mg (milligrams) with no expiration date. The observation also revealed 3 pills (one oblong white pill, one peach oval pill, and one white round pill) were loose in the medication cart. Nurse #2 revealed she was not aware the loose pills were in the cart. Nurse #2 stated she could not identify the loose pills. Nurse #2 stated the loose medications, and Aspirin were to be discarded. An observation verifying there was no expiration date on the bottle of Aspirin was conducted with the Director of Nursing on [DATE] at 4:18 PM. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:16 PM. The Director of Nursing stated the unit managers and management team were responsible for completing a medication cart and medication room check each morning. The DON stated she would need to change the process and have the Staff Development Coordinator check each cart first thing in the morning. She additionally stated that she now sees that the unit managers need to check the carts each shift.

Based on observation, record review, and staff interviews, the facility failed to change the disposable inner cannula for 1 of 1 resident observed for tracheostomy care (Resident #111). The findings included: Resident #111 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure and tracheostomy (a surgical opening through the front of the neck into the windpipe for an air passage to help breathe). Resident #111 had an active physician order dated 11/14/23 to perform tracheostomy care every shift and as needed. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #111 was coded for tracheostomy care. The care plan last reviewed on 11/22/24 revealed Resident #111 had a tracheostomy related to impaired breathing mechanics. During a continuous observation of tracheostomy care on 12/18/24 at 11:01 am through 11:13 am Nurse #1 was observed to perform hand hygiene, put on clean gloves and remove the soiled tracheostomy gauze and discard in trash. She then removed the soiled gloves and performed hand hygiene. Nurse #1 was then observed to open the sterile tracheostomy kit and put on sterile gloves and clean around Resident #111's tracheostomy site with sterile water and hydrogen peroxide solution. She was then observed to remove the sterile gloves and perform hand hygiene. Nurse #1 was observed to put on clean gloves and replace the gauze sponge around the tracheostomy site and placed a new tracheostomy tie holder. Nurse #2 removed the soiled gloves and performed hand hygiene. Nurse #1 reported Resident #111's tracheostomy care was complete because the disposable inner cannula did not have to be changed every day. An immediate interview was conducted on 12/18/24 at 11:14 am with Nurse #1 who revealed she changed Resident #111's inner cannula the day before when she completed tracheostomy care. Nurse #1 stated the inner cannula did not have to be changed every day and was only changed as needed. Nurse #1 was unable to state how often Resident #111's inner cannula was changed. During an interview on 12/18/24 at 2:26 pm with the Staff Development Coordinator she revealed tracheostomy care was provided per the physician order and was normally every shift and as needed. The Staff Development Coordinator stated the disposable inner cannula was to be replaced when tracheostomy care was completed. During an interview on 12/18/24 at 4:40 pm with the Director of Nursing (DON) she revealed Resident #111's disposable inner cannula did not have to be changed every shift but could be changed daily. She confirmed Resident #111's physician order was for tracheostomy care to be completed every shift and that the order did not exclude the inner cannula change. A follow-up interview was conducted with the DON on 12/19/24 at 2:28 pm who revealed Resident #111's disposable inner cannula should have been changed when the tracheostomy care was completed.

Based on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of vision (Resident #69), and for the use of a wander elopement alarm and hypoglycemic (medications that help lower blood sugar levels in people with diabetes) medication (Resident #74) for 2 of 26 residents whose MDS assessments were reviewed. The findings included: 1. Resident #69 was admitted to the facility on [DATE] with diagnoses which included diabetes and diabetic retinopathy (eye condition that can cause vision loss and blindness in people with diabetes). The vision provider visit note dated 5/15/24 revealed Resident #69 was legally blind. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #69 was cognitively intact and was coded for adequate vision. An interview was conducted on 12/16/24 at 1:51 pm with Resident #69 who reported he was blind. An interview was conducted with Nurse Aid #2 on 12/18/24 at 12:27 pm who revealed Resident #69 had very poor vision and he needed staff to tell him where items were located. NA #2 stated she made sure Resident #69 had his personal items in reach and he knew where they were prior to leaving the room. An interview was conducted on 12/19/24 at 2:19 pm with MDS Nurse #1 who revealed she was aware of Resident #69's blindness. MDS Nurse #1 stated she must have coded Resident #69's assessment in error. During an interview on 12/19/24 at 2:36 pm with the Administrator she stated the MDS Nurse was responsible to ensure the resident MDS assessments were accurately coded. 2. Resident #74 was admitted to the facility on [DATE] with diagnoses which included anxiety, post-traumatic stress disorder, and diabetes. a. Review of the Elopement Risk Screening assessment dated [DATE] revealed Resident #74 was at risk for elopement. Resident #74 had a physician order dated 9/24/24 for alerting bracelet to be placed on left ankle. Resident #74 had a physician order dated 9/24/24 to check alerting bracelet everyday twice a shift for placement and function. A care plan last reviewed on 10/23/24 revealed Resident #74 was at risk for elopement as evidence by cognitive impairment and ability to self-propel with an intervention of alerting bracelet to left ankle. The nursing progress note date 11/03/24 at 5:02 pm revealed Resident #74 had a wander elopement alarm on the left ankle. Review of Resident #74's Medication Administration Record (MAR) for November 2024 revealed the alerting bracelet was in place and functioning as ordered. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #74 had moderate cognitive impairment and was independent for mobility. Resident #74 was not coded for a wander elopement alarm (alerting bracelet) during the 7-day lookback period. An interview was conducted with MDS Nurse #2 on 12/18/24 at 2:15 pm who revealed he completed Resident #74's quarterly assessment. He stated he utilized order review and observations to complete resident assessments, but he stated he probably just missed Resident #74's wander elopement alarm when he completed the assessment. b. Resident #74 had a physician order dated 11/03/24 for insulin glargine (long-acting insulin) 100 units per milliliter (ml). Inject 10 units at bedtime for diabetes management. Resident #74 had a physician order dated 11/03/24 for insulin lispro (fast-acting insulin) 100 units/ml. Inject 3 units before meals for diabetes. Review of Resident #74's Medication Administration Record (MAR) for November 2024 revealed the insulin glargine and insulin lispro were administered as ordered. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident # 74 had moderate cognitive impairment. Resident #74 was not coded for use of hypoglycemic medication during the 7-day lookback period. An interview was conducted with MDS Nurse #2 on 12/18/24 at 2:15 pm who revealed he completed Resident #74's quarterly assessment. He stated he utilized record review to code for medication use. MDS Nurse #2 confirmed Resident #74's insulin was administered during the 7-day look back period. MDS Nurse #2 stated he was not sure how he missed Resident #74's insulin. An interview was conducted on 12/19/24 at 2:36 pm with the Administrator who stated the MDS Nurse was responsible to ensure the resident assessments were accurately coded.

Based on observation, record review, and interviews with resident and staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in order to sustain compliance. This included a recited deficiency in the area of Supervision to Prevent Accidents (F689) as evidenced by repeat citations resulting in harm to residents. During the [DATE] recertification and complaint investigation survey, deficient practice at F689 resulted in the resident sustaining a spleen laceration, subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane) and rib fractures. During the [DATE] complaint investigation survey, deficient practice at F689 resulted in the resident sustaining a subdural hematoma (collection of blood outside the brain), pain to her right thigh, and temporary amnesia. During the [DATE] complaint investigation survey, deficient practice at F689 resulted in the resident sustaining a hematoma (a pool of mostly clotted blood that forms in an organ, body tissue or body space) to the back of his head, shoulder pain, and left scalp pain. Prior to being evaluated at the emergency room the resident went into cardiac arrest and was unable to be revived. During the current recertification and complaint investigation survey of [DATE], deficient practice at F689 resulted in the resident sustaining a nondisplaced fracture of the left proximal (near the center of the body) tibial (shinbone) metaphysis (neck portion of the long bone) and plateau (cartilage that covers the top end of the tibia). In addition to the repeat deficiency at F689, the facility had 3 other repeat deficiencies in the in the areas of Notice Requirements Before Transfer/Discharge (F623) previously cited during the survey of [DATE], Develop/Implement Comprehensive Care Plan (F656) previously cited during the survey of [DATE], and Infection Prevention and Control (F880) previously cited during the survey of [DATE]. The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: a) F689: Based on record review, resident interviews, and staff interviews, the facility failed to safely transport a resident back to her room via wheelchair (Resident #5) when she requested to be put back to bed. Resident #5's left leg got caught under the left side of her wheelchair without leg rests attached while being pushed by a Nurse Aide (NA) and resulted in a nondisplaced fracture of the left proximal (near the center of the body) tibial (shinbone) metaphysis (neck portion of the long bone) and plateau (cartilage that covers the top end of the tibia). As a result, the resident endured acute (short-term) pain that was treated with medication. This was for 1 of 4 residents reviewed for accidents (Resident #5). During the [DATE] recertification and complaint investigation survey, an immediate jeopardy deficient practice was cited at F689 for failing to use 2 persons when transferring a resident with a mechanical lift according to the care plan resulting in the resident sliding out of the lift pad onto the floor during the transfer and sustaining multiple injuries that resulted in a spleen laceration, subarachnoid hemorrhage, and rib fractures. During the [DATE] complaint investigation survey, deficient practice was cited at F689 for failing to prevent a fall from bed during incontinence care resulting in a subdural hematoma, pain to her right thigh, and temporary amnesia. During the [DATE] complaint investigation survey, an immediate jeopardy deficient practice was cited at F689 for failing to provide care safely to a dependent resident resulting in the resident falling off the bed onto his back on the floor hitting his head causing a hematoma to the back of his head, shoulder pain, and left scalp pain. Prior to being evaluated at the emergency room the resident went into cardiac arrest and was unable to be revived. During an interview on [DATE] at 12:11 pm the Administrator revealed the facility had completed an investigation and identified wheelchair leg rests were not in place on the resident wheelchair at the time of the incident. He further stated education was completed for all nursing staff and auditing was completed to prevent future occurrences. An interview was conducted on [DATE] at 12:25 pm with the [NAME] President of Operations who revealed the facility's corporation had determined the current Administrator was not a good fit to lead the facility. He stated the corporation had taken their time to interview candidates and have found the right Administrator for the facility moving forward (following this survey). b) F623: Based on record review and staff interviews, the facility failed to notify the Ombudsman in writing of a resident discharge and failed to provide written notification for reason of discharge to hospital to the Resident or Responsible Party (RP) for 1 of 1 residents reviewed for hospitalization (Resident #104). During the recertification and complaint investigation survey of [DATE], the facility failed to send a written notice of the reason for discharge to the resident's Responsible Party. During an interview on [DATE] at 12:11 pm the Administrator revealed the facility had not identified discharge notification as a current concern from the QAA meetings. He further stated the facility had a lot of transition of management staff and the communication from previous to new staff was not consistent, so things were missed. c) F656: Based on record review and staff interviews, the facility failed to develop a written individualized person-centered care plan in the area of antidepressant medication use (Resident #100), and anticoagulant medication use (Resident #53) for 2 of 27 residents reviewed for care plans. During the recertification and complaint investigation survey of [DATE], the facility failed to develop a care plan for a resident with an indwelling urinary catheter. During an interview with the Administrator on [DATE] he revealed the facility had not identified care planning as a concern during the QAA meetings. He stated the Minimum Data Set (MDS) Nurse was responsible for resident care plans, but the position was previously covered by temporary staff and the communication was not consistent and things were missed during the transition. d) F880: Based on observation, staff interviews, and record review, the facility failed to remove soiled gloves before placing a clean inner cannula in Resident #95's tracheostomy (surgical opening in windpipe for air/oxygen) for 1 of 1 residents reviewed for tracheostomy care. During the recertification and complaint investigation survey of [DATE], the facility failed to ensure staff donned Personal Protective Equipment (PPE) when staff entered a resident's room that was under transmission-based precautions and failed to implement the facility's wound care policy during wound care when staff failed to change gloves and sanitize hands between resident's wound when cleaning and applying new dressings. During an interview on [DATE] at 12:11 pm the Administrator stated the facility had not identified a concern with tracheostomy care. He stated the Infection Preventionist (IP) role had a recent transition of staff, and the facility was behind with education and some errors were possible during the transition.

Based on record review, resident interviews, and staff interviews, the facility failed to safely transport a resident back to her room via wheelchair (Resident #5) when she requested to be put back to bed. Resident #5's left leg got caught under the left side of her wheelchair without leg rests attached while being pushed by a Nurse Aide (NA) and resulted in a nondisplaced fracture of the left proximal (near the center of the body) tibial (shinbone) metaphysis (neck portion of the long bone) and plateau (cartilage that covers the top end of the tibia). As a result, the resident endured acute (short-term) pain that was treated with medication. This was for 1 of 4 residents reviewed for accidents (Resident #5). Findings included: Resident #5 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) with hemodialysis (HD), osteoporosis, osteoarthritis of the left knee, and stroke with left sided weakness. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact and required total dependence of 1 person for locomotion on the unit. Functional limitation in range of motion (ROM) of upper and lower extremities on one side. Resident #5 used a wheelchair as a mobility device. A Change in Condition evaluation dated 7/22/23 and written by Nurse #5 revealed Resident #5 had new or worsening pain that started on 7/22/23 in the morning time. On a pain scale of 1-10, Resident expressed pain of 2/10 and then 5/10. Nurse #5 spoke with the provider on-call and received orders for an x-ray of the left knee. Resident #5's family member was notified at 2:50 PM. Outpatient x-ray results taken at the facility on 7/22/23 revealed no dislocation or fracture to the left knee, tibia/fibula, or ankle. However, moderate osteoarthritis of the left knee was noted. A Nursing Progress note dated 7/22/2023 written by Nurse #5 revealed Resident #5 was noted to be laying on her left side without pain. Resident #5 had a diagnosis of osteoarthritis in her left knee and was able to bend, move, turn side to side without any pain or difficulty. X-rays were obtained of left knee, left tibia/fibula, left ankle and left foot all noted without dislocation or fracture. Resident and her family member were updated to results. Resident #5's family member called 911 from his home due to Resident #5 continually calling him in pain but was noted without issue at the facility in her bed. Report given to paramedics and emergency room (ER) nurse regarding situation and results sent. Resident was transferred to ER via stretcher in good spirits at 8:30 PM. Review of the ER encounter notes dated 7/23/23 revealed Resident #5 had a computed tomography (CT) scan of the left lower extremity that resulted in a nondisplaced fracture of the proximal tibial metaphysis and plateau with osteopenia. The hospital provider documented that Resident #5 was placed in a knee immobilizer for comfort although she was not ambulatory. She will be given orthopedics information to follow-up with them as an outpatient and had home pain medications to take. Resident #5 was interviewed on 10/09/23 at 10:59 AM. She revealed that she was in her wheelchair after hemodialysis about 6 weeks ago (7/22/23) and indicated she wanted to get back into bed. NA #4 came to her. She was out in the hall, and he was pushing her in the wheelchair fast back to her room. Her left leg was not on the leg rest. Her left foot got hung under the wheelchair, and she hollered out in pain. Resident #5 stated she was put back into the bed and Nurse #5 assessed her leg. An x-ray technician came to x-ray her left leg and told her that there was nothing wrong with her leg. The nursing staff kept telling her nothing was wrong, but she said that her left leg kept hurting (10/10 on a pain scale). She had already received pain medication daily. That same evening, she requested to go to the hospital, but nursing staff kept telling her nothing was wrong and that it was just a sprain. At the hospital, she was told her left knee was broken. During a follow-up interview with Resident #5 on 10/09/23 at 3:53 PM, she revealed nursing staff assisted her with mobility in the wheelchair due to left sided weakness. She stated she could move her left leg slightly before the incident on 7/22/23. Resident #5 revealed that when she went to hemodialysis, there were normally leg rests on both sides of the wheelchair, and she could not remember why the left leg rest was not on her wheelchair 7/22/23. An interview was conducted with NA #4 on 10/09/23 at 12:03 PM. He revealed around 2-3 months ago (unsure of date), Resident #5 was ready to go to bed after lunch and wheeled herself out of her room. He pushed Resident #5 back to her room to put her back in bed. NA #4 stated he was not aware that the leg rests were not on the wheelchair and her left leg went under the wheelchair. He pulled back the wheelchair, and Resident #5 was crying. Then he got Nurse #1, who evaluated her. He then attached the leg rests and returned Resident #5 to her room and put her to bed. He submitted a statement to Nurse #1, and she provided her statement as well for the incident report. He stated an in-service was provided about having proper leg rests on the wheelchair, and he had a training session with the previous DON. After the incident, Resident #5 did not want him to give her care anymore. During a follow-up interview with NA #4 on 10/10/23 at 10:03 AM, he revealed that while transporting Resident #5 in the past, both leg rests were usually on the wheelchair due to Resident #5 was not able to lift her legs for long periods of time. When she returned from hemodialysis, lunch was being served but she wanted to be put to bed right away. This incident did not occur at the end of his shift (3:00 PM). This incident occurred toward the end of lunch service which was around 1:30 - 2:00 PM. NA #4 indicated he was not in a rush. Review of Nurse #1's witness statement dated 7/23/23 revealed the date of the incident was on 7/22/23 at 2:30 PM. The statement read: She (Resident #5) came back from hemodialysis then ate her lunch. After she ate her lunch, she came out of her room asking to be put back to bed. She usually eats her lunch before going back to bed. Another resident had fallen so me and the NA were busy with that. After all that was done, the NA went to get the lift to put her back to bed. When NA went to push Resident #5 back, she said her leg got bent under her wheelchair. I did not hear her yell out at the time it happened. Right after she got back from hemodialysis, she had asked for pain medication like she usually does. After the incident, I could not give her anymore pain medication, but I put her Voltaren gel (topical pain gel) on. I went to assess her when I put the gel on her. We called the on-call provider, and they ordered x-rays. Results of the x-rays came back at the time EMS arrived; x-rays were negative. Nurse #1 was interviewed on 10/10/23 at 2:15 PM. She revealed that she was not a direct witness to the incident with Resident #5 on 7/22/23. However, Resident #5 told her that when NA #4 pushed her in the wheelchair, she put her left foot down and it got caught under the chair. Nurse #5 was the nurse who evaluated Resident #5 and completed the incident report. Nurse #1 stated she was the nurse assigned to Resident #5 and administered the pain medication. Resident #5 had chronic pain and when she was comfortable her pain was at a 6/10 and if she was crying it could be as high 10/10. X-rays were ordered and came to the facility. Review of Nurse #5's witness statement dated 7/23/23 read: She (Resident #5) returned from hemodialysis around her usual time. I was at the desk doing paperwork. The NA had gone to the kitchen to get food for another resident when she (Resident #5) came to the nurses' station asking to be put back to bed. I asked her who her NA was, and she said (NA #4). I told her he had just stepped downstairs for a minute for someone else and when he came back, I would help him put her to bed. She headed back to her room, and the NA got back to the floor, so I told her he was back, and we would get her to bed. NA took her to her room, and he told me he was ready. I went to the room to help and as we were putting her in bed, Resident #5 stated watch my knee. I asked her what had happened, and she stated, Oh I hit it on the bedside table. The NA told me her leg got caught under the chair when he was wheeling her back to her room. Resident #5 said, Yeah, he ran over my foot. I assessed her left leg and there were no swelling/redness/marks of any kind. She had ROM and was able to lift her leg and she had rolled over on it trying to reach something while I was there . Nurse #5 was interviewed via telephone on 10/10/23 at 2:55 PM, and she requested to refer to her witness statement dated 7/23/23 because she could not recall all of the details from the incident on 7/22/23 with Resident #5. The DON was interviewed on 10/11/23 at 12:02 PM, and she revealed she was employed with the facility since 8/7/23. She indicated that for all residents who needed a wheelchair, leg rests must be in place. For residents who had appointments the next day, staff were expected to ensure that the wheelchairs had leg rests in place. In response to the incident with Resident #5, if there was any complaint of pain then an x-ray would be ordered. If the pain continued, then a repeat x-ray was necessary. All staff involved should have been interviewed to find out what happened and provided in-service education as needed. An interview was conducted with the previous DON via telephone on 10/11/23 at 12:26 PM. She revealed the incident with Resident #5 occurred on a weekend, and nursing staff notified her that she complained of pain and preliminary x-rays were ordered as a result. The x-rays were negative, but Resident #5 still complained of pain so they sent her out to the ER. She was notified a few days later that the CT scan at the hospital confirmed a fracture. The normal process was that the transport driver took off the leg rests, so that Resident #5 could propel herself around the hall. She requested to be put back to bed after hemodialysis on 7/22/23 and propelled herself into the hallway. When NA #4 was finished with his tasks, he pushed her back to the room and her left leg got caught up under the wheelchair. He then retrieved the leg rests and proceeded to bring Resident #5 back to her room. Nurse #1 assessed her, and an investigation was performed, which included statements from staff, education provided to staff, and evaluations of all residents to determine leg rest needs. The audits/monitoring was still going on when she left the facility in mid-August 2023. The only time that Resident #5 wanted to get out of bed was for hemodialysis and then wanted to be put right back to bed shortly after. The pain medication was changed/increased temporarily to get her comfortable post-acute fracture. During an interview with the Administrator on 10/11/23 at 3:42 PM, he revealed that there was nothing further the facility could have done to prevent the incident with Resident #5 on 7/22/23. Through the investigation and plan of correction, he stated that he had discovered the leg rests were not on the wheelchair at the time. When Resident #5 was transported to/from hemodialysis, the leg rests were normally on the wheelchair. It was not found that NA #4 was rushing while pushing Resident #5 back to her room. An intervention that developed from the incident was to ensure leg rests were always in place on the wheelchair while mobile through the facility. The facility provided the following corrective action plan with a completion date of 7/26/23. Address how corrective action will be accomplished for resident found to have been affected: On 7/22/2023, Resident #1 sustained a non-displaced fracture of the proximal tibia after her leg was caught under the wheelchair during transport. Resident was assessed by nurse. There was no swelling or deformity. The resident complained of pain 2/10 and was medicated per MD orders. NP was notified on 7/22/2023 at approximately 4:30pm. Orders for x-rays were obtained at approx. 7:00pm. Resident #1 responsible party was notified. X-ray results were obtained at approx. 8:00pm. X-ray showed no dislocation or fracture. Resident continued complaints of pain. Resident was sent to the hospital for further evaluation. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: All residents have the potential to be affected. On 7/23/23, nurse aide staff were reeducated on the need for residents' wheelchairs to be checked prior to pushing residents in the wheelchairs. The center's transport company requires residents in wheelchairs to have leg rests on as a safety requirement for transportation while in the transport vehicle. Staff educated on wheelchair safety techniques to include the use of leg rests for those that are unable to self-propel or for those that are unable to hold their legs up on command while being pushed in a wheelchair. Residents with wheelchairs are evaluated by the Rehab Team for the need of leg rests to aide in the resident's mobility via wheelchair. Residents that decline the use of leg rests will be educated regarding the use of leg rests and if continue to decline, preferences will be honored. Nurse aide staff were also educated on how to access the resident Kardex in PCC and the expectation of when to check the Kardex in order to identify if the resident requires leg rests prior to being pushed in the wheelchair. Any nurse aide staff that could not be reached within the initial reeducation timeframe of 24 hours will not take an assignment until they have received reeducation by the DON/designee. Agency nurse aide staff and newly hired nurse aide staff will have this education in orientation period by the DON/Staff Development Coordinator/designee. On 7/24/2023, a 30-day lookback of incidents involving residents dependent of wheelchairs with leg rests for mobility being transported by wheelchair was completed by the Regional Clinical Director with no findings identified. On 7/24/2023, ad-hoc QAPI conducted with Medical Director included to review the incident and plan to correct. On 7/25/2023, all wheelchairs will be checked by Maintenance and Therapy Director to ensure leg rests are available and appropriate leg rests are with each wheelchair. Any issues will be corrected immediately. Address what measures will be put in place or systemic changes made to ensure that the identified issue does not occur in the future: All CNA staff will review the Kardex prior to transporting resident in wheelchair to identify need for leg rests and they will ensure if leg rests are needed they are securely attached to the wheelchair. Monitoring: The DON/designee will perform random audits of 10 residents per week for who are in wheelchairs to ensure leg rests are available and applied to the wheelchair prior to staff pushing residents. Audits will occur 3x weekly x 4 weeks, then 2x weekly x 4 weeks, then 1x per week x 4 weeks. Data obtained during the audit process will be analyzed for patterns and trends and reported to QAPI by the Director of Nursing monthly x 3 months. At that time, the QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Date of compliance: 7/26/2023 Observations made throughout the survey revealed the resident did not leave her bed unless she went out for dialysis. While she was in her bed, the wheelchair was always observed with footrests. Residents' that were mobile throughout the facility and needed them, had leg rests on their wheelchairs. The corrective action plan was verified through record review of the education logs, audit reports of the event reporting, root cause analysis, resident care guide audits, and observations. Based on the observations and record review, the facility's compliance date of 7/26/23 was verified.

Based on record review and staff interviews, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. The findings included: During an interview with the Director of Nursing (DON) on 10/11/2023 at 9:16 A.M. she revealed the Infection Preventionist (IP) was responsible for the facility's Infection Prevention and Control Program. The DON stated the IP was new to the position and had not completed the required training program for the IP position yet. The DON stated did not have any staff members with specialized training to meet the qualifications for the IP role. An interview was conducted with the IP on 10/11/2023 at 11:04 A.M. She revealed she was new to the position and the facility planned for her to attend the next training session on 11/8/2023, to complete the required specialized training. She stated she was shown how to monitor infections in the facility but had not had the specialized training regarding the Infection Prevention and Control program. During an interview on 10/11/23 at 2:12 P.M. the Administrator revealed he was aware the IP had not completed the required training for the Infection Preventionist position. The Administrator stated he was aware the IP role required specialized training but thought the IP would continue the position until she attends the specialized training on 11/8/2023.

Based on observation and staff interviews, the facility failed to maintain the area surrounding the dumpsters free of debris and failed to close the doors to dumpsters that contained waste for 2 of 3 dumpsters observed. This practice had the potential to attract pests and rodents. The findings included: During an observation of the dumpster area with the Assistant Dietary Manager (DM) on 10/9/23 at 10:23 AM, 2 bags of trash and 2 empty cardboard boxes were found in between dumpster #1 and dumpster #2. A bag of trash was also found in front of dumpster #3. The top and left doors to dumpster #1 and the left door to dumpster #2 were found open. The assistant DM stated that the dumpster area was in this state upon arrival for her shift, and the housekeeping department was assigned to maintaining the dumpsters. During an interview with the assistant DM on 10/9/23 at 10:37 AM, she revealed that maintenance or housekeeping managed the dumpster area. If anything was left on the ground, housekeeping usually cleaned it up. An interview was conducted with the Housekeeping Manager on 10/11/23 at 7:34 AM. She revealed that dietary and maintenance were responsible for managing the dumpster area. However, the housekeeping manager indicated that she instructed the housekeepers to take the initiative and pick up trash they may have seen around the dumpsters. During an interview with the Maintenance Director on 10/11/23 at 7:46 AM, he revealed that he made daily rounds to ensure items were picked up off the ground and all doors to the dumpsters were closed. He indicated trash was picked up on Monday/Wednesday/Friday and recycling removal was designated on Tuesday/Thursday. The Maintenance Director stated that he was notified by the Director of Nursing on 10/9/23 about the items on the ground, and he picked them up soon after. The Administrator was interviewed on 10/11/23 at 2:40 PM. He stated the dumpster area should have been clean and clear of all discarded items, and anyone that disposed of garbage should have been managing that area. The Administrator indicated that no single department was delegated to the dumpster area.

Based on record review, staff interviews, and Responsible Party (RP) interview, the facility failed to provide an ongoing resident centered activities program that included activities to meet the interests of a resident that did not participate in group activities for 1 of 1 residents reviewed for activities (Resident #100). The findings included: Resident #100 was admitted to the facility on [DATE] with diagnoses which included stroke and anxiety. Resident #100's care plan dated 7/28/23 revealed his past hobbies included watching college sports, golf, soccer, and football. The interventions included providing a program of activities to accommodate Resident #100's communication abilities which included listening to music, television, and conversation that required little to no response. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #100 had severely impaired cognition and unclear speech. Resident #100 was coded for depressed feelings during the look back period and anxiety. An observation on 10/09/23 at 12:00 pm revealed Resident #100 was alone in his room sitting in his wheelchair on the left side of the bed away from the window without the television or music on. During an interview on 10/09/23 at 12:23 pm with Resident #100's Responsible Party (RP) she revealed Resident #100 was unable to participate in group activities related to his anxiety. Resident #100's RP revealed she was present every day for extended periods of time and had not seen anyone from the activity department offer activities or engage in activities with Resident #100. An observation on 10/10/23 at 12:18 pm revealed Resident #100 was alone in his room sitting in his wheelchair on the left side of the bed away from the window without the television or music on. An interview was conducted on 10/10/23 at 3:17 pm with Activity Assistant #1 who revealed she had been in the position for a few months and had never provided activities for residents that did not participate in the planned group activities. She stated she delivered an activity calendar to all residents and encouraged attendance but did not provide individual activities for Resident #100. An interview was conducted on 10/10/23 at 3:19 pm with Activity Assistant #2 who revealed she was new to the position, and she had not provided any activities for resident #100. During an interview on 10/10/23 at 3:20 pm with the Corporate Activity Director she revealed she was assisting the facility until the new Activity Director arrived. She stated she discussed individualized activities for those residents that did not participate in group activity with the activity staff when she identified they were not provided, and she updated the current activity calendar to include activities for those residents that do not attend group activities. An interview was conducted with the Administrator on 10/12/23 at 12:01 pm who revealed he was not aware the activities department did not offer individual activities to residents that did not participate in the planned group activities.

Based on record review and staff interviews, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #109). The findings included: Resident #109 was admitted to the facility on [DATE] with a diagnosis of dementia with agitation. The hospital discharge summary dated 9/14/23 for Resident #109 revealed an order for risperidone (an antipsychotic medication) 0.5 milligrams (mg) at bedtime. There was no diagnosis listed for the risperidone medication on the hospital discharge summary. A physician order dated 9/14/23 for risperidone (an antipsychotic medication) 0.5 mg at bedtime for mood disorder. Resident #109's care plan initiated on 9/14/23 revealed she had impaired cognitive function related to dementia and use of psychotropic medications. The care plan interventions included to monitor for changes in function which included level of consciousness, memory recall, mental status, difficulty expressing self/understanding others. Review of the Psychotropic Medication Note dated 9/14/23 at 3:44 pm by the Unit Manager revealed the interdisciplinary team (IDT) reviewed and discussed Resident #109's psychotropic medication. Resident #109 was prescribed risperidone tablet 0.5 mg at bedtime for dementia without behavior disturbance, psychotic disturbance, and mood disturbance. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #109 had severe cognitive impairment and was not coded for behaviors or rejection of care. Resident #109 received antipsychotic medication for 7 of 7 days during the assessment period. A review of Resident #109's electronic medical record from 9/14/23 through 10/11/23 revealed no documentation regarding the completion of an AIMS assessment since admission to the facility. The AIMS assessment was utilized to detect Tardive Dyskinesia in residents prescribed antipsychotic medications. An attempt to interview the Nurse Practitioner on 10/11/23 at 2:30 pm was unsuccessful. During an interview on 10/12/23 at 9:50 am the Unit Manager revealed she did review Resident #109's psychotropic medications upon admission but she was unable to state how the AIMS assessment was missed for the antipsychotic medication. An interview was conducted on 10/12/23 at 11:13 am with Nurse #4, who completed Resident #109's admission, stated when a resident was on an antipsychotic medication upon admission the AIMS assessment would be triggered when the medication answer box was checked. She stated she did not trigger the AIMS assessment for Resident #109's risperidone medication by error. An interview was conducted on 10/12/23 at 9:37 am with the Director of Nursing (DON) who revealed the AIMS assessment for Resident #109 should have been completed upon her admission to the facility. The DON stated the AIMS assessment was performed to monitor for side effects from antipsychotic medication and was required to be completed when a new antipsychotic medication was ordered or the dose was increased, and then repeated quarterly. The DON was unable to state how the AIMS assessment was missed during the chart review process for Resident #109's antipsychotic medication. During an interview on 10/12/23 at 12:00 pm the Administrator revealed the AIMS assessment should have been identified as not completed during the new admission review which was completed by nursing management. The Administrator stated the DON was responsible to ensure the AIMS assessment was completed for Resident #109's antipsychotic medication.

Based on record review and staff interviews, the facility failed to develop a written individualized person-centered care plan in the area of antidepressant medication use (Resident #100), and anticoagulant medication use (Resident #53) for 2 of 27 residents reviewed for care plans. The findings included: 1. Resident #100 was admitted to the facility on [DATE] with diagnoses which included anxiety and stroke. A physician order dated 6/12/23 for fluoxetine 20 milligram (mg) capsule (medication used to treat depression) daily for mood disorder. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #100 had severe cognitive impairment and was coded for antidepressant medications. Review of Resident #100's care plan last reviewed 8/03/23 revealed there was not a care plan in place for antidepressant medication use. During an interview on 10/11/23 at 11:07 am MDS Nurse #1 revealed she was responsible for developing resident care plans. The MDS Nurse was unable to state why Resident #100's care plan was not developed for the antidepressant medication. An interview was conducted on 10/11/23 at 1:54 pm with the Director of Nursing (DON) who revealed the MDS Nurse #1 was responsible for developing Resident #100's care plan for the antidepressant medication. An interview was conducted with the Administrator on 10/12/23 at 11:57 am who revealed the MDS Nurse #1 was responsible to ensure Resident #100's care plan was in place for the antidepressant medication. 45789 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation. The active physician's orders revealed an order dated 5/17/2023 for Eliquis (anticoagulant medication) tablet 5 milligrams twice a day at 8am/8pm. Resident #53's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was moderately cognitively impaired and coded for anticoagulant medication. The active comprehensive care plan last reviewed on 8/10/2023 revealed anticoagulant medication therapy was not referenced in the care plan. During an interview with the MDS Nurse #1 on 10/10/2023 at 12:38 P.M. she revealed she was not sure how she forgot to document Resident #53's anticoagulant therapy on the care plan during the quarterly review of the plan. An interview was conducted with the Director of Nursing (DON) on 10/11/2023 at 9:31 A.M. She revealed it was the responsibility of the MDS Nurse to ensure Resident #53's care plan to be comprehensive. During an interview on 10/11/2023 at 1:31P.M. the Administrator revealed a care plan was expected to be implemented for any medication or diagnosis that required monitoring or treatment.

Based on record review and staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a new antidepressant medication and placement of an alert bracelet (an elopement alarm) for 1 of 1 resident reviewed for notification of change (Resident #109). The findings included: Resident #109 was admitted to the facility on [DATE] with a diagnosis of dementia. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #109 had severely impaired cognition and was not coded for behaviors including wandering. A physician order dated 9/25/23 for trazadone (antidepressant medication) 50 milligrams at bedtime for insomnia. Record review of the Elopement Risk Screen completed on 9/27/23 revealed Resident #109 was identified as an elopement risk. A physician order dated 9/28/23 for alert bracelet to be placed on left leg for dementia. A review of the nursing progress notes from 9/14/23 through 10/11/23 revealed there was no documentation that Resident #109's RP was notified of the new antidepressant medication or the application of the alert bracelet. An interview was conducted with Resident #109's RP #1 on 10/09/23 at 11:20 am who revealed he did not know why the alert bracelet was placed on her ankle but stated it was on her ankle when he arrived one day to visit. RP #1 stated Resident #109 was started on a new medication, and he was not notified until he asked the Director of Nursing (DON) a week ago about the psychiatric consultation that was ordered and was told she was on a new medication. An interview was conducted with Resident #109's RP #2 on 10/11/23 at 2:09 pm who revealed he was not notified of the alert bracelet placement until he saw it on her ankle when visiting. He stated he was not notified about new medications when they were started until they visited and asked if the psychiatric consultation had been completed. RP #2 stated the communication from the staff regarding the care and treatment provided at the facility was not consistent. An interview was conducted on 10/12/23 at 9:50 am with the Unit Manager who revealed she entered Resident #109's physician orders for the antidepressant medication and alert bracelet. The Unit Manager stated Resident #109's RP should have been notified about the new medication and placement of the alert bracelet, but she was unable to remember if she had notified them when they were at the facility. During an interview on 10/11/23 at 1:39 pm the DON revealed Resident #109's RP should have been notified by the Unit Manager when the new medication and the alert bracelet were ordered.

Based on record review, resident and staff interviews, the facility failed to honor a resident's bathing preference when showers were not provided as scheduled for 1 of 4 dependent residents (Resident #71) reviewed for choices Findings included: Resident #71 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed that Resident #71 was cognitively intact. He was also coded as physical help in part by 1 staff member for bathing and was not coded for rejection of care. Resident #71's care plan last revised on 7/28/23 revealed he had an activities of daily living (ADL) functional deficit due to impaired vision. Interventions included 1-person assistance with bathing. Review of the facility shower book revealed Resident #71 was scheduled for showers on Tuesday and Friday on the 3:00 PM - 11:00 PM shift. Review of the facility bathing history from 9/23/23 through 9/30/23 revealed Resident #71 was provided with a bed bath on 9/26/23 and 9/29/23 instead of his scheduled shower. There was no documentation that Resident #71 received any showers during that timeframe. An interview was conducted with Resident #71 on 10/09/23 at 11:44 AM. He revealed that he had not received his scheduled showers during the last week of September 2023 and was supposed to receive showers on Tuesday and Friday. He was unsure of why he didn't receive his showers as scheduled. During a follow-up interview with Resident #71 on 10/11/23 at 1:05 PM, he revealed he had never refused a shower and did not refuse a shower during the last week of September. Nurse Aide (NA) #3, who worked from 3:00 PM - 11:00 PM with Resident #71 on 9/26/23 (Tuesday) and 9/29/23 (Friday) from 7:00 PM - 11:00 PM, was interviewed. He revealed he could not recall if he gave Resident #71 a shower on 9/26 or 9/29. NA #3 indicated Resident #71 had never refused a shower from him. An interview was conducted with NA #1 on 10/11/23 at 3:14 PM. She worked with Resident #71 on 9/29/23 (Friday) from 3:00 PM - 7:00 PM. NA #1 revealed that she offered the resident a shower on 9/29 before 7:00 PM, but he was not ready yet. At 7:00 PM, there was a shift change in room assignments, and she was not sure what happened later that evening. NA #1 stated Resident #71 had never refused showers from her before. The Director of Nursing (DON) was interviewed on 10/11/23 at 12:14 PM, and she revealed that each floor had a shower schedule to provide showers to residents on specific days. The DON indicated staff should always ask if residents wanted their shower on their designated day and if they said no, then nursing staff should ask for it to be rescheduled or provide a bed bath instead. She stated that nursing staff were expected to document the bathing activity of each resident and notify the nurse on duty if they had refused or preferred another day/time for their shower. During a follow-up interview with the DON on 10/12/23 at 8:15 AM, she stated that if Resident #71 preferred showers as the bathing activity and wanted them on his regularly scheduled day, then he should have received them per his preference. If he wanted it later in the shift, that was not considered a refusal. Nursing staff should notify the nurse on duty of the shower status, whether he refused or wanted it later with accurate documentation of what really happened. An interview was conducted with the Administrator on 10/11/23 at 2:38 PM, and he revealed the facility should have fulfilled Resident #71's preference for a shower on his scheduled days.

Based on record review, and staff and resident interviews, the facility failed to invite the resident or resident responsible party to participate in the care planning process for 1 of 27 residents whose care plans were reviewed (Resident #77). Findings included: Resident #77 was admitted to the facility on [DATE]. Review of a Social Service progress note dated 12/6/22 at 1:47 PM revealed a quarterly care plan meeting was held with Resident #77. Review of a Social Service progress note dated 2/2/23 at 10:55 AM revealed the interdisciplinary team (IDT) met with Resident #77 about his care plan. His family member joined by phone halfway through the meeting. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 had been assessed as moderately cognitively intact. Review of Resident #77's care plan revealed it had been reviewed and revised on 7/14/23, but there was no indication that the resident or responsible party had participated in the care plan meeting. During an interview on 10/9/23 at 12:49 PM, Resident #77 stated he had not been invited to attend a care plan meeting and did not recall participating in developing his plan of care since his initial admission into the facility. The Social Services Assistant (SSA) was interviewed on 10/11/23 at 9:07 AM, and she revealed that she or the Social Worker (SW) coordinated care plan meetings. After a resident was admitted , care plan meetings were held every 90 days. Documentation of care plan meetings were in progress notes of the medical record. The SSA indicated that care plan meetings were not normally held without documentation. During a follow-up interview with the SSA on 10/11/23 at 10:35 AM, she revealed that she could not recall holding a care plan meeting with Resident #77 after 2/2/23. She stated she usually followed the MDS assessment calendar and used that as a guide to schedule care plan meetings. The SSA further stated Resident #77 was not included on the MDS calendar from March through July 2023, and therefore, was not invited to a care plan meeting during that time. She indicated residents were usually notified with a verbal invitation and resident representatives via telephone. During an interview with MDS Nurse #1 on 10/11/23 at 11:02 AM, she revealed she could not give details as to why Resident #77 was not included on the MDS assessment calendar referenced for care plan meetings. She indicated Resident #77 should have been on the MDS calendar for the months of April and July because that was when his quarterly assessments were due. The SW was interviewed on 10/11/23 at 10:11 AM. She revealed that care plan meetings were organized by herself, and the Social Services Assistant based on the MDS assessment calendar. The SSD indicated that care plan meetings were supposed to be held every 3 months, and the meeting activity was documented in progress notes of the medical record. There was a care plan meeting held with Resident #77 and the SSD back in April around his birthday but was not documented. Resident #77's responsible party was included via telephone. During an interview with the Director of Nursing (DON) on 10/11/23 at 12:09 PM, she revealed Resident #77 and the responsible party should have been invited to his scheduled care plan meeting. An interview was conducted with the Administrator on 10/11/23 at 2:34 PM, and he revealed Resident #77 should have been invited to a care plan meeting at least quarterly.

Based on observation, staff interviews, and record review, the facility failed to remove soiled gloves before placing a clean inner cannula in Resident #95's tracheostomy (surgical opening in windpipe for air/oxygen) for 1 of 1 residents reviewed for tracheostomy care. The findings included: Record review of the Facility Infection Prevention and Control Program (IPCP) Policy last revised October 2018 revealed the program was based on accepted national infection control prevention and control standards. The policy further stated important facets of infection prevention included educating staff to adhere to proper techniques and procedures and communicating the importance of standard precautions. Review of the Facility Tracheostomy Care Policy last revised 4/24/18 revealed staff were to wash hands, put on clean gloves and remove the soiled dressing and inner cannula, then remove soiled gloves, discard in waste bag, and wash hands. The policy further directed staff to open sterile tracheostomy kit onto sterile drape then put on sterile gloves to clean the tracheostomy site and place new inner cannula. Record review of Nurse #1's tracheostomy care competency dated 9/27/23 revealed she was found to be competent to perform tracheostomy care to residents. During a continuous observation of tracheostomy care on 10/11/23 at 10:17 am through 10:25 am Nurse #1 was observed to perform hand hygiene, open the sterile tracheostomy kit, place the sterile gloves on and place the supplies from the sterile tracheostomy kit onto the sterile drape. Nurse #1 was then observed to remove the inner cannula and the soiled drain sponge from Resident #95's tracheostomy and placed in the trash container. Nurse #1 then took the new inner cannula and placed it into Resident #95's tracheostomy, cleaned the tracheostomy site with saline soaked gauze, and then placed a new drain sponge dressing under the tracheostomy collar. Nurse #1 did not change the gloves and perform hand hygiene after the removal of the soiled tracheostomy drain sponge and used inner cannula before placing new inner cannula and cleaning the tracheostomy site. During an interview on 10/12/23 at 9:56 am Nurse #1 revealed she thought the sterile gloves were used for the entire tracheostomy care process including removal of soiled items, cleaning, and placing new inner cannula. She confirmed she did not change her gloves or perform hand hygiene before cleaning the tracheostomy site and placing the new inner cannula in Resident #95's tracheostomy. Nurse #1 stated received training on tracheostomy care annually at the facility. An interview was conducted on 10/12/23 at 10:03 am with the Director of Nursing (DON) who revealed Nurse #1 was required to remove the soiled gloves and perform hand hygiene after she removed Resident #95's used inner cannula and soiled drain sponge. The DON stated after hand hygiene was completed the sterile gloves were to be used to place the new inner cannula and clean Resident #95's tracheostomy site. During an interview on 10/12/23 at 11:07 am with the Infection Preventionist (IP) revealed she completed Nurse #1's tracheostomy competency assessment which included return demonstration and education. The IP stated Nurse #1 was educated to use clean gloves for removal of the soiled items then perform hand hygiene before donning the sterile gloves for the placement of the new inner cannula.

Based on record review and staff interviews, the facility failed to 1) post accurate licensed nurse staffing data for 10 of 10 days reviewed for sufficient staffing (10/01/23-10/10/23), and 2) failed to post accurate census data for 2 of the 4 days during the survey (10/09/23 and 10/10/23). The findings included: A review of the posted nursing staffing data from 10/01/23 through 10/10/23 revealed the following: 1. a. A review of the Daily Staffing Hours data sheets for the 6:45 am-3:15 pm shift revealed the licensed nursing staff was not recorded accurately for the following days: 10/01/23-Daily Staffing Hours data sheet recorded 2 Registered Nurse (RN) and 4 Licensed Practical Nurse (LPN); staff assignment data recorded 1 RN and 4 LPN. 10/02/23-Daily Staffing Hours data sheet recorded 4 RN and 2 LPN; staff assignment data recorded 1 RN and 5 LPN. 10/03/23-Daily Staffing Hours data sheet recorded 2 RN and 4 LPN; staff assignment data recorded 1 RN and 5 LPN. 10/04/23-Daily Staffing Hours data sheet recorded 3 RN and 3 LPN; staff assignment data recorded 2 RN and 4 LPN. 10/05/23-Daily Staffing Hours data sheet recorded 3 RN and 2 LPN; staff assignment data recorded 0 RN and 6 LPN. 10/06/23- Daily Staffing Hours data sheet recorded 3 RN and 3 LPN; staff assignment data recorded 1 RN and 5 LPN. 10/07/23- Daily Staffing Hours data sheet recorded 3 RN and 5 LPN; staff assignment data recorded 0 RN and 7 LPN. 10/08/23- Daily Staffing Hours data sheet recorded 5 RN and 2 LPN; staff assignment data recorded 1 RN and 5 LPN. 10/09/23- Daily Staffing Hours data sheet recorded 4 RN and 3 LPN; staff assignment data recorded 1 RN and 6 LPN. 10/10/23- Daily Staffing Hours data sheet recorded 4 RN and 2 LPN; staff assignment data recorded 1 RN and 5 LPN. b. A review of the Daily Staffing Hours data sheets for the 2:45 pm-11:15 pm shift revealed the licensed nursing staff was not recorded accurately for the following days: 10/02/23- Daily Staffing Hours data sheet recorded 1 RN and 5 LPN; staff assignment data recorded 0 RN and 6 LPN. 10/03/23- Daily Staffing Hours data sheet recorded 2 RN and 4 LPN; staff assignment data recorded 0 RN and 6 LPN. 10/04/23- Daily Staffing Hours data sheet recorded 3 RN and 4 LPN; staff assignment data recorded 0 RN and 6 LPN. 10/05/23- Daily Staffing Hours data sheet recorded 3 RN and 3 LPN; staff assignment data recorded 1 RN and 5 LPN. 10/06/23- Daily Staffing Hours data sheet recorded 3 RN and 3 LPN; staff assignment data recorded 0 RN and 6 LPN. 10/07/23- Daily Staffing Hours data sheet recorded 2 RN and 5 LPN; staff assignment data recorded 1 RN and 6 LPN. 10/08/23- Daily Staffing Hours data sheet recorded 4 RN and 2 LPN; staff assignment data recorded 3 RN and 3 LPN. 10/09/23- Daily Staffing Hours data sheet recorded 2 RN and 4 LPN; staff assignment data recorded 0 RN and 6 LPN. 10/10/23- Daily Staffing Hours data sheet recorded 4 RN and 2 LPN; staff assignment data recorded 1 RN and 5 LPN. c. A review of the Daily Staffing Hours data sheets for the 10:45 pm-7:15 am shift revealed the licensed nursing staff was not recorded accurately for the following days: 10/01/23- Daily Staffing Hours data sheet recorded 3 RN and 2 LPN; staff assignment data recorded 1 RN and 4 LPN. 10/02/23- Daily Staffing Hours data sheet recorded 2 RN and 3 LPN; staff assignment data recorded 0 RN and 5 LPN. 10/03/23- Daily Staffing Hours data sheet recorded 2 RN and 3 LPN; staff assignment data recorded 1 RN and 4 LPN. 10/04/23- Daily Staffing Hours data sheet recorded 1 RN and 4 LPN; staff assignment data recorded 0 RN and 5 LPN. 10/05/23- Daily Staffing Hours data sheet recorded 2 RN and 3 LPN; staff assignment data recorded 0 RN and 5 LPN. 10/06/23- Daily Staffing Hours data sheet recorded 3 RN and 2 LPN; staff assignment data recorded 0 RN and 5 LPN. 10/07/23- Daily Staffing Hours data sheet recorded 2 RN and 3 LPN; staff assignment data recorded 1 RN and 4 LPN. 10/08/23- Daily Staffing Hours data sheet recorded 2 RN and 2 LPN; staff assignment data recorded 1 RN and 3 LPN. 10/09/23- Daily Staffing Hours data sheet recorded 2 RN and 3 LPN; staff assignment data recorded 0 RN and 5 LPN. 10/10/23- Daily Staffing Hours data sheet recorded 2 RN and 3 LPN; staff assignment data recorded 0 RN and 5 LPN. An interview was conducted with the Staffing Scheduler on 10/11/23 at 11:13 am who revealed she was responsible for completing the Daily Staffing Hours data sheets and confirmed the assignment data sheets were the actual staff that worked on a specific date. She stated she did not know why the licensed nursing data was incorrect but stated it may have been an error with the system. The Staffing Scheduler stated she could check the Daily Staffing Hours data sheets on the assignment data sheets for accuracy before she posted them, but she did not because she believed them to be correct when she printed them. An interview on 10/11/23 at 1:59 pm with the Director of Nursing (DON) revealed the Staffing Scheduler was responsible to post accurate licensed nursing information on the Daily Staffing Hours data sheet. During an interview on 10/12/23 at 12:03 pm the Administrator revealed the Staffing Scheduler was responsible for ensuring the Daily Staffing Hours data sheets were accurate for licensed nursing staff working. 2. Review of the Daily Staffing Hours data sheet dated 10/09/23 at 10:17 am revealed the facility census was listed as 120. A review of the Daily Staffing Hours data sheet dated 10/10/23 at 9:08 am revealed the facility census was listed as 120. Record review of the Resident List Report dated 10/09/23 provided by the Assistant Administrator revealed the facility census on 10/09/23 was 118. Record review of the Facility Midnight Census Report dated 10/10/23 provided by the Assistant Administrator revealed the facility census on 10/10/23 was 121. During an interview on 10/11/23 at 11:13 am the Staffing Scheduler revealed she was responsible for completing the Daily Staffing Hours data sheet. She stated she was normally given the facility census at the morning meeting, and she would update the sheets as needed. The Staffing Scheduler stated she completed and printed the Daily Staffing Hours Data sheets on Friday for Saturday through Monday with the information she had at that time, and the nursing supervisor posted the sheets. She stated she did not review the 10/09/23 or 10/10/23 Daily Staffing Hours data sheets for accurate facility census before they were printed. An interview on 10/11/23 at 1:59 pm with the DON revealed the Staffing Scheduler was responsible for posting accurate information on the Daily Staffing Hours data sheet. During an interview on 10/12/23 at 12:03 pm the Administrator revealed he was unsure who was responsible for ensuring the facility census was accurate on the Daily Staffing Hours data sheet.

Based on record review, staff and Medical Director interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On [DATE] Nursing Assistant (NA) #1 began providing care to Resident #1 who was on an alternating air pressure mattress, she left the resident on his right side with the bed at waist height and exited the room to speak with the nurse and obtain supplies. While unattended, Resident #1 fell off the bed onto his back on the floor hitting his head, resulting in a hematoma (a pool of mostly clotted blood that forms in an organ, body tissue or body space) to the back of his head, shoulder pain, and left scalp pain. Resident #1 was transferred to the emergency room and prior to Computerized Tomography (CT) scan being performed the resident went into cardiac arrest and was unable to be revived. The findings included: Resident #1 was most recently admitted to the facility on [DATE] with diagnoses that included quadriplegia, acute transverse myelitis (transverse myelitis interrupts the messages that the spinal cord nerves send throughout the body), and osteoporosis. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] revealed he was cognitively intact. He was assessed as dependent on 2 or more staff for assistance with bed mobility and upper and lower extremity impairment on both sides. Resident #1 was not coded for any falls since the prior assessment. Review of the active physician orders for [DATE] revealed Resident #1 had an order for a pressure reduction mattress (alternating air pressure mattress). Resident #1's active care plan on [DATE] (last revised on [DATE]) revealed he was at risk for falls related to quadriplegic status and immobility and muscle spasms. Interventions included assist resident with ADL's, The Occurrence note completed by Nurse #1 dated [DATE] revealed the writer was called to the room by the housekeeper yelling Resident #1 on the floor. When arriving to the room resident was noted flat on the floor beside his bed. A bump was noted on the back of his head, and when moving him he complained of left shoulder pain. He was assisted back to bed with a mechanical lift with 2 staff assist. The note indicated Resident #1 refused to go to hospital, States I'll be alright. The Fall Incident Report initiated on [DATE] and signed completed by Nurse #1 on [DATE] was reviewed. It revealed Resident #1 was found on the floor beside his bed, lying flat on his back. He was assessed for possible injury, noted with a bump/raised area on back of head. The Nurse Practitioner was notified and ordered to transfer out. NA #1 (agency staff) was interviewed on [DATE] at 5:32 PM. She indicated on [DATE] Nurse #1 stopped her in the hall and asked her to clean up Resident #1. When changing Resident #1 she noticed that his colostomy bag was leaking, she cleaned him up and told Nurse #1 the colostomy bag was leaking. Nurse #1 returned, changed the leaking bag and when NA #1 finished cleaning up the resident, he asked her to change his wound dressing. She indicated the resident was insistent that she change his dressing. NA #1 stated Resident #1 was in the middle of the bed when she stepped out of room to tell the nurse he wanted his dressing changed. She reported the next thing she knew the housekeeper was running in the hall yelling that Resident #1 was on the floor. NA #1 revealed that herself, Nurse #1, Nurse #2, and NA #2 all ran to the room and found Resident #1 lying on his back on the floor. She indicated Nurse #1 assessed the resident, and Nurse #2 encouraged him to go to the hospital and he refused. Resident #1 stated he was fine and wanted to get up off the floor. She and NA #2 used a mechanical lift to assist Resident #1 back to bed and once in bed he complained he was dizzy and nauseated. NA #1 stated she checked his vital signs, and informed Nurse #1 that he changed his mind and wanted to go to the hospital. NA #1 stated when she stepped out of the room to speak with the Nurse, Resident #1 was in the center of the bed and she had lowered his bed to her kneecaps. NA #1 stated she had no training on the alternating air pressure mattress and was not aware there was a static mode (a mode that ceased fluctuation of air pressure). NA #1 indicated she should have used pillows to support Resident #1 in bed when she left the room. NA #1 stated her staffing agency would not send her back to work at the facility. A phone interview was conducted with Nurse #1 on [DATE] at 10:39 AM. She revealed on [DATE] she had changed Resident #1's colostomy bag and when she left the room, his bed was left waist high, per the resident's choice. Shortly afterwards she heard a housekeeper running in the hall yelling, Resident #1 has fallen. Nurse #1 indicated she called Code Green (for fall) and she, the Unit Manager, NA #1, and NA #2 ran into the room. She stated Resident #1 was lying flat on his back on the floor. The bed was still at waist height. She assessed him and found a small bump on the back of his head; he was assisted back to bed using the mechanical lift. Resident #1 then insisted he did not want to go to the hospital. Nurse #1 revealed shortly after that, NA #1 came to tell her the resident complained he was dizzy and wanted to go to the hospital. She revealed when EMS arrived Resident #1's looked pale and the bump on the back of his head increased in size and fit in the palm of her hand. The Unit Manager was interviewed on [DATE] at 11:01 AM. She indicated she was called to the room [DATE] by the housekeeper and found Resident #1 was lying flat on his back on the floor. She indicated when she ran into Resident #1's, room, his bed was at waist height. She indicated that the resident did not want to go to the hospital and wanted to stay in the facility. Then staff informed her Resident #1 complained of a headache and wanted to go to the hospital. The Unit Manager indicated that Resident #1 had an oscillating air mattress and when NA #1 left the room to get supplies, he fell off the bed flat onto his back on the floor. She indicated NA #1 should not have left Resident #1 alone. She added that after the incident she took all of the third floor NA's into Resident #1's room and had them demonstrate they knew how to operate an alternating air pressure mattress. Nurse Aide #2 (NA) was interviewed on [DATE] at 11:05 AM, stated that she was called to the room on [DATE] to help get Resident #1 off the floor. She revealed after Nurse #1 had assessed the resident they (NA #1 and NA #2) used a mechanical lift to transfer Resident #1 back into bed. NA #2 indicated his bed was at waist level when she entered the room to assist. The Emergency Medical Services (EMS) report dated [DATE] revealed Resident #1 had a 3-foot fall from a nursing home bed with primary injury to his head. Other signs and symptoms included hypotension, injury to his shoulder and upper arm and nausea and vomiting. An emergency room report dated [DATE] revealed upon arrival at 11:21 AM EMS reported a Glasgow Coma Scale (a scale used to objectively describe the extent of impaired consciousness) score of 13 (indicative of a mild head injury) and an x-ray was conducted in the ER of Resident #1's pelvis and was negative for fracture. While in the trauma bay prior to CT scan, Resident #1 lost pulse and cardiopulmonary resuscitation was started. During resuscitation, he progressed through multiple irregular heartbeats and received defibrillation (delivers a dose of electric current to the heart). After greater than 40 minutes of resuscitation efforts he expired at 12:49 PM. A telephone interview was conducted with the Medical Director on [DATE] at 2:25 PM. He indicated X-rays taken in the emergency room were negative for fractures and his Glasgow Coma Scale revealed a mild head injury. He revealed the resident was on the way for a CT scan, went into bradycardia (abnormal heart rhythm), coded, and passed away in the hospital. The Medical Director revealed Resident #1 had no signs or symptoms of deterioration prior to the incident and the decline happened rapidly after the fall. He stated Resident #1 had had a high-level spinal injury prior to admission, Covid-19 within the last year and he could have been respiratory compromised. An interview on [DATE] at 3:15 PM with the Administrator revealed he and the DON were not in the facility at the time of the [DATE] fall and when staff informed him Resident #1 had passed, he reached out to his Corporate Nurse. He indicated he thought Resident #1's positioning in bed was not right and that when NA #1 left the room he rolled off the bed. The Administrator was notified of Immediate Jeopardy on [DATE] at 9:15 AM. The facility provided the following corrective action plan with a completion date of [DATE]: Overview of Event: On [DATE] at approximately 9:45am, Nurse #1 was in the room of Resident #1 administering medications. While in the room, she noted that his colostomy was leaking. She instructed Certified Nursing Assistant (CNA) #1 to clean the resident and she would return to replace the bag. Nurse #1 stated after care was provided by CNA #1, she returned to the room and changed the colostomy bag. Shortly after, CNA #1 came to Nurse #1 and asked her to change the dressing on Resident #1's buttocks because it was soiled. Nurse #1 was in the process of administering medications to other residents and stated she could not perform the dressing change at that specific time but would change the dressing as soon as possible. CNA #1 returned to Resident #1's room. CNA #1 needed to obtain a protective cover for Resident #1's wound on his buttocks. She exited Resident # 1's room again to speak with Nurse #1 leaving Resident #1 turned on his right side in the bed with bed at waist level height. Shortly after, at approximately 9:58am, a Housekeeper saw Resident #1 lying on the floor next to his bed, the housekeeper immediately called for help. At 9:59am, a Code Green (fall response code for the facility) was called by the Unit Manager and staff responded to the room. Nurse #1 entered the room and observed Resident #1 on the floor lying on his back. The resident was on the right side of the bed. Nurse #1 asked Resident #1 what happened, and he stated someone changed his mattress/setting and he fell off the bed. Nurse #1 informed Resident #1 that from her understanding, his mattress nor mattress settings were changed. Nurse #1 performed an assessment and noted a quarter size hematoma to the back of the resident's head. She assessed his shoulders and he complained of left shoulder pain. Nurse #1 instructed the CNA #1 to transfer the resident back to bed with the mechanical lift with two Certified Nursing Assistants. At 10:01am, staff retrieved the mechanical lift and transferred Resident #1 back to bed. Once Resident #1 was in bed, Nurse #1 continued to assess Resident #1 which included neuro checks. His pupils were equal and reactive, and he had no complaints of blurred vision. Nurse #1 performed range of motion and Resident #1 continued to complain of left shoulder pain. Nurse #1 informed Resident #1 that he would need to go to the hospital for further evaluation and he refused, stating he was fine. Approximately 15 minutes later Resident #1 complained of headache, dizziness, and nausea. Resident #1 agreed to go to the hospital. At 11:00am Emergency Medical Services (EMS) arrived and at 11:12am (EMS) transported the resident to the hospital. Nurse #1 notified his emergency contact and made the Provider aware of the incident. An investigation was initiated by the Administrator and Director of Nursing (DON) on [DATE]. Ad Hoc QAPI Committee Review: An Ad Hoc (Quality Assurance Performance Improvement) QAPI meeting was conducted on [DATE] by the QAPI Committee (Administrator, DON, Social Service Manager, Infection Prevention Control Officer, Minimum Data Set (MDS) Coordinator(s), Therapy Manager, Unit Manager(s), Business Office Manager, Activities Assistant Director, Maintenance Director, Dietary Assistant Manager and Medical Director) to discuss this event and plan to address the event. As well, the facility [NAME] President of Operations and Regional Clinical Director attended the meeting. Based upon record review, staff interview(s), Resident #1's environmental observation and CNA return demonstration, the QAPI Committee has identified the following root cause(s) of the event: 1. Root Cause: Resident positioned on his right side without stabilization (pillow, wedge etc.) and bed at waist level position per interview with CNA #1. CNA #1 left the room to speak to Nurse #1 to obtain supplies. Resident #1 was left unsupervised. Upon fluctuation of the air mattress, the resident's body shifted while in the turned position. Subsequently, the resident fell to the floor. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: - The Nurse assessed Resident #1 immediately when he was found on the floor. He initially refused to go to the hospital, but after further evaluation he agreed and was transported to the Hospital by EMS. Nurse #1 updated his emergency contact. At 12:49 pm per hospital records, Resident #1 was on the way for a CT scan. During transport Resident #1 became bradycardic. Subsequently, coding (cardiac arrest) and passing away. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice. - On [DATE], an audit of all residents who are currently on an air mattress was performed by the Maintenance Director to ensure they are functioning properly. No issues were identified. - On [DATE], all current residents were reviewed by the Therapy Director and Nursing Management to ensure their level of assistance for Activities of Daily Living (ADL) support accurately reflects the number of staff support needed (+1 or +2 assist) - On [DATE] an audit of all care plans/Kardex was performed by the MDS coordinator/designee to ensure ADL care plans are accurate and up to date. Any issues identified were corrected. - On [DATE], an audit of all residents who require air mattresses was performed by the DON/or designee. This audit included a review of the order to include checking function of the mattress. The care plan/Kardex was reviewed to ensure use of the air mattress is reflected. Any issues were corrected on [DATE]. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur: - On [DATE] the DON/or designee began education with all nursing staff including agency nursing staff on bed mobility, with emphasis upon turn/repositioning stabilization while in a turned position (with pillows, wedges, etc.), lowering the bed's height to a safe position prior to exiting the room and ensuring all supplies are readily available in the room prior to initiating care. If supplies are needed while in the room, call for assistance in obtaining the needed supplies. Do not leave the resident unsupervised with the bed height in a high position. - On [DATE] the DON/or designee initiated bed mobility competencies with all nursing staff including agency nursing staff, with emphasis upon turn/repositioning stabilization while in a turned position (with pillows, wedges, etc.) and lowering the bed's height to a safe position prior to exiting the room. - As a precaution on [DATE], the DON/or designee began education with all nursing staff including agency nursing staff on air mattress functionality (control modes-static and alternating). Specifically for residents on air mattresses, ensure the bed is placed into static mode for repositioning, then returned to alternate pressure (standard mode) once repositioning is completed. - On [DATE], the DON/designee began education with all licensed nurses including agency on the expectation that when dressings are soiled, they need to be changed in a timely manner by the Licensed Nurse. - Effective [DATE], nursing staff will not be allowed to work until the education including bed mobility competency is completed. - New Hire: Newly hired Nursing Staff (including agency) will be provided with this education by the facility Staff Development Coordinator (SDC) or designee during their orientation period. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision to monitor as part of this corrective action was made on [DATE]. - On [DATE], the Regional Clinical Director and [NAME] President of Operations provided education to the Administrator and Director of Nursing on the QAPI committee role in maintaining compliance with this plan. Additionally, any further identified quality issues should have interventions established to avoid further non-compliance. - Retention Questions with (5) staff related to air mattress functionality and checking Kardex for ADL support needs and bed height position to ensure safety of the residents. Questionnaires will be completed weekly for 12 weeks. - Observation competency for bed mobility will be completed weekly for 12 weeks with (3) staff to ensure emphasis upon turn/repositioning stabilization while in a turned position (with pillows, wedges, etc.), lowering the bed's height to a safe position prior to exiting the room and ensuring all supplies are readily available in the room prior to initiating care. If supplies are needed while in the room, call for assistance in obtaining the needed supplies. Do not leave the resident unsupervised with the bed height in a high position. - New Admissions will be reviewed 5x weekly in the clinical morning meeting to ensure the ADL support needs are accurate and care plan/Kardex is updated. Team Members include Director of Nursing, Unit Managers, Social Work Manager, Minimum Data Set (MDS) Coordinator, and Infection Control Nurse. The Director of Nursing will report the results of the plan of correction audits to the QAPI Committee. The QAPI committee will review the audits to make recommendations to ensure compliance is sustained and ongoing; and determine the need for further auditing beyond the three (3) months. The title of the person who is responsible for implementing and maintaining compliance with this plan: The Administrator and the Director of Nursing Completion Date: [DATE] Onsite validation was completed on [DATE] through staff interviews, observation, and record review. Inservice sign in sheets and staff interviews verified in-services were completed on bed mobility with an emphasis on turning/positioning/stabilization, ensuring all supplies are readily available prior to beginning care, calling for assistance if a need arises during care, air mattress safety and control modes, and bed height safety. Education was confirmed for agency nursing staff and facility nursing staff. Bed mobility competencies were verified. Education was also verified for the Administrator and DON on the QAPI committee's role in maintaining compliance. Observation of staff operating the air mattress control modes revealed no issues. Evidence of audits were reviewed for care plans/kardex, bed mobility, air mattress control modes and proper functioning, and bed height safety. Resident interviews were conducted with no issues identified. The facility's action plan was validated to be completed as of [DATE].

Based on observation, record review, and resident, staff, Nurse Practitioner and Medical Director interviews the facility failed to prevent a fall from bed during incontinence care. Nurse Aide #2 raised the bed to waist level to provide care and Resident #4 rolled off the bed to the floor after being turned on to her side. Resident #4 reported pain in her right thigh and denied hiting her head. Two days after the fall Resident #4 was sent to the hospital for evaluation due to tenderness on the right side of her head and temporary amnesia. A Computed Tomography (CT) of the head (a noninvasive medical exam or procedure that uses specialized X-ray equipment to produce cross-sectional images) was completed and noted a small subdural hematoma (collection of blood outside the brain). No surgical intervention was required. This was for 1 of 3 residents reviewed for accidents (Resident #4). The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a seizure disorder), hemiplegia affecting the left non dominant side, and glaucoma. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #4's cognition was intact. She had no behaviors and no rejection of care. Resident #4 required extensive assistance with 1 staff for bed mobility and the extensive assistance of 1 staff for toileting. Resident #4 had impairment of range of motion on one side upper and lower extremity and was always incontinent of bladder and bowel. Resident #4 was coded as no falls since prior assessment. Review of a physician's progress note dated 2/21/23 revealed Resident #4 had a critical hemoglobin at 6.8 on 2/10/23. She was admitted to the hospital for further workup due to chronic history of bleeding. A care plan initiated 6/7/2015 and last reviewed 2/27/23 revealed a focus that Resident #4 was at risk for falls related to stroke with left hemiplegia (paralysis) and was non ambulatory. The interventions included cue Resident #4 for safety awareness. An incident report dated 2/25/23 and written by Nurse # 5 indicated Nurse #5 was called to Resident #4's room by Nurse Aide #2. Resident #4 was lying on her back on the floor. Resident #4 had fallen from the bed onto the floor. Resident #4 complained that the top of her thigh where the brief closed was hurting. She was assessed by Nurse #5 and assisted back to bed by 2 staff. The Nurse Practitioner (NP) and Responsible Party were notified and made aware of the incident. The NP instructed the nurse to continue neurological checks and monitor the resident. An interview was conducted with Nurse Aide #2 on 3/21/23 at 3:36 PM. NA #2 stated she was completing her final care round for her shift on 2/25/23 and she went in to provide incontinence care to Resident #4. NA #2 explained she raised the bed to waist level and rolled the resident away from her on to the resident's left side. NA #2 stated Resident #4 only required one person to assist with turning to provide incontinence care. NA #2 stated she recalled an assist bar on the right side of the bed but none on the left. NA #2 stated Resident #4 was able to use the assist bar to help with turning but did not during this interaction. NA #2 stated when she reached towards the foot of the bed to retrieve a brief Resident #4 continued to roll on the floor. NA #2 stated she moved to the side of the bed where Resident #4 was laying and observed her crying a little. NA #2 stated Resident #4 complained of pain to her right groin but denied that her head hurt. A nursing progress note dated 2/25/23 and written by Nurse #5 revealed Nurse Aide (NA) #2 stated that as she rolled Resident #4 over to her left side and put brief under her, Resident #4 had a little more leeway in front of her, but she continued to roll off the bed. Resident #4 landed on her left side and rolled onto the floor on her back. NA #2 then made Nurse #5 aware of the situation. On visual assessment Resident #4 was on her back on the floor with her head pointing to the wall. She was not able to move all extremities due to decreased mobility. Nurse #5 manipulated the resident limbs. Resident #4 complained of pain in the right thigh in brief area. Resident #4 and NA #2 stated that the resident did not hit her head. Nurse #4 stated Resident #4 had a knot on the back of her head on the right side. Neurological assessments were initiated. An interview was conducted with Nurse #5 on 3/21/23 at 4:05 PM. Nurse #5 stated she was assigned to Resident #4 on 2/25/23 when she sustained a fall. Nurse #5 stated she was notified by NA #2 that Resident #4 had rolled out the bed onto the floor. Nurse #5 stated Resident #4 was laying on the floor on her back with her head towards the wall when she entered the room. Nurse #5 stated she assessed Resident #4 and felt a knot on the back of her head. Nurse #5 stated she was unsure if the knot was new or had already been there. Nurse #5 stated Resident #4 denied hitting her head and denied any tenderness to area when touched. Nurse #5 stated Resident #4 was cognitively intact and able to make her needs known. Nurse #5 stated she initiated neurological checks and notified the Nurse Practitioner. Nurse #5 stated no new orders were received and she was instructed to continue neurological checks monitor Resident #4 and report any changes. A review of the neurological assessments (a test of the mental status, motor function, cranial nerves, pupillary responses, reflexes, and vital signs) dated 2/25/23 at 6:30 AM through the assessment completed on 2/26/23 at 8:36 PM indicated no concerns with Resident #4's condition. Review of a nurse progress note dated 2/25/23 at 11:26 PM revealed Resident #4 was alert and responsive. Her neurological checks were within normal limits and there were no signs or symptoms of distress. Review of a nurse progress note dated 2/26/23 at 10:12 PM revealed Resident #4 had no signs or symptoms of distress. Resident #4 denied any pain or discomfort and neurological checks were within normal limits. Review of a nurse progress note dated 2/27/23 at 7:18 AM revealed Resident #4 had slept through the night without complaint of pain or discomfort after fall. Review of a nurse progress note entered by Nurse #6 dated 2/27/23 at 3:15 PM revealed Resident #4 was alert and responsive status post fall. Resident continued as needed acetaminophen (a pain medication) for generalized pain with effective results. An interview was conducted with Nurse #6 on 3/21/23 at 4:28 PM. Nurse #6 stated she was the nurse assigned to Resident #4 on 2/27/23. Nurse #6 stated Resident #4 was alert and oriented X 3 and did not complain of any pain during the time that she cared for her. The nurse stated Resident #4 was unable to recall the fall. During the interview Nurse #6 revealed Resident #4 was seen by the NP for follow-up after a fall. Nurse #6 further stated Resident #4 was sent to the hospital at her Resident Representative's request due to her concern that Resident #4 could not recall the fall. A Nurse Practitioner visit note dated 2/27/23 revealed Resident #4 was seen for new complaint of weakness, tremors, and poor appetite. Resident #4 had a mechanical fall on 2/25/23. There was no visible injury, however Resident #4 was unable to recall that she had fallen. The note indicated Resident #4 was cognitively at her baseline status during the examination. The Responsible Party (RP) was notified by the nurse practitioner of her assessment, and the note stated that Resident #4 ' s temporary amnesia (memory loss) was highly likely from the recent fall. The nurse practitioner offered to send Resident #4 to the hospital to get a head CT to rule out any head injury. The RP indicated that she wanted a head CT and Resident #4 was sent out to the emergency department for further evaluation. Review of a physician's order dated 2/27/23 revealed an order Xray right hip 2 view, left hip 2 view for complaint of pain. Review of the Xray results dated 2/27/23 for right hip and left hip revealed there were no fractures (cracking or breaking of the bone). An interview was conducted on 3/21/23 at 4:27 PM. The Nurse Practitioner (NP) stated she was notified by her on call team on 2/25/23 that Resident #4 had fallen and there were no changes in her neurological status. NP stated Resident #4 complained of a little tenderness on the right side of her head when she examined her on 2/27/23. The NP stated Resident #4 denied any nausea/vomiting and no complaint of a headache. The NP stated that she spoke with Resident #4 ' s RP about the temporary amnesia and she was very concerned. The NP stated she sent Resident #4 to the hospital for a CT scan, and she was admitted . A nursing note entered by Nurse #6 dated 2/27/23 revealed an order was received to send Resident #4 to the emergency room for head CT post fall and RP was made aware. The hospital discharge summary dated 3/3/23 indicated Resident #4 was seen in the emergency department on 2/27/23 after a fall on 2/25/23 and found to have a small subdural hematoma, acute on chronic anemia and acute kidney injury. The CT dated 2/27/23 revealed Resident #4 had an 8mm (millimeter) in width right subdural hematoma. Resident #4 was evaluated by neurology and no surgical interventions were recommended. A repeat brain CT conducted on 2/28/23 revealed no changes to the size of the right subdural collection. Resident #4 was to follow up with neurology as an outpatient for monitoring. The hospital records indicated Resident #4 remained in the hospital from 2/27/23 to 3/2/23 when she was discharged back to the facility. Resident #4 was alert, oriented and stable. There was no mention of tremors during Resident #4's hospital stay and her activity level was as tolerated. A nursing progress note dated 3/2/23 revealed Resident #4 was readmitted to the facility following a hospital stay for a fall resulting in a subdural hematoma. An observation of incontinence care was conducted on 3/21/23 at 10:42 AM with NA #4 that was caring for Resident #4. The NA turned Resident #4 towards her during the observation and Resident #4 was able to hold on to the assist bar to remain on her left side. The were no concerns with the observation. During an interview with Resident #4 on 3/21/23 at 2:10 PM she revealed she could not remember the fall but denied she had any pain from the fall. During an interview with the Medical Director on 3/21/23 at 4:15 PM revealed that he was made aware that Resident #4 had fallen from the bed and ended up with subdural hematoma. The Medical Director stated there was no real way to tell if the hematoma came from the fall or happened spontaneously with Resident #4's chronic history of bleeding. The Medical Director stated that Resident #4 was hemodynamically stable from a nursing point of view, and she was alert and oriented X 3 (alert to person, place and time) plus she had passed her neurological assessments. The Medical Director stated Resident #4 had no complaints or changes that would have prompted staff to send her out to the hospital prior to the NP's assessment. During an interview with the Director of Nursing (DON) on 3/21/23 at 4:53 PM, she stated that she had been notified of Resident #4 ' s fall by text on 2/25/23. The DON stated the facility initiated neurological checks and monitored Resident #4 for changes in condition. The DON stated an x-ray was conducted of Resident #4's right and left hips on 2/27/23 due to her complaint of tenderness in the groin area. The DON stated the results of the hip x-rays were both negative. The DON stated Resident #4 was cognitively at her baseline when she saw her on the morning of 2/27/23. An interview was conducted with the Administrator on 3/22/23 at 12:49 PM. The Administrator stated that upon learning of Resident #4's fall, an investigation was launched. The Administrator stated the root cause of Resident #4 ' s fall was the lack of an assist bar. The Administrator stated Therapy was involved and all residents that required assist bars were evaluated and assist bars were placed by maintenance. The Administrator stated she contacted Resident #4's responsible party about the results of the investigation and explained to her what additional steps would be followed. The Administrator stated she did not notice any tremors (shaking movements) during her interactions with Resident #4 on 2/26/23 and 2/27/23. The Administrator stated Resident #4 did not complain of any pain to her during her interactions on 2/26/23 and 2/27/23. The facility provided the following corrective action plan with a completion date of 3/17/23. 1.On 2/27/23 Resident #4 was sent to the emergency room per family request. The interdisciplinary team (IDT) reviewed the fall and implemented the following post fall interventions: scoop mattress and therapy screen. The care plan was reviewed and updated. 2.All residents that required assist bars for bed mobility were identified to be at risk. On 3/13/21 a facility observation was conducted by the IDT to determine residents with assist bars on their bed. Any resident determined to have assist bars will be reviewed by IDT to establish appropriate necessity. On 3/13/23, an audit was completed by Nursing Management to review side rail evaluations in Point Click Care to determine residents who were identified as needing assist bars to assist in mobility. These residents care plan/Kardex was reviewed to reflect use of assist bars/ 3.On 3/11/23, education was initiated by the SDC with all Nursing Staff on turning and repositioning of residents to ensure when turning a resident on their side turn the resident towards yourself. Do not turn a resident away from you. Additionally, education was provided on ensuring the Kardex was reviewed prior to performing care. The education will be included on new hire orientation for all newly hired nursing staff. Effective 3/11/23, Therapy in collaboration with Nursing Management will ensure side rail evaluations are completed quarterly on those residents identified as requiring assist bars. 4. On 3/11/23, reviews were initiated by Clinical Leadership to perform observations during ADL care to assess bed mobility and turning/repositioning. Re-education will be provided for any identified concerns observed during the observation. Observations will be conducted with (5) Nurse Aides weekly for 8 weeks or until pattern of compliance is maintained. Effective 3/11/23, observations will be made by Administrator or designee of 5 residents with assist bars ensuring that assist bar is present, location of, and it is on the care plan. Effective 3/11/23, during clinical meeting, therapy will provide any therapy/nursing communication forms for any resident including new admissions) who have been evaluated for the need for assist bars. Any resident evaluated for the need for assist bars will have assist bars placed by maintenance, Care Plan and Kardex will be reviewed and updated by MDS nurse. Audit results will be reported to the QAPI Committee by the Administrator and Director of Nursing monthly for a minimum of 2 months or until a pattern of compliance is established. DON and Administrator is responsible for implementing acceptable plan of correction. The corrective action plan was verified through record review of the education logs, audit reports of the event reporting, audits of the care plan and Kardex, audits of the side rail screen and an observation of incontinent care for Resident #4. Based on the observations and record review the facility ' s compliance date of 3/17/23 was verified.

Based on record review, staff interviews and interviews with a physician's assistant, and the hospital physician the facility failed to use 2 persons when transferring a resident with a mechanical lift according to the care plan for 1 of 1 resident (Resident #176) reviewed for accidents. The resident slid out of the lift pad onto the floor during the transfer and sustained multiple injuries that resulted in a spleen laceration, subarachnoid hemorrhage and rib fractures. The findings included: Resident #176 was admitted to the facility on [DATE] and had a diagnosis of multiple [CONDITION(S)] and age-related [CONDITION(S)]. The resident's active care plan noted the resident was at risk for falls and an intervention dated 1/13/21 was to be transferred with two staff members using a mechanical lift into a motorized wheelchair. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 6/1/21 revealed the resident was cognitively intact and required total assistance with 2 persons for transfers. The MDS noted the resident had impaired range of motion of the upper extremities on one side and impaired range of motion of the lower extremities on both sides. A nursing progress note dated 6/29/21 at 11:35 AM written by the Director of Nursing (DON) revealed the following: The DON was called to the resident's room and observed the resident lying on the floor. The resident was awake and alert and denied pain. The pelvis was manipulated with no pain. Shoulders checked with no complaints of pain or discomfort. Elbows and wrist flexed and checked for range of motion with no pain noted. Checked knees with no pain or discomfort noted. No non-verbal symptoms of pain or discomfort. Resident adamant that she was okay and she was not going to the hospital. As resident was being placed in the lift pad for assistance to the wheelchair, observed blood on the pillowcase. Upon rolling resident over, noted a laceration approximately 2 centimeters with active bleeding over top of a small hematoma. Resident informed of the need to go to the Emergency Department (ED). Resident was assisted back to bed via mechanical lift and ice applied to the area of bleeding. A note by the physician's assistant dated 6/29/21 at 2:30 PM noted the resident was evaluated post fall and had an occipital laceration approximately 1.5-2 centimeters in length observed with active bleeding. Resident was alert and oriented times 3 (person, place and time). Resident became nauseated with positional changes. Informed nursing staff to send to the ED for further evaluation. A nursing progress notes documented on 6/29/21 at 3:27 PM by Nurse #1 who was assigned to Resident #174 revealed she was called to the room and observed the resident laying on her back with the mechanical lift next to her. NA #1 stated the resident started having a spasm and slid out of the lift pad and she tried to break the resident's fall with her leg. Range of motion was within normal limits. Resident stated she was okay and did not want to go to the ED. Asked resident several times and she said she was fine and was not in any pain. When turning the resident to put her on the lift pad, noted blood on the back of her head. The resident was transferred back to bed with the mechanical lift. Ice was applied to the back of her head. The physician's assistant in the building assessed and gave new orders to send her to the ED. On 7/13/21 at 1:39 PM an interview was conducted with NA #1 who stated the resident had an appointment for a haircut on the morning of 6/29/21 and Housekeeper #1 was in the room and she thought as long as she had 2 people in the room it was okay to transfer the resident. The NA further stated when she lifted the resident in the lift the resident started shaking and having muscle spasms and slid out of the lift pad onto the floor. The NA stated she tried to break the resident's fall with her knee and the resident landed on the floor. The NA continued and stated she asked Housekeeper #1 to get the nurse. The NA was asked what she expected the housekeeper to do during the transfer of the resident and the NA stated: I don't even know. The NA stated she was trained after the incident and knows she would need another clinical person in the room with her for a lift transfer. On 7/16/21 at 9:10 AM a second interview was conducted with NA #1 in the room where Resident #176 resided when in the facility. The NA stated she raised the bed, put the lift pad under the resident and lifted the resident in the air above the bed and was moving the lift to place the resident in a motorized wheelchair when the resident started having spasms and slid out of the lift pad and fell on to the floor striking the NAs thigh/knee area on the way down. The NA stated the lift pad was approximately 4.5 to 5 feet off the floor when the resident slid out of the sling. The NA stated a housekeeper was standing about 3 feet inside the resident's room and she told the housekeeper to get the nurse. NA #1 was asked why she did not get another NA to assist with the transfer and the NA stated: I just don't know. On 7/13/21 at 2:10 PM Housekeeper #1 stated in an interview he was in the room and NA#1 had the resident up in the lift and the resident started jerking and sliding and the NA asked him to go get the nurse. The Housekeeper stated he notified the nurse and went back to his housekeeping cart. NA #1's orientation training dated 4/26/21 was reviewed and the NA was checked off as safe with transfers using a mechanical lift. The NA will request assistance as indicated and will use assistive devices according to the plan of care was checked. The NA was checked off as previous experience, demonstrated and/or instructed by the preceptor and return demonstration by the orientee. On 7/13/21 at 4:17 PM an interview was conducted with the medical records (MR) professional who was also a nursing assistant and checked off NA #1 on the skills checklist during her orientation on 4/28/21. The Medical Records person stated NA #1 was trained to transfer a resident with two persons when using a mechanical lift. On 7/14/21 at 2:25 PM an interview was conducted with PA #1 who saw the resident after the fall. The PA stated it was not his resident, but he was in the building and was asked to see the resident on the day of the fall. The PA further stated the staff had noted a cut on the back of the resident's head. The PA stated the resident was awake, alert and aware. The PA stated the staff rolled her over onto her side to view the laceration and the resident complained of nausea, so he stopped and told the staff to send her to the hospital. On 7/14/21 at 2:46 PM an interview was conducted with Nurse #1 who was assigned to Resident #176 on the day of the fall. The Nurse stated she was called to the room. The Nurse further stated the DON came in and assessed the resident with good range of motion and no pain. The Nurse further stated there was a pillow under the resident's head and when they picked her up with the lift and transferred her back to the bed they saw blood on the pillow and put an ice pack on the back of her head. The Nurse stated they called a PA that was in the building to assess the resident and the resident complained of nausea. The Nurse stated she gave her a medication for nausea and 911 was called and the resident was taken to the hospital. The Nurse stated prior to the fall the resident could move her upper body but could not move her body below the waist including her legs. Review of the ED Record dated 6/29/21 revealed the resident was admitted to the ED at 1:35 PM. The ED Physician note revealed the following: An [AGE] year old female with a past medical history of multiple [CONDITION(S)] with diffuse contractures and previous oxygen requirement who presented immediately after a fall with a chief complaint of nausea. Today, while transferring in a mechanical lift the patient fell out of the lift. She stated she struck her caregiver's knee before landing on the floor. The patient denied loss of consciousness and stated she remembered the entire event. She is not on blood thinners and denied pain anywhere. The patient's only complaint was nausea. On arrival the patient was in no apparent distress. She was afebrile, heart rate in the 80s, blood pressure 102/54 and oxygen saturation 84 percent on room air trial. The patient improved to 96 percent with 5 liters of oxygen via nasal cannula. The head laceration was irrigated and repaired with staples. At 5:34 PM the patient was found to be hypotensive with a blood pressure of 60/30. The patient stated she felt better and denied pain or any complaints. The patient was admitted to the Intensive Care Unit. The Hospital Discharge Summary revealed the following: On 6/30/21 the patient this morning was hypotensive with worsening shock. Intravenous fluids were provided as well as blood products as her hemoglobin was 5 (low). Imaging was consistent with a spleen laceration, traumatic subarachnoid (brain) hemorrhage and multiple rib fractures. The patient was also found to have a femur/tibia/fibula fracture. The patient was lethargic but arousable. On 7/1/21 the patient remained altered and non-communicative and had more difficulty managing her secretions. The power of attorney decided to focus on comfort measures only and the patient passed on the morning of 7/4/21. An interview was conducted on 7/15/21 at 12:15 PM with the Trauma Surgeon that cared for Resident #176 while in the hospital. The Trauma Surgeon stated the resident had a laceration to the back of the head and developed a subarachnoid (brain) hemorrhage, had rib fractures with a small pleural effusion (fluid in the lung), a laceration of the spleen and pelvic fractures. The Trauma Surgeon further stated the resident's fractures were acute and the resident's death was directly related to her fall. Review of the Death Certificate for Resident #176 revealed the following: Immediate cause of death was Multiple [MEDICATION(S)] force injuries. Date of injury 6/29/21. How injury occurred: fell from (name of mechanical lift.) Date pronounced: 7/4/21. On 7/15/21 at 4:28 PM an interview was conducted with the Administrator, DON and the Nurse Consultant. The Nurse Consultant stated that it was facility practice for therapy to assess a resident to determine the method of transfer and therapy would give a copy of a communication form with the way the resident was to be transferred to nursing and the DON would get a copy as well. The DON stated she checked the NAs' Kardex (care guide) and if not already on the Kardex she would add the information to the Kardex. The Nurse Consultant stated the lift pad size was based on the resident's weight and Resident #176 was transferred with the correct size lift at the time of the fall. The Administrator stated they had completed a full plan of correction related to the resident's fall. The Nurse Consultant stated Resident #176 required the use of the lift pad with a donut hole and her bottom rested over the hole to keep her in the pad. The Nurse Consultant stated they were unable to use the lift pad that went between the legs due to the resident's legs being contracted. The Nurse Consultant stated they did an investigation and their root cause analysis was that the resident had muscle spasms and was transferred with only one staff member. The Nurse Consultant further stated the staff had been educated to not ask non-clinical staff to assist with transfers of the residents. Corrective action for resident found to have been affected by the deficient practice: The affected resident was sent to the hospital and did not return to the facility. A meeting with the Therapy Director was held to validate the affected resident was utilizing the correct lift. Therapy validated the correct lift was utilized. The clinical team met to ensure the correct lift pad was utilized and it was determined the lift pad utilized was appropriate for the resident. An investigation ensued immediately with a re-enactment of the transfer. The root cause was determined to be the lack of 2 clinical staff assistance with a mechanical lift. The resident experienced muscle spasms and the employee involved was unable to assist the resident independently. Immediate education was provided to the employee involved. The education included 2 clinical staff required for any mechanical lift transfers. Validation of the involved employee's competency/education prior to 6/29/21 was verified (4/26/21). Written disciplinary action was completed for the employee. Re-education was provided on 6/29/21 to employees involved. Identification of other residents having the potential to be affected: All residents who use mechanical lifts have the potential to be affected. A facility audit was conducted of all residents utilizing a mechanical lift. Each resident transferred by a mechanical lift was reviewed by the Interdisciplinary Team (IDT) which included the Director of Nursing, Social Worker, Administrator and the Therapy Director. Therapy referrals were completed for residents who the IDT identified as needing re-evaluation. Measures to ensure the deficient practice will not recur: Staff education began on 6/29/21 regarding lift transfers and the requirement of having 2 clinical staff for any lift transfers. All clinical staff and therapy staff were educated to include the need for 2 clinical staff members for all mechanical lift transfers. Non-clinical staff were educated as well to inform they were not to assist/be the second person for lift transfers. All employees were educated. Staff education for clinical staff included validation of comprehension and return demonstrations with two clinical employees present. The education included safety components of the mechanical lift transfers. All staff education and competencies were completed by 7/6/21. A QAPI (Quality Assurance and Performance Improvement) meeting was held on 6/29/21 and 6/30/21 which included the Medical Director to review the investigation and the education. Monitoring of the performance of the measures put in place: Daily audits will be conducted on random residents requiring mechanical lift transfers for 4 weeks, weekly for 4 weeks and monthly for 3 months. The audits will be reviewed in the monthly QAPI meetings with any recommendations to ensure compliance is maintained. The QAPI committee will determine the need for further auditing or ongoing education. QAPI meetings were held on 6/29/21 and 6/30/21 which included the Medical Director, to review the investigation and the education. All components of the plan of correction were completed by 7/6/21. The audits are on-going to ensure compliance. The corrective action plan was validated on 7/16/21 and it was concluded the facility had implemented an acceptable corrective action plan on 7/6/21. Review of staff education materials and sign in sheets for the education were reviewed to determine that education was provided for all staff and the nurses and NAs did a return demonstration of a mechanical lift transfer during the education. Review of facility documents revealed audits were being done per the facility's plan of correction. Interviews were conducted with nurses and NAs in the facility who confirmed they received education regarding transfers with a mechanical lift and all transfers with a mechanical lift were to be done with 2 clinical staff members. Interviews were conducted with dietary and housekeeping personnel who verified they received education they were not to assist with mechanical lift transfers. Observations were made of residents being transferred with a mechanical lift and 2 clinical staff were used during all transfers observed.

Based on observations, record review, staff and physician interviews the facility failed to identify that a test ordered by the physician had not been completed by the laboratory as ordered that caused a delay in treatment and resulted in prolonged abdominal pain and diarrhea for 1 of 3 residents reviewed for pain (Resident #3). The facility also failed to recognize a change in a resident ' s skin condition for 1 of 4 residents reviewed for wound care. The resident required hospitalization and surgery (Resident #2). The findings included: 1. Resident #3 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. The resident ' s Care Plan dated 5/24/18 noted the resident had pain of the left upper extremity but did not include information regarding abdominal pain or diarrhea. A nurse ' s note dated 5/23/18 noted Resident #3 was alert and oriented times 3 (person, place and time), was continent of bowel and bladder at bedside commode and one person assist with activities of daily living and transfers. A nurse ' s note dated 5/26/18 at 6:07 AM noted no loose stools this shift. Temperature 97.8 degrees Fahrenheit. There were no nurses ' notes prior to this entry to indicate the resident was having loose stools. A nurse ' s note dated 5/27/18 at 2:26 PM revealed the following: Resident #3 complained of diarrhea with no visible evidence of diarrhea at the time, was Instructed to leave stool in bedside commode to be observed by staff and fluids were encouraged. The note revealed the following vital signs: Temperature 100.3 degrees Fahrenheit, Pulse 94, Respirations 20 and Blood Pressure 132/69. The PA (Physician ' s Assistant) was notified of resident ' s condition. A nurse ' s note dated 5/27/18 at 3:39 PM revealed PA #1 called and gave orders for a CBC (complete blood count), BMP (basic metabolic panel) and stool for [MEDICAL CONDITIONS] and this was reported to the on-coming nurse. [MEDICAL CONDITION] or [MEDICAL CONDITION] is a bacteria that can cause abdominal cramping and diarrhea. Review of the physician's order [REDACTED]. A nurse ' s note dated 5/27/18 at 11:01 PM revealed the following: The resident ' s temperature was down from 100.5 degrees Fahrenheit to 99.8 degrees Fahrenheit. It was noted fluids were encouraged, the resident had a good appetite. The note revealed the resident had two episodes of diarrhea and a stool sample was collected for [MEDICAL CONDITION]. Vital signs were documented as follows: Blood Pressure 114/60, Pulse 76, Respirations 18. A provider note dated 5/28/18 at 10:09 AM by Physician Assistant (PA) #3 revealed the following: Resident complained of diarrhea all weekend and felt nothing was being done and described mild abdominal cramping. Resident was on antibiotics while in the hospital but none since being here. Febrile overnight but temperature 97.8 degrees Fahrenheit this AM. A stool for [MEDICAL CONDITIONS] collected this AM. Will order [MEDICATION NAME] (medication for diarrhea) as needed and discontinue scheduled bowel medications. Labs (laboratory studies) also ordered to check white blood cell count and hydration. A nurse ' s note dated 5/30/18 at 2:52 AM noted the resident complained of pain to the abdomen about 1:00 AM and pain medications were given with good effect. A nurse ' s note dated 5/30/18 at 3:02 AM noted the stool for [MEDICAL CONDITION] still pending at this time. A lab report dated 5/30/18 revealed a stool sample was received in the lab on 5/28/18 and a stool culture had been done. There was no information in the report regarding the results for [MEDICAL CONDITION]. A provider note dated 5/31/18 by PA #1 revealed the resident ' s diarrhea was improved and the work-up negative. A nurse ' s note dated 6/2/18 at 7:19 AM revealed [MEDICATION NAME] 2mg (milligrams) was given for diarrhea. A nurse ' s note dated 6/2/18 at 9:22 AM noted the resident was given [MEDICATION NAME] for nausea and was effective. On 6/2/18 at 9:58 AM, Resident #3 stated in an interview he had been experiencing abdominal pain and diarrhea for 2 weeks and had a fever this morning. The resident was observed lying in bed grunting with a pained expression on his face. The Resident further stated a stool sample had been taken and blood work done and was told everything was Okay. The Resident stated he had received pain medication that morning as well as a medication for the diarrhea. On 6/2/18 at 2:00 PM an interview was conducted with the Medical Director who stated a stool culture would not test for [MEDICAL CONDITION]. On 6/2/18 at 2:05 PM during an interview the Director of Nursing (DON) became aware that a stool culture had been done and not a stool for [MEDICAL CONDITION]. A nurse ' s note dated 6/3/18 at 7:00 AM revealed Resident #3 was on contact precautions for possible [MEDICAL CONDITION] while waiting results. On 6/3/18 at 8:56 AM the DON stated in an interview she had ordered a STAT [MEDICAL CONDITION] yesterday and hoped to have the results today. STAT is a medical term used to let staff know the test was to be done urgently or immediately. On 6/3/18 at 10:50 AM the DON stated in an interview the test came back positive for [MEDICAL CONDITION] and she had notified the physician and an order given for [MEDICATION NAME] 1 tablet three times a day. [MEDICATION NAME] is an antibiotic used to treat [MEDICAL CONDITION]. On 6/3/18 at 12:23 PM NA #1 who worked regularly with Resident #3 stated in an interview the Resident had been having diarrhea for about one week. On 6/3/18 at 12:00 PM an interview was conducted with Unit Manager #1 who stated she knew Resident #3 had diarrhea and that a stool for [MEDICAL CONDITION] had been sent to the lab and the results were pending. The Unit Manager further stated when she got the results of the stool culture and saw no growth she reported this to the PA #1. The Unit Manager stated she noticed the results looked different but it did not dawn on her the results did not say anything about [MEDICAL CONDITION]. The Unit Manager stated the nurse on night shift does a chart check to ensure they did not miss any orders. On 6/4/18 at 8:25 AM Resident #3 stated in an interview his intestines hurt and they started his medication last night. The resident was observed sitting on the bed side commode and was grunting with pain. On 6/4/18 at 1:50 PM an interview was conducted with PA #1. The PA stated she did not order the stool for [MEDICAL CONDITION] (ordered by PA #3) and the stool culture results popped up on the computer and she saw it was negative and did not know a stool for [MEDICAL CONDITION] had been ordered. The PA stated it would take at least 3 days from the time the [MEDICATION NAME] was started for the resident to see an improvement in the abdominal pain and diarrhea. On 6/4/18 at 10:55 AM an interview was conducted with the Administrator and the DON. The DON stated when a lab test was ordered, the order was entered into the computer and a log printed for the lab technician of what tests were to be done that day. The DON provided a document from the lab that showed a [MEDICAL CONDITION] culture was entered into the computer and the specimen collected on 5/28/18 and the Daily Log dated 5/28/18 for the lab tech noted Resident #3 was to have a [MEDICAL CONDITION] culture done. The Administrator stated for some reason the lab did a stool culture and not a test for [MEDICAL CONDITION] and PA #1 signed off on the lab and did not recognize a [MEDICAL CONDITION] was supposed to have been done and not a stool culture. 2. Record review revealed Resident # 2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the resident's minimum data set assessment, dated 3/4/18, revealed the resident was cognitively intact and required extensive assistance with his hygiene and bathing needs. Review of the resident's care plan, revised on 3/20/18, revealed the staff identified the resident was at risk for skin integrity problems due to his muscle weakness, impaired mobility, and episodes of incontinence. A care plan intervention was to perform a weekly skin assessment. Review of physician progress notes [REDACTED].# 1 evaluated Resident # 2 on 4/27/18 at 2:57 PM. The PA noted the following. The resident was assessed to have a yeast infection in his groin area. A barrier cream, which was being utilized, would be discontinued. The staff were to start using [MEDICATION NAME] powder to dry the area out. Review of nursing notes revealed from 5/1/18 through 5/8/18 there were no nursing notations made regarding the resident's skin condition. On 5/7/18, Nurse # 3 placed a check mark on the resident's Medication Administration Record [REDACTED]. The check mark was placed on the MAR by directions that a skin check was to be performed and a progress note was to be entered in the resident's record. There was no corresponding progress note on 5/7/18 which contained documentation of the resident's skin assessment. On 5/8/18, PA # 2 documented at 2:26 PM the following information. She was asked to see Resident # 2 because the resident had redness to his abdomen and was febrile. The resident was assessed to have marked [DIAGNOSES REDACTED] (redness) across the lower half of his abdomen with increased warmth. The middle lower abdomen had a 6 inch by 4 inch area of induration (hardening of the soft skin tissue) and a few sites of pale pustules (small bumps on the skin that contain fluid or pus), which were not opening or draining at the time. The resident was accessed to have an abscess/[MEDICAL CONDITION]. According to the PA's note, the resident needed to start aggressive treatment given the appearance of his skin and fever. An order was given to send the resident to the emergency room . Review of hospital records revealed Resident # 2 was admitted to the hospital on [DATE] where he was identified to have abdominal wall [MEDICAL CONDITION] (infection of the skin and tissues beneath the skin) and abscess (a collection of pus underneath the skin). A surgical consult was initiated, and the resident underwent [REDACTED]. PA # 1 was interviewed on 6/4/18 at 12:40 PM. The PA reported the following. When she had assessed Resident # 2 on 4/27/18, the resident appeared to have a yeast infection in his groin area and some excoriation on his scrotal area. At the time of her exam, the resident did not have any problems on his abdomen. The resident tended to stay wet frequently due to medical reasons. Therefore, she ordered the [MEDICATION NAME] to help dry the affected areas and clear the resident's skin. NA # 2 was interviewed on 6/4/18 at 1:40 PM. NA # 2 routinely cared for the resident. NA # 2 reported the following. A few days before Resident #2 was transferred to the hospital on [DATE], she had noticed the resident had a very strange looking bubble bump which had arisen on his lower abdomen. It was located on the skin near the top of the resident's brief. It was approximately ½ inch wide and tall. It was filled with fluid. If pressure was applied to the area, then fluid could be seen moving from one side to the other. It was as if his skin was transparent in that area with the fluid beneath it. Routinely she always reported things like this to the nurse, but the resident was very alert and oriented. She asked the resident about it, and he told her the nurses said it was a bedsore. Since it appeared the nurses were knowledgeable about the area, she never reported it to a nurse. Nurse # 3 was interviewed on 6/4/18 at 5:20 PM. Nurse # 3 was the nurse who had checked on the MAR indicated [REDACTED]. According to the May, (YEAR) MAR, Nurse # 3 had also applied the resident's [MEDICATION NAME] during the dayshift of 5/6/18 and 5/7/18. Nurse # 3 reported the following during her interview. She did not recall doing a skin assessment on the resident prior to his hospitalization . The nurse stated she was new to the facility at the time of 5/6/18 and 5/7/18, and was still in orientation while working with another nurse. She recalled that she had very little care responsibilities for the resident during her orientation period, and was not able to describe any problems with Resident # 2's skin. Unit manager # 1 was interviewed on 6/4/18 at 12:05 PM. The unit manager was not familiar with Resident # 2's skin issues prior to his hospitalization . Resident # 2 was interviewed on 6/4/18 at 2:30 PM. The resident stated the bump on his abdomen was there a few days before he went out to the hospital, and was in an area that got wet when his brief was heavily soiled with urine. He said at times he felt warmth in the area, and he asked the nurses about it. He could not recall the specific nurses, with whom he had discussed it, but recalled he was told by them that it just needed some cream on it. Due to his condition and limitations, he was not able to see the area himself. PA # 2 was interviewed on 6/4/18 at 2 PM. The PA reported the following. The area appeared to be originating from below the skin. She was not aware of the area until 5/8/18 when she was asked to see the resident due to the redness and fever. Typically with an abscess, a resident would have pain. Resident # 2 had some sensory deficits due to his spinal injuries, which had possibly impaired his ability to feel the pain associated with it. At the time of her assessment, she recognized he was in immediate need to be evaluated at the hospital. Depending on the type of bacteria involved, an abscess can form and progress at different time intervals. Some develop and progress within a matter of hours while others develop and progress in days. According to the PA, either she or another PA is in the facility daily. They would have evaluated the fluid filled bump noted by the NA earlier if it had been drawn to their attention. The Administrator was interviewed on 6/4/18 at 6:30 PM. It was the administrator's expectation that nurses were to perform weekly skin assessments and document their findings in the progress note. The administrator could find no evidence this had been done on 5/7/18 when the nurse checked that it had been done on the MAR.

Based on record review, staff and physician assistant interviews the facility failed to ensure a resident ' s safety by not correctly positioning the resident prior to turning that resulted in the resident falling off of the bed sustaining a laceration to the forehead and a small subdural hematoma for 1 of 3 sampled residents that required extensive assistance for turning and positioning in bed. (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for Falls dated 1/20/17 revealed the resident had advanced Alzheimer ' s disease, was non-ambulatory and did not attempt to transfer without staff support. The CAA revealed the resident had generalized weakness and cognitive deficits which limited her mobility and falls would not be care planned. The CAA for Urinary Incontinence revealed the resident was non-verbal and unable to communicate by any means. The CAA noted the staff provided total care with toileting due to the resident ' s cognitive and physical limitations. The Care Plan for Resident #1 dated 2/12/15 noted the resident had ADL (Activities of Daily Living) self-care deficit related to overall weakness, severely impaired cognition/communication and poor physical mobility status. Anticipate and provide all ADL care as needed. The Care Plan noted the resident was incontinent. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 5/23/17 noted the resident was rarely/never understood, had severe cognitive impairment, required extensive assistance of one person for bed mobility and toileting and was incontinent of bowel and bladder. The MDS revealed the resident had no falls since the previous assessment. A nursing progress note dated 6/16/17 at 8:26 AM revealed the nurse was called to the room of Resident #1 around 4:00 AM by a NA (Nursing Assistant) who stated the resident had fallen out of bed. The note revealed upon entering the room the resident was lying face down beside her bed on the floor. The resident was noted to have bleeding from the forehead. The note revealed vital signs were taken, first aid administered to an open wound on the right forehead and 911 was called. It was noted the resident was alert and responsive and was transported to the hospital by ambulance at approximately 4:20 AM. The resident ' s Care Plan was revised on 6/17/17 and noted the resident was at risk for falls related to overall weakness, severely impaired cognition/communication, poor balance, poor postural control, non-ambulatory status and overall decline in physical mobility status. The Care Plan directed staff to anticipate and provide all needs and to use 2 person assistance with all bed mobility. The Care Plan noted staff education with return demonstration was provided. The Hospital Discharge Summary dated 6/19/17 revealed a discharge [DIAGNOSES REDACTED]. The summary noted the resident with advanced dementia was chronically bedridden and during care fell out of bed and sustained a large laceration to the right forehead. The summary noted the CAT scan showed a small subdural and subarachnoid bleeding and was at her baseline neurological status. The note revealed the resident had been seen by neurosurgery and no surgical intervention was indicated and a repeat CAT scan was stable. A nursing progress note revealed Resident #1 was re-admitted to the facility on [DATE]. The resident ' s Care Plan was revised on 6/20/17 and noted actual skin impairment due to recent fall and was readmitted with right frontal scalp laceration with intact sutures. The Care Plan directed staff to keep area clean and dry and to monitor for signs of infection daily. On 6/20/17 at 4:35 PM, NA #1 and NA #2 were observed to provide incontinent care for Resident #1. One NA was positioned on each side of the bed to assist with turning and positioning of the resident. On 6/20/17 at 4:58 PM an interview was conducted with NA #1 who was assigned to Resident #1 on 6/16/17 at the time of the fall from the bed. The NA stated she was providing incontinent care and turned the resident away from her and the resident went a little too far and fell off the other side of the bed. The NA further stated the resident was kind of heavy and it happened so fast. The NA stated she had worked with this resident for years and never had anything like this happen. The NA stated she yelled for the nurse and the nurse and another NA came to the room immediately and the nurse assessed the resident and took vital signs and other staff called 911. The NA stated the staff had received additional training and now used 2 persons to turn and position Resident #1. The NA stated they had also been trained when turning residents with one person assistance, to turn the resident toward the care giver. On 6/21/17 at 1:36 PM an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator stated they had a plan of correction in place and did a root cause of analysis of the fall for Resident #1 that occurred on 6/16/17. The Administrator further stated she re-created the incident with herself lying in the bed and had NA #1 demonstrate how she turned the resident. The Administrator stated the resident ' s legs were stiff and she stiffened her legs during the demonstration and when turned she would have fallen off of the bed if the DON had not been there to catch her. The Administrator stated it was determined the NA did not pull the resident to the center of the bed prior to turning and the resident was too close to the edge of the bed and the resident fell off of the bed. The Administrator stated all the nurses and NAs (except those who were on vacation) were in-serviced by 6/19/17 on turning and positioning dependent residents and were required to perform a return demonstration to show they understood what they were supposed to do. The Administrator further stated the staff who were on vacation had been notified they would not be allowed to work until they had received the in-service on turning and positioning of residents. The Administrator stated they had 105 residents that required assistance with turning and repositioning and therapy was in the process of re-assessing these residents to determine if 1 or 2 person assistance was required and hoped to have this completed by the end of the week. The Administrator stated the staff would then be observed to turn and reposition residents for a determined period of time to ensure this was being done appropriately. The Administrator further stated Resident #1 had been changed to 2 person assistance for all turning and repositioning and for incontinence care to ensure this would not happen again. On 6/22/17 at 11:30 AM an interview was conducted with Physician ' s Assistant (PA) #1 who cared for the resident in the facility. The PA stated prior to the fall the resident was alert and had some un-intelligible speech but for the most part was non-verbal. The PA further stated she saw the resident this morning and she was eating (fed by staff) and was at her base line.

Based on record review and staff interviews for one (Resident # 11) out of three residents, who were reviewed for transfer assistance, the facility failed to assure a resident was safely transferred in a mechanical lift resulting in a fall with a fracture of the ankle. The findings included: Record review revealed Resident # 11 had resided at the facility since 2/2/2015. The resident had [DIAGNOSES REDACTED]. Review of the resident ' s most recent minimum data set (MDS) assessment, dated 7/18/16, revealed the resident was assessed to have severe impairment of her cognitive abilities and needed extensive assistance from two people for bed mobility and transfers. Review of the resident ' s care plan, dated 7/20/16, revealed the staff had identified the resident needed total assistance for transfers. The facility ' s goal for the resident was that she safely be transferred without incident. Staff were directed on the care plan to use a mechanical lift and the assistance of two staff members for transfers. The care plan did not direct which sling to use with the mechanical lift. Record review revealed the resident sustained [REDACTED]. According to records, the resident was transferred immediately to the hospital where she was admitted on [DATE]. A review of hospital records revealed the resident was identified to have a closed fracture of her left ankle which was treated in the emergency room by placement of a splint. According to hospital records, the resident remained hospitalized until 10/18/16 in order that she receive treatment for [REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the facility ' s investigation into the incident revealed statements were obtained from the two NAs (nurse aides) who were involved in the 10/12/16 incident, NA # 6 and NA # 7. Statements were also obtained from the RN (Registered Nurse) supervisor, Nurse # 2, and from the floor nurse, Nurse # 3. The statements did not include how the resident had been positioned in the mechanical lift sling prior to the fall. NA # 6 ' s non-dated statement was reviewed. The statement read, I, (NA #6) along with (NA#7) was transferring (Resident # 11) with the Hoyer lift. The room was a little close cornered. The wheel of the Hoyer got caught on the wheel of the bed. (Resident # 11) started slipping out of the Hoyer pad. I caught the top of her body and eased her to the floor. I got (NA #7) who was assisting me with the lift to call (Nurse # 3). She checked her out then called EMS (Emergency Medical Services) to take her to the hospital. The patient seemed stable with no distress. NA #7 ' s statement, dated 10/12/16, was reviewed. The statement read, While moving (Resident # 11) from the chair to the bed she slipped out of the sling of the Hoyer. The room was a little tight and clutter with the 2 beds and chairs. The wheel of the Hoyer got caught on the wheel of the bed. As (Resident # 11) was falling (NA # 6) caught the top part of her body and gently lowered her to the floor. I, (NA #7) was assisting with the transfer. Nurse # 3 ' s statement, dated 10/12/16, was reviewed. The statement read, The resident was on the floor between the two beds, beside the Hoyer lift when I was called in. This was in patient ' s room. The aide stated that she along with another aide were transferring the patient to bed from the chair when the patient slipped from the Hoyer sling. The aide stated that she support the patient on the floor but the leg was caught by the side of the bed. Right ankle was swollen. No bleeding or bruising or swelling on any other part of the body was noted. Doctor was notified, along with patient ' s (family member) and she was sent to (hospital) for evaluation. Nurse # 2 ' s statement, dated 10/13/16 at 1 AM, was reviewed. The statement read, Called to assess (Resident # 11). Pt (patient) found on floor leaning on rail of Hoyer lift. (NA #6) reported to this supervisor that pt. was being moved from chair to bed and started to slide out of Hoyer. (NA # 6) grabbed pt ' s clothing was able to break pt ' s fall to the ground. (NA #6) said (Resident # 11 ' s) L (left) foot ' might have gotten caught under the Hoyer lift rail. ' Pt. with swelling to L foot and L foot/ankle appear in an abnormal position. EMS (Emergency Medical Services) called- Dr. notified. Pt ' s (family member) notified. Pt was taken to ER (emergency room ). Pt ' s (family member) informed that someone from (facility) would contact her tomorrow if pt was return to facility. Nurse # 2 was interviewed on 10/18/16 at 9:10 PM about the incident. Nurse # 2 stated she was the RN supervisor on duty the evening of 10/12/16 and she was called to assess Resident # 11. Nurse #2 stated the NAs were standing by the resident, who was on the floor, when she arrived in the room. Nurse # 2 stated the NAs reported that the resident had slipped from the mechanical lift. Nurse # 2 stated NA # 6 reported that she had tried to grab the resident and break her fall, and had provided support to the resident ' s head as the resident slipped but the resident ' s foot had gotten caught somehow in the incident. Nurse # 2 stated within a few minutes, the resident started to have swelling of the ankle and she recognized the resident needed evaluation and therefore had the resident transferred immediately to the hospital. Nurse # 2 stated that following the incident the facility (Director of Nursing) had talked to her to determine the details of the incident. On 10/19/16 at 2:15 PM, NA # 6 was interviewed regarding the incident. NA # 6 stated that she had worked with the resident for a very long time and had transferred the resident with the same type of lift sling and mechanical lift for many months without incident. NA # 6 stated the mechanical lift, which had been used, was a Hoyer lift. NA # 6 stated the sling, which had been used, was a flat type sling that did not go between the resident ' s legs. NA # 6 stated on the date of the incident there was limited space because of items in the room and the bottom legs of the mechanical lift hit against the bed during the transfer. NA # 6 stated when this occurred, the resident slipped from the bottom of the sling. NA # 6 stated that she tried to protect the resident ' s head as she was slipping, but the resident ' s foot got caught at the foot of the bed as the resident slipped down to the floor. NA # 6 stated there were different types of slings that the facility used with the Hoyer mechanical lift. NA # 6 stated there was an open flat sling, which was the one used with Resident # 11. NA # 6 stated there was also a sling which would cross between a resident ' s legs. NA # 6 stated the facility staff used the open flat sling with Resident # 11 because her legs were tightly contracted together, and it would be difficult to get a sling to cross between her legs. NA # 6 was interviewed in regards to how staff knew which sling was used for which residents. NA # 6 stated the staff member who trained a NA on a new assignment would tell them. On 10/24/16 at 11:45 AM the product manager for the manufacturer of the mechanical lift used by the facility was interviewed. The product manager stated he had worked in training and selling mechanical lifts for [AGE] years, and it had been his professional experience that no resident ever fell from a sling unless the sling had not been hooked correctly. It was shared with the product manager that there was a facility incident in which reportedly the legs of the mechanical lift bumped against the bed, resulting in a tilt of the sling and a resident falling. The product manager stated under normal operating circumstances it was very difficult to tilt the sling to the degree that a resident would slide out of the sling. The product manager stated the mechanical lifts were made to have very little sway and movement in the sling if operated correctly. The product manager stated from his professional experience if an individual was positioned appropriately in a sling, then they should not slide out of a sling unless the sling split or the resident had enough strength to thrust themselves forward from the sling. The product manager stated that safety testing for the lift and slings had shown that it was difficult for healthy individuals to get out of a sling when everything was done correctly. The product manager stated the facility had not informed the company there was an incident related to the mechanical lift and that their company offered inservice and training for staff following an incident if they were made aware.

Based on observations, medical record review, staff interviews, family interview and transportation staff interview, the facility failed to assure that 1 of 4 residents reviewed for accidents (Resident #86) was supervised during transportation to prevent an accident, in which Resident #86 fell from the transportation van while in the facility parking lot which caused an injury that required medical treatment. (Resident #86) Findings included: Resident #86 was admitted to the facility on [DATE] and re-entry on 1/24/14. [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set ((MDS) dated [DATE] revealed cognitive skills were moderately impaired (decisions poor, cues/supervision were required). Resident #86's balance during transitions and walking were identified on the MDS as not steady, but able to stabilize without human assistance. Functional limitation in range of motion was identified as being impaired on one side for the lower extremity. The mobility devices identified on the MDS were identified as a walker and wheelchair. A review of the most recent care plan with an initiated date of 8/17/12 and a review date of 1/15/14 revealed a problem identified as; has mood and behavioral problems as evidenced by restlessness, confusion, increased agitation, and resisting care. Resident has been observed throwing away her personal belongings, picking at skin and creates sore on arms. Interventions included; attempt to meet unmet need at the time of agitation, encourage to verbalize what her concern is and try to meet her needs, monitor and document episode of increased agitation, restlessness and resisting care, redirect and encourage not to throw away personal belongings. Another problem with an initiated date of 8/15/12 and a review date of 1/15/14 was identified as having impaired cognition and communication related to [DIAGNOSES REDACTED]. One of the interventions was listed as prompt cue and redirect resident as needed due to resident's confusion, short attention span and forgetfulness. A problem with the initiated date of 10/19/12 and a review date of 1/15/14 read resident exhibits behaviors; verbal abusive to staff, resist care at times as evidenced by easily angered when redirected by staff, refusal to take baths and change clothes daily, refusal of showers and getting her hair wet, exhibits behaviors of self inflicting wound to her forearms The care plan also identified a problem of risk for falls related to weakness, impaired balance, impaired cognition, incontinence and unsteady gait. One of the goals for this problem was identified as resident will comply with safety measures. Interventions included use walker for short distances with staff assistance and wheel chair for long distances, provide resident/family teaching to include safety measures to reduce falls and what to do if a fall occurs. A review of the nurse's notes revealed a note dated 1/15/14 at 6:00p.m. that documented an incident on the first floor at front office where resident #86 was yelling, fussing and cursing at the receptionist. The resident was assisted back to the fourth floor where she was medicated with Ativan (antianxiety) 1mg (milligram). On 1/16/14 at 2:57p.m. a nurses note documented a call from testing facility resident #86 had been transported to stating the testing was not able to be completed due to the resident complaining of pain, depression and refusing any further testing. On 1/16/14 at 3:18p.m. a nurses note documented a plan of care review with the interdisciplinary team and the residents family member occurred. Discussion included recent decline and clinical status was reviewed. Documentation stated resident #86 has been increasingly more confused and becomes agitated easily. On 1/23/14 at 11:07 p.m. a nurses note stated resident "sustained a fall exiting transportation van," emergency medical services called and transported to hospital. Family and physician notified of incident. "Happened around 6:00 p.m." A review of a consultation dated 1/24/14 documented the history of present illness as: ---------(resident identifying information) fell from her wheel chair, face planting. The resident does not recall details of the event, The resident was brought in with facial lacerations noted for which ----- (name of consulting company) was consulted for repair. The procedure performed was identified as: 1. Repair of complex nasal lacerations. 2. Repair of multiple lip lacerations. 3. Repair of partial nasal avulsion (an injury in which a body structure is forcibly detached from its normal point of insertion by either trauma <http://en.wikipedia.org/wiki/Trauma_(medicine)> or surgery (from the Latin avellere, meaning "to tear off"). The term most commonly refers to a surface trauma where all layers of the skin <http://en.wikipedia.org/wiki/Skin> have been torn away, exposing the underlying structures). The section of the consultant report titled, assessment and recommendations stated; resident is status [REDACTED]. The wound will need to be reassessed and will likely need further operative intervention. A review of the incident report from the transportation company dated 1/24/14 revealed three different residents were in the van. Two of the residents were strapped in a wheel chair and resident #86 was strapped in a passenger rear seat with a seatbelt restraint. "At approximately 5:45p.m. they arrived back at the facility." -- (van driver name) unloaded the other residents one at a time and when returning to unload resident #86 "at approximately 6:00p.m. resident was outside the rear of the van lying on the lift." A review of the hand written statement from the van driver dated and signed on 1/24/14 indicated that there was never any difficulty with resident #86 and was not notified of any concerns that he should be made aware of. On 3/11/14, Resident #86 was observed at 7:30pm in front the receptionist window cursing, yelling and crying resident was stating " you will be sorry when I blow this f------ building up " . The Director of Nursing (DON) was assisting the resident and 2 other staff members were involved in addressing the residents concerns. The resident was sitting in a wheel chair with body alarm in place. An interview with a family member of resident #86's on 3/12/14 at 12:07p.m. revealed she felt the residents medical record documented that resident could not be left alone. Further discussion revealed that she felt the driver did not know the resident was not to be left alone. The family member indicated that when the facility notified her of an outside appointment she would meet the resident there and stay with her until the transportation person arrived to return resident to the facility. An interview on 3/14/14 at 8:26a.m. with the DON was conducted regarding the incident of resident #86 falling out of a van. The DON stated the driver opened the back doors and escorted the 2nd resident out of the van into the building and as he was doing that resident #86 fell out face first to the pavement. The driver then went back into the building and called for help. The facility now only sends one resident at a time for transportation. The DON stated the facility investigated the incident and will provide the investigation. The DON indicated that they felt it was not their responsibility even though it was on their property. On 3/14/14 at 8:35a.m. with NA#2 the person who schedules all transportation needs for residents. NA#2 revealed that she told the driver resident was "antsy and that he had to watch her and not to leave her unattended until the family arrives to take over her care". NA#2 indicated that on the day of the incident the physician's office called the driver to return and pick up the resident. The driver told her that the resident was left unattended at the doctor ' s office by the family and the resident was found by him wandering around when he arrived to pick her. On 3/14/14 at 8:50a.m. the administrator and DON provided their investigation of the incident. When asked how the facility communicates with the transportation company; the administrator responded that if a resident was at risk for elopement they would communicate that to the transporter and if necessary would provide an escort for that resident. On 3/14/14 at 9:21a.m. an interview with nurse #1 who provides care to resident #86 revealed the resident forgets things quickly and almost immediately will curse at staff and then the next minute will apologize and then start cursing again. She also indicated that the resident is easily distracted and staffs need to remind her to complete a task like eating. Further discussion revealed that resident used to use a walker but uses only a wheel chair for mobility. The nurse indicated that the resident is a smoker and requires someone to be present when she is smoking. The nurse also indicated that since her fall out of the van she is not alert/oriented at all. An interview on 3/14/14 at 9:31a.m. with the nurses aide (NA) #1 who provides care to resident #86 revealed the resident can put her seatbelt on and off without assistance. She sometimes can walk from her bed to the bathroom or nurses station without any assistance or device. Further discussion revealed that if a family member meets the resident at scheduled appoint no escort is sent but if a family member is not going to meet the resident at the scheduled appointment someone will accompany the resident. NA #1 indicated she has gone with the resident twice in the last 6 months to appointments. An interview with NA#2 who arranges the transportation for residents on 3/14/14 at 9:45a.m. revealed that the rule was if a resident was alert and oriented no escort was provided but now all residents are escorted. On 3/14/14 an interview was conducted by phone with the transportation driver who provided transportation for resident #86 on 1/23/14 when she fell from van. The driver indicated he had transported this resident many times and had never had any similar situation occur, nor had she ever attempted to take a seatbelt off. He said he had no reason to believe that she would or was capable of removing her own seat belt. The driver indicated that the resident had a seatbelt on that day and that this van did not have a shoulder belt and a lap belt but this van only had lap belts. Further discussion revealed that he had taken the first resident off the van into the building, then returned and took the 2nd resident into the building. He indicated that the lift was down and the van doors had been left open. Resident #86 was still secured in the van when he took the 2nd resident into the facility. On 3/14/14 at 12noon the administrator stated that the driver involved with the incident did not transport for them while the company conducted their investigation and that the driver just never returned to facility to transport any of their residents. The administrator indicated this was the first incident they have ever had with the transportation company. Further discussion revealed he had requested the transportation company not to transport any other resident when providing transportation for their residents. When he was asked how they monitor that the transportation company honors their request to not transport any other person when they have a resident on the van he responded that they know if they do not follow that they will lose our contract.