Every finding on record at Resorts at Beaufort

Based on observations, interviews, and document review, the facility failed to maintain the facility in good repair for resident areas. Specifically, there were side rails loose, rusty toilet seats, towel bar that was separated off the wall, walls in disrepair, cove molding missing, and spacing around air conditioner (AC) units. The facility's failure to repair the residents' environment has the potential to cause injuries to residents in two of three halls (A and C halls).Findings include:1.Observation and interview with the Maintenance Director (MD) of the C hall on 05/01/26 at 3:06 PM through 3:16 PM revealed the following:Room C01-D, a two-to-three-inch movement in the right side of the side rail. Room C08-W, the wall had three large gouged areas near the bedroom door. The MD stated I don't go in every room. The wall will get fixed when the Certified Nurse Aides (CNAs) tell him. Room A17-P, rusty toilet seat with rusty handles on the toilet riser. The towel bar was lying on the floor. The MD stated, Therapy supplies the over toilet seats with handles that are rusty and no one told me about the towel bar broken and on the floor.During an interview on 04/01/26 at 3:18 PM, the Infection Preventionist/Unit Manager (IP/UM)1 on the Secured area stated, the toilet seat was stained so we just go down to therapy and they replace it. We have CNAs and Managers to check for maintenance concerns. Anyone can report it and put it in the maintenance log. The IP/UM1 stated, I have no idea how long the towel bar has been broken off the wall, how long the toilet seat was discolored, and the over toilet riser was rusted. Residents could get hurt on that equipment.2.Observation of the A wing and interview with the MD during a tour of the facility on 04/02/26 from 1:55 PM through 2:10 PM revealed the following:room [ROOM NUMBER], the wall containing the air conditioner was missing cove molding, had markings around the air conditioner and a gap was present between the air conditioner and the wall. The MD stated, This needs to be fixed. I didn't know this was like this.room [ROOM NUMBER], the AC was unplugged, and the unit cover was not fitting properly exposing internal components. The MD stated, This is a new AC unit. I don't understand why the cover is not fitting.room [ROOM NUMBER], there was a hole four inches x five inches in the wall next to B bed. The MD stated, That needs to be fixed and painted.room [ROOM NUMBER], there was a hole three inches x five inches in the wall to the side of the Left bed. The MD stated, the wall needs to be fixed.room [ROOM NUMBER], the wall next to B bed the drywall was marked and gouged. The MD stated, The wall needs to be painted. These rooms were just remodeled a few months ago. During an interview on 04/02/26 at 2:15 PM, the MD stated, There is no written policy and procedure for the reporting of maintenance issues. There are maintenance logbooks on each nursing station where staff are to write down issues that need to be fixed.During review of the maintenance logbooks on each unit, revealed no documentation for any of the concerns identified during the tour.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's fingernails were kept clean and trimmed for one of one resident (Resident (R) 9) reviewed for activities of daily living of 33 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility.Findings include:Review of the facility's policy titled, Nail Care dated 01/08/26 indicated, The purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health .3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. 5. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes . 6. Procedure: . i. Document completion of task, any complications, or if resident refuses.Review of R9's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of type two diabetes mellitus and diabetic neuropathy.Review of R9's Care Plan located under the Care Plan tab of the EMR revealed the resident is at risk for potential impairment to skin integrity and to avoid scratching and keep fingernails short dated 09/21/23.Review of R9's Progress Note located under the Progress Note tab of the EMR dated 01/31/26 through 04/01/26 revealed R9 had not refused care.Review of R9's Bathing Task located under the Task tab of the EMR dated 03/04/26 through 04/01/26 revealed R9 has not refused a bath.Review of R9's Personal Hygiene Task located under the Task tab of the EMR dated 03/04/26 through 04/02/26 revealed R9 has not refused personal hygiene.Review of R9's Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/06/26 revealed a Brief Interview for Mental Status (BIMS) score of four out 15 indicating severe cognitive impairment. The MDS indicated that R9 was dependent for personal hygiene.During an observation on 03/31/26 at 10:24 AM, R9 had fingernails approximately three fourths (3/4) inch long with black/ brown substance underneath them.During an interview on 03/31/26 at 10:24 AM, R9 said he would like his fingernails to be cut shorter.During an observation on 04/01/26 at 11:03 AM, and on 04/01/26 at 5:27 PM, R9's had fingernails approximately 3/4 inch long with black/ brown substance underneath. During an interview on 04/01/26 at 5:27 PM, R9 confirmed he had a bed bath today and would like his fingernails trimmed shorter. During an interview on 04/02/26 at 12:13 PM, the Director of Nursing (DON) at R9's bedside confirmed R9's fingernails were dirty with a brown/ black substance underneath the fingernails and that they needed trimmed. She confirmed nail care should be done as needed (PRN) as the resident allows. DON confirmed there was no documentation of R9 refusing care. During an interview on 04/02/26 at 12:15 PM, with Unit Manager (UM)2 at R9's bedside, she confirmed R9's fingernails were dirty with a brown/ black substance underneath the fingernails and that they needed trimmed. She confirmed nail care should be completed as needed (PRN) as the resident allows.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the resident's gastrostomy tube (G-tube) was patent by checking for placement prior to administering medications for one of four residents (Resident (R) 33) observed during medication administration. This failure had the potential to result in the resident not receiving the medication. Findings include:Review of the facility's policy titled Medication Administration via Enteral Tube, reviewed 01/08/26, provided by the facility, revealed Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . 11. Procedure: . h. Enteral tube placement must be verified prior to administering any fluids or medication .Review of R33's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, muscular dystrophy, and gastrostomy status. During an observation on 04/01/26 at 8:32 AM, Unit Manager (UM)3 flushed R33's G-tube with 30 milliliters (ML) of water and then administered each medication after each flush of water. UM3 did not check for placement of the G-tube by either checking for residual by pulling back on the syringe to aspirate stomach contents or by injecting air into the port while listening with a stethoscope over the left upper abdomen.During an interview on 04/01/26 at 8:42 AM, UM3 confirmed that she did not check for placement of the G-tube prior to administering the medications.UM3 stated she did not know the facility policy on checking for placement.During an interview on 04/02/26 at 9:18 AM, the Director of Nursing (DON) stated she expected the nursing staff to check placement of the G-tube prior to administering medications to ensure the resident received the medication. The DON stated placement could be checked by listening with a stethoscope while injecting air into the tube or checking residual by pulling back on the syringe while in the tube. The DON verified the facility did not have a policy on maintaining patency of the G-tube. During an interview on 04/02/26 at 2:15 PM, the Administrator stated she expected nursing staff to be trained on the procedure for checking placement of the G-tube in the facility's policy.

Based on record review, interviews, and policy review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident (R)13) of three residents reviewed for SNF ABNs. This failed practice had the potential to affect all residents receiving Medicare Part A benefits and continued to reside in the facility to make an informed decision on continuing the services. Findings include:Review of the facility's policy titled, Advanced Beneficiary Notices dated 01/08/26 revealed, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines:1. Social Services is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents/representatives of this contact person shall be posted conspicuously in the facility.2. The Social Services will provide Medicare information to residents/representatives upon request. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form.a. For Part A items and services, the facility shall use the Skilled Nursing Facility AdvanceBeneficiary Notice (SNFABN), Form CMS- 10055.The facility shall issue an ABN prior to furnishing non-covered care.Review of R13's electronic medical record (EMR) revealed an admission Record located under the Profile tab of the EMR revealed an admission date of 04/01/25. The Census tab of the EMR revealed that R13's Medicare Part A services were from 10/01/25-11/26/25. Review of the Notice of Medicare Non-Coverage (NOMNC) dated 11/24/25 revealed that the facility did not issue the ABN to the resident or the resident representative after the facility initiated the discharge from skilled services with Medicare Part A with Medicare days remaining. R13 resided in the facility after the discharge for Medicare Part A services. During an interview on 04/01/26 at 10:35 AM, the Social Service Director (SSD) stated that she does not do the Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) for residents that are coming off of skilled services under Medicare part A and remain in the facility. The SSD stated that the therapy department does the SNF ABN.During an interview on 04/01/26 at 12:10 PM, the Director of Rehab (DOR) stated that the ABNs completed by the therapy department are only for residents coming off Medicare part B services. The DOR stated that she does not know who completes the SNF ABN for Medicare part A services.During an interview on 04/01/26 at 1:35 PM, the Director of Nurses (DON) stated that she was not sure who was responsible for completing the SNF ABNs. During an interview on 04/01/26 at 3:40 PM, DON stated that it appears that the SNF ABNs have not been being done for those who require it.

Based on observations, interviews and facility policy review, the facility failed for one of one meal observation to substitute a lunch meal alternate meal item (tortellini) with another meal item (kielbasa sausage) that has the same comparable nutritive value. The failure had the potential to affects residents at risk of nutritional problems.Findings include:Review of the facility's undated policy titled provided by the DM indicated, Policy Statement: The Dietary Department may make substitutions to the posted menu when necessary; however, all substitutions must be equivalent in nutritional value, appropriate for the resident's diet order, and documented according to facility guidelines. Substitutions must never compromise resident choice, safety, or quality of care.Review of the lunch menu provided by Dietary Manager (DM) revealed, beef stew, rice, and green beans and the alternate was cheese tortellini with alfredo sauce.During an interview on 03/31/26 at 12:44 PM, the DM stated the lunch meal was beef cubes, mashed potatoes, and spinach. The alternate meal was smoked sausage.During an observation of lunch in the main dining room on 03/31/26 at 12:52 PM, revealed that the residents were offered the alternate of kielbasa sausage.During an interview on 04/01/26 at 11:55 AM, the DM stated, the residents don't eat tortellini, so I served kielbasa sausage instead.During an interview on 04/02/26 at 10:19 AM, the DM stated We have a policy about substitutions. I make changes in the computer system before the tickets went out to the residents. I would call the Registered Dietitian (RD) if I make a substitution and she would make sure there is something of equal value to substitute for it.During an interview on 04/02/26 at 11:25 AM, the Administrator stated, the menu substitutions were approved by the RD for nutritional density.During a telephone interview on 04/02/26 at 1:59 PM, the RD said would not substitute pasta for meat as an adequate nutritive substitution.

Based on interview, record review, and facility policy review, the facility failed to ensure staff implemented the care plan for 1 (Resident (R)5) of 3 sampled residents reviewed for falls. Specifically, on 07/19/2025, a staff member attempted a bed-to-chair transfer for R5 with a mechanical lift, with only one staff member present. The mechanical lift malfunctioned, and the resident fell to the floor. Findings include: Review of a facility policy titled Care Plans, Comprehensive Person-Centered, dated 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of an admission Record revealed the facility admitted R5 on 09/26/24. According to the admission Record, the resident had a medical history that included, but was not limited to, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other specified disorders of bone, morbid (severe) obesity due to excess calories, transient cerebral ischemic attack, and chronic diastolic congestive heart failure. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/25 revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff assistance to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and for transferring to and from a bed to a chair. Review of R5's Care Plan Report included a problem statement initiated on 10/03/24 that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to lack of coordination, weakness, and a cerebrovascular accident (CVA) history. An intervention initiated on 10/03/24 directed the staff to provide two-person assistance with a mechanical lift for transfers. Review of R5's Visual/Bedside Kardex Report (a documentation system used by nursing staff that directs patient care), dated 08/20/25, indicated the resident required substantial/maximal assistance of two staff for bed mobility. The report also indicated the resident required a mechanical lift with the assistance of two staff for transfers with a large sling. Review of a Progress Note dated 07/19/25 at 3:58 PM and signed by Registered Nurse (RN)1, revealed Certified Nursing Assistant (CNA)2 notified the nurse that R5 fell from the mechanical lift during a transfer from the bed to the wheelchair. The Progress Note revealed that when RN1 entered the room, R5 was observed seated on the floor with the mechanical lift pad beneath the resident. The Progress Note revealed the sling attachment bar was lying across the resident's body. The Progress Note indicated R5 was conscious but did not verbally respond to questions and could not give any details concerning the fall. The Progress Note indicated R5 was assessed and showed no signs of pain or obvious injury. Per the progress note, CNA2 was directed to call 911 for emergency response services, emergency medical services (EMS) arrived, and the resident was transported to the hospital. Review of a document titled [Facility name] Witness Interview/Statement Form signed by CNA2 on 07/19/25 revealed that CNA2 was in the hall when CNA3 asked her to come to R5's room. Per the statement, when CNA2 entered the room, R5 was lying on the floor with part of the mechanical lift on the resident's stomach. The statement indicated CNA2 got RN1, and RN1 directed the CNA to call 911. Review of a document titled [Facility name] Witness Interview/Statement Form signed by CNA3 on 07/19/25 revealed that on 07/19/25 at approximately 10:30 AM, CNA3 was assisting R5 with a transfer using the mechanical lift. The statement indicated, During the transfer process, I noticed that the lift appeared to malfunction (the bar dislodged). As a result of the malfunction, the resident slipped to the floor while still inside the sling. During an interview on 08/19/25 at 9:11 AM, R5 stated there was only one staff member present for the transfer on 07/19/25. R5 stated the aide knew how to use the mechanical lift, and she tried to get another person to assist, but no one was available. R5 stated the resident fell straight down and tipped to the left and had no fractures from the incident. During an interview on 08/19/25 at 1:18 PM, the Director of Nursing (DON) stated she was notified of R5's fall during a transfer with a mechanical lift. She stated she came to the facility the day of the incident and saw the resident when the resident returned from the hospital. CNA3 told her she was aware R5 was a two-person assist for transferring, but everyone was busy, and she did not want to bother anyone. During an interview on 08/19/25 at 3:24 PM, RN1 stated the CNAs had access to the Kardex to determine the care needs for a resident. During a phone interview on 08/20/25 at 1:46 PM, CNA3 stated she did not look at the resident's Kardex. CNA3 stated that during Coronavirus disease (COVID) they had a lack of CNAs, and she got accustomed to doing a mechanical lift by herself, and she knew that was a no, no. CNA3 stated, I do take responsibility for that. She stated R5 wanted to get up out of bed, and she looked in the hallway and did not see anyone to assist her, so she gave the resident a bed bath, got the resident dressed, placed the mechanical lift pad under the resident, positioned the resident onto the machine, and lifted the resident. During a follow-up interview on 08/20/25 at 2:44 PM, the DON stated the care plan was patient-focused, and she expected the care plan to be followed. During an interview on 08/20/25 at 3:11 PM, the Administrator stated her expectation was for staff to have two people per the care plan and per the Kardex for a mechanical lift. During an interview on 08/20/25 at 4:10 PM, the MDS Director stated care plan interventions were updated quarterly and as needed. She stated care plan interventions were included on the Kardex for staff to reference

Based on interview, record review, and review of the owner's manual for Model: F600B Bariatric Full Body Patient Lift, the facility failed to ensure staff safely transferred 1 (Resident (R)5) of 3 sampled residents reviewed for falls. Specifically, on 07/19/25, a staff member failed to follow the resident's care plan and ignored the noises emitted from the mechanical lift when she assisted the resident with a transfer from their bed to their wheelchair. During the transfer, the mechanical lift malfunctioned, and R5 fell to the floor. Findings include: Review of a document titled Competency Assessment Lifting Machine, Using a Mechanical, revised on 07/2017, revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The Steps in the Procedure section revealed, 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.An Owner's Manual for the Model: F600B Bariatric Full Body Patient Lift, undated, under the section titled, Operating Instructions, revealed, Double check all assemblies for tightness and read operating instructions carefully prior to use. The section titled, Maintenance & Inspection, revealed, The operator of the lift shall inspect the [name brand] lift before each use. Check all bolts for tightness. Make sure the base can be easily widened, and that all lift parts are in place.Review of an admission Record revealed the facility admitted R5 on 09/26/24. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other specified disorders of bone, morbid (severe) obesity due to excess calories, transient cerebral ischemic attack, and chronic diastolic congestive heart failure.Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/10/25, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff assistance to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and for transferring to and from a bed to a chair.Review of R5's Care Plan Report, included a problem statement initiated on 10/03/24 that indicated the resident had an activity of daily living (ADL) self-care performance deficit related to lack of coordination, weakness, and a cerebrovascular accident (CVA) history. An intervention initiated on 10/03/24 directed the staff to provide two-person assistance with a mechanical lift for transfers.Review of R5's Visual/Bedside Kardex Report (a documentation system used by nursing staff that directs patient care), dated 08/20/25, indicated the resident required substantial/maximal assistance of two staff for bed mobility. The report also indicated the resident required a mechanical lift with the assistance of two staff for transfers with a large sling.Review of an Incident Log, dated 08/18/25, indicated R5 had a fall on 07/18/25 at 11:00 AM.Review of a Progress Note, dated 07/19/25 at 3:58 PM and signed by Registered Nurse (RN)1, revealed Certified Nursing Assistant (CNA)2 notified the nurse that R5 fell from the mechanical lift during a transfer from the bed to the wheelchair. The Progress Note revealed that when RN1 entered the room, R5 was observed seated on the floor with the mechanical lift pad beneath the resident. The Progress Note revealed the sling attachment bar was lying across the resident's body. The Progress Note indicated R5 was conscious but did not verbally respond to questions and could not give any details concerning the fall. The Progress Note indicated R5 was assessed and showed no signs of pain or obvious injury. Per the progress note, CNA2 was directed to call 911 for emergency response services, emergency medical services (EMS) arrived, and the resident was transported to the hospital.Review of a hospital report, dated 07/19/25, under the section titled History of Present Illness, indicated R5 sustained a fall while being transferred by a mechanical lift. The section titled Activity Restrictions or Additional Instructions revealed the resident's trauma workup was negative for acute fracture or traumatic injury, and a lytic lesion was identified that was concerning for malignancy versus metastatic disease.Review of a typed document, dated 07/19/25 and signed by the Director of Nursing (DON), revealed they received a phone call from RN1 at 12:01 PM. The document indicated RN1 reported R5 fell from a mechanical lift, and the RN was sending the resident to the hospital. Per the document, RN1 reported the mechanical lift malfunctioned, causing the fall. The document further revealed that CNA3 reported that when she was lifting the resident up from the bed, she noticed the mechanical lift was making a funny noise but did not think anything about it because mechanical lifts make noises (which was normal). The document revealed the facility concluded the incident was attributed to poor judgement made by CNA3. The report revealed CNA3 was removed from the facility, not to return.Review of a document titled [Facility name] Witness Interview/Statement Form, signed by CNA2 on 07/19/25, revealed that CNA2 was in the hall when CNA3 asked her to come to R5's room. Per the statement, when CNA2 entered the room, R5 was lying on the floor with part of the mechanical lift on the resident's stomach. The statement indicated CNA2 got RN1, and RN1 directed the CNA to call 911.Review of a document titled [Facility name] Witness Interview/Statement Form, signed by CNA3 on 07/19/25, revealed that on 07/19/25 at approximately 10:30 AM, CNA3 was assisting R5 with a transfer using the mechanical lift. The statement indicated, During the transfer process, I noticed that the lift appeared to malfunction (the bar dislodged). As a result of the malfunction, the resident slipped to the floor while still inside sling.During an interview on 08/19/25 at 9:11 AM, R5 stated there was only one staff member present for the transfer on 07/19/25. R5 stated the aide knew how to use the mechanical lift, and she tried to get another person to assist, but no one was available. R5 stated the resident fell straight down and tipped to the left and had no fractures from the incident. R5 stated the mechanical lift broke, and if they had two staff on that day assisting, the resident thought it still would have happened.During an interview on 08/19/25 at 1:18 PM, the DON stated she was notified of R5's fall during a transfer with a mechanical lift. She stated she came to the facility the day of the incident and saw the resident when the resident returned from the hospital. CNA3 told her she was aware R5 was a two-person assist for transferring, but everyone was busy, and she did not want to bother anyone.During a phone interview on 08/20/25 at 1:46 PM, CNA3 stated that during Coronavirus disease (COVID) they had a lack of CNAs, and she got accustomed to doing a mechanical lift by herself, and she knew that was a no, no. She stated, I do take responsibility for that. She stated she did not look at the resident's Kardex. She stated that when she was lifting R5 up, she did not notice anything. Then, she stated, when she was backing up the mechanical lift, it started to squeak and made a funky noise, and she did not pay it any mind, but it was noticeable. She stated she thought a piece fell out or dislodged because the bar dislodged from the machine itself, and the resident slipped to the floor.During a follow-up interview on 08/20/25 at 2:44 PM, the DON stated she expected the staff to make sure they had two people with them, the appropriate sling, and make sure the mechanical lift was functioning and pins were in place and sturdy. She stated if something seemed wrong with the mechanical lift during the transfer, staff should put the resident back down.During an interview on 08/20/25 at 3:11 PM, the Administrator stated her expectation was for staff to use the lift per protocol and how they had been taught. She stated if the staff heard the mechanical lift making noises, they were to stop what they were doing and notify a supervisor.

Based on observation, interview, record review, and facility document and policy review, the facility failed to provide one-to-one (1:1) supervision as needed in accordance with Resident (R)1's fall prevention care plan and failed to recognize and address all potential accident hazards in the resident's environment for 1 (R1) of 3 residents reviewed for falls. Specifically, on 01/25/2025, approximately five to ten minutes after the resident was assisted into bed by staff, who placed a reclined geriatric chair along the side of the resident's bed, R1 was seen coming down the hallway yelling that their eye hurt, and the resident's right eye was noted to be redder and more irritated than their left eye. While in the hallway, the resident became too weak to support their weight and was lowered to the floor by a nurse for an assisted fall. During the early morning hours of 01/26/2025, it was noted that the resident cried out in pain when trying to move their neck, and the resident was sent to the hospital for further evaluation. Hospital records reflected that the resident had a history of frequent falls and fell during the night of 01/25/2025 while trying to climb over a geriatric chair; the hospital diagnosed R1 with a type II fracture of the odontoid process and a contusion of the face. When investigating the circumstances of the resident's injuries and the assisted fall, the facility failed to consider all causal factors and did not identify that the manner in which staff were using the resident's geriatric chair posed a risk for accident or injury. The facility concluded that the resident's injuries were a result of being lowered to the floor by the nurse. Additionally, during the survey, staff left a rolling computer chair in the resident's room when it was not in use, which also posed a risk of additional accidents or injuries. Findings included: An undated facility policy titled, Fall-Clinical Protocol revealed, 1. As part of the initial assessment, individual residents with a history of falls and risk factors for subsequent falling will be identified. The section of the policy titled, Assessment specified, 2. If the cause of a fall is unclear, root cause analysis should be used to attempt to determine the cause(s) or related issues that may have precipitated the fall. The section of the policy titled, Treatment/Management specified, 1. Based on assessment, the staff in conjunction with the physician will review pertinent interventions and modify existing interventions when appropriate to try to prevent subsequent falls and to address risks of serious consequences of falling. R1's admission Record indicated the facility admitted the resident on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cauda equina syndrome (a condition that occurs when the cauda equina, the bundle of nerves at the base of the spinal cord, become compressed); other mechanical complication of internal fixation device of vertebrae; history of falling; lack of coordination; muscle weakness; dementia; bipolar disorder, current episode manic severe with psychotic features; unspecified mood disorder; anxiety disorder; low back pain; spondylosis (degeneration of the vertebral column); other intravertebral disc degeneration of the lumbar region; and posterior displaced type II dens fracture (a break in the odontoid process in the cervical spine). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated R1 did not use a mobility device and required supervision or touching assistance with bed mobility; chair/bed-to-chair transfers; toilet transfers; when walking 10 feet, 50 feet with two turns, and 150 feet; and when transitioning from a seated position to lying down, from lying down to a seated position, and from a seated position to standing. R1's Care Plan Report revealed the resident's care plan was last reviewed by the facility on 04/30/2025. The Care Plan Report included a focus area, initiated on 04/08/2024, that indicated the resident had an activities of daily living (ADL) self-care performance deficit. Another focus area, initiated 04/08/2024, indicated R1 was at risk for falls related to gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, history of falls and being unaware of safety needs. An intervention initiated on 06/25/2024 directed staff to provide Supervision of 1:1 caregiver as needed, and an intervention initiated on 09/21/2024 indicated the resident may use a geriatric recliner for rest periods. An event report, dated 01/25/2025 at 10:01 PM, indicated R1 was heard repeatedly yelling from the hallway, My eye hurts. The event report indicated a nurse responded and saw the resident walking down the hallway while holding the handrails. The event report further indicated R1 had a bruise on their face. According to the event report, the resident could not bear their own weight, and the nurse assisted the resident to control slide to the floor for an assisted fall. The event report revealed, Resident unable to describe why or how [his/her] eye hurts. A Nursing Note, dated 01/25/2025 at 10:44 PM, indicated R1 was placed into bed approximately five to ten minutes prior to the incident due to the resident falling asleep in their geriatric chair. According to the note, the resident was heard yelling that their eye hurt and upon quick assessment, the resident's right eye was more irritated and redder than the left eye, which was not noted before the resident was placed in bed. The note also indicated, unknown how bruise was accrued but hit to gerichair [geriatric chair], which was beside the head of the bed is possible. A Nursing Note, dated 01/26/2025 at 7:10 AM, revealed R1 began having complaints of neck pain during the morning while the nurse was checking the resident's vitals. The note indicated the resident would only follow movement with their eyes, and when attempting to move their head, the resident cried out in pain. According to the note, the resident was sent to the hospital for further evaluation. An Emergency Physicians report, dated 01/26/2025, revealed R1 had a history of frequent falls and fell during the night on 01/25/2025 while trying to climb over a geriatric chair. The report indicated R1 was diagnosed with a type II fracture of the odontoid process and a contusion of the face. During an interview on 05/12/2025 at 11:32 AM, Nurse Aide (NA) #12 stated she recalled working at the facility on the evening of 01/25/2025 but was not assigned to R1. NA12 recalled that she was not present when the resident fell but after returning to the unit following a short break, she saw R1 on the floor, and Licensed Practical Nurse (LPN)1 and NA2 were with the resident. NA12 stated LPN1 and NA2 transferred R1 from the floor to the resident's geriatric chair, and LPN1 asked NA12 and NA2 to check the resident's vital signs (blood pressure, pulse, temperature, and respirations). NA12 stated she and NA2 wheeled R1 to the dayroom, which was near the nurses' station, and obtained the requested vital signs before she left R1 with NA2 and continued with her assigned duties for the shift. NA12 stated a geriatric chair was routinely used for R1 during the night shift when she worked. NA12 further stated the resident's geriatric chair was placed next to the resident's bed during the night shift, and the resident had a history of attempting to climb out of their geriatric chair when seated in it and also had a history of attempting to climb out of their bed and over the geriatric chair (when the geriatric chair was positioned along the side of the resident's bed). During a follow-up interview on 05/13/2025 at 8:23 AM, NA12 stated staff usually put R1 to bed between 8:00 PM and 9:00 PM and routinely placed the resident's geriatric chair in the reclined position along the length of the resident's bed, with the footrest of the geriatric chair positioned towards the bottom of the resident's bed. During an interview on 05/12/2025 at 12:53 PM, LPN1 stated she worked night shift on R1's unit. LPN1 stated that R1 was at high risk for falls, stayed up all night most of the time, and required 1:1 supervision for periods of increased agitation; however, LPN1 stated the facility was not staffed to provide 1:1 supervision on most occasions, since only two aides were normally scheduled to work during the night shift. LPN1 stated that on the evening of 01/25/2025, NA2 put R1 to bed around 9:00 PM. LPN1 stated that generally, during the night shift, when R1 was put to bed, the resident's geriatric chair was placed at the head of the right side of the bed facing the foot of the bed. LPN1 stated the geriatric chair was routinely placed next to the resident's bed in a reclined position in an attempt to prevent the resident from getting up without staff's knowledge. LPN1 further explained that the resident's geriatric chair made noise when the resident's legs hit it, which alerted staff that the resident was trying to get up. LPN1 stated that on the evening of 01/25/2025 after the resident was put to bed, she was in a room directly behind the nurses' station and not in direct visual sight of R1's room, but she heard R1 repeatedly complaining that their eye hurt, so she exited the room behind the nurses' station and proceeded towards the resident. She stated that when she reached R1 in the hallway, she noticed the resident's eye was reddened. LPN1 stated at about that same time, R1 could no longer maintain their weight and grabbed onto LPN1. LPN1 further stated she was unable to hold R1's weight, so she yelled for NA2 to retrieve R1's geriatric chair from the resident's room to assist her. LPN1 stated she then repositioned herself behind R1 and lowered the resident to the floor by sliding the resident down her legs. During an interview on 05/12/2025 at 2:53 PM, NA2 stated that she arrived at work on 01/25/2025 around 7:00 PM. She stated she put R1 to bed during her first set of rounds sometime around 8:30 PM or 9:00 PM. She stated that after she put the resident to bed, she provided incontinence care, and she thought the resident was asleep, so she left R1 in bed to complete her rounds. She stated that after completing her rounds and about 45 minutes after putting R1 to bed, she heard the resident scream, Owww. She stated she saw the resident at the end of the hallway holding onto the handrails, and she and the nurse both went to the resident. NA2 stated the nurse asked her to get the resident's geriatric chair, and as she was exiting the resident's room with the chair, she saw the nurse lower the resident to the floor in a seated position. NA2 stated the resident was complaining their eye hurt, so they transferred the resident into the geriatric chair, took the resident to the dayroom, and assessed their vital signs. NA2 further stated R1 remained in the day room for the remainder of the night, and she went into the day room throughout the night to keep a periodic watch over the resident. NA2 stated R1 was sent to the hospital for evaluation the following morning. NA2 further stated that when she put R1 to bed during the night shift, including the night of 01/25/2025, she normally put the resident to bed, then placed their geriatric chair along the side of the resident's bed in a reclined position with the wheels locked and the footrest of the geriatric chair positioned beside the head of the resident's bed, because the resident was always trying to get out of bed. NA2 stated she knew that the resident had tried climbing over the geriatric chair from their bed many times, but staff usually heard the resident when they started to get out of bed, as long as they had the geriatric chair placed next to the bed. During an interview on 05/12/2025 at 9:28 AM, Registered Nurse (RN) #14 stated she was familiar with R1 and routinely worked on the resident's unit. RN #14 stated R1 was normally cooperative with care until about lunchtime, at which point the resident became increasingly agitated and at times became combative with staff. During an interview on 05/12/2025 at 2:21 PM, NA #16 stated she normally worked dayshift and was familiar with R1. NA #16 stated R1 liked to ambulate a lot during the daytime but needed someone with them for balance and safety. NA #16 further stated R1 could become combative in the afternoons if staff did not allow the resident to walk around, but the resident normally calmed down quickly if staff walked with the resident or kept the resident engaged with something. NA #16 stated R1 did not typically use a geriatric chair during the daytime, but staff tried to have chairs available for the resident to sit in when the resident needed a rest break. She said she was not on duty on the night of R1's 01/25/2025 fall; however, she recalled that when she arrived to work on the morning of 01/26/2025, she was notified the resident had a fall during the night and was being transferred to the hospital for evaluation after complaining of neck pain. NA #16 did not know if night shift staff placed the resident's geriatric chair along the side of the resident's bed when the resident was in bed, but she stated she did know the resident had a history of climbing out of their geriatric chair when it was used during the day. A concurrent observation and interview on 05/12/2025 beginning at 3:56 PM revealed R1 was seated in a reclined geriatric chair in the dayroom area when the resident was observed to kick their legs over the left side of the geriatric chair in an attempt to rise to a standing position. NA #16 and another aide responded to the resident. NA #16 stated R1 had a known history of attempting to stand from their geriatric chair and indicated that when the resident wanted to get up, the resident would get up whether staff were there or not. During an interview on 05/12/2025 at 4:22 PM, NA21 stated she only worked at the facility occasionally, but she knew R1 often tried to get up from their geriatric chair without staff assistance. NA21 did not know where staff placed the resident's geriatric chair when the resident was put to bed. During an interview on 05/12/2025 at 4:25 PM, NA20 stated she was familiar with R1. She stated the resident had a long history of falls, attempted to get up from their geriatric chair without assistance from staff, and at times attempted to climb out of their geriatric chair. NA20 stated that during the day shift, staff tried to keep the resident up and walking when possible and allowed the resident to rest in standard chairs when needed. She stated she was not working on 01/25/2025 when R1 fell. During an interview on 05/14/2025 at 11:46 AM, NA #19 stated she primarily worked on R1's unit and was familiar with the resident. She recalled that she worked with R1 on 01/25/2025 during the day shift, and the resident was on 1:1 supervision during the day. She stated she and another aide provided 1:1 to the resident by rotating out during breaks. During a follow-up interview on 05/16/2025 at 10:10 AM, NA #19 stated staff knew they were assigned 1:1 responsibilities because it was listed on their assignment sheets. NA #19 said that R1 had various behaviors, including combativeness and getting up without assistance, and was sometimes difficult to redirect. NA #19 stated there had been times when a staff member called out that they did not have the staff available to provide 1:1 but in those situations, they usually took R1 to the hallway or a common area so everyone could keep a watch on the resident. During an interview on 05/15/2025 at 3:45 AM, LPN #23 stated she worked night shift but had not routinely worked on R1's unit until after the fall on 01/25/2025. LPN #23 stated she was unsure if R1 required 1:1 prior to the fall on 01/25/2025 but indicated that staff knew whether 1:1 was needed by reviewing the schedule, which indicated when a staff member was assigned 1:1 responsibilities. During an interview on 05/15/2025 at 4:15 AM, NA24 stated she worked the night shift, primarily on R1's unit but was not working the night of 01/25/2025 when the resident fell. NA24 stated that sometimes R1's geriatric chair was left in the hallway outside their room, and other times, it was left in the resident's room. She said that when the geriatric chair was left in the resident's room, it was placed against the resident's bed to prevent the resident from being able to get up from the bed easily in hopes the resident would not fall. NA24 reported that staff knew if a resident required 1:1 because it was listed on the schedule. During an interview on 05/13/2025 at 10:50 AM, RN #3, the Risk Management Nurse, stated that upon reviewing R1's electronic medical record (EMR), she determined the resident had sustained 16 falls since their admission to the facility in 03/2024. RN #3 stated the facility implemented 1:1 supervision as needed following a fall on 06/24/2024; however, she stated there was no documentation available for when 1:1 was provided. She further stated the resident had another fall in 09/2024 while in their room, and the facility added an intervention to use a geriatric chair for rest periods. RN #3 verified that the facility did not have any documentation for 1:1 supervision and stated she was unable to validate when 1:1 was provided for R1 or its effectiveness. During an interview on 05/13/2025 at 2:27 PM, the Director of Nursing (DON) stated that on 01/25/2025, a nurse slid R1 to the floor for an assisted fall. She stated the resident sustained a bruise (to the eye/face), but the facility was unable to determine if another fall may have occurred prior to the nurse lowering the resident to the floor or what may have happened to cause the fracture that was later identified in the emergency room. She stated she did not recall knowing that the resident's geriatric chair was used in a reclined position up against the resident's bed. She further stated that it was not determined during the facility's investigation that R1 had a history of climbing out of their geriatric chair or over the geriatric chair from their bed. During an interview on 05/14/2025 at 2:45 PM with RN #3, the DON, the Assistant Director of Nursing (ADON), the Administrator, and the MDS Coordinator present, the DON stated that the nurse management team determined when 1:1 was needed for R1. She further stated they put 1:1 in place periodically when the resident was more agitated and then discontinued it once any behaviors had calmed down for 24 hours or so. RN #3 stated the resident used to work night shift and had their days and nights mixed up. The DON stated that when 1:1 was needed for the resident, they added an additional person to the schedule. During an interview on 05/14/2025 at 6:11 PM, the Administrator stated she first learned of the incident involving R1 when she arrived to work early on Monday, 01/27/2025, and noticed that R1 was at the nurses' station sitting in a standard wheelchair. The Administrator stated it was not R1's normal routine to use a standard wheelchair, so she asked staff what was going on with the resident. She stated she was informed that the resident had an assist fall and had started complaining of neck pain and was transferred to the ER for evaluation. The Administrator stated that the facility determined that they thought R1's injuries occurred as a result of the assisted fall. During an interview on 05/16/2025 at 8:45 AM, the facility's Former Scheduler stated she currently worked as a nurse aide but was the facility's scheduler from 04/2024 until 04/2025. The Former Scheduler stated that R1's unit usually only required two nurse aides during the night shift, but a third nurse aide was added if 1:1 was needed. The Former Scheduler stated she was unsure how it was determined when 1:1 was needed. She stated that for the night of 01/25/2025, if no one informed her 1:1 was needed, then she did not schedule anyone to provide 1:1 during the night shift. She further stated she only assigned someone the responsibility of 1:1 when instructed to do so by the DON. She stated she documented a 1:1 with a circle around it beside the staff member's name on the schedule to indicate they were responsible for providing the 1:1. R1's 01/2025 Documentation Survey Report revealed staff were monitoring for the presence of the following behaviors every shift: physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, other behavioral symptoms not directed toward others, wandering, and rejection of care. According to the Documentation Survey Report, staff documented the presence of the following behaviors in the days leading up to 01/25/2025: -01/19/2025 evening shift: verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others -01/20/2025 day shift: physical behaviors directed towards others, verbal behaviors directed towards others, other behaviors not directed towards others, rejection of care, and wandering -01/21/2025 day shift: physical behaviors directed towards others, verbal behaviors directed towards others, other behaviors not directed towards others, rejection of care, and wandering -01/22/2025 night shift: other behavioral symptoms not directed towards others -01/23/2025 evening shift: wandering -01/24/2025 evening shift: other behavioral symptoms not directed towards others -01/25/2025 day shift: wandering R1's 01/2025 Medication Administration Record (MAR) revealed the transcription of an order dated 01/13/2025 for lorazepam 1 milligram (mg) every eight hours as needed for anxiety and agitation. According to the MAR, the resident's as-needed lorazepam was administered due to increased anxiety and agitation twice on 01/20/2025; twice on 01/21/2025; and once on 01/22/2025, 01/23/2025, and 01/24/2025. The facility's Daily Schedule Breakdown revealed that 1:1 was noted on R1's unit during the dayshift on 01/25/2025; however, there was no indication 1:1 was in place during the evening or night shifts on 01/25/2025. During an interview on 05/16/2025 at 7:19 PM, the DON and Administrator were referred to the prior interview in which the DON stated 1:1 was initiated for R1 periodically when agitation was increased then was discontinued after the resident's behaviors had calmed down for 24 hours or so. They were then provided copies of the Daily Schedule Breakdown for 01/25/2025 that reflected 1:1 was initiated during the dayshift but not evening or night shifts. After reviewing the Daily Schedule Breakdown, the DON and Administrator both stated they would not have done 1:1 on just day shift, but they requested time to look at documentation they referred to as a breakdown sheet and come back and answer the question further. On 05/16/2025 at 9:10 PM, the DON, RN #3, and the Administrator returned to the conference room, and the DON stated they were unable to find the documentation they were looking for. RN #3 stated that during the time of R1's fall on 01/25/2025, they were only doing 1:1 during the 7:00 AM-7:00 PM shift because the resident was sleeping better at night. The surveyor then referred the DON, RN #3, and the Administrator to the resident's medical record, including the 01/2025 MAR that reflected the resident's as-needed lorazepam was administered multiple days leading up to 01/25/2025 and the 01/2025 Survey Documentation Report that indicated the resident had been experiencing behaviors leading up to 01/25/2025. After reviewing the information in the resident's record, the DON stated there had been no period of time where R1's behaviors and agitation resolved completely, but they had lessened during the timeframe of the resident's fall on 01/25/2025. The DON stated the administration of as-needed lorazepam for agitation was not considered when evaluating whether 1:1 was needed. The DON further stated the facility did not have any documentation of when 1:1 was provided for the resident, no documentation of how the facility evaluated for the effectiveness of 1:1 supervision, no documentation of what information nurse management considered when making the determination as to whether 1:1 was needed for the resident, and no documentation regarding how or when the decision was made 1:1 was no longer needed. The DON and Administrator both stated that having a resident on 1:1 for one shift but not the next was not the facility's normal practice. During an interview on 05/14/2025 at 9:28 AM, the Medical Director (MD) stated he was aware R1 had an incident on 01/25/2025 that resulted in a cervical neck fracture. He stated he was also aware the resident had an initial bruise noted to their eye from an unknown source. He stated he did not see how injuries such as the neck fracture and eye bruising could have occurred from the assist fall or control slide by the nurse. The MD stated he was not made aware that staff were placing the resident's geriatric chair along the side of the bed to prevent falls or that the resident had a history of climbing out of their geriatric chair or over their geriatric chair from the bed. The MD stated that in his professional opinion, the injuries sustained by the resident on the night of 01/25/2025 could have occurred as a result of the resident climbing out of their bed and over the geriatric chair if the resident fell while doing so or if they hit their head or neck in the process. During a follow-up interview on 05/16/2025 at 1:26 PM, the MD stated R1 should have required 1:1 supervision at the time of the incident on 01/25/2025. He further stated 1:1 should have been provided until the resident's behaviors were fully managed and controlled effectively. The MD stated it was the facility's responsibility to keep the residents safe at all times. He stated when investigating the circumstances of R1's injuries, the facility should have assessed environmental factors and conducted extensive interviews with staff, other residents if applicable, and anyone else that could have witnessed something in an attempt to determine root cause so that they could implement appropriate and effective interventions. An observation on 05/13/2025 beginning at 9:39 AM revealed R1 was lying in bed with their eyes closed without staff present in the room. A rolling computer chair was observed positioned against the bed on the resident's right side. While the surveyor remained in the room with R1, NA #16 entered the room. NA #16 stated the rolling computer chair was in R1's room for use by staff while providing 1:1 care, although the resident was not currently assigned to 1:1 care at the time of the observation. During an interview on 05/14/2025 at 2:45 PM with RN #3, the DON, the ADON, the Administrator, and the MDS Coordinator present, RN #3 and the DON stated the rolling computer chair was for staff to sit in when providing 1:1 to R1. The DON stated she hoped staff were removing the rolling computer chair from the resident's room when it was not in use. During an interview on 05/14/2025 at 6:11 PM, the Administrator stated she had made rounds on multiple days and saw the rolling computer chair in R1's room but had not thought about the chair being a hazard. During an interview on 05/16/2025 at 5:17 PM, the DON stated that having a rolling computer chair in R1's room when not in use by staff would be an accident hazard. She stated the rolling computer chair should not be in the resident's room if staff were not using it.

Based on observation, record review, interview, and facility document and policy review, the facility failed to ensure staff did not utilize a geriatric chair without assessing whether the use of the geriatric chair was considered a restraint for 1 (Resident (R)1) of 3 residents reviewed for falls. Specifically, despite a known history of climbing out of the side of their geriatric chair and a history of climbing from their bed over their geriatric chair when staff positioned it by the resident's bed, staff placed R1 in a geriatric chair in a reclined position and also utilized the geriatric chair positioned along the side of the resident's bed while the resident was in bed to prevent the resident from getting up without staff's knowledge. Findings included: A facility policy titled, Use of Restraints, revised 04/2017, indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The policy specified, 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The policy further specified, 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility when in bed; and c. placing a resident in a chair that prevents the resident from rising. The policy indicated, 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine need for restraints and 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). R1's admission Record indicated the facility admitted the resident on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cauda equina syndrome (a condition that occurs when the cauda equina, the bundle of nerves at the base of the spinal cord, become compressed); other mechanical complication of internal fixation device of vertebrae; history of falling; lack of coordination; muscle weakness; dementia; bipolar disorder, current episode manic severe with psychotic features; unspecified mood disorder; anxiety disorder; low back pain; spondylosis (degeneration of the vertebral column); other intravertebral disc degeneration of the lumbar region; and posterior displaced type II dens fracture (a break in the odontoid process in the cervical spine). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated R1 did not use a mobility device and required supervision or touching assistance with bed mobility; chair/bed-to-chair transfers; toilet transfers; when walking 10 feet, 50 feet with two turns, and 150 feet; and when transitioning from a seated position to lying down, from lying down to a seated position, and from a seated position to standing. R1's Care Plan Report revealed the resident's care plan was last reviewed by the facility on 04/30/2025. The Care Plan Report included a focus area, initiated on 04/08/2024, that indicated the resident had an activities of daily living (ADL) self-care performance deficit. Another focus area, initiated 04/08/2024, indicated R1 was at risk for falls related to gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, history of falls and being unaware of safety needs. An intervention initiated on 06/25/2024 directed staff to provide Supervision of 1:1 caregiver as needed, and an intervention initiated on 09/21/2024 indicated the resident may use a geriatric recliner for rest periods. The Care Plan Report did not indicate that any type of restraint should have been utilized for R1. An event report, dated 01/25/2025 at 10:01 PM, indicated R1 was heard repeatedly yelling from the hallway, My eye hurts. The event report indicated a nurse responded and saw the resident walking down the hallway while holding the handrails. The event report further indicated R1 had a bruise on their face. According to the event report, the resident could not bear their own weight, and the nurse assisted the resident to control slide to the floor for an assisted fall. The event report revealed, Resident unable to describe why or how [his/her] eye hurts. A Nursing Note, dated 01/25/2025 at 10:44 PM, indicated R1 was placed into bed approximately five to ten minutes prior to the incident due to the resident falling asleep in their geriatric chair. According to the note, the resident was heard yelling that their eye hurt and upon quick assessment, the resident's right eye was more irritated and redder than the left eye, which was not noted before the resident was placed in bed. The note also indicated, unknown how bruise was accrued but hit to gerichair [geriatric chair], which was beside the head of the bed is possible. A Nursing Note, dated 01/26/2025 at 7:10 AM, revealed R1 began having complaints of neck pain during the morning while the nurse was checking the resident's vitals. The note indicated the resident would only follow movement with their eyes, and when attempting to move their head, the resident cried out in pain. According to the note, the resident was sent to the hospital for further evaluation. An Emergency Physicians report, dated 01/26/2025, revealed R1 had a history of frequent falls and fell during the night on 01/25/2025 while trying to climb over a geriatric chair. The report indicated R1 was diagnosed with a type II fracture of the odontoid process and a contusion of the face. An observation on 05/12/2025 at 9:15 AM revealed R1 was seated in the dining room in a reclined geriatric chair. The geriatric chair was pushed up to a dining table with no other individuals at the table. A concurrent observation and interview on 05/12/2025 beginning at 3:56 PM revealed R1 was seated in a reclined geriatric chair in the dayroom area when the resident was observed to kick their legs over the left side of the geriatric chair in an attempt to rise to a standing position. Nurse Aide (NA)16 and another aide responded to the resident. NA16 stated, R1 has a known history of attempting to stand from their geriatric chair. During an interview on 05/12/2025 at 11:32 AM, NA12 stated a geriatric chair was routinely used for R1 during the night shift when she worked. NA12 further stated the resident's geriatric chair was placed next to the resident's bed during the night shift, and the resident had a history of attempting to climb out of their geriatric chair when seated in it and also had a history of attempting to climb out of their bed and over the geriatric chair (when the geriatric chair was positioned along the side of the resident's bed). During a follow-up interview on 05/13/2025 at 8:23 AM, NA12 stated staff usually put R1 to bed between 8:00 PM and 9:00 PM and routinely placed the resident's geriatric chair in the reclined position along the length of the resident's bed, with the footrest of the geriatric chair positioned towards the bottom of the resident's bed. During an interview on 05/12/2025 at 12:53 PM, Licensed Practical Nurse (LPN)1 stated she worked night shift on R1's unit. LPN1 stated that R1 was at high risk for falls and stayed up all night most of the time. LPN1 stated that generally, during the night shift, when R1 was put to bed, the resident's geriatric chair was placed at the head of the right side of the bed facing the foot of the bed. LPN1 stated the geriatric chair was routinely placed next to the resident's bed in a reclined position in an attempt to prevent the resident from getting up without staff's knowledge. LPN1 further explained that the resident's geriatric chair made noise when the resident's legs hit it, which alerted staff that the resident was trying to get up. During an interview on 05/12/2025 at 2:53 PM, NA2 stated that she arrived at work on 01/25/2025 around 7:00 PM. She stated she put R1 to bed during her first set of rounds sometime around 8:30 PM or 9:00 PM. NA2 further stated that when she put R1 to bed during the night shift, including the night of 01/25/2025, she normally put the resident to bed, then placed their geriatric chair along the side of the resident's bed in a reclined position with the wheels locked and the footrest of the geriatric chair positioned beside the head of the resident's bed, because the resident was always trying to get out of bed. NA2 stated she knew that the resident had tried climbing over the geriatric chair from their bed many times, but staff usually heard the resident when they started to get out of bed, as long as they had the geriatric chair placed next to the bed. During an interview on 05/15/2025 at 4:15 AM, NA24 stated she worked the night shift, primarily on R1's unit but was not working the night of 01/25/2025 when the resident fell. NA24 stated that sometimes R1's geriatric chair was left in the hallway outside their room, and other times, it was left in the resident's room. She said that when the geriatric chair was left in the resident's room, it was placed against the resident's bed to prevent the resident from being able to get up from the bed easily in hopes the resident would not fall. NA24 stated she was taught that the definition of a restraint was when something prevented a resident's movement and that they were not to use restraints in the facility; however, NA24 acknowledged the geriatric chair would have been an attempt to restrain the resident from getting up from their bed. During an interview on 05/12/2025 at 5:00 PM, the Administrator stated that during the course of the facility's investigation into the injuries sustained by R1 on 01/25/2025, the facility had not elicited information from staff that they had placed the resident's geriatric chair up against the bed as a barrier to prevent the resident from getting up. During a follow-up interview on 05/16/2025 at 2:30 PM, the Administrator stated that the use of the geriatric chair for R1 was initiated for rest periods and was not intended to be used at all times. The Administrator said that although she knew the definition of a restraint was something that restricted movement, she did not feel she had the expertise to determine if utilizing the resident's geriatric chair in a reclined position would be considered a restraint. The Administrator stated that if a geriatric chair was pushed up close to a bed while a resident was in bed, then the geriatric chair would not be appropriate. During an interview on 05/15/2025 at 9:05 AM, Registered Nurse (RN)3, the Risk Management Nurse, stated restraints were not allowed to be used in the facility. She stated a restraint was anything that prevented the resident from rising based on the resident's ability to stand and walk independently. RN3 provided an example of a restraint to be something that prevented a resident from getting up, such as a chair in the locked position next to their bed; however, she indicated she did not consider it a restraint when staff placed the resident's geriatric chair next to R1's bed, because she believed the resident could push the geriatric chair out of the way to get up. RN3 then acknowledged that if the geriatric chair was positioned in that manner and the wheels were locked, it could possibly be considered a restraint. RN3 stated she also did not consider having R1 in the common area in a reclined geriatric chair a restraint unless the resident was pushed up to a table, which would prevent them from rising. RN3 said that in her opinion, R1 could still throw their legs over the side of the chair and get up if they wanted to, even if the chair was in the reclined position. She said she did not think the geriatric chair in a reclined position would prevent R1 from getting up. RN3 further stated the facility had not completed assessments for geriatric chair use for any resident in the facility and had not assessed R1's use of the geriatric chair as a potential restraint until after the survey began. She said she did not consider geriatric chair use a restraint as geriatric chairs were primarily used for positioning and comfort and not confinement. During an interview on 05/16/2025 at 5:17 PM, the Director of Nursing (DON) stated the use of the geriatric chair for R1 was initiated by the interdisciplinary team (IDT), and they had discussed the appropriateness for the resident during rest periods, because R1 was always go-go-go and needed the geriatric chair to use when the resident became fatigued. She said the facility did not evaluate residents for geriatric chair usage or the potential for a geriatric chair to be identified as a restraint. The DON stated she would not consider the geriatric chair a restraint when in use by R1 and in a reclined position or when the geriatric chair was placed in a locked, reclined position next to the resident's bed for the resident, because R1 was able to move the chair by pushing it. She was not aware the resident had a history of climbing out of or over their geriatric chair. During an interview on 05/14/2025 at 9:28 AM, the Medical Director (MD) stated he was aware R1 had an incident on 01/25/2025 that resulted in a cervical neck fracture. He stated he was also aware the resident had an initial bruise noted to their eye from an unknown source. He stated he did not see how injuries such as the neck fracture and eye bruising could have occurred from the assist fall or control slide by the nurse. The MD stated he was not made aware that staff were placing the resident's geriatric chair along the side of the bed to prevent falls or that the resident had a history of climbing out of their geriatric chair or over their geriatric chair from the bed. He stated that in his opinion, using the geriatric chair in this manner was not a good thing and was at least an attempt at a restraint. The MD stated that in his professional opinion, the injuries sustained by the resident on the night of 01/25/2025 could have occurred as a result of the resident climbing out of their bed and over the geriatric chair if the resident fell while doing so or if they hit their head or neck in the process. During a follow-up interview on 05/16/2025 at 1:26 PM, the MD stated that a geriatric chair should not be initiated as an intervention until the resident was assessed for its appropriateness, and the continued use of the geriatric chair should be monitored to determine if it remained appropriate. He stated that a resident placed in a reclined geriatric chair who was normally mobile and ambulatory, safe or not, would be considered a restraint.

Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected falls and resulting injuries for 1 (Resident (R)1) of 3 sampled residents. Findings included: A facility policy titled, MDS 3.0 Completion, reviewed/revised on 09/30/2024, revealed, According to federal regulations, the facility conducts initially a periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. The section of the policy titled, Care Plan Team Responsibility for Assessment Completion, 1. Interdisciplinary Responsibility for Completion of MDS Sections specified, c. Persons completing part of the assessment must attest to the accuracy of the section they completed. R1's admission Record indicated the facility admitted the resident on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cauda equina syndrome (a condition that occurs when the cauda equina, the bundle of nerves at the base of the spinal cord, become compressed); other mechanical complication of internal fixation device of vertebrae; history of falling; lack of coordination; muscle weakness; dementia; bipolar disorder, current episode manic severe with psychotic features; unspecified mood disorder; anxiety disorder; low back pain; spondylosis (degeneration of the vertebral column); other intravertebral disc degeneration of the lumbar region; and posterior displaced type II dens fracture (a break in the odontoid process in the cervical spine). R1's Care Plan Report included a focus area, initiated 04/08/2024, that indicated the resident was at risk for falls. An event report, dated 01/25/2025 at 10:01 PM, revealed R1 was heard yelling from the hallway, and a nurse responded and saw the resident walking down the hallway while holding the handrails. According to the event report, the resident could not bear their own weight, and the nurse assisted the resident to control slide to the floor for an assisted fall. An Emergency Physicians report, dated 01/26/2025, revealed R1 was seen in the emergency room for a fall the night before. The report indicted the resident injured their right eye, and a computed tomography (CT) scan revealed the resident had a type II odontoid fracture with dorsal displacement. A modified significant change in status MDS, with an Assessment Reference Date (ARD) of 02/03/2025, revealed R1's most recent admission/entry or reentry to the facility was on 03/29/2024. The MDS was coded to reflect that R1 had not had any falls since admission/entry, reentry, or their prior assessment. A Fall event report, dated 04/18/2025, revealed R1 pushed a staff member and fell backwards onto [his/her] bottom. The event report indicated the fall was witnessed and no injuries were observed at the time of the incident. A quarterly MDS, with an ARD of 05/06/2025, revealed R1's most recent admission/entry or reentry to the facility was on 03/29/2024. The MDS was coded to reflect that R1 had not had any falls since admission/entry, reentry, or their prior assessment. During an interview on 05/15/2025 at 2:15 PM, the MDS Coordinator reviewed R1's modified significant change in status MDS, with an ARD of 02/03/2025, and stated the assessment was coded to reflect that the resident had not sustained any falls since admission/entry, reentry, or their prior assessment. After reviewing R1's medical record, the MDS Coordinator stated the resident sustained a fall that resulted in a cervical neck fracture on 01/26/2025. She stated the MDS should have reflected that the resident had sustained a fall since admission/entry, reentry, or their prior assessment and also should have specified that the resident had no falls without injury, no falls with minor injury, and one fall with major injury. The MDS Coordinator also reviewed R1's quarterly MDS, with an ARD of 05/06/2024, and stated the assessment was coded to reflect that the resident had not sustained any falls since admission/entry, reentry, or their prior assessment. After reviewing R1's medical record, the MDS Coordinator stated that the resident sustained a fall without injury on 04/18/2025. She stated the MDS should have reflected that the resident had sustained a fall since admission/entry, reentry, or their prior assessment and also should have specified that the resident had one fall without injury, no falls with minor injury, and no falls with major injury. During an interview on 05/16/2025 at 5:17 PM, the Director of Nursing (DON) stated she expected MDS assessments to be complete and accurate, and the MDS Coordinator should have reviewed the medical record when completing the assessments. During an interview on 05/16/2025 at 7:19 PM, the Administrator stated she expected all MDS assessments to be completed timely and accurately.

Based on interview, record review, and facility policy review, the facility failed to ensure staff checked for incontinence and/or provided incontinence care during routine rounds for 1 (Resident (R)1) of 3 residents reviewed for falls. Specifically, on the evening 01/25/2025, after the resident experienced an assisted fall to the floor, staff placed the resident in a geriatric chair and did not check to see if the resident required incontinence care until sometime between 5:00 AM to 6:00 AM the following morning. Findings included: R1's admission Record indicated the facility admitted the resident on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cauda equina syndrome (a condition that occurs when the cauda equina, the bundle of nerves at the base of the spinal cord, become compressed); other mechanical complication of internal fixation device of vertebrae; history of falling; lack of coordination; muscle weakness; dementia; bipolar disorder, current episode manic severe with psychotic features; unspecified mood disorder; anxiety disorder; low back pain; spondylosis (degeneration of the vertebral column); other intravertebral disc degeneration of the lumbar region; and posterior displaced type II dens fracture (a break in the odontoid process in the cervical spine). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was always incontinent of bowel and bladder. R1's Care Plan Report included a focus area, initiated 04/08/2024, that indicated the resident had bowel and bladder incontinence. An intervention dated 04/08/2024 directed staff to check the resident for incontinence during rounds and as required. An event report, dated 01/25/2025 at 10:01 PM, revealed R1 was heard yelling from the hallway, and a nurse responded and saw the resident walking down the hallway while holding the handrails. According to the note, the resident could not bear their own weight, and the nurse assisted the resident to control slide to the floor for an assisted fall. The event report indicated the resident was transferred to a geriatric chair following the fall. A Nursing Note, dated 01/25/2025 at 10:44 PM, indicated that after the assisted fall, R1 was resting in the recreational room, so staff could keep a close eye on the resident. R1's 01/2025 Documentation Survey Report revealed no documentation of bladder activity, bowel activity, toileting transfer, or toileting hygiene provided to the resident during the evening or night shift on 01/25/2025. During a telephone interview on 05/12/2025 at 11:32 AM, Nurse Aide (NA) #12 stated she recalled that on 01/25/2025, after R1 had an assisted fall, the resident was placed into their geriatric chair, and she and NA2 took the resident to the dayroom (common area on the unit where meals and activities were provided) to check the resident's vital signs. NA12 stated that after obtaining the resident's vital signs, she returned to her assignment on the unit, and R1 remained in the day room with NA2. NA12 further stated she did see the resident for the remainder of the night, but she knew the resident remained in their geriatric chair in the day room until the next morning. NA12 stated that R1 was incontinent of bowel and bladder and always wore a brief. NA12 confirmed she did not assist with any transfers or provide toileting or incontinence care to the resident after their fall on 01/25/2025. During a telephone interview on 05/12/2025 at 2:53 PM, NA2 stated she recalled working the night shift on 01/25/2025. She stated that around 8:30 PM - 9:00 PM on the evening of 01/25/2025, she placed R1 in bed and provided incontinence care before the resident went to sleep. She said she then left the resident and completed rounds on other residents. NA2 stated that about 45 minutes later, R1 had a fall and was placed in their geriatric chair for assessment and taken to the day room. NA2 stated she made incontinence rounds for the remainder of the residents on the hall around midnight but left R1 in their geriatric chair in the day room for the remainder of the night until approximately 5:00 AM-6:00 AM the following morning, when she took the resident to their room and placed them in bed to provide incontinence care. NA2 stated that she did not put R1 back to bed or provide incontinence care (check or change) during the remainder of the shift after the fall, because the resident was sleeping and they did not want to wake them up for incontinence care. During an interview on 05/12/2025 at 12:53 PM, Licensed Practical Nurse (LPN)1 stated that following the assisted fall on 01/25/2025, R1 went to sleep in their geriatric chair, and staff only woke the resident up when performing neurological checks, after which the resident went right back to sleep. LPN1 stated R1 was always incontinent of bowel and bladder and always wore a brief. She stated the staff did not put the resident to bed or check the resident for incontinence during the remainder of the shift after the fall, because the resident was resting peacefully. During an interview on 05/14/2025 at 5:35 PM, the Assistant Director of Nursing (ADON) stated that staff should check residents for incontinent episodes every two hours and provide incontinence care, if indicated. During an interview on 05/16/2025 at 2:30 PM, the Administrator stated she expected staff to make rounds and provide resident care, including incontinence care, every two hours.

Based on observations, interviews, and facility policy, the facility failed to identify and complete a Significant Change in Status Assessment (SCSA) for 2 of 2 residents reviewed for significant change in condition. Specifically Resident (R)42's comprehensive assessment was not updated after the election of hospice services, or a major decline within the fourteen-day status change requirement. Findings include: Review of the facility policy titled, Policy-MDS 3.0 Completion, revised 09/30/24, states: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 2c. Significant Change Assessment- completed within fourteen (14) days of the identification of a status change that meets the requirements outlined in Chapter 2 of the 3.0 Version RAI Manual. i. A significant change is defined, according to the RAI Manual, MDS version 3.0, as a decline or improvement in a resident's status that: 1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only); 2) Impacts more than one area of the resident's health status; AND 3) requires interdisciplinary review and/or revision of the care plan. ii. A SCSA is required when a resident enrolls in a hospice program and remains in the facility, or a resident in the facility receiving hospice services discontinues those services (known as revocation of hospice care) and remains in the facility. Review of R42's face sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's disease, weakness, abnormalities of gait and mobility, and history of falling. Review of R42's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/19/24 revealed R42 had a Brief Interview of Mental Status (BIMS) score of 00 of 15, indicating that the resident was unable to complete the interview. The MDS did not reveal an update of a significant change of a hip fracture on 12/06/24. The hip fracture was documented on 01/07/24 as a modified significant change. R42 was admitted to Hospice on 11/20/24. The MDS reflects a significant change for hospice 12/20/24. Review of R42's Care Plan with a start date of 12/06/24 revealed a focus that a fall occurred on 12/06/24 and a right hip fracture occurred. Care plan with a start date of 11/20/24 revealed a focus that resident has a terminal prognosis related to Alzheimer's Disease. The Resident elected to Amedisys Hospice. During an interview on 01/07/25 at 2:12 PM, with the MDS2 stated the significant change for R42 should have been updated when the hip fracture occurred and when he was admitted to hospice services. MDS2 was unsure why it wasn't updated. MDS2 updated the MDS on 01/07/24 with the significant change for the hip fracture that occurred on 12/06/24. During an interview on 01/08/25 at 9:51 AM, with MDS1, she states the significant change for R42 was the hip fracture that occurred on 12/06/24 but has been since modified on 01/08/25 by MDS2. MDS1 explains that the MDS should be updated in less than 14 days and when any major changes occur. MDS1 explains that the MDS was not updated in the correct timeframe and admits, it was a mistake. During an interview on 01/08/25 at 10:25AM, the Administrator stated the policy on MDS is to ensure that the facility follows the regulations. She states the importance of documenting in the MDS is that they are completed timely. It depends on the issue that is being addressed when the MDS needs to be updated. She ensures her staff are following the regulation by viewing monthly validation reports. During an interview on 01/08/25 at 10:18 AM with the Director of Nursing (DON), the DON states that she couldn't verbalize the MDS policy, unless she is looking at it. She states, the MDS is used to update the patients' health condition. During an interview on 01/08/25 at 10:28 AM with the Risk Manager (RM) revealed the RM states the minimum data assessment tool is used to evaluate a resident's condition and provide guidelines. She states the MDS needs to be updated quarterly and with any change in the residents' condition, whether it's an improvement or a decline in resident's condition.

Based on observations, interviews, and facility policy, the facility failed to maintain the dignity for 1 of 3 residents reviewed for dignity and infection control. Specifically, the facility did not provide a privacy bag for Resident (R)33's catheter bag. Furthermore, the catheter bag was found on the resident's floor during multiple observations. Cross-reference F880. Findings include: Review of the policy titled, Resident Rights, revised on 10/01/24, states: Employees shall treat all residents with kindness, respect and dignity. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Review of CDC Infection Control Summary of Recommendations with a revised date of 03/25/24 states, III.B.2. Keep the collecting bag below the bladder. Do not rest the bag on the floor. Review of R33's face sheet revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, Cerebral Palsy, neuromuscular dysfunction of bladder, retention of urine, and lack of coordination. Review of R33's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/04/24 revealed R33 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating that the resident has moderate cognitive impairment. R33 is always incontinent of bowel and bladder and has an indwelling catheter. Review of R33's Care Plan with a start date of 08/21/24, revealed R33 prefers some activities out of room as well as all things Catholic. It also includes, R33 has a suprapubic catheter related to urinary retention and neurogenic bladder. Interventions include: The resident has a (16Fr) indwelling catheter, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks during rounds each shift initiated on 08/12/24. Review of R33's Progress Note dated 11/05/24 revealed, Resident is s/p antibiotic therapy, completed Keflex r/t urinary tract infection (UTI) on 11/02/24. No adverse reactions noted at this time. RR e/u w/o any distress noted. No concerns or complaints at this time. Resident resting in bed with call light in reach. Plan of care ongoing. During an observation on 01/06/25 at 12:00 PM, R33 was in bed watching television. Her foley bag was full of urine and lying on the floor. There was no privacy cover over the foley catheter bag. During an observation on 01/07/25 at 4:30 PM, R33 was sitting in her wheelchair in her room watching television. Her foley catheter bag was on the floor behind her wheelchair with no privacy covering. During an interview on 01/07/25 at 4:44 PM, with the Unit Manager (UM), revealed R33's catheter bag was on the floor behind her wheelchair and did not have a privacy covering. UM stated the privacy catheter bag wasn't present and she is aware that the catheter bag should not be on the floor because that could cause infection, and the covering is a dignity issue for the patient. The UM stated that she will take care of this matter now. During an interview on 01/08/25 at 9:21 AM, the Director of Nursing (DON), stated that staff uses stat locks in place on residents to keep catheter tubing from kinking. DON stated that her staff visually observes the foley catheters to see whether it is kinking as well. She stated that the foley catheter bag should never be on the floor and should have a privacy bag covering to protect the patient and prevent infection. The DON states she has never witnessed the foley bag being on the floor in R33's room.

Based on observations, record reviews, interviews and manufacturer package inserts, the facility failed to ensure that 1 of 3 medication room refrigerators, containing refrigerated medications, were operative. Findings include: Review of the facility policy entitled Storage of Medications revised 11/1/2015 states Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Manufacturer package inserts for insulin recommend storage for not in-use (unopened) insulin be stored in a refrigerator at approximately 36-46 degrees F. On 1/07/25 at approximately 10:49 AM, inspection of the Hall A Medication Room revealed the refrigerator thermometer reading was 48 degrees F (Fahrenheit) and plastic bags of insulin for approximately three residents were lying on shelves in standing water with thawed ice packs in the freezer compartment. The temperature log affixed to the refrigerator door had a recorded temperature on 1/6/25 of 38 degrees with numerous prior entries reading 38 degrees. On 1/07/25 at approximately 10:54 AM, Registered Nurse (RN)1 confirmed the refrigerator thermometer reading was 48 degrees F, started cleaning water from the refrigerator and stated the 3rd shift was responsible for checking and recording refrigerator temperatures. On 1/07/25 at approximately 11:30 AM, the Administrator stated maintenance had found that the refrigerator wasn't working and was being replaced.

Based on observations, interviews, and facility policy, the facility failed to maintain the dignity for 1 of 3 residents reviewed for dignity and infection control. Specifically, the facility did not provide a privacy bag for Resident (R)33's catheter bag. Furthermore, the catheter bag was found on the resident's floor during multiple observations. Cross-reference F880. Findings include: Review of the policy titled, Resident Rights, revised on 10/01/24, states: Employees shall treat all residents with kindness, respect and dignity. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Review of R33's face sheet revealed she was admitted to the facility on [DATE] with diagnosis including, but not limited to, Cerebral Palsy, neuromuscular dysfunction of bladder, retention of urine, and lack of coordination. Review of R33's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/04/24 revealed R33 had a Brief Interview of Mental Status (BIMS) score of 10 of 15, indicating that the resident has a moderate cognitive impairment. Resident 33 is always incontinent of bowel and bladder and has an indwelling catheter. Review of R33's Care Plan with a start date of 08/21/24, revealed R33 prefers some activities out of room as well as all things Catholic. It also includes, R33 has a suprapubic catheter related to urinary retention and neurogenic bladder. Interventions include: The resident has a (16Fr) indwelling catheter, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks during rounds each shift initiated on 08/12/24. Review of R33's Progress Note dated 11/05/24 revealed, Resident is s/p antibiotic therapy, completed Keflex r/t urinary tract infection (UTI) on 11/02/24. No adverse reactions noted at this time. RR e/u w/o any distress noted. No concerns or complaints at this time. Resident resting in bed with call light in reach. Plan of care ongoing. During an observation on 01/06/25 at 12:00 PM, R33 was in bed watching television. Her foley bag was full of urine and lying on the floor. There was no privacy cover over the foley catheter bag. During an observation on 01/07/25 at 4:30 PM, R33 was sitting in her wheelchair in her room watching television. Her foley catheter bag was on the floor behind her wheelchair with no privacy covering. During an interview on 01/07/25 at 4:44 PM, with the Unit Manager (UM), revealed R33's catheter bag was on the floor behind her wheelchair and did not have a privacy covering. UM stated the privacy catheter bag wasn't present and she is aware that the catheter bag should not be on the floor because that could cause infection, and the covering is a dignity issue for the patient. The UM stated that she will take care of this matter now. During an interview on 01/08/25 at 9:21AM, with the Director of Nursing (DON), stated that staff uses stat locks in place on residents to keep catheter tubing from kinking. DON stated that her staff visually observes the foley catheters to see whether it is kinking as well. She stated that the foley catheter bag should never be on the floor and should have a privacy bag covering to protect the patient and prevent infection. The DON states she has never witnessed the foley bag being on the floor in R33's room.

Based on observations, record reviews and interview, the facility failed to ensure it is free of medication error rate of 5 % (percent) or greater. The error rate was 7.14 % based on 1 of 5 residents observed during med pass. There were two observed errors related to Resident (R)46, who was admitted to the facility on [DATE] with diagnoses including, but not limited to vitamin deficiency and essential (primary) hypertension. Findings: The facility policy entitled Medication Administration - General Policies and Procedures revised 11/1/2015 states Medications are administered as prescribed in accordance with good nursing principle and practices Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. On 01/07/25 at approximately 09:58 AM, LPN (Licensed practical Nurse)1 administered the following medications to R46: -Vitamin D3 125 mg (milligram) (5,000 IU (International Units) ) x 1 -Metoprolol Tartrate 25 mg x 1 On 1/7/25 at approximately 11:10 AM, during medication reconciliation, a review of the January 2025 physician's orders for R46, provided by the (DON) Director of Nursing, revealed: -an order dated 8/12/2024 for Vitamin D2 Oral Tablet (Ergocalciferol) Give 1250 mcg (microgram) orally one time a day every Tue (Tuesday) related to VITAMIN DEFICIENCY. -an order dated 6/10/2024 for Metoprolol Tartrate Oral Tablet 25 mg (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN (hypertension) Hold if SBP (systolic blood pressure) less than 100 or dbp (diastolic blood pressure) less than 80. On 1/7/25 at approximately 11:15 AM, a review of the January 2025 medication administration record provided by the DON revealed that Metoprolol Tartrate Oral Tablet 25 mg had been also been administered when the dbp was less than 80 on 1/1/2025 and 1/2/2025. On 01/07/25 at approximately 11:26 AM, during an interview, LPN1, after reviewing the physician's orders, acknowledged the two errors and stated I'm not used to having orders read less than 80 dystolic.

Based on a review of facility policy, observation, and interview, the facility failed to ensure the removal of expired foods from the cooler in 1 of 1 kitchen. Findings include: Review of the facility's policy and procedure titled, Food Receiving and Storage revised on [DATE], revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Procedure: Policy interpretation and Implementation to be followed: 8.) All foods Stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). During the initial kitchen tour on [DATE] at 10:33 AM, an observation of Cooler 1 revealed, a clear plastic bag containing six heads of lettuce, each containing pink and brown spots on each. The bag had no opening date or expiration date. Interview with the CDM (Certified Dietary Manager) on [DATE] at 9:00 AM confirmed the findings.

Based on observation, record review, review of the facility policy, and interviews, the facility failed to implement a Care Plan established for Resident (R)41, 1 of 1 resident reviewed for Care Plans, to assist with meals, presenting challenging efforts of using fine motor skills, resulting in decreased will to eat. Findings Include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022 states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to: g. receive the services and/or items included in the plan of care. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting with a revision date of March 2018 states, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are unavoidable .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . Review of R41's Face Sheet revealed R41 was admitted with an initial date of 01/09/2017 and a re-entry date of 01/21/2021 with diagnoses including, but not limited to, cerebral palsy, displaced bimalleolar fracture of right lower leg, contracture of muscle right upper arm, lack of coordination, and muscle weakness. Review of R41's Care Plan dated 11/21/2022, reveals a focus that R41 has Cerebral Palsy with limited mobility, upper extremity spasticity, and requires extensive assist of at least one with ADLs. She has a contracture of her right hand. Interventions include: EATING: The resident requires is able to feed self with set up. Additionally, R41 is at risk for weight loss r/t (related to) mobility deficits, risk of chewing difficulties. Has a history of less than required calories and protein. Weight can fluctuate related to lower extremity edema and use of diuretics. Interventions include: Set up tray and assist as needed uses divided plate per order. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2022 revealed R41 had a Brief Interview of Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. The MDS indicated the resident rejected care one to three times during the assessment as it relates to providing necessary services related to the resident's care plan. Further review of the MDS revealed that R41 requires Extensive assistance with bed mobility, transfer, toilet use and personal hygiene with one staff member for assistance. The MDS also revealed that the resident needed limited assistance, required for eating with one staff member needed for assistance. According to the MDS, the resident had limited range of motion, as there is impairment to the upper and lower extremity. Review of a Task Documentation Survey Report for eating, dated 01/01/2023 through 01/31/2023 notated three times a day for thirty-one days revealed that R41 only received limited assistance or was totally dependent on staff, 15 of 93 opportunities for the month. The report documents the other eating times as being independent or supervision by staff. During an observation of R41 on 01/08/2023 at 12:12 PM, she was observed preparing for lunch in her room due to COVID restrictions for the facility. A disposable take out plate was provided with utensils in a plastic pack. Beverages to include juice and water were provided on the tray, of which was just placed on her over-the-bed tray, as she was in a lying position in her bed. R41 spent an extensive amount of time attempting to open the utensil pack to begin eating her lunch. Observation of R41 on 01/09/2023 at approximately 12:30 PM revealed R41 was provided with a lunch tray of which was placed on her table and the resident had to make her way to the table and adjust herself to be able to reach the items that were provided on her tray. No setup was observed, as the staff delivered the tray and exited the room and did not return. During an interview with Licensed Practical Nurse (LPN)2, MDS Coordinator, on 01/08/23 at 2:42 PM revealed that R41 completes more upper body than lower body activities but movements fluctuate because sometimes she is shaky and then she can tell when she is need of more assistance. LPN2 also included R41's eating capabilities requires her to need help with setup because she does not have the dexterity to open things, to include condiment type things that is consistent with her MDS. During an interview with 01/08/23 at 2:51 PM with LPN3, Unit Manager D wing, revealed that she is familiar with R41's care and she just needs setup, but they like to provide as much independence as possible. LPN3 describes setup as taking the lid off the tray and opening the residents' drinks and utensils. She also included that they ensure that staff are following/implementing care plans by following up behind them and rounds are completed every one to two hours, if the staff is not sure what the resident's care plan consists of, they can ask or look up in the Kardex.

Based on review of the facility policy, observations, interviews, and record review, the facility failed to label the oxygen tubing for 1 of 1 Resident (R)43 reviewed for respiratory care. Findings include: Review of the facility's policy titled,Departmental (Respiratory Therapy)-Prevention of Infection dated (revised) November 2011, revealed,It is policy's general guidelines distilled water used in respiratory therapy must be dated and initiated when opened and discarded after twenty-four hours. Under Steps in the Procedure- Infection Control Consideration related to Oxygen Administration lists: (3) Mark bottle with date and initials upon opening and discard after twenty four (24) hours. (4) Change the reservoir every forty-eight hours and disinfect with 2% alkaline glutaraldehyde or sterilize. R43 was admitted to the facility on [DATE] with diagnoses including but not limited; dementia, absence of right leg below knee, cerebral infarction due to stenosis, and adult failure to thrive. Review of R43's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/23 documented R43 had a Brief Interview for Mental Status (BIMS) score of 02 out of 15, indicating R43 is severely cognitively impaired. Review of R43's Physician orders dated 01/27/21 revealed an order that read, Medication of O2 via nasal canula; Vimpat oral solution. Observation on 02/07/23 at approximately 11:45 AM revealed R43 lying in bed with oxygen tube in his nose, body was rolled in the fetal position facing his bedroom wall. Oxygen tube was not labeled with a date nor initials indicating when it had been changed. Observation on 02/07/23 at approximately 12:00 PM revealed staff placed the red Oxygen in Room sign on the door casing of R43's room. Observation on 02/08/23 at approximately 12:15 PM revealed R43's Oxygen tubing had not been labeled with a date to indicate the date it had been changed. During an interview with Certified Nursing Assistant (CNA)1 at approximately 10:20 AM on 02/09/23 revealed R43 required total care. CNA1 stated the nurse does the changing of the oxygen tube, but the CNA will check it to make sure it's clean. During an interview with Registered Nurse (RN)1 at approximately 10:39 AM on 02/09/23 revealed, when asked when to change the tubing and when cleaning or checking occurs? He stated he believes every shift; every day at night.When asked where is it documented? He stated in Point Click Care (PCC) but could not locate the documentation in the system. He stated he would change the oxygen tube. At approximately 10:43 AM on 02/09/23, RN1 went into R43's room and noted a date on the tubing for 02/08/23. He stated it should state 02/09/23 from the changing of tubing on night shift. When asked what is the protocol according to your policy for oxygen administration? He stated he believes it is every day; but will check with the manager to verify when.

Based on review of the facility policy titled, Storage of Medications, observations, and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use by residents in 2 of 4 medication carts and 1 of 2 medication rooms. Findings include: Review of the facility policy titled, Storage of Medications, states, The facility stores all drugs and biological's in a safe, secure and orderly manner. The Policy Interpretation and Implementation, states under number five, Discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed. An observation on 02/07/23 at 10:45 AM of the A Wing, Hall 1 medication cart 1 for Rooms 1 through 12 revealed 29.75 milliliters of Morphine Sulfate 100 milligrams per 5 milliliters with Lot #AB3265C expired, December 2022. During an interview on 02/07/23 at 10:47 AM with Licensed Practical Nurse (LPN)1 confirmed the expired medication that was locked on the medication cart with narcotics in use for residents. She then called the Director of Nursing (DON) and locked the medication back in the narcotic drawer in the medication cart and stated, that the DON would come and get the medication to be destroyed. An observation on 02/07/23 at 11:05 AM of the A Wing medication storage room revealed 2 bottles of Major Stress Formula, High Potency Stress Formula Vitamins, 120 tablets with Lot #194370 expired, 11/22. Additionally, Habitrol Nicotine Patch 21 milligrams, 10 patches with Lot #C3019151A expired, 12/22. LPN1 confirmed the expired medications. An observation on 02/09/23 at 8:45 AM of the D Wing medication cart 1 revealed a bottle of Artificial Tears, Manufactured by Geri-Care with Lot #20P04, expired 12/22. An interview on 02/09/23 at 8:45 AM with Registered Nurse (RN)1 confirmed the eye drops was expired 12/22.

Based on interview, record review, and facility policy, the facility failed to allow residents to exercise their right to refuse transfer/discharge without interference or coercion, for 14 of 20 Residents (R) reviewed for residents' rights. During [DATE] - [DATE] Residents were transferred to another skilled nursing facility (SNF) due to the facility closing units of the facility for staffing purposes. R1, R2, R3, R4, R5, R6, and R15 were discharged to Ridgeland Nursing Center in Ridgeland, South Carolina. R7, R8, R9, R10, R11, R12, and R13 were discharged to The Palms Nursing and Rehab at Orange Park in Orange Park, Florida, approximately 3 hours from Bayview Manor in [NAME], South Carolina. Four (4) out of the 14 Residents that were discharged from the facility have a Brief Interview of Mental Status (BIMS) score of 9 or below which indicates cognitive impairment, (R1, R5, R7, R12). Facility failure to allow residents their right to exercise his or her rights without interference or coercion has potential adverse outcome on resident's psycho/social wellbeing due to residents being discharged from a familiar environment and away from family members in the nearby community. On [DATE] at 6:03 PM, the facility Administrator and Director of Nursing (DON) were provided a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F550 due to facility's failure to allow residents to exercise their right of choice without interference or coercion as of [DATE]. On [DATE] at 12:59 PM the Administrator provided an acceptable IJ removal plan related to F550. The immediacy of the IJ was removed as of [DATE] at 2:30 PM. The IJ was lowered to scope and severity of an E. Additionally, this failure constituted substandard quality of care, warranting an extended survey which was completed on [DATE]. Findings include: Review of facility policy titled, Resident Rights last revised, ,d+[DATE] revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination; be supported by the facility in exercising his or her rights; and exercise his or her rights without interference, coercion, discrimination or reprisal from the facility. An interview on [DATE] at 1:20 PM with the Administrator and DON revealed during a Resident Council Meeting the facility explained to the residents in attendance that the B-Wing of the facility would be closing due to staffing. The facility would like to close that unit because it would decrease the amount of money going toward staffing agencies. Residents were discharged and transferred to a facility located in Florida which is about 3 hours away, and the facility would cover the cost of the resident's stay until their Medicare and Medicaid transferred. The Administrator provided the name of the facility the residents were sent to: The Palms at Orange Park. The Administrator and the DON were asked if Bayview Manor was in the process of being sold and or closing and they stated No, the facility is trying to use less agency staff for staffing purposes. The Administrator was asked if the facility provided any of the residents that were transferred a notice of transfer and she replied, We did not have to since they requested to move. The Administrator also stated the facility in Florida reached out to them (Bayview Manor) asking if they had residents who wanted to move. She stated they were told by the facility in Florida, that until insurances could be switched from South Carolina to Florida, the facility in Florida would eat the costs of the residents moving there. An interview on [DATE] at 1:45 PM with the DON revealed only the residents with a high BIMS were asked about transferring to another skilled nursing facility, and they were not sure if a 30-day notice was provided or if resident were informed about their right to refuse transfer. Review on [DATE] of the Resident Council Minutes dated [DATE] at 3:00 PM revealed Administrator, Social Services, and the DON was in meeting and explained about C Wing closing, and was asking about volunteers that might want to go to a Florida facility. A phone interview on [DATE] at 2:06 PM with R10's Resident Representative (RR) revealed she was notified of R10's discharge/move to Florida the day of his transfer. The RR reported that R10 did not want to go to Florida, and she was not provided any notice of his move. The RR reported that R10 is not happy in Florida, he is acting out and has told her he was kidnapped and taken to Florida against his will. An interview on [DATE] at 12:30 PM with the Social Worker (SW) revealed, they did not provide residents or their RRs with written notification of transfer discharge because the residents approached them (staff) about transferring to a facility closer to their families. The SW further stated that several residents had families that lived in Florida, other residents had family in other areas of South Carolina and that they would like to be closer as well. The SW further stated that the facility did not approach the residents about being discharged from the facility and that all the residents that were discharged had requested to be transferred and that is why the facility did not provide residents with a 30-day discharge notice. The SW reported that medical records will have the signed discharge instructions. When asked how the facility would ensure the resident would receive the same level of care she replied, I assume they would get the same level of care since they are licensed nursing homes. She was asked if the facility documented the transfer/discharge in each residents care plan, she replied yes. R10 was admitted to the facility on [DATE] with diagnoses including, but not limited to: chronic kidney disease, alcohol abuse, type 2 diabetes, and hypertension. Review of the R10's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R10 has a BIMS score of 12 out of 15 which indicates he is mildly cognitively intact. Review on [DATE] of R10's Social Services Progress note dated [DATE] revealed, Social Worker spoke with Resident Representative this AM. She feels that Resident has community influences in [NAME] County that affect his addiction and recovery. She requested that he be moved to The Palms in Orange Park, Florida. Resident to be transferred today. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: seizure, fragile chromosome Autism Spectrum Disorder, hypertension, and aphasia. Review of R1's Quarterly MDS with an ARD of [DATE] revealed R1 has a BIMS score of 6 out of 15 which indicates mild cognitive impairment. A phone interview on [DATE] at 12:42 PM with R1's Resident Representative (RR) revealed [R1] has Autism and did not handle changes very well, which is why they visited often before being transferred. When [R1] arrived at this facility his health began to decline. R1's RR further stated that they had no choice but to move R1 because the unit he was on was closing. The only choice I had was if [R1] went to a facility in Florida or in South Carolina, so I chose the South Carolina facility because it was closer, and we could still get to visit. R1's RR further stated R1expired soon after transferring to the facility in Ridgeland. Review on [DATE] of R1's Progress Note dated [DATE] revealed Social Worker contacted RP to review plan of care. Resident is a [AGE] year-old, African American male. He is a Full Code. He is rarely never understood. Staff must anticipate needs. His PHQ-9 score is a 6. He has a diagnosis of Fragile Chromosome X (Autism). RP stated that he would like to consider Ridgeland Rehab. He feels that he and his brother would be able to visit more frequently. Record review on [DATE] of R1's Progress Note dated [DATE] revealed resident discharged to another facility. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to dysphagia, cerebral infarction affecting right dominant side, mild cognitive impairment, and hypertension. Review of R2's Quarterly MDS with an ARD of [DATE] revealed R2 has a BIMS score of 15 out of 15, indicating intact cognition. An attempted phone interview with R2 and their RR on [DATE] was unsuccessful. Review on [DATE] of R2's progress note dated [DATE] revealed Family requested that Resident's paperwork be sent to a facility in Ridgeland. She has been accepted. She will be admitted to that facility on [DATE]. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to type 2 diabetes, dementia without behavioral disturbances, psychotic disturbance, Alzheimer's disease, and anxiety. Review R3's Quarterly MDS with an ARD of [DATE] revealed R3 has a BIMS score of 15 out of 15, indicating intact cognition. An interview on [DATE] at 2:20 PM with R3's RR revealed they were unaware that R3 had been discharged from the facility until the new facility called them to let her know. R3's RR further stated that they spoke with the SW at Bayview and was not treated with respect and concerns related to R3's discharge were dismissed by staff. Record review on [DATE] of R3's progress note dated [DATE] revealed Resident came to Social Worker's office. She wanted to be sure that she would be moving to Ridgeland. She stated that she had lived in Ridgeland previously. She wanted to be back there. She would feel more at home just being in the town. Record review on [DATE] of R3's progress note dated [DATE] revealed Resident transported to Ridgeland facility at 2:30 PM via transportation, belongings and medications sent with transportation. Record review on [DATE] of R3's progress note dated [DATE] revealed Resident's daughter called facility today. Social Worker returned her call. She stated that Resident does not have the right to move to a facility of her choice because she has Power of Attorney (POA). Social Worker explained that a POA goes into effect when Resident is unable to make her decisions. Resident's BIMS is a 15. Daughter stated that Resident still does not have the right to make her own decisions. Even though it was the resident's choice for her own psychosocial well-being to return to a town that she felt was home and she would feel at home. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to hypertension, insomnia, hearing loss, and need for assistance with personal care. Review R4's Quarterly MDS with an ARD of [DATE] revealed R4 has a BIMS score of 13 out 15, indicating intact cognition. A phone interview with R4 and their RR on [DATE] was attempted but was unsuccessful. Review on [DATE] of R4's progress note dated [DATE] revealed Resident's daughter requested that her paperwork be sent to be reviewed by another long-term care facility. She will be admitted to Ridgeland on [DATE]. Review on [DATE] of R4's progress note dated [DATE] revealed Social Worker met 1:1. Resident asked Social Worker if she could move back to Ridgeland. Social Worker faxed paperwork to Ridgeland. She was accepted. To be admitted on [DATE]. Review on [DATE] of R4's progress note dated [DATE] revealed resident was transferred to another facility with all medications. R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to intellectual disabilities, adult failure to thrive, g-tube placement, and major depressive disorder. Review of R5's Quarterly MDS with an ARD of [DATE] revealed, R5 has a BIMS score of 1 out of 15, indicating cognitive impairment. Review on [DATE] of R5's progress note dated [DATE] revealed Social Worker spoke with RR, he will be transferred to Ridgeland Healthcare tomorrow. He is missing the friends that he visited with in the lobby. Review on [DATE] of R5's progress note dated [DATE] revealed Resident transferred to Ridgeland facility by Bayview staff. A phone interview on [DATE] at 11:45 AM with R5's RR revealed they were contacted by the facility on the same day the resident was discharged . When the SW called me, they told me that the resident was being discharged to a facility in Florida and I told the SW that I was not in agreement with that, because it is too far. When the SW called me back later, she told me that they were moving the resident to Ridgeland and I told her that I was still not in agreement, but then it was explained to me that he was already in transport to the new facility. Since the [R5] has moved, I have only been able to see him once because I have my own health issues and I can't drive far anymore. R5's RR further stated they knew another resident (R3) that had also been moved and their family didn't know about the discharge until the day of. R6 was admitted to the facility on [DATE] with diagnosis including but not limited to chronic obstructive pulmonary disease, Alzheimer's disease, and dementia without behaviors. Review of R6's Annual MDS with an ARD of [DATE] revealed R6 has a BIMS score of 13 out of 15, indicating intact cognition. Review on [DATE] of R6's progress note dated [DATE] revealed Resident has a friend that is being transferred to a facility in Ridgeland. He requested that his paperwork be sent there today. He will be admitted to that facility on [DATE]. Review on [DATE] of R6's progress note dated [DATE] revealed Social Worker met with Resident 1:1. He stated that he wants to be transferred on Wednesday, [DATE]. Social Worker will arrange for transportation and contact Ridgeland. Review on [DATE] of R6's progress note dated [DATE] revealed Resident discharged to Ridgeland Rehab. A phone interview on [DATE] was attempted with R6 and their RR but was unsuccessful. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to hemiplegia and hemiparesis following cerebral infarction, personal history of traumatic brain injury, and major depressive disorder. Review of R7's Annual MDS with an ARD of [DATE] revealed R6 has a BIMS score of 9 out of 15, indicating mild cognitive impairment. Review on [DATE] of R7's progress note dated [DATE] revealed Resident transfer to The Palms Nursing and Rehab at Orange Park via The Palms facility van. Resident alert with no s/s [signs and symptoms] of distress noted. Resident denies any pain or discomfort. Resident was transported with all personal belongings including his TV with remote, and right prosthetic leg. No problems or concerns noted upon discharge. Record review on [DATE] of R7's progress note dated [DATE] revealed Late entry [DATE]. Social Worker met with Resident 1:1. He make his decisions. [sic] He felt that he would like to discharge to another long-term care facility in Orange Park, Florida. A phone interview on [DATE] with R7 and their representative was attempted, but unsuccessful. Record review and interview on [DATE] of R7's Face Sheet revealed R7's does not have a RR listed. RR is the facility, since they are not cognitively intact. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to major depressive disorder, adult failure to thrive, and insomnia. Review of R8's Quarterly MDS with an ARD of [DATE] revealed R8 has a BIMS score of 12 out of 15, indicating mild cognitive intactness. Review on [DATE] of R8's progress notes dated [DATE] revealed Late entry [DATE]. Social Worker contacted RP. She lives in Florida. Resident would benefit from transferring to a facility near her daughter. An interview on [DATE] at 11:49 AM with Licensed Practical Nurse (LPN)2 revealed They worked at the facility on the day of the Florida resident discharge (7 residents). LPN2 stated that 3 of the residents were given their belongings, medications, discharge paperwork on the day of discharge. LPN2 further stated that the facility had plans to move to an 88-bed facility to decrease the budget. LPN2 stated R8 and R12 had family in Florida and are now closer to them since the transfer, R9 was also moved, and Bayview Manor was his RR because he had no family. When asked if residents were informed of their rights as a resident to refuse discharge and if 30-day notices were provided to residents, LPN2 stated she was unsure. R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to schizophrenia disorder, anxiety disorder, hypertension, and age-related cataract. Review of R9's Quarterly MDS with an ARD of [DATE] revealed R9 has a BIMS score of 14 out of 15, indicating intact cognition. Review of R9's progress note dated [DATE] revealed Social Worker met with Resident and spoke with RR. Resident feels that she would benefit from transferring to a facility in Orange Park, Florida. R11 was admitted to the facility on [DATE] with diagnoses including, but not limited to dementia, major depressive disorder, anxiety disorder, and mood disturbance. Review of R11's Discharge MDS with an ARD of [DATE] revealed R11 has a BIMS score of 10 out of 15, indicating mild cognitive impairment. Review on [DATE] of R11's progress note dated [DATE] revealed Late entry for [DATE]. Social Worker spoke with RP and Resident. Resident has been refusing medications and having some behaviors. RP thought that Resident would benefit from a change in environment. Resident to transferred to The Palms in Orange Park, Florida. Review on [DATE] of R11's progress note dated [DATE] revealed Administration Note-Note Text: pt. discharged to another facility. A phone interview on [DATE] was attempted to R11 and their RR but was unsuccessful. R12 was admitted to the facility on [DATE] with the diagnosis including but not limited to dementia with behavioral disturbances, generalized epilepsy, anxiety disorder, and congestive heart failure. Review of R12's Discharge MDS with an ARD of [DATE] revealed R12's BIMS score is 2 out of 15, indicating cognitive impairment. Review on [DATE] of R12's progress note dated [DATE] revealed RP came to speak with Social Worker. She requested that Resident's information be faxed to The Palms in Florida. She says that is close to family. She met with the rest of her family and feels that this is the best for Resident. She will be able to have more interaction with family. Review on [DATE] of R12's progress note dated [DATE] revealed Social Worker contacted RP. Resident's family lives in Florida. They have requested that she be moved to a facility near them. The Palms at Orange [NAME] can take resident on ,d+[DATE]. Family is still in agreement. Review on [DATE] of R12's progress note dated [DATE] revealed Resident being transferred to The Palms Nursing and Rehab at Orange Park. Resident, and belongings was assisted to receiving facility van. No s/s of distress noted. Resident took all personal belongings including television with remote, and hangers. RP called and asked to be notified when resident left the building. Staff notified RP, and report was called in to [staff member] at receiving facility. A phone interview on [DATE] with R12's RR revealed, The facility called and told me that they had plans to close the unit R12 was on, and the resident would be getting discharged to another facility in Florida. I was not in agreement with this decision because I live close by and visit with the resident often but was not given a choice in this transfer and was not provided any discharge paperwork. R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to peripheral vascular disease, acquired absence of left leg, surgical aftercare, and cognitive communication deficit. Review of R13's Discharge MDS with an ARD of [DATE] revealed R13 has a BIMS score of 15 out of 15, indicating they are cognitively intact. Review on [DATE] of R13's progress note dated [DATE] revealed Resident had requested to move to a facility in Florida. They called with approval and can transport on ,d+[DATE]. Social Worker notified Resident's son. Review on [DATE] of R13's progress note dated [DATE] revealed medications administered as ordered this morning. Medications reviewed and sent with transportation; paperwork also sent with transportation. Resident transported via wheelchair with the palms facility transportation. A phone interview was attempted on [DATE] with R13 and their RR with no success. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to major depressive disorder, hypertension, hemiplegia, hypertension, and muscle weakness. Review of R15's Annual MDS with an ARD of [DATE] revealed R15 has a BIMS score of 15 out of 15, indicating intact cognition. Review on [DATE] of R15's progress note dated [DATE] revealed Resident came to visit Social Worker. He requested to move to Ridgeland Nursing and Rehab. Social Worker faxed information and he was accepted. To be admitted on [DATE]. Review on [DATE] of R15's progress note dated [DATE] revealed Resident discharged to Ridgeland Rehab today. A phone interview on [DATE] at 3:54 PM with R15's RR, revealed they were not informed about the resident being discharged from the facility and they only knew the resident was leaving because R15 called them. RR further stated that resident was told by the facility that they wanted him to transfer to the facility in Florida because it was nicer, and the resident would receive better care but disagreed so facility transferred him to Ridgeland in South Carolina which they did not agree with but it was closer. RR stated that the facility did not provide them with any transfer or discharge paperwork and has not been able to get in contact with anyone at the facility (Bayview Manor) since the resident was discharged . As a result, RR had to get in contact with R15's health insurance company because they were not sure how to make payments to the resident's new facility in South Carolina. R20 was admitted to the facility on [DATE] with the diagnosis including but not limited to acute chronic respiratory failure, type 2 diabetes, hypertension, and seizures. Review of R20's Quarterly MDS with an ARD of [DATE] revealed R20 has a BIMS score of 15 out of 15, indicating intact cognition. An interview on [DATE] at 4:34 PM with R20 revealed During the COVID-19 pandemic the facility had to use a lot of agency staff and the facility staff came into a resident council meeting in August. Staff informed them that a facility in Florida had reached out to them and asked if any resident was interested in a move to their facility. R20 further stated that the facility asked who wanted to move and they spoke with the resident and their family. R21 was admitted to the facility on [DATE] with diagnoses including, but not limited to adult failure to thrive, post-traumatic seizures, and major depressive disorder. Review of R21's MDS with an ARD of [DATE] revealed R21 has a BIMS score of 14 out of 15, indicating intact cognition. An interview on [DATE] at 4:19 PM with R21 revealed R21 was in the resident council meeting when the facility told them they had budget issues and the facility wanted to know if anyone was interested in a move to another facility in Florida. R21further stated that she was asked if she wanted to move, and she told them she did not want to move to Florida or any other facility. R21 stated, staff kept pressuring her to discharge, but she continued to tell them no because her family is nearby. A phone interview on [DATE] at 11:45 AM with the local Ombudsman revealed they received multiple complaints from residents and their families related to being discharged from the facility. The Ombudsman further stated they spoke with the Administrator and DON related to the discharges and was told the facility had no plans to close the facility or reduce the bed size they are just reducing the census to decrease the amount of agency staff in use. The Ombudsman stated that they were unaware that residents were being discharge out of state until residents and their families contacted them with complaints related to being discharged from the facility. The Ombudsman concluded that there are two (2) residents in house that has recently spoke with them in relation to the facility attempting to discharge them from the facility R20 and R21. An interview on [DATE] at 11:52 AM with LPN1 revealed they have been working at the facility since August and the Administrator and DON informed her and other staff that the facility is down-sizing due to staffing and budget issues. LPN1 further stated that several residents were getting sent out weekly to different facilities. An interview on [DATE] with Certified Nursing Assistant (CNA)1 revealed they have been employed by the facility for several years and knows that the facility transferred several residents to Florida. CNA1 further stated that the facility told her that they were short-staffed and trying to get the staffing under control. An interview on [DATE] at 11:49 AM with CNA2 revealed they have been working at the facility for over a year and that the facility is discharging residents due to staffing issues but were unsure if residents had a choice on being transferred or were provided discharge paperwork. An interview on [DATE] at 11:50 AM with the Risk Manager revealed she has been with the facility for two years. She stated that several residents were transferred to Florida and Ridgeland. She stated they were given a choice and she met with them at a Resident Care Meeting. On [DATE] at 12:59 PM the facility provided an acceptable Allegation of Compliance which included the following: 1) R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R15 no longer resident in the facility, and are not able to be contacted as they reside in an alternate skilled nursing facility. R1 is now deceased and R14 no longer resides in the facility per a planned resident and RP initiated transfer to an alternate skilled nursing facility that occurred 56 days prior to the facilities agency elimination plan. 2) The DON has reviewed all current residents to validate any with plans to transfer or discharge were given the right to choose their transfer/discharge destination. This was completed on [DATE] and no current facility residents have plans to transfer/discharge at this time. 3) The Regional Nurse Consultant has educated the Administrator, DON, Risk Manager, and Social Services on the resident's right or RP right to choose their transfer/discharge plan as per federal regulation F 550, this was completed on [DATE]. 4) An additional Quality Assurance and Performance Improvement (QAPI) committee meeting was held on [DATE] to present information stated by the state agency via phone regarding F550. 5) Future, non-emergent, resident transfers, and discharges will be reviewed by the Risk Manger prior to occurrence to validate resident and or RP choices are honored for 3 months. 6) The Risk Manager will monitor all resident transfers and discharged for the choice of planning, if applicable, for the next 3 months. 7) Results of the monitoring will be presented to the QAPI committee by the Risk Manager for recommendations for a period of 3 months. Any concerns identified will be addressed at time of discovery. 8) Allegation of compliance date is [DATE].

Based on interview, record review, and facility policy, the facility failed to provide transfer/discharge agreements prior to discharge or transfer for 14 of 20 Residents (R) reviewed for residents rights. During [DATE] - [DATE] Residents were transferred to another skilled nursing facility (SNF) due to the facility closing units of the facility for staffing purposes. R1, R2, R3, R4, R5, R6, and R15 were discharged to Ridgeland Nursing Center in Ridgeland, South Carolina. R7, R8, R9, R10, R11, R12, and R13 were discharged to The Palms Nursing and Rehab at Orange Park in Orange Park, Florida, approximately 3 hours from Bayview Manor in [NAME], South Carolina. 4 out of 14 Residents that were discharged from the facility have a Brief Interview of Mental Status (BIMS) score of 9 or below which indicates cognitive impairment, (R1, R5, R7, R12). Facility failure to allow residents their right to exercise his or her rights without interference or coercion has potential adverse outcome on resident's psycho/social wellbeing due to residents being discharged from a familiar environment and away from family members in the nearby community. On [DATE] at 6:03 PM, the facility Administrator and Director of Nursing (DON) were provided with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, notifying the facility IJ existed at F623 due to facility's failure to allow residents to exercise their right of choice without interference or coercion as stated in facility policy as of [DATE]. On [DATE] at 12:59 PM the Administrator provided an acceptable IJ removal plan related to F623 . The immediacy of the IJ was removed as of [DATE] at 2:30 PM. The IJ was lowered to scope and severity of an E. Findings include: Record review on [DATE] of facility policy titled Transfer/Discharge revealed the facility must provide resident and the resident representative notice of transfer or discharge and the reasons for the move in a writing and language and manner they understand. And, the facility must send a copy of the notice to the Ombudsman. The reason allowable for transfer or discharge are A) the safety of individuals in the facility would be endangered. B) The health of individuals in the facility would be endangered. C) The resident's health improves sufficiently or D) An immediate transfer or discharge is required by the resident's urgent medical needs. Additionally, the notice must include the reason for transfer/discharge, the effective date of transfer or discharge, and the location to which the resident is transferred or discharged . An interview on [DATE] at 1:20 PM with the Administrator and DON revealed during a Resident Council Meeting the facility explained to the residents in attendance that the B-Wing of the facility would be closing due to staffing. The facility would like to close that unit because it would decrease the amount of money going toward staffing agencies. Residents were discharged and transferred to a facility located in Florida which is about 3 hours away, and the facility would cover the cost of the resident's stay until their Medicare and Medicaid transferred. The Administrator provided the name of the facility the residents were sent to: The Palms at Orange Park. The Administrator and the DON were asked if Bayview Manor was in the process of being sold and or closing and they stated No, the facility is trying to use less agency staff for staffing purposes. The Administrator was asked if the facility provided any of the residents that were transferred a notice of transfer and she replied, We did not have to since they requested to move. The Administrator also stated the facility in Florida reached out to them (Bayview Manor) asking if they had residents who wanted to move. She stated they were told by the facility in Florida, that until insurances could be switched from South Carolina to Florida, the facility in Florida would eat the costs of the residents moving there. An interview on [DATE] at 1:45 PM with the DON revealed only the residents with a high BIMS were asked about transferring to another skilled nursing facility, and they were not sure if a 30-day notice was provided or if resident were informed about their right to refuse transfer. Review on [DATE] of the Resident Council Minutes dated [DATE] at 3:00 PM revealed Administrator, Social Services, and the DON was in meeting and explained about C Wing closing, and was asking about volunteers that might want to go to a Florida facility. A phone interview on [DATE] at 2:06 PM with R10's Resident Representative (RR) revealed she was notified of R10's discharge/move to Florida the day of his transfer. The RR reported that R10 did not want to go to Florida, and she was not provided any notice of his move. The RR reported that R10 is not happy in Florida, he is acting out and has told her he was kidnapped and taken to Florida against his will. An interview on [DATE] at 12:30 PM with the Social Worker (SW) revealed, they did not provide residents or their RRs with written notification of transfer discharge because the residents approached them (staff) about transferring to a facility closer to their families. The SW further stated that several residents had families that lived in Florida, other residents had family in other areas of South Carolina and that they would like to be closer as well. The SW further stated that the facility did not approach the residents about being discharged from the facility and that all the residents that were discharged had requested to be transferred and that is why the facility did not provide residents with a 30-day discharge notice. The SW reported that medical records will have the signed discharge instructions. When asked how the facility would ensure the resident would receive the same level of care she replied, I assume they would get the same level of care since they are licensed nursing homes. She was asked if the facility documented the transfer/discharge in each residents care plan, she replied yes. R10 was admitted to the facility on [DATE] with diagnoses including, but not limited to: chronic kidney disease, alcohol abuse, type 2 diabetes, and hypertension. Review of the R10's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R10 has a BIMS score of 12 out of 15 which indicates he is mildly cognitively intact. Review on [DATE] of R10's Social Services Progress note dated [DATE] revealed, Social Worker spoke with Resident Representative this AM. She feels that Resident has community influences in [NAME] County that affect his addiction and recovery. She requested that he be moved to The Palms in Orange Park, Florida. Resident to be transferred today. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: seizure, fragile chromosome Autism Spectrum Disorder, hypertension, and aphasia. Review of R1's Quarterly MDS with an ARD of [DATE] revealed R1 has a BIMS score of 6 out of 15 which indicates mild cognitive impairment. A phone interview on [DATE] at 12:42 PM with R1's Resident Representative (RR) revealed [R1] has Autism and did not handle changes very well, which is why they visited often before being transferred. When [R1] arrived at this facility his health began to decline. R1's RR further stated that they had no choice but to move R1 because the unit he was on was closing. The only choice I had was if [R1] went to a facility in Florida or in South Carolina, so I chose the South Carolina facility because it was closer, and we could still get to visit. R1's RR further stated R1expired soon after transferring to the facility in Ridgeland. Review on [DATE] of R1's Progress Note dated [DATE] revealed Social Worker contacted RP to review plan of care. Resident is a [AGE] year-old, African American male. He is a Full Code. He is rarely never understood. Staff must anticipate needs. His PHQ-9 score is a 6. He has a diagnosis of Fragile Chromosome X (Autism). RP stated that he would like to consider Ridgeland Rehab. He feels that he and his brother would be able to visit more frequently. Record review on [DATE] of R1's Progress Note dated [DATE] revealed resident discharged to another facility. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to dysphagia, cerebral infarction affecting right dominant side, mild cognitive impairment, and hypertension. Review of R2's Quarterly MDS with an ARD of [DATE] revealed R2 has a BIMS score of 15 out of 15, indicating intact cognition. An attempted phone interview with R2 and their RR on [DATE] was unsuccessful. Review on [DATE] of R2's progress note dated [DATE] revealed Family requested that Resident's paperwork be sent to a facility in Ridgeland. She has been accepted. She will be admitted to that facility on [DATE]. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to type 2 diabetes, dementia without behavioral disturbances, psychotic disturbance, Alzheimer's disease, and anxiety. Review R3's Quarterly MDS with an ARD of [DATE] revealed R3 has a BIMS score of 15 out of 15, indicating intact cognition. An interview on [DATE] at 2:20 PM with R3's RR revealed they were unaware that R3 had been discharged from the facility until the new facility called them to let her know. R3's RR further stated that they spoke with the SW at Bayview and was not treated with respect and concerns related to R3's discharge were dismissed by staff. Record review on [DATE] of R3's progress note dated [DATE] revealed Resident came to Social Worker's office. She wanted to be sure that she would be moving to Ridgeland. She stated that she had lived in Ridgeland previously. She wanted to be back there. She would feel more at home just being in the town. Record review on [DATE] of R3's progress note dated [DATE] revealed Resident transported to Ridgeland facility at 2:30 PM via transportation, belongings and medications sent with transportation. Record review on [DATE] of R3's progress note dated [DATE] revealed Resident's daughter called facility today. Social Worker returned her call. She stated that Resident does not have the right to move to a facility of her choice because she has Power of Attorney (POA). Social Worker explained that a POA goes into effect when Resident is unable to make her decisions. Resident's BIMS is a 15. Daughter stated that Resident still does not have the right to make her own decisions. Even though it was the resident's choice for her own psychosocial well-being to return to a town that she felt was home and she would feel at home. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to hypertension, insomnia, hearing loss, and need for assistance with personal care. Review R4's Quarterly MDS with an ARD of [DATE] revealed R4 has a BIMS score of 13 out 15, indicating intact cognition. A phone interview with R4 and their RR on [DATE] was attempted but was unsuccessful. Review on [DATE] of R4's progress note dated [DATE] revealed Resident's daughter requested that her paperwork be sent to be reviewed by another long-term care facility. She will be admitted to Ridgeland on [DATE]. Review on [DATE] of R4's progress note dated [DATE] revealed Social Worker met 1:1. Resident asked Social Worker if she could move back to Ridgeland. Social Worker faxed paperwork to Ridgeland. She was accepted. To be admitted on [DATE]. Review on [DATE] of R4's progress note dated [DATE] revealed resident was transferred to another facility with all medications. R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to intellectual disabilities, adult failure to thrive, g-tube placement, and major depressive disorder. Review of R5's Quarterly MDS with an ARD of [DATE] revealed, R5 has a BIMS score of 1 out of 15, indicating cognitive impairment. Review on [DATE] of R5's progress note dated [DATE] revealed Social Worker spoke with RR, he will be transferred to Ridgeland Healthcare tomorrow. He is missing the friends that he visited with in the lobby. Review on [DATE] of R5's progress note dated [DATE] revealed Resident transferred to Ridgeland facility by Bayview staff. A phone interview on [DATE] at 11:45 AM with R5's RR revealed they were contacted by the facility on the same day the resident was discharged . When the SW called me, they told me that the resident was being discharged to a facility in Florida and I told the SW that I was not in agreement with that, because it is too far. When the SW called me back later, she told me that they were moving the resident to Ridgeland and I told her that I was still not in agreement, but then it was explained to me that he was already in transport to the new facility. Since the [R5] has moved, I have only been able to see him once because I have my own health issues and I can't drive far anymore. R5's RR further stated they knew another resident (R3) that had also been moved and their family didn't know about the discharge until the day of. R6 was admitted to the facility on [DATE] with diagnosis including but not limited to chronic obstructive pulmonary disease, Alzheimer's disease, and dementia without behaviors. Review of R6's Annual MDS with an ARD of [DATE] revealed R6 has a BIMS score of 13 out of 15, indicating intact cognition. Review on [DATE] of R6's progress note dated [DATE] revealed Resident has a friend that is being transferred to a facility in Ridgeland. He requested that his paperwork be sent there today. He will be admitted to that facility on [DATE]. Review on [DATE] of R6's progress note dated [DATE] revealed Social Worker met with Resident 1:1. He stated that he wants to be transferred on Wednesday, [DATE]. Social Worker will arrange for transportation and contact Ridgeland. Review on [DATE] of R6's progress note dated [DATE] revealed Resident discharged to Ridgeland Rehab. A phone interview on [DATE] was attempted with R6 and their RR but was unsuccessful. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to hemiplegia and hemiparesis following cerebral infarction, personal history of traumatic brain injury, and major depressive disorder. Review of R7's Annual MDS with an ARD of [DATE] revealed R6 has a BIMS score of 9 out of 15, indicating mild cognitive impairment. Review on [DATE] of R7's progress note dated [DATE] revealed Resident transfer to The Palms Nursing and Rehab at Orange Park via The Palms facility van. Resident alert with no s/s [signs and symptoms] of distress noted. Resident denies any pain or discomfort. Resident was transported with all personal belongings including his TV with remote, and right prosthetic leg. No problems or concerns noted upon discharge. Record review on [DATE] of R7's progress note dated [DATE] revealed Late entry [DATE]. Social Worker met with Resident 1:1. He make his decisions. [sic] He felt that he would like to discharge to another long-term care facility in Orange Park, Florida. A phone interview on [DATE] with R7 and their representative was attempted, but unsuccessful. Record review and interview on [DATE] of R7's Face Sheet revealed R7's does not have a RR listed. RR is the facility, since they are not cognitively intact. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to major depressive disorder, adult failure to thrive, and insomnia. Review of R8's Quarterly MDS with an ARD of [DATE] revealed R8 has a BIMS score of 12 out of 15, indicating mild cognitive intactness. Review on [DATE] of R8's progress notes dated [DATE] revealed Late entry [DATE]. Social Worker contacted RP. She lives in Florida. Resident would benefit from transferring to a facility near her daughter. An interview on [DATE] at 11:49 AM with Licensed Practical Nurse (LPN)2 revealed They worked at the facility on the day of the Florida resident discharge (7 residents). LPN2 stated that 3 of the residents were given their belongings, medications, discharge paperwork on the day of discharge. LPN2 further stated that the facility had plans to move to an 88-bed facility to decrease the budget. LPN2 stated R8 and R12 had family in Florida and are now closer to them since the transfer, R9 was also moved, and Bayview Manor was his RR because he had no family. When asked if residents were informed of their rights as a resident to refuse discharge and if 30-day notices were provided to residents, LPN2 stated she was unsure. R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to schizophrenia disorder, anxiety disorder, hypertension, and age-related cataract. Review of R9's Quarterly MDS with an ARD of [DATE] revealed R9 has a BIMS score of 14 out of 15, indicating intact cognition. Review of R9's progress note dated [DATE] revealed Social Worker met with Resident and spoke with RR. Resident feels that she would benefit from transferring to a facility in Orange Park, Florida. R11 was admitted to the facility on [DATE] with diagnoses including, but not limited to dementia, major depressive disorder, anxiety disorder, and mood disturbance. Review of R11's Discharge MDS with an ARD of [DATE] revealed R11 has a BIMS score of 10 out of 15, indicating mild cognitive impairment. Review on [DATE] of R11's progress note dated [DATE] revealed Late entry for [DATE]. Social Worker spoke with RP and Resident. Resident has been refusing medications and having some behaviors. RP thought that Resident would benefit from a change in environment. Resident to transferred to The Palms in Orange Park, Florida. Review on [DATE] of R11's progress note dated [DATE] revealed Administration Note-Note Text: pt. discharged to another facility. A phone interview on [DATE] was attempted to R11 and their RR but was unsuccessful. R12 was admitted to the facility on [DATE] with the diagnosis including but not limited to dementia with behavioral disturbances, generalized epilepsy, anxiety disorder, and congestive heart failure. Review of R12's Discharge MDS with an ARD of [DATE] revealed R12's BIMS score is 2 out of 15, indicating cognitive impairment. Review on [DATE] of R12's progress note dated [DATE] revealed RP came to speak with Social Worker. She requested that Resident's information be faxed to The Palms in Florida. She says that is close to family. She met with the rest of her family and feels that this is the best for Resident. She will be able to have more interaction with family. Review on [DATE] of R12's progress note dated [DATE] revealed Social Worker contacted RP. Resident's family lives in Florida. They have requested that she be moved to a facility near them. The Palms at Orange [NAME] can take resident on ,d+[DATE]. Family is still in agreement. Review on [DATE] of R12's progress note dated [DATE] revealed Resident being transferred to The Palms Nursing and Rehab at Orange Park. Resident, and belongings was assisted to receiving facility van. No s/s of distress noted. Resident took all personal belongings including television with remote, and hangers. RP called and asked to be notified when resident left the building. Staff notified RP, and report was called in to [staff member] at receiving facility. A phone interview on [DATE] with R12's RR revealed, The facility called and told me that they had plans to close the unit R12 was on, and the resident would be getting discharged to another facility in Florida. I was not in agreement with this decision because I live close by and visit with the resident often but was not given a choice in this transfer and was not provided any discharge paperwork. R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to peripheral vascular disease, acquired absence of left leg, surgical aftercare, and cognitive communication deficit. Review of R13's Discharge MDS with an ARD of [DATE] revealed R13 has a BIMS score of 15 out of 15, indicating they are cognitively intact. Review on [DATE] of R13's progress note dated [DATE] revealed Resident had requested to move to a facility in Florida. They called with approval and can transport on ,d+[DATE]. Social Worker notified Resident's son. Review on [DATE] of R13's progress note dated [DATE] revealed medications administered as ordered this morning. Medications reviewed and sent with transportation; paperwork also sent with transportation. Resident transported via wheelchair with the palms facility transportation. A phone interview was attempted on [DATE] with R13 and their RR with no success. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to major depressive disorder, hypertension, hemiplegia, hypertension, and muscle weakness. Review of R15's Annual MDS with an ARD of [DATE] revealed R15 has a BIMS score of 15 out of 15, indicating intact cognition. Review on [DATE] of R15's progress note dated [DATE] revealed Resident came to visit Social Worker. He requested to move to Ridgeland Nursing and Rehab. Social Worker faxed information and he was accepted. To be admitted on [DATE]. Review on [DATE] of R15's progress note dated [DATE] revealed Resident discharged to Ridgeland Rehab today. A phone interview on [DATE] at 3:54 PM with R15's RR, revealed they were not informed about the resident being discharged from the facility and they only knew the resident was leaving because R15 called them. RR further stated that resident was told by the facility that they wanted him to transfer to the facility in Florida because it was nicer, and the resident would receive better care but disagreed so facility transferred him to Ridgeland in South Carolina which they did not agree with but it was closer. RR stated that the facility did not provide them with any transfer or discharge paperwork and has not been able to get in contact with anyone at the facility (Bayview Manor) since the resident was discharged . As a result, RR had to get in contact with R15's health insurance company because they were not sure how to make payments to the resident's new facility in South Carolina. R20 was admitted to the facility on [DATE] with the diagnosis including but not limited to acute chronic respiratory failure, type 2 diabetes, hypertension, and seizures. Review of R20's Quarterly MDS with an ARD of [DATE] revealed R20 has a BIMS score of 15 out of 15, indicating intact cognition. An interview on [DATE] at 4:34 PM with R20 revealed During the COVID-19 pandemic the facility had to use a lot of agency staff and the facility staff came into a resident council meeting in August. Staff informed them that a facility in Florida had reached out to them and asked if any resident was interested in a move to their facility. R20 further stated that the facility asked who wanted to move and they spoke with the resident and their family. R21 was admitted to the facility on [DATE] with diagnoses including, but not limited to adult failure to thrive, post-traumatic seizures, and major depressive disorder. Review of R21's MDS with an ARD of [DATE] revealed R21 has a BIMS score of 14 out of 15, indicating intact cognition. An interview on [DATE] at 4:19 PM with R21 revealed R21 was in the resident council meeting when the facility told them they had budget issues and the facility wanted to know if anyone was interested in a move to another facility in Florida. R21further stated that she was asked if she wanted to move, and she told them she did not want to move to Florida or any other facility. R21 stated, staff kept pressuring her to discharge, but she continued to tell them no because her family is nearby. A phone interview on [DATE] at 11:45 AM with the local Ombudsman revealed they received multiple complaints from residents and their families related to being discharged from the facility. The Ombudsman further stated they spoke with the Administrator and DON related to the discharges and was told the facility had no plans to close the facility or reduce the bed size they are just reducing the census to decrease the amount of agency staff in use. The Ombudsman stated that they were unaware that residents were being discharge out of state until residents and their families contacted them with complaints related to being discharged from the facility. The Ombudsman concluded that there are two (2) residents in house that has recently spoke with them in relation to the facility attempting to discharge them from the facility R20 and R21. An interview on [DATE] at 11:52 AM with LPN1 revealed they have been working at the facility since August and the Administrator and DON informed her and other staff that the facility is down-sizing due to staffing and budget issues. LPN1 further stated that several residents were getting sent out weekly to different facilities. An interview on [DATE] with Certified Nursing Assistant (CNA)1 revealed they have been employed by the facility for several years and knows that the facility transferred several residents to Florida. CNA1 further stated that the facility told her that they were short-staffed and trying to get the staffing under control. An interview on [DATE] at 11:49 AM with CNA2 revealed they have been working at the facility for over a year and that the facility is discharging residents due to staffing issues but were unsure if residents had a choice on being transferred or were provided discharge paperwork. An interview on [DATE] at 11:50 AM with the Risk Manager revealed she has been with the facility for two years. She stated that several residents were transferred to Florida and Ridgeland. She stated they were given a choice and she met with them at a Resident Care Meeting. The facility's removal plan for F623 included: 1) R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R #15 no longer resident in the facility, and are not able to be contacted as they reside in an alternate skilled nursing facility. R1 is now deceased and R14 no longer resides in the facility per a planned resident and RP iniated transfer to an alternate skilled nursing facility that occurred 56 days prior to the facilities agency elimination plan. 2) The DON has reviewed all current residents to validate any with plans to transfer or discharge were given the right to choose their transfer/discharge destination. This was completed on [DATE] and no current facility residents have plans to transfer/discharge at this time. 3) The Regional Nurse Consultant has educated the Administrator, DON, Risk Manager and Social Services Director on providing the resident and the resident representative notice of transfer or discharge and the reasons for the move in a writing and language and manner they understand. And, the facility must send a copy of the notice to the Ombudsman. The reason allowable for transfer or discharge are A) the safety of individuals in the facility would be endangered. B) The health of individuals in the facility would be endangered. C) The resident's health improves sufficiently or D) An immediate transfer or discharge is required by the resident's urgent medical needs. Additionally, the notice must include the reason for transfer/discharge, the effective date of transfer or discharge, and the location to which the resident is transferred or discharged . Lastly, a discharge summary must be sent to the receiving entity. This education was completed on [DATE]. 4) An additional Quality Assurance and Performance Improvement (QAPI) committee meeting was held on [DATE] to present identified corresponding information. An additional QAPI committee was held on [DATE] to present newly obtained pertinent information regard F623. 5) Future, non-emergent, resident transfers and discharge will be reviewed by the Risk Manger prior to occurrence to validate the required notice is provided per the regulatory requirements for F623. 6) The Risk Manager will monitor all resident transfers and discharged to confirm the required notice was given for the next 3 months. 7) Results of the monitoring will be presented to the QAPI committee by the Risk Manager for recommendations for a period of 3 months. Any concerns identified will be addressed at time of discovery. 8) Allegation of compliance date is [DATE]. 43313

Based on observations, interview, record review, manufacturer ' s guidelines for medication use, and facility policy; the facility failed to ensure Resident (R)3 was free from unnecessary psychotropic medication Olanzapine (Zyprexa) for 1 of 1 resident reviewed for unnecessary medications. Specifically, an antipsychotic medication was used by the facility without proper medical rationale and proper indication for usage. Findings include: Review of the facility ' s policy titled Psychoactive Drug Monitoring last revised [DATE], revealed Residents who receive antidepressant, hypnotic, anti-anxiety, or anti-psychotic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medication obtain the maximum benefit with the minimum of untoward effects. 1) Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the residents ' medical record. 2) Non- pharmacological interventions such as behavior modification or social services and their effects are documented as part of the care planning process and are utilized by the prescriber in assessing the continued need for psychoactive medications. 3) Initiation and dosing of the psychoactive medication follows recommendations from the medial literature, clinical practice guidelines, and regulations and standards. 4) All of the following conditions are satisfied prior to initiation and/or continuation of therapy: possible reversible causes for the resident ' s distress have been ruled out; use results in maintenance or improvement in the resident ' s functional status; long-term daily use has been accompanied by unsuccessful gradual dosage reductions; the need for the response to therapy are monitored and documented in the residents medical record. 5) Antipsychotics are given only if the residents have been diagnosed with one the following indications as defined by the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) or subsequent editions and the diagnosis is documented in the medical or for a diagnosis not included on the list: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, organic mental syndromes (dementia, delirium, and cognitive disorder). 6) Residents receive antipsychotic mediation only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism. 7) Residents receive antipsychotic medication only for behaviors that are persistent, that are not caused by preventable reasons, and are impairing personal functioning (physical aggression, verbal aggression, or socially inappropriate behaviors). 8) Antipsychotics are not used solely for the following conditions if there is no other indication: wandering; poor-self-care; restlessness; anxiety; insomnia; agitated behaviors that do not represent danger to the resident or others. Review on [DATE] of the manufacturer's prescribing information for Zyprexa (Olanzapine) revealed WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS See full prescribing information for complete boxed warning. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis . ZYPREXA Intra-Muscular is indicated for the treatment of acute agitation associated with Schizophrenia and Bipolar I Mania. 'Psychomotor agitation' is defined in DSM-IV as 'excessive motor activity associated with a feeling of inner tension.' Patients experiencing agitation often manifest behaviors that interfere with their diagnosis and care, e.g., threatening behaviors, escalating or urgently distressing behavior, or self-exhausting behavior, leading clinicians to the use of intramuscular antipsychotic medications to achieve immediate control of the agitation [see Clinical Studies (14.3)]. R3 was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia with behavioral disturbances, type 2 diabetes, Alzheimer ' s disease, psychosis not due to substance or known physiological condition, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R3 has a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicates they are not cognitively intact and had no significant mood or behaviors during this assessment period. Record review on [DATE] of a Discharge MDS dated [DATE] revealed R3 has a BIMS score of 3 out of 15 which indicates they are not cognitively intact. Further review revealed R3 had no significant mood or behaviors during this assessment period. Record review on [DATE] of R3 ' s Physician Orders revealed Zyprexa 5 MG tablet ordered by Psychiatric Physician #1 on [DATE] for unspecified psychosis. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE] which stated, resident started on new medication today olanzapine mg (Zyprexa). Resident was pleasant this morning when administering medications around lunch time in dining area, resident had an unresponsive episode with no appropriate response to pain. Resident sent to hospital for evaluation/treatment, Medical Director (MD) and Resident Representative (RP) made aware of transfer. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident to remain in the hospital, follow up call to RP in regards to bed hold, RP verbalized understanding, telephone number to hospital provide to RP. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident returned to facility on stretcher via transportation. Resident is alert to self, verbally responsive, confusion noted. Resident talking unintelligibly and rambling, no acute distress note and no signs of pain or discomfort noted. Resident can ambulate independently, abdomen soft, non-distended, resident is incontinent of bowel and bladder wear adult briefs. MD called and made aware of residents return. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE] order received by Nurse Practitioner (NP) to discontinue olanzapine (Zyprexa) use. Record review on [DATE] of R3 ' s Progress Notes revealed a follow-up encounter dated [DATE] revealing R3 is an [AGE] year-old black or African American female admitted for syncope (fainting) on [DATE]. R3 has advanced dementia patient at Bayview Nursing Center who was coming back from the sitting room walking with assistance when she experienced a syncopal episode. Syncopal episode lasted about 2 minutes and the staff could not feel a pulse and started Cardiopulmonary Resuscitation (CPR) for roughly 2 minutes. On arrival fire and rescue she alert and with a low blood pressure ,d+[DATE]- but she was almost back at baseline. While spending a few hours in the hospital she is now back to baseline and her blood pressure is better. She has little ecchymosis (bruise) of the left eye imaging is currently pending. Will follow closely this patient is unable to give me any history due to advanced dementia. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read staff reports that resident was having some increased pacing and was started on Zyprexa, which was later discontinued related to possible adverse effects and non-responsive episode in which CPR was initiated. Since re-admission from hospital staff reports restless behaviors. Antihypertensives were also adjusted, gait is unsteady, resident able to ambulate independently and is re-directed as needed, encourage rest periods. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident was assisted to bed by staff but would not lie down, resident preferred to sit in Geri chair and stay at nurse ' s station with staff. Resident did allow staff to put her back in bed around 3 am, no other complaints were observed. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident was unresponsive, 911 was called and transported to hospital. MD was notified of transfer, on call nurse and RP notified of transfer, will continue to monitor. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident returned via personnel care via stretcher, resident returned with order for Keflex 500 mg four times daily for Urinary Tract Infection (UTI), will continue to monitor. Record review on [DATE] of R3 ' s Psych Progress Note dated [DATE] revealed Patient is a [AGE] year-old female that is being seen today for initial psychiatric evaluation. Per provider records patient has a past psychiatric history of anxiety and psychosis. Patient is currently on Buspar (Anxiety medication), Zyprexa recently stopped after what appears to be potential allergic reaction per NP today. Patient currently being treated for UTI, has been restless per staff. On exam patient is sitting up, awake and alert, calm and in no distress. Speech is coherent, regular rate and tone, fair eye contact, thought process is confused. Oriented to person only, mood is good, affect is appropriate. Record review of R3 ' s Medication Administration Record (MAR) for the month of [DATE] revealed no documentation of inappropriate behaviors for behavior monitoring. Record review of R3 ' s MAR for the month of [DATE] revealed no documentation of inappropriate behaviors for behavior monitoring. Record review of R3 ' s MAR for the months of November and [DATE] revealed the medication Zyprexa was administered on [DATE], [DATE], and [DATE]. An observation of R3 on [DATE] at 10:15 AM revealed her asleep in a Geri-chair near other residents, appropriately dressed. Upon attempt, it was determined she was non-interviewable. A phone interview on [DATE] at 1:22 PM with R3 ' s Resident Representative revealed I was notified that R3 went to the hospital and when she returned to the facility. They (the facility) never explained to me why she went to the hospital. I thought something was off (R3), but he didn ' t know exactly what was wrong. The facility has contacted me twice, but I can ' t remember the dates, but both were about her going to the hospital. I live hours away, so I don ' t get to see her often and have not been able to visit since the recent hospitalization s. An interview on [DATE] at 12:51 PM with Certified Nursing Assistant (CNA)1 revealed It is not normal for R3 to sleep all day, however since she returned from the hospital last week she sleeps a lot. Staff wakes up the resident every two hours and takes her to be changed. Resident prior to her hospital stay she was eating on her own and walking on her own. She now is fed prior to a week ago she was eating feeding herself. An interview on [DATE] at 1:01 PM with Licensed Practical Nurse (LPN)1 revealed I have worked at the facility for many years and have been working with R3 since her admission. Staff use music as a non-pharmacological approach for R3. The electronic system is the monitoring tool that is used. For psychotropic medications, the MAR is utilized to monitor and assess behaviors. The resident had been running down the hall prior to receiving the medication Zyprexa. The Zyprexa was ordered when I was off, and the nurse practitioner discharged it because of the side effects. Resident now is in the [NAME]-chair most days and prior to the new medication, she was not. A phone interview on [DATE] at 2:25 PM with the Director of Nursing (DON) revealed non-pharmacological approaches are first used prior to the administration of psychotropic medication to attempt to re-direct the behavior. If behaviors are occurring with a resident we expect staff to document the behavior in the MAR. With R3 we are unsure that the medication Zyprexa was the cause of the resident's fainting and having to be hospitalized . R3 had a hospitalization days after the medication (Zyprexa) was discharged from her physician's orders and was last administered. Because R3 is on our dementia unit we utilize a Psychiatrist for residents that have dementia with behaviors rather than our Medical Director or Nurse Practitioner all interventions are discussed within the IDT and QAPI team. A phone interview on [DATE] at 3:51 PM with the Psychiatrist for the facility revealed I go to the facility about once a week to visit the residents under my care. A lot of the residents have dementia with behaviors. I spoke with the Nurse Practitioner, and he informed me that the resident had to have a hospitalization and they (the facility) were wondering to the medication Zyprexa had anything to do with it. I was aware and that the NP had discharged the medication after the hospitalization . I prescribed this medication because of the resident ' s psychosis because she was being combative with care and with staff and paranoid when staff attempted to give her care. We tend to undertreat psychosis in long-term care facilities (hallucinations) as long as they aren ' t harming themselves or others it is fine, but if it is and they are having negative consequences (paranoid behavior) then we attempt non-pharmacological approaches. But when the facility finally calls us (for treatment) we look into psychotropic medications and we look at the risk-benefit ratio. We consider diagnoses during the risk-benefit ratio along with black box warnings. The risk is there but the risk of not treating the psychosis is harmful as well. I was aware of the black box warning and contradiction for the medication Zyprexa when I prescribed the medication to R3. It is not true that the medication Zyprexa is not licensed for use for patients with dementia. It has a warning that you clinically take into account prior to prescribing, it is something that you take into the risk-benefit ratio. I was aware that there is a higher risk of mortality when this medication is prescribed to older adults with dementia however, there is a risk of mortality when you don ' t treat psychosis as well. I was aware of the facilities' policies and federal regulations related to antipsychotic medication usage in adults with dementia.

Based on observations, interview, record review, manufacturer ' s guidelines for medication use, and facility policy; the facility failed to ensure Resident (R)3 was free from unnecessary psychotropic medication Olanzapine (Zyprexa) for 1 of 1 resident reviewed for unnecessary medications. Specifically, an antipsychotic medication was used by the facility without proper medical rationale and proper indication for usage. Findings include: Review of the facility ' s policy titled Psychoactive Drug Monitoring last revised [DATE], revealed Residents who receive antidepressant, hypnotic, anti-anxiety, or anti-psychotic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medication obtain the maximum benefit with the minimum of untoward effects. 1) Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the residents ' medical record. 2) Non- pharmacological interventions such as behavior modification or social services and their effects are documented as part of the care planning process and are utilized by the prescriber in assessing the continued need for psychoactive medications. 3) Initiation and dosing of the psychoactive medication follows recommendations from the medial literature, clinical practice guidelines, and regulations and standards. 4) All of the following conditions are satisfied prior to initiation and/or continuation of therapy: possible reversible causes for the resident ' s distress have been ruled out; use results in maintenance or improvement in the resident ' s functional status; long-term daily use has been accompanied by unsuccessful gradual dosage reductions; the need for the response to therapy are monitored and documented in the residents medical record. 5) Antipsychotics are given only if the residents have been diagnosed with one the following indications as defined by the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) or subsequent editions and the diagnosis is documented in the medical or for a diagnosis not included on the list: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, organic mental syndromes (dementia, delirium, and cognitive disorder). 6) Residents receive antipsychotic mediation only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism. 7) Residents receive antipsychotic medication only for behaviors that are persistent, that are not caused by preventable reasons, and are impairing personal functioning (physical aggression, verbal aggression, or socially inappropriate behaviors). 8) Antipsychotics are not used solely for the following conditions if there is no other indication: wandering; poor-self-care; restlessness; anxiety; insomnia; agitated behaviors that do not represent danger to the resident or others. Review on [DATE] of the manufacturer's prescribing information for Zyprexa (Olanzapine) revealed WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS See full prescribing information for complete boxed warning. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis . ZYPREXA Intra-Muscular is indicated for the treatment of acute agitation associated with Schizophrenia and Bipolar I Mania. 'Psychomotor agitation' is defined in DSM-IV as 'excessive motor activity associated with a feeling of inner tension.' Patients experiencing agitation often manifest behaviors that interfere with their diagnosis and care, e.g., threatening behaviors, escalating or urgently distressing behavior, or self-exhausting behavior, leading clinicians to the use of intramuscular antipsychotic medications to achieve immediate control of the agitation [see Clinical Studies (14.3)]. R3 was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia with behavioral disturbances, type 2 diabetes, Alzheimer ' s disease, psychosis not due to substance or known physiological condition, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R3 has a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicates they are not cognitively intact and had no significant mood or behaviors during this assessment period. Record review on [DATE] of a Discharge MDS dated [DATE] revealed R3 has a BIMS score of 3 out of 15 which indicates they are not cognitively intact. Further review revealed R3 had no significant mood or behaviors during this assessment period. Record review on [DATE] of R3 ' s Physician Orders revealed Zyprexa 5 MG tablet ordered by Psychiatric Physician #1 on [DATE] for unspecified psychosis. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE] which stated, resident started on new medication today olanzapine mg (Zyprexa). Resident was pleasant this morning when administering medications around lunch time in dining area, resident had an unresponsive episode with no appropriate response to pain. Resident sent to hospital for evaluation/treatment, Medical Director (MD) and Resident Representative (RP) made aware of transfer. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident to remain in the hospital, follow up call to RP in regards to bed hold, RP verbalized understanding, telephone number to hospital provide to RP. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident returned to facility on stretcher via transportation. Resident is alert to self, verbally responsive, confusion noted. Resident talking unintelligibly and rambling, no acute distress note and no signs of pain or discomfort noted. Resident can ambulate independently, abdomen soft, non-distended, resident is incontinent of bowel and bladder wear adult briefs. MD called and made aware of residents return. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE] order received by Nurse Practitioner (NP) to discontinue olanzapine (Zyprexa) use. Record review on [DATE] of R3 ' s Progress Notes revealed a follow-up encounter dated [DATE] revealing R3 is an [AGE] year-old black or African American female admitted for syncope (fainting) on [DATE]. R3 has advanced dementia patient at Bayview Nursing Center who was coming back from the sitting room walking with assistance when she experienced a syncopal episode. Syncopal episode lasted about 2 minutes and the staff could not feel a pulse and started Cardiopulmonary Resuscitation (CPR) for roughly 2 minutes. On arrival fire and rescue she alert and with a low blood pressure 80/4- but she was almost back at baseline. While spending a few hours in the hospital she is now back to baseline and her blood pressure is better. She has little ecchymosis (bruise) of the left eye imaging is currently pending. Will follow closely this patient is unable to give me any history due to advanced dementia. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read staff reports that resident was having some increased pacing and was started on Zyprexa, which was later discontinued related to possible adverse effects and non-responsive episode in which CPR was initiated. Since re-admission from hospital staff reports restless behaviors. Antihypertensives were also adjusted, gait is unsteady, resident able to ambulate independently and is re-directed as needed, encourage rest periods. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident was assisted to bed by staff but would not lie down, resident preferred to sit in Geri chair and stay at nurse ' s station with staff. Resident did allow staff to put her back in bed around 3 am, no other complaints were observed. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident was unresponsive, 911 was called and transported to hospital. MD was notified of transfer, on call nurse and RP notified of transfer, will continue to monitor. Record review on [DATE] of R3 ' s Progress Notes revealed a Nursing Note dated [DATE], which read resident returned via personnel care via stretcher, resident returned with order for Keflex 500 mg four times daily for Urinary Tract Infection (UTI), will continue to monitor. Record review on [DATE] of R3 ' s Psych Progress Note dated [DATE] revealed Patient is a [AGE] year-old female that is being seen today for initial psychiatric evaluation. Per provider records patient has a past psychiatric history of anxiety and psychosis. Patient is currently on Buspar (Anxiety medication), Zyprexa recently stopped after what appears to be potential allergic reaction per NP today. Patient currently being treated for UTI, has been restless per staff. On exam patient is sitting up, awake and alert, calm and in no distress. Speech is coherent, regular rate and tone, fair eye contact, thought process is confused. Oriented to person only, mood is good, affect is appropriate. Record review of R3 ' s Medication Administration Record (MAR) for the month of [DATE] revealed no documentation of inappropriate behaviors for behavior monitoring. Record review of R3 ' s MAR for the month of [DATE] revealed no documentation of inappropriate behaviors for behavior monitoring. Record review of R3 ' s MAR for the months of November and [DATE] revealed the medication Zyprexa was administered on [DATE], [DATE], and [DATE]. An observation of R3 on [DATE] at 10:15 AM revealed her asleep in a Geri-chair near other residents, appropriately dressed. Upon attempt, it was determined she was non-interviewable. A phone interview on [DATE] at 1:22 PM with R3 ' s Resident Representative revealed I was notified that R3 went to the hospital and when she returned to the facility. They (the facility) never explained to me why she went to the hospital. I thought something was off (R3), but he didn ' t know exactly what was wrong. The facility has contacted me twice, but I can ' t remember the dates, but both were about her going to the hospital. I live hours away, so I don ' t get to see her often and have not been able to visit since the recent hospitalizations. An interview on [DATE] at 12:51 PM with Certified Nursing Assistant (CNA)1 revealed It is not normal for R3 to sleep all day, however since she returned from the hospital last week she sleeps a lot. Staff wakes up the resident every two hours and takes her to be changed. Resident prior to her hospital stay she was eating on her own and walking on her own. She now is fed prior to a week ago she was eating feeding herself. An interview on [DATE] at 1:01 PM with Licensed Practical Nurse (LPN)1 revealed I have worked at the facility for many years and have been working with R3 since her admission. Staff use music as a non-pharmacological approach for R3. The electronic system is the monitoring tool that is used. For psychotropic medications, the MAR is utilized to monitor and assess behaviors. The resident had been running down the hall prior to receiving the medication Zyprexa. The Zyprexa was ordered when I was off, and the nurse practitioner discharged it because of the side effects. Resident now is in the [NAME]-chair most days and prior to the new medication, she was not. A phone interview on [DATE] at 2:25 PM with the Director of Nursing (DON) revealed non-pharmacological approaches are first used prior to the administration of psychotropic medication to attempt to re-direct the behavior. If behaviors are occurring with a resident we expect staff to document the behavior in the MAR. With R3 we are unsure that the medication Zyprexa was the cause of the resident's fainting and having to be hospitalized . R3 had a hospitalization days after the medication (Zyprexa) was discharged from her physician's orders and was last administered. Because R3 is on our dementia unit we utilize a Psychiatrist for residents that have dementia with behaviors rather than our Medical Director or Nurse Practitioner all interventions are discussed within the IDT and QAPI team. A phone interview on [DATE] at 3:51 PM with the Psychiatrist for the facility revealed I go to the facility about once a week to visit the residents under my care. A lot of the residents have dementia with behaviors. I spoke with the Nurse Practitioner, and he informed me that the resident had to have a hospitalization and they (the facility) were wondering to the medication Zyprexa had anything to do with it. I was aware and that the NP had discharged the medication after the hospitalization. I prescribed this medication because of the resident ' s psychosis because she was being combative with care and with staff and paranoid when staff attempted to give her care. We tend to undertreat psychosis in long-term care facilities (hallucinations) as long as they aren ' t harming themselves or others it is fine, but if it is and they are having negative consequences (paranoid behavior) then we attempt non-pharmacological approaches. But when the facility finally calls us (for treatment) we look into psychotropic medications and we look at the risk-benefit ratio. We consider diagnoses during the risk-benefit ratio along with black box warnings. The risk is there but the risk of not treating the psychosis is harmful as well. I was aware of the black box warning and contradiction for the medication Zyprexa when I prescribed the medication to R3. It is not true that the medication Zyprexa is not licensed for use for patients with dementia. It has a warning that you clinically take into account prior to prescribing, it is something that you take into the risk-benefit ratio. I was aware that there is a higher risk of mortality when this medication is prescribed to older adults with dementia however, there is a risk of mortality when you don ' t treat psychosis as well. I was aware of the facilities' policies and federal regulations related to antipsychotic medication usage in adults with dementia.

Based on observation, records review, including the facility policy titled Elopement and Wandering Residents and interviews, the facility to provide adequate supervision to prevent elopement. R1 exited the facility without proper authorization or the necessary supervision. He exited the facility on 3/9/22, at an unknown time and from an unknown location and walked to an adjacent street identified as Spanish Point Drive. The distance from the facility to the street where the resident was found is 0.2 miles. He was found by the local police department on 03/09/22 at 11:00 PM and taken to the hospital. The facility's failure also constituted substandard quality of care, warranting the completion of an extended survey. On 03/16/22 at 2:58 PM, the Administrator and the Director of Nursing were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R)1. R1 exited the facility without proper authorization or the necessary supervision at an unknown time on 03/09/22. R1 exited the facility from an unknown location and walked to an adjacent street identified as, Spanish Point Drive. The distance from the facility to the street where R1 was found is 0.2 miles. He was found by the local police department on 03/09/22 at 11:00 PM and taken to the hospital for evaluation. R1 was unharmed and did not obtain any injuries. The facility's failure to provide adequate supervision to a resident diagnosed with [CONDITION(S)], adult failure to thrive, A PEG (percutaneous endoscopic gastronomy) Dependence, depression, and mood disorder has the potential for serious injury, serious harm, serious impairment, or death, and constituted Immediate Jeopardy (IJ) at F689. The immediate jeopardy existed from 03/09/22 to 03/17/22. The facility presented an acceptable removal plan on 03/17/22 at 3:21 PM, indicating a plan was put in place to remove the immediacy. The survey team validated the removal plan. The facility remained out of compliance at F689 at a lower scope and severity of D (pattern with potential for minimal harm) following removal of the IJ. Findings include: Review of the facility policy titled Elopement and Wandering Residents reads the following: Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 3. If the resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on authorized leave. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). An anonymous report was submitted to the State Agency on 3/14/22 alleging an elderly gentlemen, who was somewhat hostile and hard to get answers from and understand, was found in the rain at about 11pm. He was found on Spanish Point Drive on March 9, 2022. Where he was found was about .2 miles from the facility. The temperature outside was 57 degrees. The facility was not aware that he was gone . Resident was sent to the hospital for treatment, he weighs 86 lbs with a BMI of 12.4. When he arrived at the hospital, he had a temperature of 100.4 and his G-tube was crusty. When resident was asked by the police where he was going, he reported you know where I am going. Resident has no family, he is an only child. He was discharged from the hospital on 3-10-2022 and returned to the facility. A review of the Resident Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed R1 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)], adult failure to thrive, protein-calorie malnutrition, A PEG (percutaneous endoscopic gastronomy) dependence, depression and mood disorder. Review of the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/10/22, located in the EMR under the MDS tab, revealed R1 had a Brief Interview of Mental Status (BIMS) score of ninety-nine, indicating the resident was unable to complete the interview. Under functional status, R1 requires supervision with bed mobility, personal hygiene, and eating, limited assistance with transfer and walking in the room, and extensive assistance with dressing and toilet use. A review of R1's undated Care Plan, revealed that he has impaired cognitive function and communication deficit and is an elopement risk related to a history of attempts to leave the facility unattended. New interventions include, relocation to a room past the nurses' station for the resident to pass by the station and movement recognized. The resident was placed on 1:1 for 72 hours. A wander-guard was placed to the resident's left ankle and check functionally at every shift. A review of R1's March 2022 Medication Administration Record (MAR) revealed an order with a start date of 3/10/22 for wanderguard to left ankle. Check placement and functioning properly every shift. Additional review of the MAR indicate wanderguard checks in place starting 3/10/22 to current. A review on 3/16/22 at 12:15 PM of R1's Physician Chart Note indicated he was assessed by the facility's Physician. Per the note, the facility has been unable to obtain the hospital records, but R1 was referred/sent back to the facility without new orders or evidence of incident. No obvious change in condition noted .We feel R1 is most likely fatigued/tired from his long night. Just really looks tired and worn from lack of rest . The noted plan is to continue to assist with ADLs and monitor for possibly leaving the building. R1 gives no explanation when asked. Condition stable. A review of R1's Nursing Progress Notes, dated 01/01/22 to 03/17/22, located in the EMR under the Progress Notes tab, revealed the following: 3/10/22: R1 was moved from room D17 to D35. Wander-guard placed to the left ankle and 15 minutes safety checks initiated to continue x 7 days. 3/14/22: R1's physicians were made aware of behaviors noted by staff since Thursday upon arrival back to the facility. Safety measures in place including 1:1 supervision. 3/16/22: R1 continues 1:1 supervision. Some confusion was noted. His wander-guard to left ankle remains in place and functioning as intended. 3/17/22: R1 continues 1:1 supervision and his wander-guard remains in place to the left ankle and is working properly. A review of R1's Elopement Evaluation-V2 with an initiated date of 01/05/22 and effective date of 01/05/22 revealed a score of N/A indicating that R1 is not at risk for elopement. A second Elopement Evaluation-V2 with an initiated date of 01/05/22 and an effective date of 03/10/22 revealed a score of 5 (4-6 Medium), indicating that R1 is at medium risk for elopement. Review of the facility's investigative file on 03/16/22 at 12 PM revealed a summary which stated the following: Approx 11:20 PM on 3/9/2022, Nurse called on call nursing phone to report that local law enforcement observed R1 outside down the road at Spanish Point House 165. 11:25 PM call to Administrator to inform of current situation with resident. Spoke with Corporate Quality Assurance Nurse during time. Last observation of R1 by Nurse at approximately 9:45 PM during med pass. R1 present in his room fully clothed with shoes, which is his baseline. Certified Nursing Assistant (CNA)1, last observed R1 in hallway in front of his door by nursing station around 9:30 PM in his wheelchair, just sitting fully clothed with shoes on. Resident at baseline. CNA2, last observed at approx. 10:30 PM sitting in hallway by room, stated R1 was up and down all night and stated to her that some man was supposed to come see him. Further review identified LPN1 as the nurse mentioned in the summary. Multiple attempts were made to contact CNA1 and CNA2 via telephone for interview, with no success. Additional review of the facility's investigative file revealed an undated document that contained multiple staff names with statements indicating there were no alarms sounding, nor did any of the staff interviewed had to deactivate alarms due to them sounding on 03/09/22. Interview with the Administrator and Director of Nursing (DON) on 03/16/22 at 12:24 PM revealed that R1 walked out the front door on 03/09/22 between 10:30 PM and 11:00 PM. There was no receptionist on duty because they get off at 5:00 PM. All exit doors in the facility are equipped with a wander guard system, even the front door. The front door is secured, meaning you can exit out, but you cannot re-enter. The police officer identified the local law enforcement department contacted the facility to inform the facility that they had one of the facility's residents and were sending him to the hospital. The Administrator stated that the facility performed a headcount to ensure all other residents were present. R1 was returned to the facility, via ambulance, the next morning. The resident was placed on supervision checks every 15 minutes and eventually placed on 1:1 supervision. The facility conducted an elopement assessment, updated his care plan to reflect elopement, and placed a wander guard bracelet on his ankle. The facility also conducted a body audit on the resident, which resulted in no injuries or concerns. The facility ordered a new security system for the front door. The Administrator said that the facility did not consider this an elopement because they knew the resident was coming back. After all, there was a newspaper wedged in the front door to keep it open. In an attempted interview with R1 on 03/16/22 at 1:20 PM, he could not recall the incident that took place. After further general questions, it was determined that R1 was not responding appropriately to questioning and the interview was stopped. During an observation of R1 on 03/16/22 at 1:20 PM, it was noted staff was sitting outside the resident's room, at a desk. A staff member confirmed that she was there for one on one supervision with R1. R1 was laying in the bed, slightly elevated. R1 was wearing a shirt and jacket, while lying in bed. In an interview with Licensed Practical Nurse (LPN1) on 03/16/22 at 1:36 PM, she stated that the facility received a call from the police department around 10:55 PM notifying her that R1 had been found by a police officer, and was being transported to the local hospital. The facility was not aware the R1 was missing at the time of the call. LPN1 stated she notified all administrative staff and the DON. The facility proceeded to perform a headcount of all residents. She added that she contacted the hospital to try and get more information, but the hospital did not have much information and did not know why R1 was there. LPN1 did not know how R1 exited the building but stated I think he got out through the front door. LPN1 was able to confirm that she last saw R1 around 9:45 PM to 10:00 PM, when she performed medication administration. LPN1 further stated that the resident wears a lot of clothes and always wears a jacket. In an interview with Registered Nurse (RN1) on 03/16/22 at 2:26 PM, she stated that R1 arrived in the facility before noon and he didn't seem like himself. The facility put him on one on one supervision and conducted a body audit, which revealed no concerns. RN1 stated the facility was using the term elopement to discuss the incident that happened with R1. RN1 does not believe that R1 had the authorization to leave the facility and could not recall the exact weather the previous night but did reveal that there was inclement weather. RN1 further stated, I believe he was wearing jeans, shirt and a jacket of some kind, I do not recall if he was wearing shoes, possibly mismatch shoes, one slipper, and one sneaker. In an additional interview with the DON and Administrator on 03/17/22 at 3:05 PM, they both acknowledged that on 03/09/22, R1 exited the facility without the proper authorization and was unsupervised and was found on Spanish Point Drive by a police officer of the local law enforcement department. The removal plan included the following: 1. On 3/9/22, at approximately 11:15 PM, local law enforcement contacted the facility on-site staff stating R1 was observed off of facility property, uncooperative, and being transported to the local hospital via emergency services for evaluation. As a result, on-site staff immediately notified both the Administrator and Director of Nursing. This was completed by 11:25 PM on 3/9/22. 2. A full count was completed to validate all other residents were present in the facility-no other concerns were identified. This was initiated on 3/9/22 at 11:35 PM. 3. Following verification that all other residents were present in the facility, an investigation was initiated per facility policy that confirmed R1 was observed by staff at 10:30 PM to be in his room, sitting in his chair, fully dressed, and at his baseline with no complaints voiced. R1 accepted his ordered HS (nighttime) medication from another staff member at 9:45 PM and displayed no evidence of intent to exit the facility without notification. Further investigation, including interviews of on-site staff, indicates no facility exit door alarms were triggered or disarmed on the night of 3/9/22. Visual observation of the facility's main entrance revealed a newspaper had been placed in the door to prevent the auto-lock from engaging. This information was obtained on 3/10/22 prior to the conclusion of the night shift at 7:00 PM. 4. The Maintenance Director completed an inspection of all facility exit doors to validate proper functioning-no concerns were identified. This was completed on 03/10/22 and compared to the door function audit of 3/9/22 with no changes noted and completion of facility door function audit confirmed to be occurring 5 times per week. At the time of occurrence, the facility main door did not have an alarming function, and all other facility doors did alarm when engaged, require a key and/or code to disable, and remain engaged at all times. 5. A review of the medical record completed on 3/10/22 indicates R1 had elopement evaluations completed per policy, had no prior factors predisposing him to the current situation, and had given no prior indication he would depart the facility at a later hour, on foot, without informing the staff of his intentions. The record reflects no diagnosis of cognitive impairment, no medications ordered for cognitive impairment, an intact short-term memory capable of executing planned actions, and provider notes as current as 3/8/22, confirming orientation. 6. Based on evidence obtained in the facility's investigation, the Maintenance Director concluded an alarming device to alert of the facility's main door opening will be activated when the Receptionist is not on duty to prevent future issues of a similar nature. This was completed on 3/10/22 and the device order was placed on 3/10/22 with an expected delivery date of 3/18/22 and installation time prior to 5:00 PM, the same day. 7. Education was initiated on 3/9/22 at 11:50 PM with on-site facility employees on the supervision of residents that prefer to remain out of bed after the general population has gone to bed for the night to prevent exiting of facility without staff knowledge. This education was completed with all licensed Nurses, nursing assistants, Licensed Therapists, therapy assistants, dietary staff, environmental services, staff, and ancillary staff by 3/11/22. Any employee not receiving this education by 3/11/22 will receive it prior to the next scheduled shift. This information will be presented in new hire orientation. 8. On 3/10/22, at 8:31 AM, R1's elopement evaluation was updated to reflect the recent occurrence. 9. R1 returned to the facility from the emergency department on 3/10/22 at 8:41 AM to a different room in the facility, that requires passing the nurse's station to access the main door. No new diagnoses or orders accompanied R1. He arrived in stable condition as evidenced by a body audit and vital signs performed at 8:45 AM. Clothing items present in belongings upon return included; pants, shirt, jacket, socks, and shoes-further confirming R1 left the facility appropriately dressed for temperature in the mid 60's as stated on Accuweather.com. The resident was noted to be resting soundly and unable to participate in the investigation interview, therefore, at 9:06 AM, a wanderguard was placed to the ankle per provider order and 15-minutes location observation checks were initiated pending the investigation outcome. 10. On 3/10/22 at approximately 10:30 AM, R1's attending physician conducted an assessment confirming R1 sustained no injury or latent effect from leaving the facility the previous night, and at approximately 11:30 AM, met with the Responsible Party to discuss prognosis and confirm treatment plan. 11. On 3/10/22, the Administrator made attempts to contact the local law enforcement officer that initially observed R1 outside the facility on 3/9/22, but was repeatedly directed to alternate individuals that did not respond to phone calls or messages. 12. On 3/10/22, the facility attempted to obtain emergency department records detailing R1's brief evaluation and is still awaiting a response to the request. 13. On 3/10/22, at approximately 4:00 PM, R1 awoke from resting with significant evidence of anxiety. Once in a wheelchair, he propelled himself directly to the facility main door, while repeatedly verbalizing a desire to leave the building. The facility staff successfully prevented him from exiting the building with redirection and, at 4:30 PM, constant 1:1 supervision was initiated, the provider was notified with multiple new medication orders received and implemented, and the Responsible Party was updated on the treatment plan with agreement confirmed. 14. On 3/10/22, R1's care plan was updated to reflect applicable information. 15. On 3/10/22, Nurse Managers validated all other residents had an elopement evaluation completed within the past 3 months. 16. On 3/10/22, all residents, confirmed to be at risk for wandering/elopement not residing in the facility's secured unit, were validated to have a wander guard in place and functioning to prevent unsupervised exiting of the facility. 17. On 3/10/22, an ad Hoc QAPI meeting was informally conducted to present related information for recommendations, members included; Administrator, Director of Nursing, D-wing Unit Manager, Maintenance Director, Regional Nurse Consultant, Regional Director of Operations, and Medical Director-also attending physician. 18. On 3/11/22, R1's care plan was further updated to reflect applicable information. 19. On 3/17/22, at 12:00 Noon, the Maintenance Director applied a temporary auditory alert device to the facility's main door. The device will be activated when the receptionist is not on duty. The device will be replaced with an expected alarming appliance that arrives and is installed. 20. The Maintenance Director or Maintenance Assistant will monitor the facility main door alarm daily, Monday-Friday to validate functioning and the Director of Nursing or Assistant Director of Nursing will monitor the 24-hour report, daily, Monday-Friday, for 4 weeks for 2 months for evidence of residents exiting the facility without staff knowledge. 21. Results of monitoring will be presented to the Quality Assurance and Performance Improvement Committee for recommendations for a period of 3 months. Any concerns identified will be addressed at the time of discovery.

Based on observation, records review, including the facility policy titled Abuse Prohibition/Investigation Policy and interviews, the facility failed to provide adequate supervision to prevent elopement. Resident (R)1 exited the facility without proper authorization or the necessary supervision. He exited the facility at an unknown time and from an unknown location and walked to an adjacent street identified as, Spanish Point Drive. The distance from the facility to the street where the resident was found is 0.2 miles. He was found by the local police department on 03/09/22 at 11:00 PM and taken to the hospital for evaluation. This failure constituted substandard quality of care, warranting an extended survey. On 03/16/22 at 2:58 PM, the Administrator and the Director of Nursing were notified that the facility neglected to provide adequate supervision to prevent elopement for Resident (R)1. R1 exited the facility without proper authorization or the necessary supervision at an unknown time on 03/09/22. R1 exited the facility from an unknown location and walked to an adjacent street identified as, Spanish Point Drive. The distance from the facility to the street where R1 was found is 0.2 miles. He was found by the local police department on 03/09/22 at 11:00 PM and taken to the hospital for evaluation. R1 was unharmed and did not obtain any injuries. The facility's failure to provide adequate supervision to a resident diagnosed with [CONDITION(S)], adult failure to thrive, A PEG (percutaneous endoscopic gastronomy) Dependence, depression, and mood disorder has the potential for serious injury, serious harm, serious impairment, or death, and constituted Immediate Jeopardy (IJ) at F600. The immediate jeopardy existed from 03/09/22 to 03/17/22. The facility presented an acceptable removal plan on 03/17/22 at 3:21 PM, indicating a plan was put in place to remove the immediacy. The survey team validated the removal plan. The facility remained out of compliance at F600 at a lower scope and severity of D (pattern with potential for minimal harm) following removal of the IJ. Findings include: Review of the facility's Abuse policy, titled Abuse Prohibition/Investigation Policy, The facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. Definition: Neglect; is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. An anonymous report was submitted to the State Agency on 3/14/22 alleging an elderly gentlemen, who was somewhat hostile and hard to get answers from and understand, was found in the rain at about 11pm. He was found on Spanish Point Drive on March 9, 2022. Where he was found was about .2 miles from the facility. The temperature outside was 57 degrees. The facility was not aware that he was gone . Resident was sent to the hospital for treatment, he weighs 86 lbs with a BMI of 12.4. When he arrived at the hospital, he had a temperature of 100.4 and his G-tube was crusty. When resident was asked by the police where he was going, he reported you know where I am going. Resident has no family, he is an only child. He was discharged from the hospital on 3-10-2022 and returned to the facility. A review of the Resident Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed R1 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)], adult failure to thrive, protein-calorie malnutrition, A PEG (percutaneous endoscopic gastronomy) dependence, depression and mood disorder. Review of the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/10/22, located in the EMR under the MDS tab, revealed R1 had a Brief Interview of Mental Status (BIMS) score of ninety-nine, indicating the resident was unable to complete the interview. Under functional status, R1 requires supervision with bed mobility, personal hygiene, and eating, limited assistance with transfer and walking in the room, and extensive assistance with dressing and toilet use. A review of R1's undated Care Plan, revealed that he has impaired cognitive function and communication deficit and is an elopement risk related to a history of attempts to leave the facility unattended. New interventions include, relocation to a room past the nurses' station for the resident to pass by the station and movement recognized. The resident was placed on 1:1 for 72 hours. A wander-guard was placed to the resident's left ankle and check functionally at every shift. A review of R1's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Check placement and functioning properly every shift. Additional review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review on 3/16/22 at 12:15 PM of R1's Physician Chart Note indicated he was assessed by the facility's Physician. Per the note, the facility has been unable to obtain the hospital records, but R1 was referred/sent back to the facility without new orders or evidence of incident. No obvious change in condition noted .We feel R1 is most likely fatigued/tired from his long night. Just really looks tired and worn from lack of rest . The noted plan is to continue to assist with ADLs and monitor for possibly leaving the building. R1 gives no explanation when asked. Condition stable. A review of R1's Nursing Progress Notes, dated 01/01/22 to 03/17/22, located in the EMR under the Progress Notes tab, revealed the following: 3/10/22: R1 was moved from room D17 to D35. Wander-guard placed to the left ankle and 15 minutes safety checks initiated to continue x 7 days. 3/14/22: R1's physicians were made aware of behaviors noted by staff since Thursday upon arrival back to the facility. Safety measures in place including 1:1 supervision. 3/16/22: R1 continues 1:1 supervision. Some confusion was noted. His wander-guard to left ankle remains in place and functioning as intended. 3/17/22: R1 continues 1:1 supervision and his wander-guard remains in place to the left ankle and is working properly. A review of R1's Elopement Evaluation-V2 with an initiated date of 01/05/22 and effective date of 01/05/22 revealed a score of N/A indicating that R1 is not at risk for elopement. A second Elopement Evaluation-V2 with an initiated date of 01/05/22 and an effective date of 03/10/22 revealed a score of 5 (4-6 Medium), indicating that R1 is at medium risk for elopement. Review of the facility's investigative file on 03/16/22 at 12 PM revealed a summary which stated the following: Approx 11:20 PM on 3/9/2022, Nurse called on call nursing phone to report that local law enforcement observed R1 outside down the road at Spanish Point House 165. 11:25 PM call to Administrator to inform of current situation with resident. Spoke with Corporate Quality Assurance Nurse during time. Last observation of R1 by Nurse at approximately 9:45 PM during med pass. R1 present in his room fully clothed with shoes, which is his baseline. Certified Nursing Assistant (CNA)1, last observed R1 in hallway in front of his door by nursing station around 9:30 PM in his wheelchair, just sitting fully clothed with shoes on. Resident at baseline. CNA2, last observed at approx. 10:30 PM sitting in hallway by room, stated R1 was up and down all night and stated to her that some man was supposed to come see him. Further review identified LPN1 as the nurse mentioned in the summary. Multiple attempts were made to contact CNA1 and CNA2 via telephone for interview, with no success. Additional review of the facility's investigative file revealed an undated document that contained multiple staff names with statements indicating there were no alarms sounding, nor did any of the staff interviewed had to deactivate alarms due to them sounding on 03/09/22. Interview with the Administrator and Director of Nursing (DON) on 03/16/22 at 12:24 PM revealed that R1 walked out the front door on 03/09/22 between 10:30 PM and 11:00 PM. There was no receptionist on duty because they get off at 5:00 PM. All exit doors in the facility are equipped with a wander guard system, even the front door. The front door is secured, meaning you can exit out, but you cannot re-enter. The police officer identified the local law enforcement department contacted the facility to inform the facility that they had one of the facility's residents and were sending him to the hospital. The Administrator stated that the facility performed a headcount to ensure all other residents were present. R1 was returned to the facility, via ambulance, the next morning. The resident was placed on supervision checks every 15 minutes and eventually placed on 1:1 supervision. The facility conducted an elopement assessment, updated his care plan to reflect elopement, and placed a wander guard bracelet on his ankle. The facility also conducted a body audit on the resident, which resulted in no injuries or concerns. The facility ordered a new security system for the front door. The Administrator said that the facility did not consider this an elopement because they knew the resident was coming back. After all, there was a newspaper wedged in the front door to keep it open. In an attempted interview with R1 on 03/16/22 at 1:20 PM, he could not recall the incident that took place. After further general questions, it was determined that R1 was not responding appropriately to questioning and the interview was stopped. During an observation of R1 on 03/16/22 at 1:20 PM, it was noted staff was sitting outside the resident's room, at a desk. A staff member confirmed that she was there for one on one supervision with R1. R1 was laying in the bed, slightly elevated. R1 was wearing a shirt and jacket, while lying in bed. In an interview with Licensed Practical Nurse (LPN1) on 03/16/22 at 1:36 PM, she stated that the facility received a call from the police department around 10:55 PM notifying her that R1 had been found by a police officer, and was being transported to the local hospital. The facility was not aware the R1 was missing at the time of the call. LPN1 stated she notified all administrative staff and the DON. The facility proceeded to perform a headcount of all residents. She added that she contacted the hospital to try and get more information, but the hospital did not have much information and did not know why R1 was there. LPN1 did not know how R1 exited the building but stated I think he got out through the front door. LPN1 was able to confirm that she last saw R1 around 9:45 PM to 10:00 PM, when she performed medication administration. LPN1 further stated that the resident wears a lot of clothes and always wears a jacket. In an interview with Registered Nurse (RN1) on 03/16/22 at 2:26 PM, she stated that R1 arrived in the facility before noon and he didn't seem like himself. The facility put him on one on one supervision and conducted a body audit, which revealed no concerns. RN1 stated the facility was using the term elopement to discuss the incident that happened with R1. RN1 does not believe that R1 had the authorization to leave the facility and could not recall the exact weather the previous night but did reveal that there was inclement weather. RN1 further stated, I believe he was wearing jeans, shirt and a jacket of some kind, I do not recall if he was wearing shoes, possibly mismatch shoes, one slipper, and one sneaker. In an additional interview with the DON and Administrator on 03/17/22 at 3:05 PM, they both acknowledged that on 03/09/22, R1 exited the facility without the proper authorization and was unsupervised and was found on Spanish Point Drive by a police officer of the local law enforcement department. The removal plan included the following: 1. On 3/9/22, at approximately 11:15 PM, local law enforcement contacted the facility on-site staff stating R1 was observed off of facility property, uncooperative, and being transported to the local hospital via emergency services for evaluation. As a result, on-site staff immediately notified both the Administrator and Director of Nursing. This was completed by 11:25 PM on 3/9/22. 2. A full count was completed to validate all other residents were present in the facility-no other concerns were identified. This was initiated on 3/9/22 at 11:35 PM. 3. Following verification that all other residents were present in the facility, an investigation was initiated per facility policy that confirmed R1 was observed by staff at 10:30 PM to be in his room, sitting in his chair, fully dressed, and at his baseline with no complaints voiced. R1 accepted his ordered HS (nighttime) medication from another staff member at 9:45 PM and displayed no evidence of intent to exit the facility without notification. Further investigation, including interviews of on-site staff, indicates no facility exit door alarms were triggered or disarmed on the night of 3/9/22. Visual observation of the facility's main entrance revealed a newspaper had been placed in the door to prevent the auto-lock from engaging. This information was obtained on 3/10/22 prior to the conclusion of the night shift at 7:00 PM. 4.The Maintenance Director completed an inspection of all facility exit doors to validate proper functioning-no concerns were identified. This was completed on 03/10/22 and compared to the door function audit of 3/9/22 with no changes noted and completion of facility door function audit confirmed to be occurring 5 times per week. At the time of occurrence, the facility main door did not have an alarming function, and all other facility doors did alarm when engaged, require a key and/or code to disable, and remain engaged at all times. 5. A review of the medical record completed on 3/10/22 indicates R1 had elopement evaluations completed per policy, had no prior factors predisposing him to the current situation, and had given no prior indication he would depart the facility at a later hour, on foot, without informing the staff of his intentions. The record reflects no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Based on evidence obtained in the facility's investigation, the Maintenance Director concluded an alarming device to alert of the facility's main door opening will be activated when the Receptionist is not on duty to prevent future issues of a similar nature. This was completed on 3/10/22 and the device order was placed on 3/10/22 with an expected delivery date of 3/18/22 and installation time prior to 5:00 PM, the same day. 7. Education was initiated on 3/9/22 at 11:50 PM with on-site facility employees on the supervision of residents that prefer to remain out of bed after the general population has gone to bed for the night to prevent exiting of facility without staff knowledge. This education was completed with all licensed Nurses, nursing assistants, Licensed Therapists, therapy assistants, dietary staff, environmental services, staff, and ancillary staff by 3/11/22. Any employee not receiving this education by 3/11/22 will receive it prior to the next scheduled shift. This information will be presented in new hire orientation. 8. On 3/10/22, at 8:31 AM, R1's elopement evaluation was updated to reflect the recent occurrence. 9. R1 returned to the facility from the emergency department on 3/10/22 at 8:41 AM to a different room in the facility, that requires passing the nurse's station to access the main door. No new diagnoses or orders accompanied R1. He arrived in stable condition as evidenced by a body audit and vital signs performed at 8:45 AM. Clothing items present in belongings upon return included; pants, shirt, jacket, socks, and shoes-further confirming R1 left the facility appropriately dressed for temperature in the mid 60's as stated on Accuweather.com. The resident was noted to be resting soundly and unable to participate in the investigation interview, therefore, at 9:06 AM, a wanderguard was placed to the ankle per provider order and 15-minutes location observation checks were initiated pending the investigation outcome. 10. On 3/10/22 at approximately 10:30 AM, R1's attending physician conducted an assessment confirming R1 sustained no injury or latent effect from leaving the facility the previous night, and at approximately 11:30 AM, met with the Responsible Party to discuss prognosis and confirm treatment plan. 11. On 3/10/22, the Administrator made attempts to contact the local law enforcement officer that initially observed R1 outside the facility on 3/9/22, but was repeatedly directed to alternate individuals that did not respond to phone calls or messages. 12. On 3/10/22, the facility attempted to obtain emergency department records detailing R1's brief evaluation and is still awaiting a response to the request. 13. On 3/10/22, at approximately 4:00 PM, R1 awoke from resting with significant evidence of anxiety. Once in a wheelchair, he propelled himself directly to the facility main door, while repeatedly verbalizing a desire to leave the building. The facility staff successfully prevented him from exiting the building with redirection and, at 4:30 PM, constant 1:1 supervision was initiated, the provider was notified with multiple new medication orders received and implemented, and the Responsible Party was updated on the treatment plan with agreement confirmed. 14. On 3/10/22, R1's care plan was updated to reflect applicable information. 15. On 3/10/22, Nurse Managers validated all other residents had an elopement evaluation completed within the past 3 months. 16. On 3/10/22, all residents, confirmed to be at risk for wandering/elopement not residing in the facility's secured unit, were validated to have a wander guard in place and functioning to prevent unsupervised exiting of the facility. 17. On 3/10/22, an ad Hoc QAPI meeting was informally conducted to present related information for recommendations, members included; Administrator, Director of Nursing, D-wing Unit Manager, Maintenance Director, Regional Nurse Consultant, Reginal Director of Operations, and Medical Director-also attending physician. 18. On 3/11/22, R1's care plan was further updated to reflect applicable information. 19. On 3/17/22, at 12:00 Noon, the Maintenance Director applied a temporary auditory alert device to the facility's main door. The device will be activated when the receptionist is not on duty. The device will be replaced with an expected alarming appliance that arrives and is installed. 20. The Maintenance Director or Maintenance Assistant will monitor the facility main door alarm daily, Monday-Friday to validate functioning and the Director of Nursing or Assistant Director of Nursing will monitor the 24-hour report, daily, Monday-Friday, for 4 weeks for 2 months for evidence of residents exiting the facility without staff knowledge. 21. Results of monitoring will be presented to the Quality Assurance and Performance Improvement Committee for recommendations for a period of 3 months. Any concerns identified will be addressed at the time of discovery.

Based on review of facility files and interview, the facility failed to ensure the developed care plan for Resident #120 was followed, resulting in the resident's right hip being fractured for 1 of 3 residents reviewed for abuse/neglect. The findings included: The facility reported an improper transfer to the State Agency for Resident #120 by CNA #2. Review of the facility's Five-Day Report dated 11/08/17 indicated after the review of presented evidence and documentation, the staff member admitted to not following the facility's established policy and procedures for properly transferring residents and was terminated for her/his actions that resulted in the harm of Resident #120. Resident # 120 was admitted to the facility with [DIAGNOSES REDACTED]. Nurse's notes were reviewed on 02/14/18 at approximately 4:35 p.m., for the date of the incident, and revealed at approximately 7:50 p.m. a Certified Nursing Assistant (CNA) notified the nurse on duty that s/he was putting the resident in bed from the wheelchair when a snap was heard and the resident cried out. The on-call physician was notified and ordered the resident be sent to the hospital for evaluation, where she was admitted for a right [MEDICAL CONDITION]. Review of the resident's care plan revealed a handwritten approach dated 10/01/17 that stated, Assist x2. In the comments section, on the 'Nurse Aide's Information Sheet' it read, 2 apple bites. Per the Assistant Director of Nursing, the 'Apple Bite System' is the facility transfer protocol for staff to determine what type of assistance is required for transfers and it is utilized for every resident in the facility. Two bites in the apple indicates a 2 person transfer. During an interview with the Medical Director and the Assistant Director of Nursing (ADON) on 02/15/18 at approximately 5:25 p.m., it was discussed what the role of each party was concerning the incident that occurred resulting in Resident #120's right hip being fractured. Per the ADON, her/his role was to investigate how the fall occurred. S/he completed the incident report, obtained witness statements, spoke with the nurse on duty and to the Certified Nursing Assistant (CNA) working with the Resident at that time, CNA #2. The CNA was able to provide the ADON with a step -by-step reenactment, by phone which was similar to the statement s/he provided at the time of the incident. The ADON stated that the CNA had the proper training and understood the transfer was incorrect. Per the ADON, the resident was able to assist with her/his arms with transfers, with 2 CNAs to help her/him; without that assistance the resident would lose balance. Once the ADON determined the facility's policies had been breached, the CNA was terminated for improper transfer of the resident that resulted in serious bodily injury. The Medical Director indicated that the on-call doctor was notified of the incident at approximately 7:55 p.m. The Medical Director stated the resident's transfer status changed after the hospital stay following the fracture. S/he indicated that the resident had been in the facility for many years and has never had usage of her/his lower extremities, with atrophic legs and no muscle tone. Attempted to reach CNA #2 on two occasions, on 02/15/18 at 4:46 p.m. and on 02/16/18 at 3:17 p.m. with no answer. Review of the facility's policy, entitled, Safe Lifting and Movement of Residents, Revised (MONTH) (YEAR), on 2/13/18 at 12:41 p.m. revealed the statement, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Furthermore the policy stated in item 3,Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.

Based on review of facility files and interview, the facility failed to ensure Resident #120 was free from neglect, that resulted in harm for 1 of 3 residents reviewed for neglect. The findings included: The facility reported an improper transfer to the State Agency for Resident #120 by CNA #2. Review of the facility's Five-Day Report dated 11/08/17 indicated after the review of presented evidence and documentation, the staff member admitted to not following the facility's established policy and procedures for properly transferring residents and was terminated for her/his actions that resulted in the harm of Resident #120. During an interview with the Medical Director and the Assistant Director of Nursing (ADON) on 02/15/18 at approximately 5:25 p.m., it was discussed what the role of each party was concerning the incident that occurred resulting in Resident #120's right hip being fractured. Per the ADON, her/his role was to investigate how the fall occurred. S/he completed the incident report, obtained witness statements, spoke with the nurse on duty and to the Certified Nursing Assistant (CNA) working with the Resident at that time, CNA #2. The CNA was able to provide the ADON with a step -by-step reenactment, by phone which was similar to the statement s/he provided at the time of the incident. The ADON stated that the CNA had the proper training and understood the transfer was incorrect. Per the ADON, the resident was able to assist with her/his arms with transfers, with 2 CNAs to help her/him; without that assistance the resident would lose balance. Once the ADON determined the facility's policies had been breached, the CNA was terminated for improper transfer of the resident that resulted in serious bodily injury. The Medical Director indicated that the on-call doctor was notified of the incident at approximately 7:55 p.m. The Medical Director stated the resident's transfer status changed after the hospital stay following the fracture. S/he indicated that the resident had been in the facility for many years and had never had usage of her/his lower extremities, with atrophic legs and no muscle tone. Attempted to reach CNA #2 on two occasions, on 02/15/18 at 4:46 p.m. and on 02/16/18 at 3:17 p.m. with no answer. Review of the facility's policy, entitled, Abuse Prohibition/Investigative Policy, Revised (MONTH) (YEAR), on 02/14/18 at 4:34 p.m. revealed the statement, The facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. The policy continues and explains that Neglect; is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Furthermore, the policy describes actions to prevent such occurrences, as evidenced by the following statement, .Developing a care plan identifying appropriate intervention to prevent occurrences.

Based on closed record review, record review, observation, staff interview, review of facility policy the facility failed to ensure that 2 residents (Residents #1 and #2) of 9 sample residents received the care and services necessary to promote healing and prevent the development of pressure ulcers. Specifically, the facility: -Failed to identify and implement measures to promote healing for existing pressure sores. - The facility failed to timely implement measures for preventing development of new pressure ulcers. -The facility ' s failures contributed to the delay in healing and worsening of the resident ' s pressure ulcers. The findings include: The facility Wound Care Policy (dated 10/2010) documents the purpose of this procedure is to provide information regarding the identification of pressure ulcers risk factors and interventions for specific risk factors. Item #6 documents the facility should have a system/procedure in place to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, ad family and addressed. 1. [AGE] year-old sample Resident #1 was originally admitted to the facility on [DATE]. The facesheet indicated Resident #1 s most recent admission from the hospital to facility was on 11/20/15. The resident was admitted for therapy treatment . A hospital physician discharge summary dated 11/20/15, indicated resident #1's primary [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for skilled therapy. RECORD REVIEW: MINIMUM DATA SET (MDS) According to the most recent MDS, dated [DATE], Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. The MDS indicated the resident refused care at times and had a catheter in place. Resident #1 had a stage 1 or higher pressure ulcer with three unstageable deep tissue injury pressure sores on admission. The MDS indicated Resident #1 had pressure ulcer on prior assessment and received therapy. CARE PLAN : On 11/20/15, an admission temporary pressure ulcer care plan was initiated. The temporary care plan indicated a problem of an unstageable sacral wound and DTI (deep tissue injury) to bilateral feet. The goals indicated pressure ulcer will decrease in size, monitor for incontinence, provide care if soiled, turn q 2 hrs, administer treatment as ordered, measure ulcer monitor depth, odor and drainage at least weekly. A care plan dated 11/26/15, indicated Resident #1 had a potential for skin breakdown related to (R/T) decreased mobility, although documentation indicated no healed pressure sores. The goals indicated skin would remain intact, although the Resident was admitted with pressure sores which were still present by 11/26/16. Interventions included admistration of medications, diet as ordered, labs were to be monitored. Although the resident was identified with multiple pressure sores, other than the temporary care plan, no care plan was updated for indication of the presence of actual pressure sores. No specific goals or approaches were set in regards to healing/worsening of actual pressure sore or prevention of development of more pressure sore. Instead, the care plan set goals and approaches for potential skin breakdown, for a resident with actual pressure sores. PHYSICIAN ORDERS: Admission Physician (MD) orders dated 11/20/15-11/30/15, indicated clean right (R) lateral calf with wound cleanser apply skin prep daily. Clean sacral wound with wound cleanser, apply Duoderm MWF. Clean the left (L) heel wound with wound cleanser apply skin prep daily. Clean (R) heel and lateral foot with wound cleanser apply skin prep daily. Admission skin assessment dated [DATE], indicated Resident #1 had a scab to the middle of his head, a bruising and an unstagable necrotic area measuring 6.5 cm to 8.5 cm to the sacral area. The assessment indicated multiple bruises to both arms, scabs, bruising were noted to the left foot and toes. The assessment indicated multiple bruises to the right leg, the right heel was red with bruising measuring 3.5cm x 6.0cm and multiple bruised right toes (middle and 3rd toes). A Wound Assessment Report dated 11/20/15, indicated Resident #1 was admitted with the following wounds: a. An unstageable sacral wound with slough/eschar. The wound had scant seranguineous drainage, and in length (L) 6.50 cm X width (W) 8.5 cm X depth (D) 0.0 cm. The wound had no infection. The wound bed had [MEDICATION NAME] tissue, granulation tissue, slough and eschar. The wound edges had well defined and normal healthy tissue. The physician was notified of the wound status. b. The Wound Assessment Report dated 11/20/15, further indicated a wound to the top of lateral (R) right foot , The measurements indicated were : (L) 1.50 cm X (W) 1.50 cm X (D) 0.0 cm. The wound had [MEDICATION NAME] tissue with granulation, and the surrounding skin was normal. The (R) lower extremity had normal color, normal temperature and was warm to touch. The skin had normal elasticity. c. On 11/20/15 the left heel was assessed with [REDACTED]. The measurements indicated were : (L) 14.50 cm X (W) 3.5 cm X (D) 0.0 cm. The wound had [MEDICATION NAME] tissue with granulation, and the surrounding skin was normal. The left lower extremity had normal color, normal temperature and was warm to touch. The skin had normal elasticity. Although, the resident had deep tissue injury to the left foot, the care plan indicated no floating of the injured foot. As indicated above, Resident #1 was admitted with multiple pressure sores and deep tissue injury, no specialized mattress was ordered, no documentation or care plan indicated floating of the left heel was initiated for Resident #1. There were no specific interventions in place for prevention of worsening of existing pressure sores or prevention of facility acquired pressure sores, as indicated by the Director of Nursing on 6/17/16, below. Nurse ' s notes dated 12/1/15, in pertinent parts indicated, Resident #1 had new blisters and bruising to the right lateral calf and low air loss mattress was initiated for the resident, after he acquired more skin breakdown. A Wound Assessment Report dated 12/1/15 revealed a nursing assessment of the resident ' s right shin. The Wound Assessment Report documented a new right lateral shin pressure ulcer identified on 12/1/15. The pressure ulcer was unstagable due to slough/eschar. The right shin wound measured 23.00 (L) x 10.00 (W) x 0.0 cm (D). Nurse ' s assessment furtherdescribed an area with multi color with a small area of eschar to the top of the wound (towards the knee) area with presence of fluid. The Wound Assessment Report indicated, the physician was notified and ordered a low air loss mattress, after the resident acquired the above pressure, 10 days, after he was admitted to the facility. Wound Assessment Report indicated resident refused to get out bed at times and wife was aware. However, a review of nurses documentation revealed the resident had no refusals for getting out of bed or refusals for wound treatment between 11/20/15 and 12/1/15. On12/1/15 Physician (MD) orders indicated, place Resident#1 on a low air loss mattress, after the Resident acquired a pressure sore to shin. Again, there was no indication the care plan was updated for indication Resident #1 had acquired skin breakdown to his shin on 12/1/15 or indication a low air loss mattress was initiated on that date, as ordered by the Physician. STAFF INTERVIEWS: Wound Care Nurse Interview: The Wound Care Registered Nurse (WCRN) was interview on 6/17/16 at 4:00 PM. In the interview with the WCRN, she confirmed the current care plan was inaccurate. The WCRN stated the care plan erroneously indicated care for potential skin breakdown, did not identify actual skin breakdown for a resident with actual skin breakdown. The WCRN stated she initiated the temporary care plan but did not initiate the care plan dated 11/26/15. The WCRN stated the skin issues she identified on the interim care plan should have been carried over onto the final care plan but they were not. The WCRN stated, she would have care planned each one of the wounds, then would have identified Resident #1 ' s risk for further skin breakdown related to his decreased mobility, incontinence and presence of multiple wounds. Director of Nursing (DON) interview: On 6/17/16 at 8:11 PM, the DON was interviewed. In the interview, the DON stated the facility regular mattresses were rated as pressure relief mattresses. The DON stated, in good judgment Resident #1 should have been placed on a low air loss mattress, as the specialized mattress was better for prevention of additional pressure sites and also easier for positioning and turn, created less friction therefore less risk of sheer for resident #1. The DON confirmed Resident #1 ' s assessment indicated Resident # 1 was a high risk for pressure sores as he was admitted with multiple pressure sores and should have been placed on a low air loss mattress on admission. The DON indicated clinical judgment would have been to place Resident #1 on a low air loss mattress on admission to the facility. The DON further confirmed, each one of the pressure wounds should have been identified on the care plan. The DON stated the care plan should have indicated the Resident was at risk for further skin breakdown related to his decreased mobility, incontinence and presence of multiple wounds. The DON confirmed the care plan should have identified the presence of actual pressure sores, goals and interventions for the actual skin breakdown. Within twelve days of admission, nurses notes indicated Resident #1 had acquired another pressure sore to his right shin and no specialized mattress had been initiated by that time, the facility failed to identify and intiate timely measures for prevention of further skin breakdown, for a resident who was admitted with unstageable skin breakdown. The facility failed to update care plan with proper care and prevention of pressure ulcers. 2. Resident #2 was admitted to the facility original admitted [DATE] with readmitted [DATE] with [DIAGNOSES REDACTED]. Annual MDS dated [DATE] Brief Interview Mental Status (BIMS) 11 coded for behaviors towards others; resident coded for total dependence on staff for all levels of care with 2+ person assistance; receives tube feeding, has limited functional range of motion of both upper and lower extremities; incontinent of bowel and bladder; at risk for pressure ulcers and falls. Quarterly MDS 3/9/16 BIMS 5, coded for resisting care 4 to 6 days; resident completely dependent on staff all activities of daily living (ADLs), impairment of both upper and lower extremities; incontinent of bowel and bladder; assessed as frequently having pain; no falls during the assessment period; at risk for pressure ulcers. Care Area Assessment summary dated 12/29/15 triggered for these care areas cognition, mood/depression, nutritional status/dehydration, communication, pain, ADL functions, pressure ulcers, falls, and [MEDICAL CONDITION] drugs. Care plans dated 12/4/15 with latest revision date of 6/15/16 revealed the resident problems included at risk for skin breakdown related to decreased mobility, fragile skin, incontinent B&B, [MEDICAL CONDITION] skin on back observe for skin breakdown, and report findings to MD, assess skin weekly and record findings; notify MD of any abnormal findings; turn and reposition during rounds and PRN; ensure staff places soft or cushioned nasal cannula on resident; treatment as ordered by MD; provide low air mattress and heel protectors to both heels per order. Review of the Unit ' s Weekly Summary Schedule documents the following instructions weekly summaries are to be completed on all Medicare A residents on assigned days. Complete body audits must be done. Weekly summaries will be checked by the unit manager. If weekly summary is not completed you will be called in to complete it. According to the schedule Resident #2 was scheduled for weekly summaries on Saturday 7p-7a shifts. A review of the weekly summaries obtained from the wound care nurse revealed summaries for the following dates 4/9, 4/16, 5/7, and 5/14/16. Each summary identifies Resident #2 had reddened areas on both ears from the nasal oxygen tubing. The facility was unable to provide any documentation related to assessing this resident ' s reddened areas on the ears after 5/14/16 weekly summary. Nurse ' s notes dated 6/9/16 at 7:00am document the CNA providing care noted an open area behind the left ear. Nurse cleaned and prepped area and covered with bandage. Responsible Party notified and obtained a physician order [REDACTED]. However the facility failed to complete a body audit sheet per facility policy when residents receive shower. MD orders 6/9/16 clean area behind ear with wound cleanser and bandage prn. Monitor area for signs and symptoms of infection every sift convert O2 mask until area healed. 6/15/16 9:45am -During initial tour resident was observed in bed positioned on back; HOB elevated 15 degrees with tube feeding infusing. O2 face mask positioned incorrectly on resident ' s face, not completely covering her mouth and nose, straps putting pressure on resident ' s ears; resident has open area on left ear. Bilateral hand contractures, not wearing splints. 6/15/16 4:45pm Remains positioned on back. Wedge cushion on floor behind the bed. HOB elevated 35 degrees; still no splints bilaterally. CNA checked resident for incontinence, adult diaper; wearing bilaterally heel protectors. CNA unaware if resident is supposed to wear hand protectors/splints and cannot explain why resident has floor mat at bedside. Oxygen mask placed improperly, CNA readjusted oxygen mask to completely cover face and adjusted straps to relieve pressure on ear. On 6/16/16 at 5:30pm in an interview RN#2 stated if weekly assessment and body audits were completed according to policy the issue of the resident ' s skin break down behind the ear should have been identified earlier. RN #2 states the weekly assessments and body audits reviewed and signed off by unit manager. At this time B wing does not have a unit manager and the issue of incomplete reports has not been addressed. The assessment and body audit sheets go to the WCN who review the sheets and assessment to determine if any residents identified with new break down areas. The WCN should have identified those areas on the resident ' s ears before it developed into an open area. The WCN is also responsible for maintaining those sheets for QA purposes. Interview with WC #1 on 6/16/16 at 7:00pm revealed the staff will send her note a when a resident develops an open area or requires wound care treatment. WC#1 was unaware that she was responsible for assessing residents with gastrostomy feedings. Asked the WC #1 who was responsible for the assessment and body audit sheets, WC#1 responded it was the responsibility of the unit manager. WC#1 stated she did not always review the body audit sheets and weekly summaries. WC#1 then admitted the sheets were maintained in her office but did not know why. Requested the WC#1 to bring the body audit and summaries for the past 8 weeks for Resident #2. The WC#1 provided body audit sheets for 4/30/16 and 5/3/16 (shows redness on resident ' s back and buttock). And weekly summaries for 4/9/16, 4/16/16, 5/7/17 and 5/14/16 which documents the resident with redness on the ears. The sheets were reviewed with the WC#1 confirmed the resident was identified with redness on the ears which was probably the beginning of skin breakdown. The WC#1 stated she had not seen the resident until this morning when the staff brought it to her attention about the resident ' s hands and the resident ' s ears. The facility failed to properly assess Resident #2 after it was identified starting on 4/9/16 to 5/7/16 the resident had reddened areas on the ears from the oxygen tubing. The facility failed to conduct body audits and weekly summaries to assess the resident ' s skin. It was documented on 6/9/16 that the resident had developed an open area behind the ear from the oxygen tubing.

Based on record review, observation, interview, and review of facility policy the facility failed to provide wound care services to meet the professional standards of quality for 1 resident from a sampled 9 nine residents (Resident #2) The findings include: Wound Care Policy (dated 10/2010) documents the purpose of this procedure is to provide information regarding the identification of pressure ulcers risk factors and interventions for specific risk factors. Item #6 documents the facility should have a system/procedure in place to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. Resident #2 was admitted to the facility original admitted [DATE] with readmitted [DATE] with [DIAGNOSES REDACTED]. Annual MDS dated [DATE] Brief Interview Mental Status (BIMS) 11 coded for behaviors towards others; resident coded for total dependence on staff for all levels of care with 2+ person assistance; receives tube feeding, has limited functional range of motion of both upper and lower extremities; incontinent of bowel and bladder; at risk for pressure ulcers and falls. Quarterly MDS 3/9/16 BIMS 5, coded for resisting care 4 to 6 days; resident completely dependent on staff all activities of daily living (ADLs), impairment of both upper and lower extremities; incontinent of bowel and bladder; assessed as frequently having pain; no falls during the assessment period; at risk for pressure ulcers. Care Area Assessment summary dated 12/29/15 triggered for these care areas cognition, mood/depression, nutritional status/dehydration, communication, pain, ADL functions, pressure ulcers, falls, and [MEDICAL CONDITION] drugs. Care plans dated 12/4/15 with latest revision date of 6/15/16 revealed the resident problems included at risk for skin breakdown related to decreased mobility, fragile skin, incontinent B&B, [MEDICAL CONDITION] skin on back observe for skin breakdown, and report findings to MD, assess skin weekly and record findings; notify MD of any abnormal findings; turn and reposition during rounds and PRN; ensure staff places soft or cushioned nasal cannula on resident; treatment as ordered by MD; provide low air mattress and heel protectors to both heels per order. Review of the Unit ' s Weekly Summary Schedule documents the following instructions weekly summaries are to be completed on all Medicare A residents on assigned days. Complete body audits must be done. Weekly summaries will be checked by the unit manager. If weekly summary is not completed you will be called in to complete it. According to schedule Resident #2 was scheduled for weekly summaries on Saturday 7p-7a shifts. A review of the weekly summaries obtained from the wound care nurse revealed summaries for the following dates 4/9, 4/16, 5/7, and 5/14/16. Each summary identifies Resident #2 had reddened areas on both ears from the nasal oxygen tubing. The facility was unable to provide any documentation related to assessing this resident ' s reddened areas on the ears after 5/14/16 weekly summary. Nurse ' s notes dated 6/9/16 at 7:00am document the CNA providing care noted an open area behind the left ear. Nurse cleaned and prepped area and covered with bandage. Responsible Party notified and obtained a physician order [REDACTED]. However the facility failed to complete a body audit sheet per facility policy when residents receive shower. MD orders 6/9/16 clean area behind ear with wound cleanser and bandage prn. Monitor area for signs and symptoms of infection every sift convert O2 mask until area healed. 6/15/16 9:45am -During initial tour resident was observed in bed positioned on back; HOB elevated 15 degrees with tube feeding infusing. O2 face mask positioned incorrectly on resident ' s face, not completely covering her mouth and nose, straps putting pressure on resident ' s ears; resident has open area on left ear. Bilateral hand contractures, not wearing splints. 6/15/16 4:45pm Remains position on back. Wedge cushion on floor behind the bed. HOB elevated 35 degrees; still no splints bilaterally. CNA checked resident for incontinence, adult diaper; wearing bilaterally heel protectors. CNA unaware if resident is supposed to wear hand protectors/splints and cannot explain why resident has floor mat at bedside. Oxygen mask placed improperly, CNA readjusted oxygen mask to completely cover face and adjusted straps to relieve pressure on ear. On 6/16/16 at 5:30pm in an interview RN#2 stated if weekly assessment and body audits were completed according to policy the issue of the resident ' s long fingernails and skin break down behind the ear should have been identified earlier. RN #2 states the weekly assessments and body audits reviewed and signed off by unit manager. At this time B wing does not have a unit manager and the issue of incomplete reports has not been addressed. The assessment and body audit sheets go to the WCN who review the sheets and assessment to determine if any residents identified with new break down areas. The WCN should have identified those areas on the resident ' s ears before it developed into an open area. The WCN is also responsible for maintaining those sheets for QA purposes. Interview with WC #1 on 6/16/16 at 7:00pm revealed the staff will send her note when a resident develops an open area or requires wound care treatment. WC#1 was unaware that she was responsible for assessing residents with gastrostomy feedings. Asked the WC #1 who was responsible for the assessment and body audit sheets, WC#1 responded it was the responsibility of the unit manager. WC#1 stated she did not always review the body audit sheets and weekly summaries. WC#1 then admitted the sheets were maintained in her office but did not know why. Requested the WC#1 to bring the body audit and summaries for the past 8 weeks for Resident #2. The WC#1 provided body audit sheets for 4/30/16 and 5/3/16 (shows redness on resident ' s back and buttock). And weekly summaries for 4/9/16, 4/16/16, 5/7/17 and 5/14/16 which documents the resident with redness on the ears. The sheets were reviewed with the WC#1 confirmed the resident was identified with redness on the ears which was probably the beginning of skin breakdown. The WC#1 stated she had not seen the resident until this morning when the staff brought it to her attention about the resident ' s hands and the resident ' s ears. The facility failed to provide services in accordance with the facility wound care policy and acceptable professional standards of practice. Cross reference to F314.

On the day of the complaint inspection, based on record review and interview, the facility failed to provide the necessary care and services for Residents #1. The facility failed to obtain a stool specimen for [MEDICAL CONDITION] ordered on [DATE] for 1 of 2 residents reviewed for [MEDICAL CONDITION] (C Diff); document and address the frequency/description of the resident's stool and monitor and address the resident's weight loss. The findings included: Review of Resident #1's medical record revealed a physician's orders [REDACTED]. An order dated 7/8/13 for a stool specimen for [MEDICAL CONDITION] and a urinalysis with culture and sensitivity (UA C& S) was also noted. Further review revealed no lab results for a [DIAGNOSES REDACTED] ordered for 7/8/13. Review of the Daily Skilled Nurses Notes from 7/3/13 through 7/20/13 documented on 7/7/13 at 6:30 PM that the resident was found in his/her bathroom with loose stool on his/her skin. A new order was obtained for a tab alarm and [MEDICATION NAME] for loose stools. On 7/8/13 the note stated, "...continues to have loose stools. Order to check stool for [MEDICAL CONDITION] and UA/CS..." Further review revealed an entry dated 7/9/13 "6 AM did a straight cath (eter) on resident to obtain UA, urine was dark amber and had a strong odor..." Daily Skilled Nurse's Notes were reviewed 7/8/13 - 7/10/13 with no documentation related to attempting to obtain a stool sample for the [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 7/10/13 - 7/11/13 stated the resident had no loose stools. On 7/12/13 at 7:05 AM a Nurse's Note stated, "...loose stool with mucous. No foul odor. Will monitor." From 7/12/14 through 7/15/13 there was no documentation regarding loose stools. At 2:00 PM on 7/16/13 a Nurse's Note stated, "...Resident continues with loose stool. Order obtained to collect stool for [MEDICAL CONDITION] 10:00 PM ...continued to have loose stools. Stool sample in fridge to test for Cdiff." The Nurse's Notes for 7/17 and 7/18/13 indicated no loose stools. On 7/18/13 at 11:30 PM the Nurse's Note stated, "...received lab results showing positive for [MEDICAL CONDITION]. Called Dr. at 10:30 PM received new order..." The Nurse's Note for 7/19/13 revealed no information related to Resident #1's elimination, s/he was found unresponsive at 9:55 PM and transferred to the emergency room at 10:05 PM for evaluation. Resident #1 did not return to the facility. Review of the Treatment Encounter Notes revealed on 7/9/13 an entry by Physical Therapy "...pt (patient) with no c/o (complaints of), however s/he appeared to be lethargic... NSG (nursing) made aware of pt having diarrhea and lethargic..." There was an entry on 7/9/13 by Occupational Therapy "...nursing staff notified of increased bowel urgency w/(with) loose and watery stools...". Review of the CNA (Certified Nurse Aide) Flow Record related to Resident #1's bowel function revealed the following: 7/4/13 7-3 shift continent/no episodes 3-11 shift continent/ no episodes 7/5/13 11-3 shift continent/no episodes 7-3 shift continent/no episodes 3-11 shift no documentation 7/6/13 11-3 shift continent/no documentation 7-3 shift no documentation 3-11 shift continent/ no documentation 7/7/13 11-3 shift no documentation 7-3 shift continent/1 episode 3-11 shift continent/ XXL (extra, extra large) episode 7/8/13 11-7 shift continent/1 lg (large) episode 7-3 shift continent/4 episodes 3-11 shift no documentation 7/9/13 11-7 shift incontinent/1 episode 7-3 shift continent/1 episode 3-11 shift incontinent/1 episode 7/10/13 11-7 shift incontinent/1 episode 7-3 shift incontinent/XL 3-11 shift (unable to read) 7/11/13 11-7 shift incontinent/no documentation 7-3 shift incontinent/1 episode 3-11 shift no documentation 7/12/13 11-7 shift incontinent/large episode 7-3 shift continent/1 episode 3-11 shift no documentation 7/13/13 11-7 shift incontinent/1 episode 7-3 shift no documentation 3-11 shift incontinent/2 episodes 7/14/13 11-3 shift incontinent/2 episodes 7-3 shift incontinent/1 episode 3-11 shift incontinent/1 episode 7/15/13 11-3 shift incontinent/2 episodes 7-3 shift incontinent/2 episodes 3-11 shift no documentation 7/16/13 11-3 shift incontinent/0 episodes 7-3 incontinent/1 episode 3-11 shift no documentation 7/17/13 11-3 shift no documentation 7-3 shift incontinent/2 episodes 3-11 shift incontinent/3 episodes 7/18/13 11-3 shift incontinent/1 episode 7-3 shift incontinent/3 episodes 3-11 shift incontinent/3 episodes 7/19/13 11-3 shift incontinent/2 episodes The CNA Flow Record regarding bowel movements documented if Resident #1 was continent or incontinent and the number of episodes, no other description was available. There was no consistent documentation in the Nurse's Notes that corresponded to the CNA's documentation or if the information was provided to the licensed nursing staff. Review of the 7/3/13 - 7/31/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 2 mg (milligrams) PO (by mouth) q (every) 6 hours PRN (as needed) for loose stool." [MEDICATION NAME] was given on "7/7/13 at 1819 (6:19 PM)" one time between 7/7 - 7/20/13. Review of the Daily Lab Log dated 7/9/13 indicated Resident #1 was listed on the form as having a UA/ CS ordered. The order for [DIAGNOSES REDACTED] was not listed on the Daily Lab Log. Further review of the medical record revealed an order on 7/16/13 to collect stool for [DIAGNOSES REDACTED] related to loose stool. An order dated 7/18/13 for [MEDICATION NAME] 500 milligrams four times a day for 10 days for [DIAGNOSES REDACTED]. There was also an order [REDACTED]. Diff. Review of Resident #1's lab results revealed a report dated 7/18/13 for a positive [DIAGNOSES REDACTED] result. Review of the facility's [MEDICAL CONDITION] policy statement indicated preventative measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [MEDICAL CONDITION] (to prevent transmission of [MEDICAL CONDITION] to others). During interview on 9/5/13 at approximately 3:00 PM the Administrator stated that Resident #1's responsible party complained about the care Resident #1 received while at the facility after the resident was discharged from the facility. The Administrator stated that staff then went back and reviewed the resident's medical record and found that the [DIAGNOSES REDACTED] that was ordered on [DATE] was not completed. When the Administrator provided the surveyor with the copy of the Lab Log Form on 9/5/13 at approximately 4:30 PM the Administrator stated that s/he was not aware that the [DIAGNOSES REDACTED] lab was never put on the lab log to be completed. During interview on 9/5/13 at approximately 3:15 PM the DON stated that the nurse who takes the order should add the order to the lab book. The nurse should let the Certified Nurse Aide know that a stool sample needs to be collected. Resident #1 was admitted to the facility on [DATE] and noted with an admission weight of 172 pounds. Resident #1 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the Nutrition Risk Assessment for New admitted d 7/16/13 revealed that the facility's Registered Dietitian documented Resident #1's usual body weight as 172 pounds, the weight documented at the 6/25/13 initial admission. The current weight was noted to be blank. Further review of the nutrition assessment revealed that Resident #1 was noted to have diarrhea and poor food intake. Review of Resident #1's Food Intake Record for the month of July revealed the resident refused 10 meals between 7/3/13 and 7/20/13. Food intake was blank for 15 meals between 7/3/13 and 7/20/13. Food intake was documented as 10 - 25% at 11 meals between 7/3/13 and 7/20/13. Review of the Nurse's Notes between 7/3/13 and 7/16/13 revealed no documentation that Resident #1 was referred to the Registered Dietitian regarding his/her food intake. During interview on 9/10/13 at approximately 3:55 PM the Registered Dietitian stated that weights should be documented under the vital signs on the resident's medical record. The Registered Dietitian reviewed the computer program s/he uses to monitor weights and stated that s/he could only pull Resident #1's admission weight from 6/25/13.

On the days of the complaint inspection based on limited record review and interview the facility failed to consult the resident's physician regarding persistent pain and swelling following an injury to Resident #2 left arm/hand/wrist. The resident fell on [DATE], the facility notified the physician and an order was obtained for an x-ray of the hand/wrist. Review of the x-ray report revealed that only the hand was x-rayed and reported as negative for fracture. On 11/25/2010 a call was placed to the physician to notify him of the x-ray results, the physician did not return the call. The resident continued to complain of pain in the left arm/wrist and swelling/bruising was noted; on 11/28/2010 the physician was notified and the resident was sent to the hospital for evaluation. Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The findings included: Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: "11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NAME] for pain... 11/26/2010 7 P to 7 A (M) Arm bruised/swollen as well as hand R/T previous fall... 11/27/2010 3 p continues to c/o pain (L) arm. (L) arm elevated on pillow bruising to (L) forearm noted... 7 P - 7 A (L) arm/hand elevated on a pillow. Bruise and slight swelling remains the same due to last fall...Receives scheduled pain medication. 11/28/2010 11 A Resident continues to c/o pain (L) arm bruising and swelling to (L) arm. (L) arm elevated on pillow. Notified Dr. ... N.O. (new order) transport to ER (emergency room ) for evaluation... 12/03/2010 6 pm Resident readmitted with Dx (diagnosis) of Fx (fracture) to (L) wrist and UTI (urinary tract infection)..." In an interview with the Director of Nurses on 12/13/2010 at approximately 4:10 PM she was unable to provide information as to why the physician was not notified about the persistent pain and swelling of the resident's left arm/wrist. She stated that the resident was treated for [REDACTED].

On the days of the complaint inspection, based on observation, interview and record review, the facility failed to provide care and services to maintain the highest practicable physical well being for 1 of 3 residents reviewed for a change in condition. Resident #2 injured her left arm/hand/wrist on 11/24/2010, and was not treated for [REDACTED]. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: "11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NAME] for pain... 11/26/2010 7 P to 7 A (M) Arm bruised/swollen as well as hand R/T previous fall... 11/27/2010 3 p continues to c/o pain (L) arm. (L) arm elevated on pillow bruising to (L) forearm noted... 7 P - 7 A (L) arm/hand elevated on a pillow. Bruise and slight swelling remains the same due to last fall...Receives scheduled pain medication. 11/28/2010 11 A Resident continues to c/o pain (L) arm bruising and swelling to (L) arm. (L) arm elevated on pillow. Notified Dr. ... N.O. (new order) transport to ER (emergency room ) for evaluation... 12/03/2010 6 pm Resident readmitted with Dx (diagnosis) of Fx (fracture) to (L) wrist and UTI (urinary tract infection)..." Review of the physician's orders [REDACTED]. Review of the Mobliex Radiology Report dated11/24/2010 at 5:01 pm stated, "...Examination: Exam: Hand 2 views, Left - Results: ...No fracture or dislocation is seen. [MEDICAL CONDITION] is present...Conclusion: Moderate [MEDICAL CONDITION] of the left hand, but no fracture or dislocation seen..." Review of the Beaufort Memorial Hospital Discharge Summary dated 12/03/2010 stated, "...Reason for admission: ...The patient presented with left upper extremity cellulites and fracture... Hospital course: The patient was admitted and placed on IV [MEDICATION NAME] for cellulites..." Review of the x-ray report revealed that only the hand was x-rayed and reported as negative for fracture. On 11/25/2010 a call was placed to the physician to notify him of the x-ray results, the physician did not return the call. The resident continued to complain of pain in the left arm/wrist and swelling/bruising was noted; on 11/28/2010 the physician was notified and the resident was sent to the hospital for evaluation. Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. In an interview with the Director of Nurses on 12/13/2010 at approximately 4:10 PM she was unable to provide information as to why only the hand was x-rayed on 11/24/2010. She could not explain why the physician had not seen Resident #2 following the injury or why the physician was not notified about the persistent pain and swelling of the left arm/wrist.