Every finding on record at Richmond Pines Healthcare and Rehabilitation Cente

Based on record review, and staff, Pharmacist, and Physician interviews, the pharmacy failed to provide the correct dose of Depakote (an anticonvulsant medication used to treat epilepsy) for a resident. This was for 1 of 6 residents reviewed for medications (Resident #53).The findings included:Resident #53 was admitted to the facility on [DATE] with diagnoses that included unspecified convulsions/epilepsy. Review of Resident #53's active orders revealed an order dated 03/16/25 for Depakote Sprinkle Capsule 125mg (milligram), give 2 capsules by mouth three times a day. Review of Resident 53's nursing progress notes revealed a note dated 04/02/25 at 5:30 PM written by Nurse #1 that she received a call from Pharmacist #2 revealing that pharmacy sent the wrong dose of Depakote for Resident #53. Pharmacist #2 indicated to discontinue the order for Depakote and pharmacy would send the correct Depakote dosage. Nurse #1 was unavailable for interview during the survey period.Review of a copy of the Smartpass pouch revealed Resident #52's name, Depakote 500mg DR (delayed release). tablets, pink oblong, with the RX (prescription) number and physician's name. Take 2 capsules = (equals) 250mg PO (by mouth) three times a day. A phone interview was conducted on 12/18/25 at 10:20 AM with Pharmacist #1. She stated that according to the pharmacy tracking system, Resident #53 did receive 3 separate deliveries of Depakote 500mg tablets with instructions on the pill packet to give 2 capsules three times a day to equal 250mg. These included on 03/17/25 she received a 3 day supply, on 03/20/25 a 7 day supply, and on 03/27/25 a 7 day supply.Review of a pharmacy Packing Slip dated 03/17/25 revealed 18 Depakote 500mg tablets were delivered, the Packing Slip dated 03/20/25 revealed 42 Depakote 500mg tablets were delivered, and the Packing Slip dated 03/27/25 revealed 42 Depakote 500mg tablets were delivered. A phone interview was conducted on 12/18/25 at 10:25 AM with Pharmacist #2. When asked how the Depakote 500mg tablets were mistakenly sent instead of the Depakote 125mg capsules she stated the pharmacists did not pay attention and entered the incorrect dose into the system. Pharmacist #2 further stated it was a human error. Pharmacist #2 indicated Pharmacist #3 had entered the incorrect Depakote dose into the Smartpass system. A phone interview was conducted on 12/18/25 at 12:28 PM with the Pharmacy Operations Manager and the Pharmacy Chief Clinical Officer. The Pharmacy Chief Clinical Officer stated that when the pharmacist entered the Depakote dose into the Smartpass system she entered the incorrect dose. He indicated they were unsure exactly who originally entered the incorrect dose however it was a human error. Once the medication name and dose with the instructions were entered the medication was then dispensed into the pouches and sent to the facility. The pharmacist completed a drug regimen review on 04/02/25 and caught the discrepancy. Pharmacist #2 called to notify the facility of the error and requested they remove the medication from the medication cart, and they would send the correct dose to them. Pharmacist #2 also recommended the facility to obtain a Depakote (valproic acid/sodium valproate) level. The Pharmacy Chief Clinical Officer explained they completed an incident report, reviewed and provided education to pharmacy technicians and pharmacists, and are reviewing the incident in their quality assurance meetings to prevent further occurrences. A phone interview was conducted on 12/18/25 at 12:43 PM with Pharmacist #3. She stated she did not recall entering the incorrect Depakote dose for Resident #53 into Smartpass system (Smartpass is an automated system where medications are pre-packaged by the pharmacy into clearly labeled, single-dose plastic pouches. Each pouch features clear, detailed labeling to help ensure the correct dosage and time for administration. Nursing staff use electronic scanners to scan each pouch, instantly matching the medication to a specific resident and verifying the dosage and time against the electronic health record) prior to filling the order on 03/17/25. An interview was conducted on 12/18/25 at 9:50 AM with the Director of Nursing (DON). She stated she was not working at the facility when the medication error occurred in March/April 2025 with Resident #53's Depakote. She explained she expected the pharmacy to send the correct medication, correct medication dose, and correct medication form; however, it was also the nurse's responsibility to check all medications with the active orders.

Based on observations, record review, and staff, Pharmacist, and Physician interviews, the facility failed to administer the correct dose of Depakote (an anticonvulsant medication used to treat epilepsy). This was for 1 of 6 residents reviewed for medications. The findings included: Resident #53 was admitted to the facility on [DATE] with diagnoses that included unspecified convulsions/epilepsy. Review of Resident #53's active orders revealed an order dated 03/16/25 for Depakote Sprinkle Capsule 125mg (milligram), give 2 capsules by mouth three times a day unspecified convulsions.Resident #53's significant change Minimum Data Set (MDS) dated [DATE] indicated her cognition was severely impaired. She had no behaviors and no rejection of care coded. Resident #53 received scheduled anticonvulsant medications during the MDS review period. Resident #53's March 2025 electronic Medication Administration Record (MAR) indicated she received Depakote Sprinkle Capsule 125mg, 2 capsules by mouth three times a day from 03/17/25 through 03/31/25. The MAR indicated she refused a dose on 03/28/25 at 9:00 PM. Review of Resident 53's nursing progress notes revealed a note dated 04/02/25 at 5:30 PM written by Nurse #1 that she received a call from Pharmacist #2 revealing that pharmacy sent the wrong dose of medication for Resident #53. Pharmacist #2 indicated to discontinue the order for Depakote and pharmacy would send the correct Depakote dosage. Unsuccessful attempts were made to contact Nurse #1 for interview during the survey period. Resident #53's April 2025 electronic MAR indicated she received Depakote Sprinkle Capsule 125mg, 2 capsules by mouth three times a day on 04/01/25 through 04/02/25 at 5:33 PM. The medication was put on hold from 04/02/25 at 5:33 PM through 04/05/25 at 7:51 PM. Medication Error Report dated 04/02/25, completed by the Previous Director of Nursing (DON), revealed pharmacy dispensed Depakote 500mg, 2 capsules to be given by mouth three times a day to Resident #53. Resident #53's active order read Depakote 125mg 2 capsules to be given by mouth three times a day. The Medication Error Report indicated Resident #53 received the incorrect dose for 6 days. Immediate action taken included a medication review for corrections, medication removed from Smartpass pouches. (Smartpass is an automated system where medications are pre-packaged by the pharmacy into clearly labeled, single-dose plastic pouches. Each pouch features clear, detailed labeling to help ensure the correct dosage and time for administration. Nursing staff use electronic scanners to scan each pouch, instantly matching the medication to a specific resident and verifying the dosage and time against the electronic health record). The report also indicated the pharmacy would send pill cards with the corrected dose and for the facility to obtain lab work. No change in level of consciousness and no pain was noted. Investigation Summary dated 04/02/25, completed by the Previous DON, revealed on 03/27/25 pharmacy delivered the weekly Smartpass medication rolls to the facility. On 04/02/25 pharmacy notified the facility that the wrong dosage of Depakote was dispensed to the facility for Resident #53. The Physician and Responsible Party were notified. The facility initiated education on 04/03/25 for medication scanners. Routine labs were obtained on 04/04/25 with normal results. Lastly, on 04/14/25 Depakote (valproic acid/sodium valproate) level was obtained per pharmacy recommendation. A phone interview was conducted on 12/18/25 at 10:26 AM with the Previous DON. She stated she recalled the occurrence with pharmacy sending the incorrect dose of Depakote for Resident #53. She explained that she received an email from the pharmacy consultant that the pharmacy had identified the error and the facility needed to pull the incorrect dose from the medication cart immediately. She stated that the medication had been removed from the medication cart when Nurse #1 received the phone from Pharmacist #2. The Previous DON then explained that pharmacy felt the error occurred due to nursing not utilizing the medication scanner when preparing the medications for administration. She indicated she provided education with nurses regarding using the scanner instead of clicking the medications off with the computer mouse. She further explained if staff had used the scanner during medication preparation, it would have alerted them Resident #53's Depakote dose was not matching the MAR. Lab draws were ordered to get the Depakote levels however Resident #53 had a history of refusing lab draws and taking her medications. Review of lab work obtained revealed a blood draw was attempted on 04/04/25 at 5:00 AM. Lab cancelled order due to quantity of blood was not sufficient for the test. Another blood draw was attempted on 04/04/25 at 4:21 PM however Resident #53 refused to allow the technician to obtain the blood. A blood draw was completed on 04/14/25 at 12:58 PM with the valproic acid level being 18.1 (normal range 50-100). A follow-up phone interview was conducted on 12/18/25 at 10:53 AM with the Previous DON. She stated she did not in-service nursing on reading and comparing the Smartpass medication pouches with the orders on the MAR because she did not feel that was part of the reason that caused the medication error. The Previous DON did verify that the active order for the Depakote on Resident #53's MAR and the order on the Smartpass pouch was not the same. She also explained that staff did monitor Resident #53 and she had no signs or symptoms of a change in condition or an increased valproic acid/sodium valproate level. (High valproic acid/sodium valproate levels can cause symptoms ranging from mild gastrointestinal upset and drowsiness to severe and life-threatening conditions like coma, respiratory depression, and cerebral edema). The Previous DON also verified she worked the medication cart on 03/29/25 and 03/30/25 from 7:00 PM to 7:00 AM but did not remember identifying the medication error at that time. The Previous DON indicated she administered Resident #53 the incorrect dose of Depakote and she did not use the scanner or compare the pouch to the order on the MAR.Nursing schedules from 03/17/25 through 04/02/25 indicated the following nurses and medication aide worked on the days and times the incorrect dose of Depakote was administered. An interview was conducted on 12/17/25 at 2:12 PM with Nurse #11. She verified that she did work on 03/25/25 and 04/01/25 from 7:00 AM to 7:00 PM and knew Resident #53. She indicated she recalled getting education on utilizing the scanners for scanning the medications but not the medication error. She explained when she pulled a resident's medications, she scanned each Smartpass pouch and compared it to the residents MAR. She further explained she read the orders and compared them with the MAR. If the dose was different than what the MAR had on it she would have seen that. A phone interview was conducted on 12/17/25 at 5:34 PM with Medication Aide (MA) #2. She verified that she did work on 03/24/25 and 03/25/25 from 7:00 PM to 7:00 AM and was familiar with Resident #53. MA #2 indicated she did not recall education or a medication error involving Resident #53's Depakote. A phone interview was conducted on 12/18/25 at 10:25 AM with Nurse #8. She verified that she did work on 03/22/25 and 03/23/25 from 7:00 AM to 7:00 PM and knew Resident #53. Nurse #8 indicated she did not recall education or a medication error involving Resident #53's Depakote dosage. An interview was conducted on 12/18/25 at 1:22 PM with Nurse #12. She verified that she did work on 03/24/25 from 7:00 AM-7:00 PM and on 03/28/25 from 7:00 PM to 7:00 AM. She stated she did not work with Resident #53 very often. She indicated she did not recall receiving education on the medication error related to Resident #53's Depakote. She explained and demonstrated when she pulled a resident's medications she scanned each Smartpass pouch and compared it to the residents MAR. She further explained she read the orders and compared them with the MAR and if the dose was different than what the MAR had on it, she would have noticed that. A phone interview was conducted on 12/18/25 at 4:54 PM with Nurse #2. Nurse #2 worked on 03/26/25 from 7:00 AM to 7:00 PM. She verified that she did work at the facility at the end of March 2025 and knew Resident #53. She indicated she did not recall the medication error that occurred at the end of March 2025 in reference to Resident #53's Depakote. She explained when she gathered a resident's medications she scanned each Smartpass pouch and compared it to the residents MAR. She could not recall if she was utilizing the scanner at that time but stated she always read the orders and compared them with the MAR and she did not know how she would have missed the incorrect dose.Unsuccessful attempts were made to contact the following nurses for interviews during the survey period: Nurse #1 worked on 03/19/25, 03/27/25, 03/28/25, 03/31/25, and 04/02/25 from 7:00 AM to 7:00 PM. Nurse #3 worked 03/29/25, 03/30/25 from 7:00 AM to 7:00 PM. Nurse #5 worked 03/20/25 and 03/21/25 from 7:00 AM to 7:00 PM. Nurse #6 worked 03/20/25 from 7:00 PM to 7:00 AM. Nurse #7 worked 03/21/25 from 7:00 PM to 7:00 AM. Nurse #9 worked 03/22/25, 03/23/25, and 03/26/25 from 7:00 PM to 7:00 AM. Nurse #10 worked 03/31/25 from 7:00 PM to 7:00 AM.An interview was conducted on 12/18/25 at 9:50 AM with the DON. She stated she was not working at the facility when the medication error occurred in March/April 2025 with Resident #53's Depakote. The DON also stated if she had a medication error occurred where the Smartpass pouch medication order did not match the active order that was on the MAR she would immediately pull the incorrect medication from the medication cart, notify pharmacy, Physician, and Responsible Party. She explained she would obtain needed blood work and educate the nursing staff on reading and comparing the medication on hand with the active medication order for accuracy. She also explained she felt if the nursing staff had read and compared the Smartpass pouch with the active order for Depakote the incorrect dose would have been identified prior to administering it. A phone interview was conducted on 12/18/25 at 4:25 PM with Physician #1. She stated she had been contacted by staff about the medication error that had occurred in March and April 2025 with Resident #53's Depakote. She indicated she believed the nursing staff that administered the Depakote should have read the order on the MAR and compared it to the medication on hand. She explained that staff were monitoring Resident #53 and she did not act any differently than prior to the medication error. Physician #1 also explained that staff did not report any signs or symptoms of Depakote toxicity such as upset stomach, drowsiness, or respiratory depression. Physician #1 continued by saying valproic levels were requested and came back as being low and she felt the levels were low due to Resident #53 refusal of medications on a regular basis. She then stated she felt that Resident #53 refused medications at times, but the nursing staff forgot to mark the MAR as the medications being refused. Physician #1 was not concerned that Resident #53 had received 1000mg of Depakote three times a day because Resident #53 did not exhibit a change in condition.

Based on record review, observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 3 residents reviewed for privacy (Resident #86).The findings included: Resident #86 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #86 was cognitively intact and provided personal care for herself with set-up and supervision. An observation of Resident #86's room on 12/16/25 at 2:40 PM, revealed no privacy curtains. Another observation of Resident #86's room occurred on 12/17/25 at 9:55 AM and revealed no privacy curtains were present.On 12/17/25 at 10:50 AM, an interview occurred with Resident #86. She stated the privacy curtains in the room had been missing for about 7 to 8 months but couldn't recall if she had told any staff member about it. She further stated that she provided her personal care in the bathroom of her room but that when she had a privacy curtain, she liked to utilize it for privacy from her roommate when there were visitors in the room or when she was resting in bed. Nurse Aide (NA) #1 was interviewed on 12/17/25 at 1:03 PM, who indicated she routinely provided care to Resident #86. She reported that she had not noticed Resident #86 did not have a privacy curtain. An interview with Resident #86's Medication Aide (MA) #1 on 12/17/25 at 2:50 PM, stated that she normally provided medications and some supervision with personal care tasks but had not noticed that the privacy curtains were missing from Resident #86's room. A review of Resident #86's medical record revealed an order dated 4/3/25 to wash all clothes, bed linens, coats and blankets with hot water for a skin infection. The Environmental Services Manager (ESM) was interviewed on 12/17/25 at 1:32 PM and stated that when privacy curtains were removed for laundering, a fresh set would be put back up the same day. He recalled that Resident #86's privacy curtains were removed for laundering a while back due to a skin infection and that he forgot to have a new set of privacy curtains put back up. The Administrator was interviewed on 12/18/25 at 4:10 PM. She stated that she had been at the facility for five weeks but would have expected privacy curtains to be replaced the same day if they were taken down to be laundered. She further stated that room rounds were completed daily by multiple members of the management team and couldn't explain why the missing privacy curtains had not been identified previously.

Based on record review, resident representative, and staff interviews, the facility failed to administer influenza and pneumonia vaccines on admission for 1 of 5 residents reviewed for immunizations (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses including heart failure and hypertension. The admission consent dated 11/5/25 and signed by Resident #13's Representative and the Admissions staff included the following: Flu vaccine authorization I acknowledge that the resident is not allergic to eggs, and I give permission for the administration of the flu vaccine which is given annually unless medically contraindicated. The checkbox yes was checked beside this statement. The space for the date of the last flu vaccine was blank. Pneumonia vaccine authorization I give permission for the administration of the pneumonia vaccine, which is given on admission unless medically contraindicated. The checkbox yes was checked beside this statement. The space for the date of the last pneumonia vaccine was blank.The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #13 to be severely cognitively impaired. The MDS documented that immunizations (influenza and pneumonia) were not given because they were not offered. Review of the medical record for Resident #13 revealed no immunizations were documented as administered and no documentation that indicated the consent for immunizations had been withdrawn. There was no documentation indicating Resident #13 had received the flu and pneumonia vaccine in the recent year. The Resident Representative was interviewed by phone on 12/17/25 at 9:34 AM. The Representative reported Resident #13 had not received his flu or pneumonia vaccines on admission to the facility. The Representative reported she had signed the consents on admission and expected Resident #13 to receive the vaccines from the facility, but no one from the facility had communicated Resident #13 had received the flu or pneumonia vaccines to her. The former Infection Control nurse (IC nurse) was interviewed by phone on 12/17/25 at 12:37 PM. The IC nurse explained that prior to her leaving her position in November 2025, she had not provided a flu or pneumonia vaccine to Resident #13. The IC nurse explained that new admissions were discussed during the morning meeting and she was aware Resident #13 requested a flu and pneumonia vaccine, but she did not administer the vaccines. When questioned, the IC nurse reported she had no reason for not administering the flu or pneumonia vaccines to Resident #13.The Administrator was interviewed on 12/18/25 at 12:50 PM. The Administrator reported that new admissions were discussed during the daily morning meeting and residents who requested immunizations were communicated to the team. The Administrator explained that Resident #13's Representative was not certain if he received the vaccines prior to admission to the facility and she was going to get that information for the facility. Administrator reported she expected residents to receive vaccines when they or the Representative requested.

Based on record review, Resident Representative, and staff interviews, the facility failed to administer COVID-19 vaccine on admission for 1 of 5 residents reviewed for immunizations (Resident #13).The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses including heart failure and hypertension. The admission consent dated 11/5/25 and signed by Resident #13's Representative and the Admissions staff included the following: COVID-19 vaccine authorization, I give permission for the administration of the COVID-19 vaccine, which is given annually unless medically contraindicated. The checkbox yes was checked beside this statement. The space for the last date COVID-19 vaccine received was blank. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #13 to be severely cognitively impaired. The MDS documented that immunization (COVID-19) was not given because the vaccine was not offered. Review of the medical record for Resident #13 revealed no COVID-19 immunization was documented as administered. Review of the medical record revealed no documentation that indicated the consent for immunizations had been withdrawn. There was no documentation indicating Resident #13 had received the COVID-19 vaccine in the recent year. The Resident Representative was interviewed by phone on 12/17/25 at 9:34 AM. The Representative reported Resident #13 had not received his COVID-19 vaccines on admission to the facility. The Representative reported no one from the facility had communicated Resident #13 had received the COVID-19 vaccine to her. The former Infection Control nurse (IC nurse) was interviewed by phone on 12/17/25 at 12:37 PM. The IC nurse explained that prior to her leaving her position in November 2025, she had not provided a COVID-19 vaccine to Resident #13. The IC nurse explained that new admissions were discussed during the morning meeting and she was aware Resident #13 requested a COVID-19 vaccine, but she did not administer the vaccine. When questioned, the IC nurse reported she had no reason for not administering the COVID-19 vaccine to Resident #13. The Administrator was interviewed on 12/18/25 at 12:50 PM. The Administrator reported that new admissions were discussed during the daily morning meeting and residents who requested immunizations were communicated to the team. The Administrator explained that Resident #13's Representative was not certain if he received the vaccines prior to admission to the facility and she was going to get that information for the facility. Administrator reported she expected residents to receive vaccines as they or their Representative request.

Based on record review and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff schedule for licensed nursing staff for 13 out of 57 days reviewed for sufficient staffing. The facility also failed to ensure the resident census was present on the daily nurse staffing sheets for 54 out of 57 days. The findings included: 1) A review of the facility's daily posting for nursing staff for the past 57 days as compared to the daily staffing schedule included an inaccurate total number of nursing staff worked. The nursing schedules for 11/4/24, 11/8/24, 11/11/24, 11/15/24, 11/18/24, 11/22/24, 11/25/24, 11/26/24, 11/29/24, 12/1/24, 12/2/24, 12/13/24 and 12/30/24, indicated that one Registered Nurse (RN), the Unit Manager, was scheduled to work the day shift (7:00 AM to 3:00 PM). The daily posted nurse staffing sheets for 11/4/24, 11/8/24, 11/11/24, 11/15/24, 11/18/24, 11/22/24, 11/25/24, 11/26/24, 11/29/24, 12/1/24, 12/2/24, 12/13/24 and 12/30/24 documented that there was no RN coverage. The Staff Scheduler was interviewed on 1/15/25 at 2:50 PM. She reviewed the staffing schedule and daily postings and verified the postings did not correlate for the RN coverage. She explained that the Unit Manager, who is a RN, was working on those days and didn't realize that she should be counted as RN coverage on the daily nurse staffing sheets. The Administrator was interviewed on 1/15/25 at 3:40 PM, and stated he expected the daily staff posting to be an accurate reflection of the staff that worked. 2) A review of the facility's daily posting for nursing staff for the past 57 days did not include a resident census number for 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM. This included all days from 11/4/24 to 11/30/24 as well as all days from 12/1/24 to 12/31/24 except for 12/18/24, 12/24/24 and 12/26/24. The Staff Scheduler was interviewed on 1/15/25 at 2:50 PM. She reviewed the daily staff postings and verified they did not include a resident census. She stated she was unaware this was required to be completed. The Administrator was interviewed on 1/15/25 at 3:40 PM and stated he would expect the resident census to be present on the daily staff posting as required.

Based on record review and staff interviews, the facility failed to ensure a process was in place for tracking COVID-19 testing of Health Care Personnel (HCP) for 4 of 4 weeks reviewed and failed to ensure HCP were tested twice a week during an outbreak status for 4 of 4 staff reviewed for infection control. The findings included: On 7/13/2022 the Administrator provided a paper document tilted, PLTC COVID-19 Testing Schedule. The document indicated the facility was in an area with high community transmission rate, was in outbreak status, and required twice week COVID-19 testing of all staff regardless of vaccination status, unless they tested positive in the last 90 days. A paper document titled, Guidelines for COVID-19 Testing, with a created dated of 9/1/2020 and revision date of 9/14/2021 indicated state and local testing mandates required twice week testing of all employees and weekly testing of all residents who had not tested positive in the last 90 days regardless of vaccination status. On 7/13/2022 at 1:55 PM an interview was conducted with the Infection Control Preventionist (ICP). She stated the facility was testing all residents weekly and all employees twice weekly on Mondays and Thursdays. The IP stated she did not have supporting documentation for June testing of employees, she could not find the documents. She further stated she placed an employee roster at the nurse's station along with testing supplies. She stated employees were aware of the testing dates and it was her expectation they test themselves twice weekly. She stated she did not audit the sign in sheets to ensure all employees were testing twice a week. When asked about contract staff who were not on the employee list, she stated they could write their name in at the bottom of the form and place their results next to their name. On 7/13/2022 at 2:30 PM an interview was conducted with housekeeping staff #1. She stated she was contract staff. She further stated the facility was testing twice weekly, but she is not in the facility every day. Stated she tests herself if she worked on a testing day. She stated she did work the week of Jully 4th but did not recall testing 7/4/2022 or 7/7/2022 and her name did not appear on the sign in sheets for those dates. An interview was conducted with Nurse #4 on 7/13/2022 at 2:32PM. She stated she did not recall if she tested on ce or twice the week of July 4th. Her named appeared on the sign-in sheet for 7/10/2022 only. On 7/13/2022 at 2:35 PM and interview was conducted with Nurse #2. She stated she worked the week of July 4th. She did not recall if she tested that week and her name did not appear on the sign in sheet for July 4th or July 7th. An interview was conducted with Nurse #3 on 7/13/2022 at 2:45 PM. She stated she was an agency nurse. She stated she tested on test days but she did not recall testing twice the week of July 4th. She tested on ce that week on 7/7/2022. Her name did not appear on the 7/11/2022 sign in sheet and she stated she did not recall if she tested on [DATE]. She further stated there is not always a sign in sheet to document you tested or the results of your test. On 7/13/2022 at 2:47PM an interview was conducted with the Director of Nursing (DON). She stated it was her expectation that all employees tested twice weekly during outbreak status. The DON stated she was not aware the ICP nurse was not maintaining a log or ensuring employee testing was completed.

Based on record review, resident and staff interviews, and interviews with the health department, the facility failed to notify all residents, responsible parties (RP)/family members, and the health department of new confirmed COVID-19 infections no later than 5:00 PM the next calendar day for 1 of 3 residents reviewed for notification. The findings included: A paper document titled, Guidelines for Reporting COVID-19 Positive Cases with a creation date of 3/10/2020 and revised date of 10/1/2020 was provided by the Administrator. The document indicated all residents in the facility, their family members/legal guardians, and staff should be notified of new confirmed or suspected (residents or staff) no later than 5:00 PM the next calendar day following the occurrence. The document also indicated the expectation and practice was to have individual communication with residents, families, and staff, in persona or via phone, in conjunction with mailing letters. Resident #4 was admitted on [DATE]. Resident #4's quarterly Minimum Data Set (MDS) indicated the resident was cognitively intact, had adequate hearing and vision, and could understand and be understood by others. On 7/13/2022 a 10:45 AM an interview was conducted with Resident #4. She stated she was in the facility the weekend of July 4th and noticed the staff placing signs and personal protective equipment on the doors of residents on the 100 hall. She further stated the facility typically notified residents of new COVID-19 positive cases but no one came around to notify her over that holiday weekend. She was notified on July 5th. An interview was conducted with Resident #4's family member, who was also listed as her emergency contact. He stated he was in the facility the weekend of July 4th and was not notified by phone or face to face of any new COVID-19 cases in the facility. He stated he did not receive notification until the following week but he could not recall what date. An interview was conducted with the local Health Department on 7/13/2022 at 11:20 AM. She stated the Health Department received a fax dated 7/5/2022 notifying them of new COVID-19 positive cases in the facility. On 7/13/2022 at 11:29 AM an interview was conducted with the ICP nurse. She stated there were 4 new confirmed positive residents on 7/1/2022. She and the Social Worker (SW) notified those residents who were confirmed positive and the family members of those who tested positive but they did not notify any other residents or their RPs. She further stated she was not sure why those notifications were not done other than it was a holiday weekend and there was no administrative staff to assist her and the SW in making those calls. She also stated she was not aware of any regulation regarding timeliness of notification. An interview was conducted with the SW on 7/13/2022 at 12:45 PM. She confirmed she as in the facility 7/1/2022 and assisted the ICP nurse with notification. She stated she notified the residents who tested positive and their family members/ RPs. She stated she did not notify any other residents or RPs. When asked why, she stated it was a holiday weekend and late on a Friday afternoon, so they did not stay to make those notifications. She further stated she was not aware of a regulation regarding timeliness of notification. An interview was conducted with the Administrator on 7/13/2022 at 1:00 PM. She stated she was out of town 7/1/2022 and the weekend. She was made aware of the new COVID -19 positive cases in the facility on 7/1/2022. She stated the ICP nurse and SW were responsible for notification, and she was not aware notification to residents, RPs, and Health Department were not completed. She had staff begin notification on her return, 7/5/2022. Additionally, she conducted in service training with administrative staff on 7/8/2022. The in-service included calling all resident's RPs or guardians, faxing notification to the Health Department, and notifying the Ombudsman the day of positive identification. The Administrator stated it was her expectation that notification occur the day of the new confirmed positive or no later than 5:00 PM the following day.

Based on observations, staff and Medical Director (MD) interviews and record review, the facility failed to ensure MD ordered specialty air mattress was set according to the weight of the resident (Resident #30 and Resident #38). The facility also failed to ensure the MD ordered air mattress was implemented for Resident #26. This was for 3 of 3 residents reviewed for pressure ulcers. The findings included: 1. Resident #30 was admitted [DATE] cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. He was coded for a urinary catheter, 2 stage one pressure ulcers and coded for a pressure relieving device to his bed. The MDS read Resident #30's admission weight was 190 pounds. Resident #30 was care planned on 3/4/22 for the risk of development of further pressure ulcers and the redness to his right and left buttocks. Interventions included ensuring the appropriate pressure relieving devices were in place. Review of Resident #30's skin assessment dated [DATE] indicated his stage 1 pressure ulcer to his left buttock had opened. Review of Resident #30's skin assessment dated [DATE] indicated the area to his left buttock progressed to a stage 3 and his skin assessment dated [DATE] indicated the area was unchanged. The MD ordered Resident #30 to be referred to the wound clinic due to increased drainage on 4/25/22. Review of Resident #30's wound consult dated 5/2/22 indicated the area on his left buttock was described as his sacrum. The area was debrided and a new order for an alternating air mattress (AAM). Review of a MD order dated 5/9/22 read for Resident #30 to be placed on an air mattress and to validate AAM setting range weekly on every Tuesday. Resident #30's electronic medical record read the last weight for Resident #30 was 182 pounds on 4/13/22. An interview was conducted with Resident #30 on 5/9/22 at 11:46 AM. He stated the air mattress was added to his bed while he was out for his wound clinic appointment earlier this morning. Observation of the AAM indicated the weight was set at 400 pounds. An observation of Resident #30's AAM was completed on 5/10/22 at 10:35 AM. The Treatment Nurse (TN) was present but did not noticed the AAM was set for the weight of 400 pounds. He stated that all ordered AAM's should be set accurately based on the resident's weight. An interview was conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. She stated the aides were not responsible for setting up or checking the AAM for function or settings. She stated to her knowledge, it was either the responsibility of the floor nurse or the TN. An interview was conducted with the Staff Development Coordinator (SDC) on 5/10/22 at 10:47 AM. She stated it was the responsibility of the floor nurses to ensure any AAM's function and setting were accurate. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated she was not sure who was responsible for ensuring AAM's were functioning properly and the air mattress pump settings were accurate based on the resident's weight. She stated she was under the impression that the TN and Assistant Director of Nursing (ADON) did it since they did wound rounds together weekly. An interview was conducted with the ADON on 5/10/22 at 11:15 AM. She confirmed she and the TN performed weekly wound assessments. The ADON stated during the wound rounds, the AAM was assessed for proper function and settings but it was the responsibility of the floor nurses to ensure the function and setting were accurate daily. An observation of Resident #30's AAM was completed on 5/11/22 at 8:45 AM. The AAM was still set for a weight of 400 pounds but he was not in his room. The Assistant Director of Nursing (ADON) stated Resident #30 was transferred to the hospital yesterday from the wound clinic. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated Resident #30 was known to him and had a previous stay in 2021. The MD stated after this most recent hospital admission and subsequent admission to the facility, Resident #30's medical condition had progressively declined. He stated Resident #30's AAM was ordered to be set according to his weight and it was his expectation that the AAM be set according to his actual weight of 182 pounds. Another observation of Resident #30's AAM was completed on 5/11/22 at 4:45 PM. The AAM had been adjusted to the proper weight setting. An interview with the TN was completed on 5/11/22 at 4:50 PM. He stated the MD told him about the incorrect AAM settings earlier and he adjusted the setting in accordance with Resident #30's weight. He stated that all ordered AAM should be set accurately based on the resident's weight. An interview was completed with Nurse #2 on 5/12/22 at 10:10 AM. She stated it was her understanding that all the nurses and TN were responsible for ensuring proper function and setting of any resident ordered an AAM. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated Resident #30's AAM was to be set according to his most recent weight of 182 pounds and not at 400 pounds. 2. Resident #38 was admitted on [DATE]and recently readmitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38 was care planned on 6/24/21 and last revised on 9/17/21 for a pressure ulcer to his left heel. He was care planned on 1/26/21 and last revised 9/17/21 for bilateral arterial ulcers to his lower extremities. Interventions included ensuring the appropriate pressure relieving devices were in place. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact. He was coded for a urinary catheter one stage 3 pressure ulcer and 3 venous ulcers. His weight was recorded as 240 pounds. Review of Resident #38's wound ulcer flowsheet dated 4/8/22 indicated his left heel pressure ulcer acquired inhouse (date unknown) was healed as of 4/22/22. He still was receiving wound care for his venous ulcers. An interview and observation was completed with Resident #38 on 5/9/22 at 12:26 PM. He was lying on an alternating air mattress (AAM) with the weight set at 340 pounds. He stated he had a significant history of pressures to his feet and buttocks along with his venous ulcers. Review of Resident #38's May 2022 on Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An observation and interview was conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. Resident #38's AAM was set for 340 pounds. She stated the aides were not responsible for setting up or checking the AAM for function or settings. She stated to her knowledge, it was either the responsibility of the floor nurses or the TN. An interview was conducted with the Staff Development Coordinator (SDC) on 5/10/22 at 10:47 AM. She stated it was the responsibility of the floor nurses to ensure any AAM's function and setting were accurate. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated she was not sure who was responsible for ensuring AAM's were functioning properly and the air mattress pump settings were accurate based on the resident's weight. She stated she was under the impression that the TN and Assistant Director of Nursing (ADON) did it since they did wound rounds together weekly. An interview was conducted with the ADON on 5/10/22 at 11:15 AM. She confirmed she and the TN performed weekly wound assessments. The ADON stated during the wound rounds, the AAM was assessed for proper function and settings but it was the responsibility of the floor nurses to ensure the function and setting were accurate daily. An observation of wound care was completed on 5/10/22 at 11:20 AM with the TN and the ADON. The area to Resident #38's left heel was healed but noted were 3 venous ulcers to his bilateral lower extremities. The TN and ADON were not observed assessing or adjusting Resident #38's AAM setting. An observation was completed on 5/11/22 at 8:35 AM. NA #7 was observed assisting Resident #38 with breakfast. His AAM was set at 340 pounds. NA #7 stated she was not aware of who checked the AAM for function and settings. She stated she assumed it was the floor nurses. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated Resident #38's AAM was ordered to be set according to his weight and it was his expectation that the AAM be set according to his actual weight of 240 pounds. Another observation was completed on 5/11/22 at 5:05 PM. Resident #38's AAM was still set for a weight of 340 pounds. An interview was completed with Nurse #2 on 5/12/22 at 10:10 AM. She stated it was her understanding that all the nurses and the TN were responsible for ensuring proper function and setting of any resident ordered an AAM. An interview was completed with the TN on 5/12/22 at 12:00 PM. He stated the MD informed him of the inaccurate weight setting on Resident #38's AAM but he forgot to correct the setting until late yesterday afternoon. He stated that all ordered AAM's should be set accurately based on the resident's weight. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated Resident #38's AAM was to be set according to his most recent weight of 240 pounds and not at 340 pounds. 3.Resident #26 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was severely cognitively impaired and nonverbal. The resident was dependent on staff for all activities of daily living including bed mobility, dressing, toileting, and personal hygiene during the assessment period. Resident #26 was coded as high risk for pressure injuries and had pressure reducing devices and nonsurgical dressing applied during the assessment period. Resident #26's comprehensive care plan dated 3/9/2022 contained a focus for risk of skin breakdown or pressure injuries. Interventions included ensuring appropriate pressure reducing devices and air mattress were in place. The resident's active orders revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was entered by staff development coordinator (SDC). On 5/10/2022 at 3:43 PM an observation of wound care by the treatment nurse, with the Assistant Director of Nursing (ADON) present, was conducted. Resident #26 was observed to have blanchable redness to bilateral buttocks and scrotum. When writer asked the treatment nurse to characterize the wound, the treatment nurse stated it was a stage 1. Additionally, the resident was observed to have broken skin in a linear pattern on his right buttock. When asked about the mattress, both the ADON and the treatment nurse stated the resident was not on an air mattress, he was on a wing mattress. On 5/11/2022 at 11:40 AM an interview was conducted with the treatment nurse. He reviewed Resident #26's active order set and stated he did not know the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with the SDC on 5/12/2022 at 11:42 AM. She stated the facility recently transitioned from paper medical records to electronic medical records. When she transcribed Resident #26's active orders form paper to electronic format, the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not know if Resident #26 was on an air mattress.

Based on record reviews, observations and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints and alarms (Residents #25, #50, #59 and #67), bladder and bowel (Resident #78) and discharge disposition (Resident #89). This was for 6 of 24 resident records reviewed. The findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a nursing progress note dated 12/18/20, read Resident #25 ambulated in the hallways frequently with a walker. She has a history of wandering and forgetfulness per family. A wander/elopement bracelet was applied to her ankle. The quarterly MDS assessment dated [DATE] indicated Resident #25 was able to understand others and make herself understood. She was independent with ambulation and was not coded for a wander/elopement alarm. An observation occurred of Resident #25 on 5/10/22 at 2:25 PM, ambulating in the hallways with her walker. A wander alarm was present to her ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE], confirmed the wander/elopement alarm was not coded and stated it was an oversight since Resident #25 had an alarm bracelet on her ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 2. Resident #50 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #50's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] indicated Resident #50 had moderately impaired cognition and was not coded for a wander/elopement alarm. On 5/9/22 at 10:15 AM, an observation occurred of Resident #50 while she was sitting in a chair in the TV lounge. A wander-alarm bracelet was visible to her right ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight since Resident #50 had an alarm bracelet on her ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 3. Resident #59 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #59's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] indicated Resident #59 had severely impaired cognition and was not coded for a wander/elopement alarm. On 5/9/22 at 12:35 PM, an observation occurred of Resident #59 while she was sitting with a wander-alarm bracelet visible to her right ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight since Resident #59 had an alarm bracelet on her ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 4. Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #67's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] indicated Resident #67 had severely impaired cognition and was not coded for a wander/elopement alarm. A review of Resident #67's active care plan, last reviewed on 4/18/22, included a focus area for wandering and/or at risk for unsupervised exits from the facility related to impaired cognition. One of the interventions was for a wander-guard alarm bracelet, that was initiated on 6/12/19. On 5/9/22 at 10:00 AM, an observation occurred of Resident #67 while he was lying in bed with a wander-alarm bracelet to his ankle. On 5/12/22 at 12:26 PM, an interview occurred with the MDS Nurse. She reviewed the MDS assessment dated [DATE] and confirmed the wander/elopement alarm was not coded. She stated it was an oversight since Resident #67 had an alarm bracelet on his ankle. An interview occurred with the Director of Nursing on 5/12/22 at 1:14 PM and indicated it was her expectation for the MDS assessment to be coded accurately. 5. Resident #78 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's previous quarterly Minimum Data Sets (MDS) dated [DATE] and 1/26/22 indicated he was incontinent of bowel. His most recent quarterly MDS dated [DATE] indicated he was continent of bowel. Resident #78 was care planned 10/24/18 last revised 2/15/22 for toileting assistance due to incontinence related to his left sided weakness. An interview was conducted with Nursing Assistant (NA) #9 on 5/11/22 at 5:00 PM. She stated that she had worked with Resident #78 and that he has been incontinent of bowel for as long as she could recall. An interview was conducted with NA #10 on 5/11/22 at 5:05 PM. She stated Resident #78 was incontinent of bowel for as long as she could recall. An interview was conducted with the MDS Nurse on 5/12/22 at 12:26 PM. She stated she was aware that she had incorrectly noted Resident #78's bowel status and this had been an oversight. She explained she had completed a modification to the quarterly MDS dated [DATE] on 5/11/22. An interview was completed with the Administrator on 5/12/22 at 1:15 PM. She stated she expected Resident #78's MDS to be completed accurately. 6. Resident #89 was admitted [DATE] from the acute hospital setting. Resident #89's discharge Minimum Data Set (MDS) dated [DATE] indicated the resident was discharged to acute hospital setting and return was not anticipated. The discharge summary, dated 2/15/2022, with medications, physical therapy orders, and recapitulation of stay was reviewed. The discharge summary indicated Resident #89 was discharged to home. The resident's medical record indicated the resident was discharged home with her daughter on 2/15/2022 with home health services. Resident #89's medical record also contained a progress note by the social worker dated 2/21/2022 that indicated a follow up call was made to the resident's daughter to confirm home health care was in place and resident received physical therapy services at home. On 2/11/2022 at 2:11 PM and interview was conducted with the MDS nurse. She stated she had been working as MDS nurse for approximately one year. She reviewed Resident #89's discharge MDS dated [DATE] and stated the discharge was coded for acute hospital setting with return not anticipated. She reviewed the resident's discharge summary and stated the MDS was coded in error. The MDS should have been coded to reflect the resident was discharged to home. On 5/12/2022 at 1:14 PM and interview was conducted with the Director of Nursing (DON). She stated it was her expectation MDS be coded accurately.

Based on observations, staff, resident and family interviews and record review, the facility failed to provide shaving assistance for Resident #17 and Resident #34 dependent on assistance with activities of daily living (ADLs). The facility also failed to provide nail care for ADL dependent residents (Resident #17, Resident #38, Resident #78, Resident #34 and Resident #26). This was for 5 of 20 residents reviewed for ADLs. The finding included: 1. Resident #17 was admitted on [DATE] and readmitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His readmission Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact, exhibited no behaviors and he required extensive staff assistance with his personal hygiene. Resident #17 was care planned on 2/20/22 for assistance with his ADLs but the care plan did not include assistance with personal hygiene. An observation and interview was completed with Resident #17 on 5/9/22 at 2:40 PM. His fingernails were observed with a dark substance underneath and the nails extended past his fingertips. Resident #17's facial hair was disheveled, long and extended down onto his neck. He stated he only preferred a mustache but not the beard. He stated he could not remember the last time he had a shave or had his fingernails trimmed. An observation was completed on 5/10/22 at 10:15 AM with the Treatment Nurse (TN) and the Assistant Director of Nursing (ADON) providing wound care. The TN and ADON did not mention the appearance of his fingernails or facial hair. An interview was completed on 5/10/22 at 12:20 PM with the ADON. She stated the aides provided all fingernail care and shaving during ADLs and it should be done as needed or noticed. An interview was completed on 5/11/22 at 8:35 AM with Nursing Assistant (NA) #6. She confirmed she was assigned Resident #17 on 5/9/22 and 5/10/22 but she did not notice his fingernails or facial hair. NA #6 stated nail care and shaving was completed by the aides as needed. She stated she was not aware of any refusals of assistance with his ADLs. An interview was completed on 5/11/22 at 8:55 AM with the ADON. She stated Resident #17 did not refuse assistance with his ADLs. An interview and observation was completed on 5/11/22 at 11:13 AM. Resident #17 was in his room with his wife present. He appeared unshaven and his fingernails had not trimmed. His wife stated Resident #17 never wore a beard but only a mustache and he never allowed his fingernails to extended past his fingertip. She stated he needed assistance with shaving and trimming his nails and was uncertain why the aides had not assisted him with his personal hygiene. An interview was completed on 5/11/22 at 11:22 AM with NA #8. She stated the night shift aides completed Resident #17's ADLs in order for him to be ready for [CONDITION(S)] but she would shave his face and trim his fingernails today. Attempts to contact NA #11 assigned Resident #17 third shift on 5/9/22, 5/10/22 and 5/11/22 were unsuccessful. An observation was conducted on 5/11/22 at 5:07 PM. Resident #17 appeared clean shaven except for his mustache and his fingernails had been trimmed and cleaned. He stated he felt much improved. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she expected the staff to assist Resident #17 with shaving and nail care as needed. 2. Resident #38 was admitted on [DATE]and most recently readmitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38 was care planned on 10/4/18 last revised 9/17/21 for total assistance with his personal hygiene due to his contracture to his left upper extremity. He was also care planned on 4/8/19 last revised 9/41/21 for resistance to care and treatments and was known to refuse medications, treatments and showers at times. Interventions included allowing flexibility in his ADL routine to accommodate his mood. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact, exhibited rejection of care and coded for total assistance with all of his activities of daily living (ADLs). An interview and observation was completed with Resident #38 on 5/9/22 at 12:26 PM. He had bilateral hand contractures and a left elbow contracture. His appeared fingernails jagged, extended beyond his fingertips and had a dark looking substance under the nails. He stated the staff had to trim his fingernails and could not recall when they were last trimmed. An observation of wound care was completed on 5/10/22 at 11:20 AM with the Treatment Nurse (TN) and the Assistant Director of Nursing (ADON). Neither the TN nor the ADON noticed the appearance of Resident #38's fingernails. An interview was completed on 5/10/22 at 12:20 PM with the ADON. She stated the aides provided all fingernail care during ADLs and it should be done as needed or noticed. An interview was conducted on 5/11/22 at 8:20 AM with Nursing Assistant (NA) #6 stated she was assigned Resident #38 on 5/9/22 and 5/10/22 but she did not observe the condition of his fingernails. She stated she had not known Resident #38 to refuse his nail care but he would say his fingernails were sensitive and picky about who he allowed to trim them. NA #6 stated the ADON trimmed and cleaned his fingernails yesterday. An interview and observation was completed on 5/11/22 at 8:35 AM. NA #7 was assisting Resident #38 with his breakfast. He stated the ADON trimmed his fingernails yesterday and they felt better because when his fingernails grew out as long as they were yesterday, they become very sensitive. NA #7 stated nail care should be done when needed. She stated Resident #38 did not refuse nail care or personal hygiene assistance. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she expected the staff to assist Resident #38 with nail care as needed. 3. Resident #78 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] His quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #78 was cognitively intact, exhibited no behaviors and was coded for extensive staff assistance with his personal hygiene. Resident #78 was care planned on 10/24/18 last revised 12/20/19 for assistance with his personal hygiene due to left sided weakness. An interview and observation was completed on 5/09/22 1:36 PM with Resident #78. His fingernails extended past his fingertips and appeared for have a dark substance underneath his fingernails. He stated he needed the staff to trim his nails but he always forgot to ask. An observation was completed on 5/10/22 at 3:55 PM. He was sitting in a wheelchair outside in the hall near the doorway of his room. The appearance of his fingernails were unchanged. An interview was completed on 5/11/22 at 5:00 PM with Nursing Assistant (NA) #9. She stated Resident #78 was only known to refuse showers but he did not refuse assistance with his personal hygiene or nail care. An interview was completed on 5/11/22 at 5:05 PM with NA #10. She stated Resident #78 was known to refuse ADL assistance but would agree to allow staff to assist him in his time. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she expected the staff to assist Resident #78 with nail care as needed. 4. Resident #34 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #34 was cognitively intact and was coded with no behaviors or refusal of care. He required extensive assistance with personal hygiene and bathing. A review of Resident #34's active care plan, last reviewed 3/14/22, included a focus area for activities of daily living/personal care. The interventions included to provide extensive assistance with tasks such as combing hair and shaving. A review of the nursing progress notes from 12/31/21 to 5/9/22, revealed no refusals of nail care or shaving assistance documented. An interview and observation was made of Resident #34 on 5/9/22 at 1:15 PM while he was sitting on the side of the bed. He was noted with a thick, long beard and long fingernails with a brown substance under them to both hands. Resident #34 stated it had been awhile since he was shaved and normally wore only a moustache. Stated he would like to be shaved but could not recall being offered. In addition, Resident #34 stated I've never kept my fingernails this long. They just cut my toenails not long ago, but not sure why they haven't done my fingernails. On 5/10/22 at 11:09 AM, Resident #34 was observed lying in bed. He stated no one had offered to shave him or cut his fingernails. The Assistant Director of Nursing (ADON) was interviewed on 5/10/22 at 3:15 PM and stated nail care was provided when needed. She observed Resident #34 and stated his fingernails did need to be cut and cleaned. She was unable to state why he had not been shaven or had his fingernails cared for during personal care assistance. Nurse Aide (NA) #1 was interviewed on 5/10/22 at 3:51 PM and explained nail care and shaving assistance was completed on shower days, when needed or requested by the resident. She further stated if a resident refused the nurse would be informed so a progress note could be written. She was unaware of any refusals from Resident #34. Resident #34 was observed on 5/11/22 at 10:43 AM. His face was clean shaven with a moustache remaining and his fingernails were short and clean. Resident #34 stated someone came by the prior evening and assisted with shaving and caring for his fingernails and added he felt much better. On 5/12/22 at 9:45 AM, NA #3 was interviewed. She indicated she was familiar with Resident #34. She explained nail care and shaving assistance should have occurred during personal care, shower days and when needed but was unable to state why Resident #34 had not been offered nail care or shaving assistance prior to 5/10/22. The Director of Nursing (DON) was interviewed on 5/12/22 at 1:15 PM and indicated it was her expectation for NAs to monitor, clean and trim nails during personal care, retrieving a nurse if the resident was a diabetic or refused. Additionally, the DON stated it was her expectation that Resident #34 be free of unwanted facial hair and expected NAs to offer shaving assistance during his scheduled shower days and during personal care tasks. 5. Resident #26 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was severely cognitively impaired and nonverbal. The resident was dependent on staff for all activities of daily living including eating, dressing, toileting, and personal hygiene during the assessment period. Resident #26 was not coded for moods or behaviors and did not reject care during the assessment period. Resident #26's comprehensive care plan dated 3/9/2022 contained a focus for skin impairment related to having fragile skin and scratching himself. Interventions included checking fingernails frequently and keeping fingernails trimmed and filed as needed. During an observation of wound care on 5/10/2022 at 3:43 PM the Assistant Director of Nursing (ADON) and the Treatment nurse were present. The Treatment nurse stated the resident had scratched his buttocks on 5/9/2022 and had a new area of broken skin. The resident's incontinent brief was clean and dry when removed. The bilateral buttocks were observed to have blanchable redness and the right buttock had broken skin in long linear patterns. The ADON was asked to examine the resident's fingernails. The fingernails on both hands were observed to be long and had a brown substance under the nails. The resident also had a brown substance on the palm of his left hand. The ADON stated the resident needed his nails cleaned and trimmed. She further stated nail care was provided as needed by the staff. On 5/10/2022 at 3:51 PM an interview was conducted with Nursing Assistant (NA) #1. She stated she was assigned to Resident #26. She stated fingernails were checked and trimmed as needed on shower days. She stated she had not trimmed Resident #26's fingernails recently and she did not know what day he got showers. She further stated she saw that the resident's nails and hands were dirty. She was going to clean his hands and nails after she answered another resident's call bell. On 5/12/2022 at 1:14 PM an interview was conducted with the Dirctor of Nursing (DON). She stated she expected the NAs to monitor, clean , and trim nails when they provided personal care.

Based on observations, staff, resident and Medical Director (MD) interviews and record review, the facility failed to ensure Physician orders were obtained and implemented for the care and assessment of residents with indwelling urinary catheters (Resident #30, Resident #38 and Resident #74). The facility also failed to place a securement device for an indwelling urinary catheter (Resident #30). This was for 3 of 6 residents reviewed for urinary catheters. The findings included: 1. Resident #30 was admitted [DATE] cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact, required extensive staff assistance with his activities of daily living (ADLs) and was coded for a urinary catheter. Resident #30's care plan last revised 4/1/22 read he had an altered pattern of urinary elimination with an indwelling urinary catheter. Interventions included catheter care per the facility protocol, change the catheter per MD orders and/or facility protocol, maintain an unobstructed urine flow and ensure the urinary was below the level of the bladder. There was no intervention of a securement device. Review of Resident #30's weekly electronic urinary catheter assessments from admission 3/4/22 to 5/5/22 all completed by the facility Treatment Nurse (TN) and once by the Assistant Director of Nursing (ADON) did not include any documentation regarding the appearance of the catheter insertion site. Review of Resident #30's May 2022 Physician orders did not include any orders for a urinary catheter, catheter changes, assessment or the maintenance of his urinary catheter. There were also no orders to follow the facility protocol for urinary catheters. Review of Resident #30's March, April and May 2022 Treatment Administration Records (TAR) did not include any documented evidence of urinary catheter care, assessment or maintenance. Review of a nursing note dated 5/9/22 at 11:05 PM read Nurse #9 noted some blood around his catheter insertion site and she notified the MD. There were no new orders. An interview and observation were conducted with Resident #30 on 5/9/22 at 11:46 AM. He stated his urinary catheter insertion site was stinging and the tube was tugging on the insertion site. He pulled back his top sheet to reveal there was no securement device attached to either thigh. He stated when he was first admitted , the staff put some sort of device that held his urinary catheter in place. He stated they stopped using it several weeks ago. An observation of Resident #30's urinary catheter insertion site was completed on 5/10/22 at 10:35 AM with the TN. Resident #30 stated his urinary catheter was hurting, pulling, tugging and the catheter insertion site was stinging. The TN pulled back the top sheet and noted no securement device. He stated the stat locks (a urinary catheter stabilization device used for securing a catheter in place to prevent pulling and trauma) had been on back order for a couple of months. The TN stated there should be some sort of securement in place even if the stat locks were on back order. He stated it could be stabilized with tape or a leg strap. The TN removed Resident #30's brief to reveal dried blood to the inside of his brief. There was also observed of dark red blood at the catheter insertion site. The TN stated he was not aware of the observed trauma. He stated he would clean the area and ensure a securement device was placed. The TN stated he was under the impression there was a urinary catheter protocol on his Physician orders. The TN stated he was not aware of where to locate the facility's urinary catheter protocol. An interview was conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. She stated the aides were allowed the clean around the urinary catheter insertions sites but not allowed to place a securement device on Resident #30's leg. She stated the TN, or the floor nurses did that. NA #6 stated she did not notice any evidence of trauma or blood during his ADL care on 5/9/22. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated it was her understanding that the TN changed the urinary stat locks weekly. She stated she was not aware that Resident #30 did not have a securement device in place or about the observed trauma at the urinary catheter insertion site. An interview was conducted with the Assistant Director of nursing (ADON) on 5/10/22 at 11:15 AM. She stated the and the TN performed weekly wound rounds together. She stated normally if the resident had a wound and a urinary catheter, the catheter was part of the weekly assessment as well. An interview was completed on 5/10/22 at 4:00 PM, Nurse #9 stated she observed blood in Resident #30's brief yesterday and she notified the MD but there were no orders were given. Nurse #9 stated she could not recall if there was a urinary securement device in place on 5/10/22. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated he was under the impression that the facility had a protocol for the care of residents with urinary catheters and was not aware there were no orders for the care and assessment of Resident #30's urinary catheter. He stated Resident #30's catheter should always have a securement device in place to prevent trauma or accidental removal of his urinary catheter. The MD stated the nurses, or the TN should have obtained monthly Physician orders for Resident #30's urinary catheter, assessed and cleaned his urinary catheter insertion site daily. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated there should be Physician orders for his urinary catheter, be secured and assessed daily. 2. Resident #38 was admitted on [DATE]and most recently readmitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38's care plan last revised 9/17/21 read he had an altered pattern of urinary elimination with a suprapubic urinary catheter (a catheter used to drain urine from the bladder). Interventions included catheter care per the facility protocol, change the catheter per MD orders and/or facility protocol, maintain unobstructed urine flow, ensure the urinary was below the level of the bladder and the catheter secured with an anchoring device. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact, coded for a urinary catheter and total assistance with all his activities of daily living (ADLs). Review of Resident #38's May 2022 Physician orders did not include any orders for a suprapubic catheter, catheter changes, assessment or maintenance of his urinary catheter. There were also no orders for the facility protocol for urinary catheters. Review of Resident #38's April and May 2022 Treatment Administration Record (TAR) did not include any documented evidence of urinary catheter care, assessment or maintenance. Review of Resident #38's nursing notes dated 1/28/22, 2/27/22, 3/16/22, 3/23/22, 4/9/22 and 4/20/22 all contained documentation regarding his suprapubic catheter sliding out or leaking. An interview and observation were completed with Resident #38 on 5/9/22 at 12:26 PM. He stated he was worried about the hole in his stomach. He confirmed he was describing his suprapubic insertion site. An observation and interview were conducted with Nursing Assistant (NA) #6 on 5/10/22 at 10:45 AM. She was in the process of providing Resident #38's morning ADLs. The aide lifted his abdominal fold to reveal a suprapubic insertion site with an open area to the right of the insertion site with bright red blood. His securement device was in place. NA #6 stated the area did not appear that way on 5/9/22 because she would have reported it to the nurse. An observation and interview were conducted with the Staff Development Coordinator (SDC) on 5/10/22 at 10:47 AM. She stated she was not aware Resident #38's catheter insertion site looked the way it did. The SDC stated the floor nurses and the aides provided catheter care but the Treatment (TN) and the Assistant Director of Nursing (ADON) assessed the catheter insertion sites weekly. An interview was conducted with Nurse #1 on 5/10/22 at 11:10 AM. She stated she thought the floor nurses, or the TN assessed and cleaned Resident #38's suprapubic insertion site daily. She stated she had not completed care or assessment of Resident #38's catheter on 5/9/22 or 5/10/22 and she was not aware of bleeding at the insertion site. An observation and interview were completed on 5/10/22 at 11:20 AM with the TN and the ADON. Both assessed Resident #38's suprapubic insertion site and stated the area did not appear that way when assessed last week. The TN proceeded to clean the area with gauze with fresh blood observed. The ADON stated she would notify the MD of the appearance of Resident #38's suprapubic catheter insertion site. The TN stated he was under the impression there was a suprapubic catheter protocol on his Physician orders. The TN stated he was not aware of where to locate the facility's suprapubic catheter protocol. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated he was under the impression that the facility had a protocol for the care of residents with suprapubic catheters and was not aware that there were no orders for the care and assessment of Resident #38's suprapubic catheter. He stated the ADON contacted him on 5/10/22 and notified of the appearance of his catheter insertion site. He stated he gave new orders to clean the area daily. The MD stated the nurses, or the TN should have obtained monthly Physician orders for his suprapubic catheter, assessed and cleaned his suprapubic site daily. Review of Resident #38's Physician orders included an order dated 5/11/22 for daily and as needed cleaning of his suprapubic catheter site using normal saline and gauze, pat dry with gauze, cover site the with a T-Sponge (a precut, snug fit sponge designed to wick moisture away from the catheter site) and secure the sponge with tape for wound healing. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated The DON stated there should be Physician orders for Resident #38's suprapubic and assessed daily. 3. Resident #74 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #74's quarterly Minimum Data Set (MDS) dated [DATE] and indicated the resident was mildly cognitively impaired, required assistance with activities of daily living (ADL), and had an indwelling urinary catheter. Resident #74's comprehensive care plan, last revised on 3/16/2022, included a focus for altered pattern or urinary elimination related to indwelling urinary catheter. Interventions included catheter care per physician's order or the facility protocol, catheter changes per MD orders and/or facility protocol, maintain unobstructed urine flow, ensure the urinary was below the level of the bladder and the catheter secured with an anchoring device. Resident #74 had a physician's order dated 4/22/2022 for reinsertion of urinary catheter for wound healing. The order was entered by the ADON. Resident #74's May 2022 Physician orders did not include orders for changes, assessments, or maintenance of his urinary catheter. The facility's protocol for indwelling urinary catheters did not address care and maintenance of a urinary catheters. Resident #74's April and May 2022 Treatment Administration Record (TAR) did not include any documented evidence of urinary catheter care, assessment or maintenance. An interview was conducted with Resident #74 on 5/11/2022 at 2:05 PM. She stated the staff cleaned her urinary catheter every shift. An interview was conducted with the ADON on 05/11/2022 at 2:48 PM. She stated she did put in the order for Resident #74's indwelling urinary catheter. She further stated the urinary catheter was placed for wound healing. The ADON stated she should have put in catheter care orders but she did not. On 5/11/2022 at 4:11 PM an interview was conducted with Nurse #9. She stated she was assigned to Resident #74 and she provided urinary catheter care to the resident every shift. Nurse #9 reviewed Resident #74's medical record and stated she could not find urinary catheter care orders for the resident. An interview was conducted with the MD on 5/11/22 at 9:50 AM. He stated he thought the facility had a protocol for the care of residents with indwelling urinary catheters. He further stated he was not aware there were no orders for the care and assessment of Resident #74's indwelling urinary catheter. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated there should be Physician orders for daily care and maintenance of Resident #74's urinary catheter.

Based on staff interviews and record review, the facility failed to maintain complete and accurate medical records in the areas pressure ulcer treatments, (Resident #30, Resident #38 and Resident #17) and surgical wound treatments (Resident #40). This was for 4 of 20 residents reviewed for accurate and complete medical records. The findings included: 1. Resident #30 was admitted on [DATE] with a pressure ulcer to his sacrum. His admission Minimum Data Set (MDS) dated [DATE] indicated he was coded for 2 stage pressure ulcers. Review of Resident #30's wound consult dated 5/2/22 indicated the area on his left buttock was described as his sacrum. The area was debrided and a new order for an alternating air mattress (AAM). Review of Resident #30's May 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's May 2022 Treatment Administration Record (TAR) revealed no documented evidence his wound care was provided on 5/3/22, 5/5/22, 5/6/22, 5/8/22 and 5/11/22. Review of Resident #30's nursing notes from 5/1/22 to 5/11/22 did not include any documented evidence of wound care refusals. An interview with the Treatment Nurse (TN) was completed on 5/11/22 at 4:50 PM. He reviewed Resident #30's May TAR and acknowledged there was no documentation of his wound care on the days identified. He stated the wound care was completed as ordered for Resident #30 but he needed to improve his documentation by initialing off in Resident #30's electronic medical record (EMR). He stated he had not gotten used to documenting in the EMR. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident. 2. Resident #38 was admitted on [DATE]and recently readmitted on [DATE] with pressure ulcers to his right and left heels. His quarterly Minimum Data assessment dated [DATE] indicated he was coded for one stage 3 pressure ulcer and 3 venous ulcers. Review of Resident #38's April 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's April 2022 Treatment Administration Record (TAR) revealed no documented evidence his wound care was provided on 4/21/22, 4/24/22, 4/26/22 and 4/30/22. Review of Resident #38's May 2022 TAR revealed no documented evidence his wound care was provided from 5/6/22 through 5/10/22. Review of Resident #38's nursing notes from 4/19/22 to 5/11/22 did not include any documented evidence of wound care refusals. An interview with the Treatment Nurse (TN) was completed on 5/11/22 at 4:50 PM. He reviewed Resident #38's May TAR and acknowledged there was no documentation of his wound care on the days identified. He stated the wound care was completed as ordered for Resident #38 but he needed to improve his documentation by initialing off in Resident #38's electronic medical record (EMR). He stated he had not gotten used to documenting in the EMR. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident. 3. Resident #17 was admitted on [DATE] and readmitted on [DATE] after an amputation of all the toes on his left foot. His readmission Minimum Data Set, dated dated dated [DATE] was coded for a surgical wound. Review of Resident #17's April 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's April 2022 Treatment Administration Record (TAR) revealed no documented evidence his wound care was provided on 4/20/22, 4/21/22, 4/23/22 and 4/24/22. Review of Resident #17's May 2022 TAR revealed no documented evidence his wound care was provided on 5/3/22, 5/5/22, 5/6/22, 5/8/22 and 5/11/22. An interview with the Treatment Nurse (TN) was completed on 5/11/22 at 4:50 PM. He reviewed Resident #17's May TAR and acknowledged there was no documentation of his wound care on the days identified. He stated the wound care was completed as ordered for Resident #17 but he needed to improve his documentation by initialing off in Resident #17's electronic medical record (EMR). He stated he had not gotten used to documenting in the EMR. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident. 4. Resident #40 was originally admitted to the facility on [DATE] with a readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was cognitively intact and had surgical wounds present. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Clean the perineal wound with normal saline using gauze, pat dry with clean gauze, apply Calcium Alginate with Silver (a highly absorbent gel-like covering to help maintain a moist environment that promotes wound healing) and secure every day. - Clean the right buttock wound with normal saline using gauzes, pat dry with clean gauze, apply Calcium Alginate with Silver and secure every day. The April 2022 and May 2022 Treatment Administration Record (TAR) was reviewed and demonstrated the surgical wound care to Resident #40's perineum and right buttock was not initialed as completed or refused by the resident at 9:00 AM on 4/21/22, 4/26/22, 5/3/22, 5/5/22 and 5/6/22. Review of the nursing progress notes from 1/3/22 to 5/6/22 did not include any refusals of wound care by Resident #40. The Treatment Nurse was interviewed on 5/11/22 at 4:50 PM and explained he completed wound care dressing changes Monday through Friday on the day shift (7:00 AM to 3:00 PM). After reviewing the missing documentation for Resident #40, on the April 2022 and May 2022 TARs, he stated he would have been on duty on those dates. The Treatment Nurse stated he had completed the wound care to Resident #40 as ordered and needed to get better with signing off treatments in the new Electronic Medical Record system. It's just a bunch of clickity clacks on the computer and I've just not gotten the hang of it yet. On 5/12/22 at 1:15 PM, an interview was held with the Director of Nursing (DON). She explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22 but expected the Treatment Nurse as well as any other nursing staff to sign off when wound care was completed or indicate if it was refused by the resident.

Based on record review, observations, resident and staff interviews, the facility failed to promote dignity by not providing a privacy cover over a urinary drainage bag for 1 of 1 residents reviewed for dignity (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 was cognitively intact. He required extensive assistance from staff for toileting needs and had an indwelling urinary catheter. During an interview and observation with Resident #34, on 5/9/22 at 10:22 AM, he was noted to have an indwelling urinary catheter with the drainage bag attached to the right side of the bed. The drainage bag did not have a privacy cover, had dark yellow urine in the drainage bag and could be seen from the hallway. Resident #34 stated he knew the bag was visible from the hallway and to others and would prefer for it to be covered. On 5/9/22 at 1:15 PM, an observation was made of Resident #34 with the urinary drainage bag attached to the right side of the bed. The drainage bag did not have a privacy cover, had yellow urine in the bag, and could be seen from the hallway. An observation occurred of Resident #34 while he was lying in bed on 5/10/22 at 11:09 AM. The urinary drainage bag was clipped to the right side of the bed, without a privacy cover, and visible from the hallway with dark yellow urine in the drainage bag. On 5/11/22 at 10:28 AM, Resident #34 was observed while lying in bed. The urinary drainage bag with dark yellow urine, remained without a privacy cover and was visible from the doorway. An interview occurred with Nurse #1 on 5/11/22 at 10:35 AM and stated all residents with urinary catheters should have a privacy cover on the drainage bags. She stated Resident #34 had recently been to the emergency room and could be the reason why he didn't have a privacy cover on the drainage bag. Nurse #1 indicated she would make sure one was provided for Resident #34. During an interview with the Administrator and Director of Nursing on 5/12/22 at 1:14 PM, they both indicated it was their expectation for nursing staff to use a privacy cover for urinary drainage bags and was unable to state why Resident #34's drainage bag was not covered.

Based on observations, staff and resident interviews and record review, the facility failed to ensure an adaptive call light was positioned within resident's access. This was for 1 of 1 resident (Resident #38) reviewed for accommodation of needs. The findings included: Resident #38 was admitted on [DATE]and most recently readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #38's revised care plan dated 9/17/21 read due to the inability to use a regular call light due to contractures, he required a soft touch call light to make his needs known. Interventions included ensuring the call light was placed so Resident #38 could reach it. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact and was coded with impairment of range of motion (ROM) to his bilateral upper and lower extremities. An interview and observation were completed with Resident #38 on 5/9/22 at 12:26 PM. He had bilateral hand contractures and a left elbow contracture. His adaptive call light was observed clipped to the right upper top of his fitted sheet. He stated he could not get to his call light most of the time, so he had to yell out when he needed something. Resident #38 attempted to lift his right arm and hand in an effort of reach the call light but stated his arm was too stiff. He stated he often forgot to ask the staff to ensure his call light was accessible because it had been out of his reach so much, he resorted to yelling. An observation was completed on 5/10/22 at 10:51 AM of Resident #38's. His adaptive call light was observed clipped to the right upper top of his fitted sheet. An interview was conducted on 5/11/22 at 8:20 AM with Nursing Assistant (NA) #6 stated she was assigned Resident #38 on 5/9/22 and 5/10/22. She stated he used a special soft call light because of his contractures. She stated she was uncertain if he yelled out for assistance when his adaptive call light was not in reach because it only happened on occasion. An interview was completed on 5/10/22 at 12:20 PM with the ADON. She stated Resident #38 required an adaptive call light due to his hand contractures and the contracture of his left elbow. An observation was completed on 5/12/22 at 10:05 AM of Resident #38. His call light was clipped to the upper right side of his pillow case. He stated he was unable to reach it and had not asked anyone to move it within his reach. An observation and interview were completed on 5/12/22 at 10:40 AM of Resident #38 with NA #8 present in the room. His call light was still clipped to the upper right side of his pillow case. When questioned about Resident #38's adaptive call light placement, NA #8 stated he was unable to reach his call light where it was, and she moved the call light and clipped it to the chest area of his gown within his reach. She stated Resident #38's call light should always be within his reach. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she excepted Resident #38's adaptive call light remain within his reach at all times.

Based on record reviews, observations, resident, staff and physician interviews, the facility failed to provide surgical wound care as ordered for 1 of 3 residents reviewed for non-pressure related wound care (Resident #40). The findings included: Resident #40 was originally admitted to the facility on [DATE] with a readmitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing progress notes were reviewed from 1/3/22 to 5/8/22 and indicated Resident #40 had no episodes of refusal of wound care. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was cognitively intact and had surgical wounds present. Review of a Wound Clinic assessment dated [DATE] revealed the perineal surgical wound measured 8.2 centimeters (cm) in length, 0.5 cm in width and 0.5cm in depth. There was tunnelling at three o'clock with a maximum distance of 3 cm. The right buttock surgical wound measured 1.8 cm in length, 0.3 cm in width and 2 cm in depth. There was tunnelling at three o'clock with a maximum distance of 3 cm. Resident #40's active care plan, last reviewed 3/31/22, revealed a focus area for potential for/actual skin integrity impairment: diabetic/neuropathic ulcers related to: diabetic ulcer to foot, left buttock surgical incision. The interventions included to provide treatments as ordered. A review of a Wound Clinic assessment dated [DATE] revealed Resident #40's open surgical wound to the perineum measured 5 cm in length, 0.3 cm in width and 0.3 cm in depth. There was no tunneling present. The right buttock open surgical wound measured 1 cm in length, 0.2 cm in width and 0.5 cm in depth. There was tunneling at three o'clock with a maximum distance of 2.9 cm. There was no necrotic (dead) tissue in the wound bed. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Clean the perineal wound with normal saline using gauze, pat dry with clean gauze, apply Calcium Alginate with Silver (a highly absorbent gel-like covering to help maintain a moist environment that promotes wound healing) and secure every day. - Clean the right buttock wound with normal saline using gauzes, pat dry with clean gauze, apply Calcium Alginate with Silver and secure every day. A review of a Wound Clinic assessment dated [DATE] revealed Resident #40's open surgical wound to the perineum measured 8 cm in length, 1 cm in width and 0.5 cm in depth. There was no tunneling present. The right buttock open surgical wound measured 1.5 cm in length, 0.5 cm in width and 3 cm in depth. There was no tunneling or necrotic tissue in the wound bed. The April 2022 Treatment Administration Record (TAR) was reviewed and demonstrated the surgical wound care to Resident #40's perineum and right buttock were not initialed as completed on 4/23/22, 4/24/22 and 4/30/22 at 9:00 AM. On 5/12/22 at 9:20 AM, an interview was completed with the Staff Development Coordinator (SDC) who was assigned to Resident #40 on 4/24/22. She explained nursing staff were responsible for wound care when the treatment nurse wasn't present and normally the weekend supervisor (Nurse #4) completed the wound care on the weekends. The SDC further stated the weekend supervisor had been on medical leave since 4/20/22 and had not returned to work yet. The SDC reviewed Resident #40's April 2022 TAR and stated she didn't provide any wound care on 4/24/22 to the perineal or right buttock surgical wound, because she was covering the house and pushing a cart and thought the second shift (3:00 PM to 11:00 PM) nurse would complete the care. A phone interview occurred with Nurse #6 on 5/12/22 at 9:32 AM. She was the nurse assigned to Resident #40 on the second shift on 4/24/22. She could not recall being told the wound care had not been completed that morning and stated the electronic TAR did not show the wound care was needed for her shift. Nurse #6 explained she was asked by Resident #40 to change the dressing on his perineal wound, which she did, and a progress note was written, but she did not change the right buttock surgical wound dressing as she was under the impression it had already been completed on the day shift as ordered. Review of a nursing progress note written by Nurse #6 and dated 4/24/22, indicated per Resident #40's request the perineal surgical wound was cleansed and wound care was provided. The May 2022 TAR was reviewed and revealed the surgical wound care to Resident #40's perineum and right buttock were not initialed as completed on 5/1/22, 5/7/22 or 5/8/22 at 9:00 AM. On 5/11/22 at 2:50 PM, an interview was conducted with Nurse #1, who had been assigned to Resident #40 on 4/30/22 and 5/1/22. She stated she could not recall completing any wound care for Resident #40's perineal or right buttock surgical wounds and was unaware he had any wound orders. Multiple attempts were made during the course of the survey to contact Nurse #4, who was the weekend supervisor; Nurse #5, who was assigned to Resident #40 on 4/23/22; and Nurse #7, who was assigned to Resident #40 on 5/7/22 and 5/8/22, without success. A review of the Wound Clinic assessment dated [DATE] indicated Resident #40's open surgical wound to the perineum measured 3.5cm in length, 0.4 cm in width and 0.1 cm in depth. The right buttock open surgical wound was healed with all measurements at zero. The Treatment Nurse was interviewed on 5/9/22 at 3:45 PM and explained he completed wound care dressing changes Monday through Friday on the day shift (7:00 AM to 3:00 PM) and that nursing staff were responsible for completing their own wound care in the afternoon and evening shifts, if there was a need, as well as on the weekend. Another interview occurred with the Treatment Nurse on 5/11/22 at 4:50 PM. He reiterated nursing staff were responsible for wound care when he was not on duty as well as on the weekend and stated normally on the weekends the nursing supervisor completed wound care but had been out for several weeks. An observation of Resident #40's surgical wound care occurred on 5/10/22 at 2:33 PM with the treatment nurse and Assistant Director of Nursing (ADON). Resident #40 had an open surgical wound to the right posterior perineal area that had a small amount of brown drainage on the dressing and minimal odor. The wound bed was beefy red with no necrotic areas observed. Wound care was completed as ordered. The surgical wound to the right buttock area was healed. An interview occurred with Resident #40 on 5/11/22 at 12:00 PM. He was up in his wheelchair at bedside and stated that for the last month or so his surgical wound care had not been completed on the weekend as it was during the week. Resident #40 indicated the lack of wound care had occurred as recently as the weekend of 5/7/22 and 5/8/22. When he asked for someone to change the dressings he would be told they would be there soon. On 5/12/22 at 1:15 PM, an interview was held with the Director of Nursing (DON). She explained the facility had recently transitioned from paper to electronic TAR's on 4/19/22. The DON stated she was unaware surgical wound care was not provided to Resident #40 as ordered. She expected the nurses on day shift to report any wound care that had not been completed to the oncoming shift so it could be completed as well as all nursing staff to review the TARs for any needed wound care. The DON added a better system needed to be put into place to prevent wound care being missed as ordered. On 5/11/22 at 9:45 AM, an interview was completed with the Medical Director. The missing documentation for the April and May 2022 TARs were reviewed. The Medical Director stated he had not been informed the surgical wound care was not completed as ordered on the days no initials were present and stated he would have expected nursing staff to complete the wound care as ordered and document that it was done. Attempts were made to speak to the Wound Clinic during the course of the survey which were unsuccessful.

Based on observations, staff and resident interviews and record review, the facility failed to apply splints as ordered for contracture management (Resident #38). This was for 1 of 1 residents reviewed for range of motion (ROM). The findings included: Resident #38 was admitted on [DATE] and most recently readmitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's revised care plan dated 12/1/21 indicted he required assistance to restore or maintain his maximum potential and risk for worsening of his present contractures. Interventions included the application of a left elbow splint 6 days a week for 4 hours each day. His quarterly Minimum Data assessment dated [DATE] indicated he was cognitively intact and coded for impairment to his bilateral upper and lower extremities. Review of Resident #38's April and May 2022 Physician orders did not include any orders for splinting to his contractures. Review of Resident #38's restorative documentation for April and May 2022 indicated he was to receive restorative nursing for passive range of motion (PROM) to his bilateral shoulders, left elbow, right elbow, bilateral wrist and bilateral fingers on each hand 5 times each week. Resident #38 was also to receive restorative nursing for the application of a left elbow splint and bilateral hand splints for 4 hours a day for 6 times a week. An interview and observation was completed with Resident #38 on 5/9/22 at 12:26 PM. He had bilateral hand contractures and a left elbow contracture. There was a folded pillow case placed in the crease of his left elbow contracture and nothing to his bilateral hands. He stated at one time recently, the staff were applying his bilateral hand splints and his left elbow splint but it had not been done in a while. An observation was completed on 5/10/22 at 10:51 AM of Resident #38's. There was a folded pillow case placed in the crease of his left elbow contracture and nothing to his bilateral hands. An interview was conducted on 5/11/22 at 8:20 AM with Nursing Assistant (NA) #6 stated she was assigned Resident #38 on 5/9/22 and 5/10/22. She stated she did not apply Resident #38's splint because he was on the restorative nursing caseload. An observation was completed on 5/12/22 at 9:40 AM of Resident #38. There were no observed splints in use for his left elbow and bilateral hand contractures. An interview was completed on 5/12/22 at 9:50 AM with the Assistant Director of Nursing (ADON). She stated she was over the restorative program. The ADON was questioned as to why no splints were observed in use on 5/9/22, 5/10/22, 5/11/22 and 5/12/22, she was unable to provide an answer. An interview was completed on 5/12/22 at 11:45 AM with the Restorative Aide (RA). She stated she has had to work the floor all week and that was why Resident #38 did not receive any PROM or splinting. She stated the ADON was aware but the Scheduler continued to assign her to work on the floor and nobody assisted her with splinting when she was assigned to work the floor. An interview was completed on 5/12/22 at 12:03 PM with the facility scheduler. She stated the RA was only scheduled to work the floor today. She stated anytime she needed to pull the RA to work the floor she always notified either the ADON or the Director of Nursing (DON). An interview was completed with the Administrator and the DON on 5/12/22 at 1:15 PM. The DON stated she expected the RA and ADON to ensure Resident #38's splints were applied as ordered.

Based on observations, resident, staff, Vascular Nurse and Medical Director (MD) interviews, the facility failed to provide a dressing change to a Peripherally Inserted Central Catheter (PICC) line as ordered. This was for 1 (Resident #73) of 1 residents reviewed for infections. The findings included Resident #73 was admitted on [DATE] and readmitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Her quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and she exhibited no behaviors. Review of Resident #73's hospital discharge summary dated 4/28/22 read a PICC line was placed on 4/27/22 and she was to continue to receive an Intravenous (IV) antibiotic for another 36 doses. Review of Resident #73's readmission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The completion date of her IV antibiotic was 5/7/22. Resident #73 was care planned on 5/3/22 for an actual urinary tract infection. Interventions included observation of the PICC line for signs of infection and notify the MD, PICC line site care, flushes to the PICC line per the facility protocol or as ordered by the Physician. The Administrator provided a copy of the facility's PICC Reference Sheet dated June 2020 from a procedure manual. The transparent dressing should be changed at least every 7 days or immediately when the dressing appeared compromised. Review of Resident #73's May 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #73's April and May 2022 Medication Administration Records and Treatment Administration Records did not include any documented evidence of Resident #73's dressing change to her PICC line for 13 days. An interview and observation was completed on 5/9/22 at 11:06 AM with Resident #73. The PICC was observed to her right upper arm. There was a dressing in place that appeared rolled up around the edges but still intact at the insertion site. Resident #73 stated she just completed her IV antibiotics and she thought the PICC line dressing was the same one she was discharged from the hospital with. An observation was completed on 5/10/22 at 10:45 AM. The same dressing was still in place to Resident #73's PICC line. An interview was conducted with the Assistant Director of nursing (ADON) on 5/10/22 at 11:15 AM. She stated it was the facility's protocol to change the dressing to a PICC line every 7 days. An observation and interview was completed on 5/11/22 8:50 AM with the Vascular Nurse (VN). She stated she was there to remove Resident #73's PICC line. The PICC line dressing had been changed on 5/10/22 by the Staff Development Coordinator (SDC). She stated she was not familiar with the facility's policy on PICC lines. The VN stated the dressing changes to the PICC line site should be completed every 7 days and as needed. An interview was completed on 5/11/22 at 10:23 AM with the SDC. She stated on 5/10/22 she noticed Resident #73's PICC line dressing had not been changed since her readmission so she did it. The SDC stated PICC line dressing changes were done every 7 days and as needed. She stated she was unsure why Resident #73's PICC line dressing was not changed 7 days after her readmission on 4/28/22. An interview was completed on 5/11/22 at 9:50 AM with the MD. He stated it was his expectation that Resident #73's PICC line dressing to be changed every 7 days. An interview was completed with the Administrator and the DON on 5/12/22 at 1:15 PM. The DON stated Resident #73's PICC line dressing should have been changed last week on day 7 prior to 5/10/22.

Based on observations, staff and Medical Director (MD) interviews and record review, the facility failed to administer continuous oxygen at the prescribed rate (Resident #73 and Resident #80). This was for 2 of 3 residents reviewed for respiratory care. The findings included: 1. Resident #73 was admitted on [DATE] and readmitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her quarterly Minimum Data Set, dated dated dated [DATE] indicated she was coded for the use of oxygen. Resident #73 was care planned for ineffective breathing pattern related to [CONDITION(S)]. This care plan was last revised on 3/11/22 and included the intervention of oxygen therapy 2L/Min via nasal cannula as ordered. Review of Resident #73's readmission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was dated 10/12/21. Review of Resident #73's April 2022 Medication Administration Records (MAR) included documentation that the nurses were assessing Resident #73's oxygen rate every shift prior to her hospital transfer on 4/24/22 but it was not continued after her readmission on 4/28/22. Review of Resident #73's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview and observation was completed on 5/9/22 at 11:06 AM with Resident #73. She was wearing her oxygen with the concentrator rate set at 3.5 L/Min. Resident #73 stated she required oxygen at all times due to her [CONDITION(S)]. An observation was completed on 5/10/22 at 10:45 AM. Resident #73 was wearing her oxygen with the concentrator rate set at 3.5 L/Min. An interview was completed with the Assistant Director of nursing (ADON) on 5/10/22 at 11:15 AM. She stated the floor nurses check the oxygen concentrators settings every shift on the residents prescribed continuous oxygen. An observation was completed on 5/11/22 8:50 AM. Resident #73 was wearing her oxygen with the concentrator set at 4.5 L/Min. An interview was completed on 5/11/22 at 9:00 AM with Nurse #3. She stated Resident #73 was prescribed continuous oxygen and she was very compliant about wearing it. Nurse #3 stated the nurses check Resident #73's oxygen concentrator setting every shift to make sure the setting was at the prescribed rate. An interview was completed on 5/11/22 at 9:50 AM with the MD. He stated it was his expectation that Resident #73's continuous oxygen be administrated at the ordered rate of 2 L/Min unless otherwise indicated. An interview was completed with the Administrator and the DON on 5/12/22 at 1:15 PM. The DON stated Resident #73's oxygen should be administered at the ordered rate of 2 L/Min. 2.Resident #80 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #80's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, was dependent upon staff for assistance with activities of daily living (ADL) and received oxygen during the assessment period. The resident's comprehensive care plan was last updated on 4/27/2022 and contained a focus for potential for ineffective breathing patter related to [CONDITION(S)], oxygen dependence, and respiratory failure. Interventions included administer oxygen at 2 liters per minute via nasal cannula. Resident #80's medical record contained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date for the order was 3/9/2022 and the order was entered in the electronic medical record by the SDC. On 5/9/2022 Resident #80 was observed lying in bed, alert, oriented, and using an electronic device. She was observed to be on 4 liters of oxygen via nasal cannula. On 5/10/2022 at 1:50 PM resident #80 was observed resting in bed with her eyes closed. The oxygen concentrator was set on 4 liters per minute and being administered via nasal cannula. An interview was conducted with Medication Aide #2 on 5/10/2022 at 1:54 PM. She stated she was assigned to Resident #80. She reviewed the resident's active order for oxygen and stated she thought the resident was on 4 liters, not 2 liters, per minute of oxygen continuously. She had not noticed the order was for 2 liters per minute. An interview was conducted with the SDC on 5/12/2022 at 11:42 AM. She did not recall a written order for oxygen at 4 liter per minute for Resident #80. On 5/12/2022 at 1:15 PM and interview was conducted with the Director of Nursing (DON). She stated she expected oxygen to be accurate and oxygen administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record review and resident, staff, Medical Director (MD) and Physician #1 interviews, the facility failed to obtain and implement Physician orders for the care and monitoring of a resident on hemodialysis (Resident #17). This was for 1 of 1 resident reviewed for [CONDITION(S)]. The findings included: Resident #17 was admitted on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His readmission Minimum Data Set, dated dated dated [DATE] was coded for receiving [CONDITION(S)] treatments. Resident #17 was care planned on 3/9/22 for [CONDITION(S)] with a risk for complications due to hemodialysis. Interventions included [CONDITION(S)] on Tuesdays, Thursdays and Saturdays, no blood draws or blood pressure (BP) in his [CONDITION(S)] access arm, monitoring the access site for bleeding/infection and monitoring his vital signs per facility protocol. Review of Resident #17's April and May 2022 Physician orders did not include any orders related to [CONDITION(S)] or his [CONDITION(S)] access site. Review of Resident #17's April and May 2022 medication administration records (MARs) and treatment administration records (TARs) did not include any documentation related to [CONDITION(S)] or his [CONDITION(S)] access site. Review of Resident #17's [CONDITION(S)] communication sheets from 4/12/22 to 5/10/22 included 3 occasions of documented evidence that his right upper arm [CONDITION(S)] fistula was assessed for a thrill (vibrations felt when touching the fistula) and a bruit (a loud swishing sound when listening to the fistula using a stethoscope). The [CONDITION(S)] communication sheets did not include any documented evidence that his fistula site was monitored for bleeding. Review of Resident #17's nursing notes from 4/10/22 through 5/11/22 included 2 occasions of documented evidence that his [CONDITION(S)] fistula was assessed on 5/5/22 at 5:30 PM for a thrill and bruit and on 5/6/22 at 9:20 AM his fistula was assessed for a thrill and bruit and the appearance of his fistula dressing. There was no documented evidence that his fistula was monitored after his [CONDITION(S)] treatments for signs of bleeding. An observation and interview was completed with Resident #17 on 5/9/22 at 2:40 PM. He stated he just returned from having his [CONDITION(S)] fistula unclogged (image-guided surgical procedure to reopen a fistula). An interview and observation was completed on 5/11/22 at 11:13 AM with Resident #17. He was wearing a white undershirt under a short sleeve button down shirt. Observed were several spots of blood each approximately the size of nickel on his white undershirt over his fistula site. Resident #17 stated he removed the dressing earlier this morning and it bled a little bit. He also presented a white wash cloth with multiple small spots of blood on it. Resident #17 stated the facility staff did not routinely check his vital signs or look at his fistula dressing for bleeding after his treatments, but sometimes they checked his fistula for a thrill and bruit. He stated the facility staff knew not to get any lab work or BP's in his right arm. An interview was completed on 5/10/22 at 10:50 AM with Nursing Assistant (NA) #6. She stated no lab work or blood pressure (BP) checks were done to Resident #17's right arm because that was where his [CONDITION(S)] site was. NA #6 stated the nurses normally asked the aides to get vital signs on Resident #17 when he returned from his treatments but the nurses were responsible for checking his fistula to make sure it wasn't clogged, absent of bleeding and removing his fistula dressing after each treatment. She stated if she noticed any bleeding from his fistula, she would immediately inform his nurse. An interview was completed on 5/11/22 at 11:30 AM with Nurse #1. She confirmed she was assigned to Resident #17 on 5/9/10, 5/10/22 and today. She stated she obtained Resident #17's vital signs before each [CONDITION(S)] treatment, but she was not aware that his vital signs should be obtained after his treatments. Nurse #1 stated she was not aware that Resident #17's [CONDITION(S)] fistula should be assessed daily for a thrill and bruit, his fistula dressing monitored for signs of bleeding or leaving the fistula dressing in place for 24 hours after his treatments. She stated Resident #17 would remove his own dressing after his [CONDITION(S)] treatments sometime the following day. An interview was completed on 5/11/22 at 4:10 PM with Nurse #9. She stated she received Resident #17's from [CONDITION(S)] on 5/5/22 and was aware that Resident #17's vital signs should be obtained before and after each [CONDITION(S)] treatment but must have forgotten to document it. She stated she routinely checked his fistula dressing for signs of bleeding and his fistula for a thrill and bruit. Nurse #9 stated Resident #17 knew not to remove his fistula dressing until the following day. An interview was completed on 5/12/22 at 10:10 AM with Nurse #2. She stated she was not aware of the need to obtain Resident #17's vital signs after his [CONDITION(S)] treatments. She stated she did assess his fistula dressing for bleeding but frequently forgot to assess for a thrill and bruit. An interview was completed on 5/11/22 at 8:55 AM with the Assistant Director of Nursing (ADON). She stated the nurses monitored Resident #17's fistula for bleeding and obtained his vital signs after each treatment. An interview was completed with the Administrator and the Director of Nursing (DON) on 5/12/22 at 1:15 PM. The DON stated she excepted the staff to obtain Physician orders, implement those orders and be knowledgeable regarding the care of a [CONDITION(S)] resident to include Resident #17. The DON stated it was the responsibility of the floor nurses to ensure all Physician orders were obtained and any required monitoring be entered into the electronic medical record (EMAR) on admission and readmission. A telephone interview was completed on 5/12/22 at 10:44 AM with Physician #1. He stated he was under the impression that the facility implemented standing orders for [CONDITION(S)] residents and was not aware Resident #17 did not have any orders. The Physician stated it was his expectation that the facility contact him for any missing orders and implement those orders for Resident #17 An interview was completed on 5/11/22 at 9:05 AM with the MD. He stated he was not Resident #17's Physician but it was his expectation that there be written orders for [CONDITION(S)]. He stated there should be orders for the assessment of a thrill and bruit, vital signs, signs of bleeding and leaving his fistula dressing in place for 24 hours before removing.

3a) Resident #3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's active care plan, last reviewed 4/1/21, included a focus area for admitted with pressure ulcer to sacrum and was at risk of developing further pressure areas related to immobility. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact and displayed no behaviors or refusal of care during the 7 day look back period. She required extensive assistance with Activities of Daily Living (ADL's) and was coded with 1 stage 3 pressure ulcer. The June 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack with Calcium Alginate (a wound dressing used for wounds with drainage) and [MEDICATION(S)] (medical grade honey that has antibacterial actions) and cover with a foam dressing 3 times a week. A review of the facility's Wound Ulcer Flowsheet dated 6/4/21 revealed the pressure area to the coccyx measured 1.5 centimeters (cm) in width, 1 cm in length and 0.2 cm in depth and indicated the wound was slow in healing. The June 2021 Treatment Administration Record (TAR) revealed wound care to Resident #3's coccyx pressure ulcer was completed on 6/4/21 and not initialed as completed on 6/7/21. The nursing progress notes from 12/1/20 to 6/16/21 were reviewed and indicated Resident #3 had no episodes of refusals of wound care or any type of behavior. A phone interview was completed with the Medical Director on 6/16/21 at 10:05 AM and stated he was unaware the wound care for Resident #3 had not been completed as ordered on 6/7/21. He added he would have expected the treatment to be completed as ordered even when the Treatment Nurse was out of the facility or to be notified if there was a reason the wound care could not be completed as ordered. An interview occurred with Nurse #4 on 6/16/21 at 11:42 AM, who was familiar with Resident #3. She was scheduled for the 7:00 AM to 3:00 PM shift on 6/7/21 and explained when the treatment nurse was out of the facility the floor nurses were expected to complete wound care as ordered. The June 2021 TAR was reviewed, and stated she was not aware the treatment nurse was out of the facility nor was she informed that she would be responsible to complete wound care for Resident #3 on 6/7/21. An interview was conducted with the Director of Nursing (DON) on 6/16/21 at 4:50 PM. The DON explained she was unaware the treatment nurse was out of the facility until the afternoon of 6/11/21 and at that time she informed the floor nurses they would be responsible for wound care of their residents until 6/14/21. 3b) Resident #3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's active care plan, last reviewed 4/1/21, included a focus area for admitted with pressure ulcer to the sacrum and was at risk of developing further pressure areas related to immobility. The interventions included an air mattress to the bed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact and displayed no behaviors or refusal of care during the 7 day look back period. She required extensive assistance with Activities of Daily Living (ADL's), was coded with 1 stage 3 pressure ulcer and had a pressure reducing device to the bed. Review of Resident #3's June 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's weight on 6/11/21 was 229 pounds (lbs.). Resident #3's alternating pressure reducing mattress machine was observed on 6/15/21 at 10:25 AM and was set at 450 lbs. The machine had settings from 50 to 450 lbs. and indicated to set according to resident's weight per lbs. On 6/15/21 at 2:45 PM, Resident #3 was observed sitting in the wheelchair at her bedside. The alternating pressure reducing mattress machine was set at 450 lb. The Treatment Nurse was interviewed on 6/16/21 at 10:48 AM, who stated he checked the functionality of the air mattresses daily and was unaware Resident #3's alternating pressure reducing mattress machine being set at 450 lbs. but would check on it. On 6/16/21 at 1:32 PM, Resident #3 was observed sitting up in her wheelchair. The alternating pressure reducing mattress machine was set at 280 lbs. An interview was conducted with the Director of Nursing (DON) on 6/16/21 at 4:50 PM and indicated she was unaware whose responsibility it was to check the functionality of the air alternating pressure mattresses, but felt it should be done at least daily, most likely by the Treatment Nurse. She further indicated she expected the alternating air mattresses to be set according to the resident's weight for residents with pressure ulcers to promote healing. On 6/16/21 at 5:20 PM, the Treatment Nurse indicated he had checked on Resident #3's alternating air mattress earlier, confirmed it had been set for 450 lbs. and stated he adjusted it. He indicated he was checking the setting of the air mattress daily but was unable to state the last time it was observed. The Treatment Nurse indicated Resident #3's alternating air mattress machine should have been set for 230 lbs. as her weight was 229 lbs. and the machine should have been locked.

Based on record review, observation, and staff interview, the facility failed to implement fall prevention interventions, and also failed to thoroughly investigate and analyze falls to determine causative factors and implement appropriate interventions to reduce the risk of further falls for 1 of 5 residents reviewed for falls. Resident #28 sustained 10 falls in 5 months with 2 of these falls resulting in multiple staples to her head. The findings included: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28's cognition was severely impaired. Resident #28 required the extensive assistance of 2 or more for bed mobility, dressing, toileting, and personal hygiene and the extensive assist of 1 for transfers. She was assessed as requiring supervision of 1 for walking in room and locomotion on the unit and supervision with set up help only for walking in corridor. Resident #28 was not steady on her feet, but she was able to stabilize without staff assistance. Resident #28 ' s care plan included the focus area of the risk for falls characterized by a history of falls and injury. This area was initiated on 12/22/17 and the interventions included: - Bed in lowest position (initiated 12/22/17) - Encourage resident to take rest periods as needed when ambulating (initiated 4/2/18) - Rehabilitation therapy referral as needed (initiated 6/5/18) - Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs and other medications with physician for possible decrease in dosage/elimination of medication (initiated 12/22/17 and revised 6/7/18) - Resident to wear proper non-slip footwear (initiated 6/7/18) - Provide diversional activities (initiated 6/7/18) - Have commonly used items within reach (initiated 6/18/18) - Encourage resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility (initiated 6/21/18) - Toilet resident frequently as needed and prior to going to bed at night (initiated 6/22/18 and revised 6/25/18) - Encourage resident to take rest periods as needed when resident was pacing a lot. Offer resident snacks and pain medication as needed. (initiated 4/30/18 and revised 6/25/18) - Assist during transfer and mobility. Anticipate needs and intervene when resident was bending, stooping and/or reaching (initiated 6/25/18) - Keep wheelchair within reach of the resident with anti-rollbacks (initiated 4/30/18 and revised 7/27/18) - Observe for potential medication side effects that may increase risk for falls (initiated 9/4/18) - Provide frequent staff observation of resident (initiated 9/10/18) - Ensure environment free of clutter (initiated 9/10/18) - Encourage resident to use handrails or assistive devices properly (initiated 10/8/18) - Keep call light within reach and answer timely (initiated 10/15/18) An incident report dated 10/20/18 completed by Nurse #7 indicated Resident #28 had unwitnessed fall on 10/20/18 at 10:50 AM that resulted in small bump to the left side of her forehead. Resident #28 was found lying on her left side in front of her wheelchair on the floor in the hallway of the memory care unit. The fall investigation checklist form dated 10/20/18 completed by Nurse #7 indicated the new intervention that was put into place to prevent a repeat fall was to add anti-rollbacks to Resident #28's wheelchair. This checklist indicated that the 10/20/18 fall for Resident #28 was reviewed on 10/22/18 during the morning meeting and the fall investigation was signed as complete by Unit Manager (UM) #1. The investigation follow up form, undated and unsigned, indicated Resident #28 had a fall on 10/20/18 at 10:50 AM. Resident #28 used a wheelchair with no pedals and was able to self-propel the wheelchair and to ambulate independently. She was noted with no safety awareness related to Alzheimer's. The interventions to prevent reoccurrence indicated that Resident #28 was to be encouraged to take frequent rest periods and to sit in wheelchair. Anti-rollbacks were to be put into place on Resident #28's wheelchair to stabilize it for her. Resident #28's care plan related to falls was updated on 10/23/18 with the intervention of anti-rollbacks on wheelchair. This was a repeat intervention as it was initiated on Resident #28's care plan on 4/30/18. A fall risk assessment dated [DATE] indicated Resident #28 was at high risk for falls. A work order dated 10/24/18 completed by UM #1 indicated anti-rollbacks were to be added to Resident #28's wheelchair. This work order indicated the anti-rollbacks were added on 10/25/18. A phone interview was conducted with Nurse #7 on 4/3/19 at 2:43 PM. Nurse #7 stated that the nurse assigned to the resident at the time of the fall completed an incident report and initiated the fall investigation checklist form. She explained that this form had a question on it about what new interventions were going to be implemented to prevent repeated falls. Nurse #7 further explained that sometimes she had a tough time answering this question if it was related to a resident who already had multiple interventions in place. She reported that if she was unable to think of an appropriate intervention that she left this question blank and let one of UMs determine what new intervention was appropriate. The incident report, investigation checklist, and investigation follow up form that indicated anti-rollbacks were to be implemented for Resident #28 after the 10/20/18 fall were reviewed with Nurse #7. The care plan that indicated that the intervention of anti-rollbacks was already in place on Resident #28's care plan (initiated on 4/30/18 and last revised 7/27/18) was reviewed with Nurse #7. Nurse #7 stated she believed one of the UMs had added that intervention onto the investigation checklist. She was unable to recall with certainty if Resident #28's wheelchair had anti-rollbacks at the time of the 10/20/18. She indicated that if it was noted as a new intervention that the anti-rollbacks were probably not in place on Resident #28's wheelchair. An interview was conducted with UM #1 on 4/2/19 at 2:40 PM. UM #1 stated the nurse assigned to the resident at the time of the fall completed an incident report and initiated the fall investigation checklist form. She reported this nurse was supposed to identify a new fall prevention intervention that related to the fall. She stated that during the morning meetings on Mondays through Fridays all falls were reviewed with management staff and she and UM #2 were responsible for ensuring the investigation checklist was completed and that a new fall prevention intervention was identified. UM #1 was asked if the investigation into the fall included a review of the current fall prevention interventions to ensure they were in place. She stated that the investigation should include a review of this information. The incident report, investigation checklist, and investigation follow up form that indicated anti-rollbacks were to be implemented for Resident #28 after the 10/20/18 were reviewed with UM #1. The work order that indicated anti-rollbacks were added to Resident #28's wheelchair on 10/25/18 was reviewed with UM #1. The care plan that indicated the intervention of anti-rollbacks was already in place on Resident #28 ' s care plan (initiated on 4/30/18 and last revised 7/27/18) at the time of her 10/20/18 fall was reviewed with UM #1. UM #1 was unable to explain why Resident #28's anti-rollbacks were not in place at the time of her 10/20/18 fall when this intervention was already on her care plan. She was also unable to explain why the investigation failed to identify that this care planned intervention had not been implemented. An incident report dated 11/5/18 completed by Nurse #8 indicated Resident #28 had a witnessed fall on 11/5/18 at 10:10 AM that resulted in a knot to the right back of her head. Resident #28's Nursing Assistant (NA) reported that while she was giving Resident #28 a bed bath the resident stood up and fell . The NA was noted as NA #8. The fall investigation checklist form dated 11/5/18 completed by Nurse #8 indicated the new intervention that was put into place to prevent a repeat fall for Resident #28 was to watch during bathing. The section on this checklist that provided a date the fall was reviewed during the morning meeting was blank and there was no signature by UM #1 or UM #2 to indicate the investigation was complete. A phone interview was attempted on 4/3/19 at 9:04 AM with Nurse #8 but she was unable to be reached. A phone interview was attempted on 4/3/19 at 9:05 AM with NA #8 but she was unable to be reached. An interview was conducted with UM #1 on 4/2/19 at 2:40 PM. The incident report and the fall investigation checklist form that was partially completed for Resident #28's 11/5/18 fall were reviewed with UM #1. The new intervention identified on the fall investigation checklist that stated watch during bathing was reviewed with UM #1. UM #1 verified that this investigation checklist was incomplete, but she was unable to provide an explanation as to why. She revealed that NA #8 should not have turned her back on Resident #28 while she was giving her a bed bath. She further revealed that watch during bathing was not a new intervention as this should have been normal protocol for the NA while bathing Resident #28. UM #1 was unable to recall if any re-education had been provided to NA #8 after this incident. She stated that NA #8 was no longer employed at the facility. A physician's note dated 11/19/18 indicated Resident #28 was a fall risk related to mobility impairment. He reported that because of Resident #28's dementia there was a slow physical decline which required frequent monitoring as well as preventative measures to prevent falls with potential injuries or fractures. The physician wrote that Resident #28's had multiple comorbid factors that created poor activity endurance while performing essential activities of daily living without assistance which made safety a priority for Resident #28. An incident report dated 12/2/18 completed by Nurse #9 indicated Resident #28 had an unwitnessed fall on 12/2/18 at 10:39 PM. Resident #28 was found on the floor, sitting on her buttocks, with bleeding noted to the back of her head. She was sent to the emergency room (ER) for evaluation. An ER note dated 12/2/18 indicated Resident #28 had laceration to her scalp 2 centimeters (cm) in length and 3 millimeters (mm) in depth. The laceration was repaired with 4 staples. The fall investigation checklist form dated 12/2/18 completed by Nurse #9 indicated the new intervention that was put into place to prevent a repeat fall for Resident #28 was observe and intervene for causative factors. This checklist indicated that the 12/2/18 fall for Resident #28 was reviewed on 12/3/18 during the morning meeting and the fall investigation was signed as complete by UM #2. The care plan for Resident #28 related to falls was revised on 12/4/18 with the new intervention to observe and intervene for factors causing falls . A phone interview was conducted with Nurse #9 on 4/3/19 at 8:49 AM. Nurse #9 stated that the nurse assigned to the resident at the time of the fall completed an incident report and initiated the fall investigation checklist form. She stated that she never completed the question that asked about new interventions on the Investigation checklist. She reported she left this question blank and that UM #1 or UM #2 answered the question. The incident report for Resident #28's 12/2/18 fall was reviewed with Nurse #9. The fall investigation checklist that indicated the new intervention that was implemented was observe and intervene for causative factors was reviewed with Nurse #9. Nurse #9 stated that this intervention was already in place as the staff were supposed to be observing Resident #28 and trying to figure out the cause of every fall. An interview was conducted with UM #2 on 4/2/19 at 3:08 PM. The incident report and the fall investigation checklist form for Resident #28's 12/2/18 fall were reviewed with UM #2. The new intervention identified on the fall investigation checklist that stated observe and intervene for causative factors was reviewed with UM #2. UM #2 acknowledged that the intervention of observing Resident #28 and trying to figure out the cause of her falls was not a new intervention as this was normal procedure for all resident falls. He revealed that he was aware the interventions noted on the investigation checklists were not always related to the fall that occurred. He indicated it was an ongoing process to educate the nurses on how to properly fill out the investigation checklist form. An incident report dated 1/13/19 completed by Nurse #14 indicated Resident #28 had an unwitnessed fall on 1/13/19 at 10:13 PM. Resident #28 was found in the hallway, seated on her buttocks, with bleeding noted to the right side of her scalp. She was sent to the ER for evaluation. An ER note dated 1/13/19 indicated Resident #28 had a laceration to her scalp 2 cm in length. The laceration was repaired with 5 staples. The fall investigation checklist form dated 1/13/19 completed by Nurse #14 indicated the new intervention that was put into place to prevent a repeat fall was to assist Resident #28 with ambulation when in the hallway and to direct to an activity. This checklist indicated that the 1/13/19 fall for Resident #28 was reviewed on 1/14/19 during the morning meeting and the fall investigation was signed as complete by UM #1. A phone interview was attempted on 4/3/19 at 9:08 AM with Nurse #14 but she was unable to be reached. An incident report dated 1/17/19 completed by Nurse #7 indicated Resident #28 had an unwitnessed fall with no injury in the dining room of the memory care unit on 1/17/19 at 8:40 AM. Resident #28 was found lying on the floor on her back in the dining room on the memory care unit. The fall investigation checklist form dated 1/17/19 completed by Nurse #7 indicated the new intervention that was put into place to prevent a repeat fall for Resident #28 was to observe routinely for needs. This checklist indicated that the 1/17/19 fall for Resident #28 was reviewed on 1/18/19 during the morning meeting and the fall investigation was signed as complete by UM #2 on 1/21/19. A phone interview was conducted with Nurse #7 on 4/3/19 at 2:43 PM. The incident report related to the 1/17/19 fall for Resident #28 was reviewed with Nurse #7. The investigation checklist form that identified the new intervention of observing Resident #28 routinely for needs was reviewed with Nurse #7. Nurse #7 reported that this was not a new intervention as staff had to frequently monitor Resident #28 at all times. An interview was conducted with UM #2 on 4/2/19 at 3:08 PM. The incident report and the fall investigation checklist form for Resident #28 ' s 1/17/19 fall were reviewed with UM #2. The new intervention identified on the fall investigation checklist that stated observe routinely for needs was reviewed with UM #2. UM #2 acknowledged that the intervention of observing Resident #28 routinely for needs was not a new intervention as staff were expected to observe all residents routinely for needs. An incident report dated 1/20/19 completed by Nurse #10 indicated Resident #28 had an unwitnessed fall with no injury in the television room on the memory care unit on 1/20/19 at 11:44 AM. The fall investigation checklist form dated 1/20/19 completed by Nurse #10 indicated Resident #28 was reaching for a cup when she fell . The new intervention that was put into place to prevent a repeat fall was to transfer and change position slowly. This checklist indicated the 1/20/19 fall for Resident #28 was reviewed on 1/21/19 during the morning meeting and the fall investigation was signed as complete by UM #1. The care plan related to falls for Resident #28 was updated on 1/21/19 with the interventions of transfer and change position slowly and observe resident routinely for needs. The care plan related to falls for Resident #28 was updated on 1/22/19 with the intervention of assist to ambulate when in hallway and direct to an activity. A phone interview was conducted with Nurse #10 on 4/3/19 at 9:15 AM. Nurse #10 stated that the nurse assigned to the resident at the time of the fall completed an incident report and initiated the fall investigation checklist form. She revealed that she had just received education on 4/2/19 from UM #1 on how to properly fill out the fall investigation checklist form and how to develop new interventions that correlated with the cause of the fall in an effort to prevent a repeat fall. She further revealed that prior to 4/2/19 she had not understood how to fill out the fall investigation checklist form correctly. The incident report related to the 1/20/19 fall for Resident #28 was reviewed with Nurse #10. The investigation checklist form that identified the new intervention of transferring and changing positions slowly was reviewed with Nurse #10. Nurse #10 stated that this new intervention about transferring and changing positions was not related to the 1/20/19 fall for Resident #28. She reported that Resident #28 had dropped her cup on the floor and fell when she was reaching for it. An interview was conducted with UM #1 on 4/2/19 at 2:40 PM. The incident report and the fall investigation checklist form for Resident #28 ' s 1/20/19 fall were reviewed with UM #1. The new intervention to transfer and change position slowly that was identified on the fall investigation checklist was reviewed with UM #1. UM #1 was unable to explain how this intervention correlated to Resident #28's 1/20/19 fall. An incident report dated 2/5/19 completed by Nurse #9 indicated Resident #28 had an unwitnessed fall in her room with no injury on 2/5/19 at 6:01 AM. Resident #28 was found lying on her right near her bed. The fall investigation checklist form dated 2/5/19 completed by Nurse #9 indicated the new intervention that was put into place to prevent a repeat fall for Resident #28 was adequate lighting and leaving the bathroom light on. This checklist indicated that the 2/5/19 fall for Resident #28 was reviewed on 2/6/19 during the morning meeting and the fall investigation was signed as complete by UM #1. The care plan related to falls for Resident #28 was updated on 2/6/19 with the new intervention of adequate environmental lighting in resident's room and bathroom. A phone interview was conducted with Nurse #9 on 4/3/19 at 8:49 AM. The incident report for Resident #28's 2/5/19 fall was reviewed with Nurse #9. The fall investigation checklist that indicated the new interventions implemented for adequate lighting and keeping Resident #28's bathroom light on were reviewed with Nurse #9. Nurse #9 stated that she had not written that intervention. She indicated that it would've been dark in Resident #28's room at the time of the 2/5/19 fall (6:01 AM) and maybe the resident couldn't see what she was doing. She added that Resident #28 was able to get up from bed independently, but that she never went to the bathroom on her own. An incident report dated 2/10/19 completed by Nurse #14 indicated Resident #28 had an unwitnessed fall on 2/10/19 at 6:00 AM. Resident #28 was found lying on the floor beside her bathroom door. Her right eye was noted to be purple with bruising noted to the face and right deltoid. Resident #28 was sent to the ER for evaluation. An ER note dated 2/10/19 indicated the evaluation of Resident #28 resulted in no treatment changes and required no surgical interventions. The fall investigation checklist form dated 2/10/19 completed by Nurse #14 for the 6:00 AM fall left the question about new interventions blank. This checklist indicated that the 2/10/19 fall for Resident #28 was reviewed on 2/11/19 during the morning meeting and the fall investigation was signed as complete by UM #1. A phone interview was attempted on 4/3/19 at 9:08 AM with Nurse #14 but she was unable to be reached. An incident report dated 2/10/19 completed by Nurse #11 indicated Resident #28 had an unwitnessed fall with no injury on 2/10/19 at 6:37 PM in the dining room of the memory care unit. Resident #28 was in her wheelchair in the dining room as Nurse #11 was preparing trays. A thump was heard and Nurse #11 then saw Resident #28 on the floor in front of her wheelchair. The fall investigation checklist form dated 2/10/19 completed by Nurse #11 for the 6:37 PM indicated the new interventions that were put into place to prevent a repeat fall were for Resident #28's wheelchair to be locked when she attempted to ambulate, toilet as needed, and monitor closely. This checklist indicated that this 2/10/19 fall for Resident #28 was reviewed on 2/11/19 during the morning meeting and the fall investigation was signed as complete by UM #1. A phone interview was conducted with Nurse #11 on 4/3/19 at 9:11 AM. The incident report related to the 2/10/19 fall at 6:37 PM for Resident #28 was reviewed with Nurse #11. The investigation checklist form that identified the new interventions of Resident #28's wheelchair to be locked when she attempted to ambulate, toilet as needed, and monitor closely were reviewed with Nurse #11. Nurse #11 stated that she had written these interventions on the checklist. She indicated she was still learning how to fill out the form properly at that time. She revealed that after this checklist was turned in, she received re-education from the Director of Nursing (DON) and UM #1 on how to develop an intervention that related to the fall. An incident report dated 2/21/19 completed by Nurse #7 indicated Resident #28 had a witnessed fall with no injuries on 2/21/19 at 10:50 AM. Resident #28 was observed walking in the hall while another resident was in her pathway and she slowly fell to the floor. The fall investigation checklist form dated 2/21/19 completed by Nurse #7 indicated the new intervention that was put into place to prevent a repeat fall was to make sure environment is free of clutter including other residents. This checklist indicated that this 2/21/19 fall for Resident #28 was reviewed on 2/22/19 during the morning meeting and the fall investigation was signed as complete by UM #1. The care plan related to falls for Resident #28 was revised on 3/6/19. The previous intervention, initiated on 9/10/18, of ensuring Resident #28's environment was free of clutter was updated to include the environment also being free of people in her path. A phone interview was conducted with Nurse #7 on 4/3/19 at 2:43 PM. The incident report related to the 2/21/19 fall for Resident #28 was reviewed with Nurse #7. The investigation checklist form that identified the new intervention of ensuring the environment was free of clutter and people was reviewed with Nurse #7. Nurse #7 stated that she believed this fall happened at the time other residents were returning from an activity so there were a lot of people in the hallway. She explained that the intent of the intervention was to keep Resident #28 clear of the hallway when it was known there was going to be a lot of people moving about. An observation was conducted of Resident #28 on 4/3/19 at 3:40 PM. Resident #28 was self-propelling in her wheelchair throughout the hallway of the memory care unit. She independently propelled her wheelchair from one end of the unit to the other, maneuvered her wheelchair to face the opposite direction, and then propelled back to the other end of the unit. The care planned fall prevention interventions were observed to be in place at the time of this observation. An interview was conducted with the DON on 4/2/19 at 3:10 PM. She acknowledged that the facility's fall investigation process had not included analyzing the pattern of falls as a whole in an attempt to drill down to the root cause. She additionally acknowledged that the interventions noted on the investigation checklist were not always related to that specific fall. On 4/3/19 at 8:30 AM the DON stated she reviewed each of Resident #28's falls from 10/20/18 through present on the evening of 4/2/19. She reported she was looking for a possible pattern for days of the week, time, staffing, and other factors that could correlate to the falls. The DON revealed that the facility had not been analyzing these details for residents with multiple falls to determine if any patterns were evident. She additionally revealed that although she felt it was impossible to prevent all falls for Resident #28, that it was possible to reduce the risk of falls by drilling down to the root cause and implementing interventions that addressed the root cause. A final interview was conducted with the DON on 4/3/19 at 3:15 PM. She stated she expected fall prevention interventions to be implemented. She indicated that she expected falls to be thoroughly investigated and analyzed to determine causative factors and to implement interventions based on the causative factors in an effort to reduce the risk of further falls.

Based on medical record review, resident and staff interviews, the facility failed to protect one of one sampled residents from harm. During an altercation, NA#1 hit Resident #1 in the left upper arm with her hand. The findings included: Resident #1 was admitted to the facility 5/10/16. Cumulative [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact. No behaviors were noted on the assessment. Resident #1 required supervision with bed mobility, transfers, ambulation in the room, ambulation in the corridor only occurred one or two times, supervision with locomotion on and off the unit, extensive assistance with toilet , personal hygiene and total dependence with bathing, Balance was impaired but resident #1 was able to stabilize without staff assistance for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfers. No impairment with range of motion for upper and/or lower extremities. An Incident/ Investigation Report from the (name) Police Department dated 10/6/17 at 7:51 AM stated the crime/ incident was simple assault, assault and battery by striking the victim causing physical injury. Weapon used was hand. Victim was Resident #1. Offender was Nursing Assistant (NA) #1. Narrative stated the following: On 10/6/2017 at 7:52 AM, (name) Police Department received a call in reference to an assault at 769 Cheraw Road. Upon his arrival, the police officer spoke to Nurse #1 (witness) who advised that NA #1 and Resident #1 had gotten into an altercation resulting in Resident #1 getting physically struck in the arm. At that time, the officer went inside and spoke with Resident #1 who advised that himself and NA #1 had gotten into several arguments and that the incident had started earlier that morning. Resident #1 stated that, after the initial argument, he went to the front hallway of the facility near the entrance. He stated that when NA #1 came back around into the front hallway, she gave him a mean look to which he told her to not look at him in that way. He then stated that she went crazy and began to swing at him and struck him in the top part of his left arm. Both his and the witness stories were consistent with each other in explaining the incident. Upon further investigation, it was determined the name of the nursing assistant was (offender/ suspect) and that she was from an outside agency. She was staying at 769 Cheraw Road and had left prior to the officer ' s arrival. Warrants were advised to both parties involved and obtained on behalf of Resident #1 due to his inability to get into a vehicle to proceed to the magistrate ' s office. The police officer called the magistrate who advised that the officer could swear out the warrants on the behalf of Resident #1 due to the issue. Same were obtained in reference to the assault. A review of the emergency room record dated 10/6/17 stated Patient states that he feels anxious. Has altercation with CNA (certified nursing assistant) at Richmond Pines. Feels like they are out to get me. She jumped on me twice. Past medical history significant for anxiety, asthma, [MEDICAL CONDITION] disorder, depression. Resident #1 stated he got into an altercation with a CNA and she assaulted him but also stated he did not want to get into it. He provided very little information. He stated he tried to press charges but the law was against him. When asked if he sustained any injuries, he stated No and denied any injuries. He stated however it caused him to have anxiety. He reported throughout the day the anxiety worsened so he decided to come in for evaluation. Psychiatric/ behavioral: negative for agitation, behavioral problem and suicidal ideas. The patient was nervous/ anxious. He was given [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] ([MEDICATION NAME]). At that time, it was safe for him to be discharged to the facility with outpatient follow-up. He denied any trauma or injury from the incident that had occurred 10/6/17. A review of the 24 hour report dated 10/6/17 at 9:45 AM stated Resident #1 alleged NA #1 yelled and hit him. A statement from NA #4 dated 10/6/17 (no time) stated she assisted NA #3 in the shower room when Resident #1 was given a shower on 10/6/17 around 6:45 AM. Resident #1 told them that he was done with her and her snide comments. I ' ll see to it she ' s off my hall. She ' s out of here. Both NA #4 and NA #3 thought he meant he would go to the Administrator as he had done previously. On 10/10/17 at 9:40 AM, an interview was conducted with NA #4. She stated she was working on the back half of 100 hall (112-116) on 10/6/17. NA #4 said she had walked into room [ROOM NUMBER] with a breakfast tray when she heard a commotion in the hallway. It had gotten so loud and you could hear curse words flying. NA #4 came to the opening of 100 hall and could see Resident #1 in his wheelchair beside the nursing station and there was a crowd of people surrounding NA #1 trying to pull her back and she was shouting and screaming at the top of her lungs. NA #4 said it was all Nurse #3 could do to try and contain NA #1 and calm her down. NA #4 said she did not witness any physical contact between NA #1 and Resident #1. A statement from Nurse #1 dated 10/6/17 at 8:30 AM stated shortly after clocking in, Resident #1 approached her in his wheelchair. As he began reporting incidents of the earlier morning to Nurse #1 concerning NA #1, NA #1 and several other employees came walking down the hallway. Nurse #1 was facing Resident #1 with her back to the employees. She stated she did not remember whether the resident spoke first to NA #1 or the other way around but NA #1 swung around towards Resident #1 and called him a (profanity) and struck him on his upper arm. The two began yelling at each other. Employees were struggling with NA #1 to prevent her from engaging further with Resident #1. Nurse #1 stayed with the resident who was upset saying You ' re going to jail. Nurse #1 directed Nurse #2 to call 911 and have the employees remove NA #1 from the building. This interaction began at 7:50 AM. NA #1 was removed from the building by 7:55 AM. On 10/10/17 at 11:30 AM, an interview was conducted with Nurse #1. She stated she met Resident #1 at the time clock when she clocked in at 7:45 AM. He was facing towards the front door in his chair and Nurse #1 had her back to the front door. He pulled up and just looked at her not saying anything. She asked him if he was ok and he said no. He started to tell Nurse #1 what had happened before she got there. He told her he had hurt his knee because a nursing assistant went to hit him or some threat had been made and he hurt his knee when he stood up. Resident #1 told Nurse #1 that NA #1 had cussed him out and called him a (profanity). The time was between 7:45 and 7:50AM. At that point, several staff members including NA #1 were walking towards the nursing station and the next thing Nurse #1 knew, NA #1 screams (profanity), swung with her left hand and hit Resident #1 on his left upper arm. Nurse #1 stated NA #1 ' s fingers were not open but not clenched in a fist. At that point, the staff grabbed her, Nurse #1 jumped in front of Resident #1 and yelled for Nurse #2 to call 911. Resident #1 had moved his chair closer to the nursing station telling NA #1 she was going to jail. NA #1 was still fighting, kicking, swinging and trying to get away from the staff holding her and trying to get to Resident #1 again. That was when Resident #1 stood up from his wheelchair. Nurse #1 told him he needed to sit down and he took ½ step with one foot, then sat back down. Staff pulled NA #1 out of the building. The whole episode lasted about 5 minutes. A statement from NA #1 dated 10/6/17 (no time) stated she was threatened and cussed out very badly that morning by Resident #1. He cussed her out as she was walking on to the 200 hall to start her work. He sat at the top of 200 hall and was cursing the scheduler out for telling his business to the supervisor in charge at the time and as NA #1 was passing by, Resident #1 started yelling and cursing at NA #1 crazy like and saying that she was supposed to be on a certain hall. He proceeded to stand up like he wanted to hit NA #1 so she left the hall and walked outside to calm down. When she came back in the building to go back to her hall, she stated she was looking straight ahead. Resident #1 said, while he was talking to the nurse why are you looking at me with the side eye. NA #1 stated she did not say anything. Resident #1 kept talking and cussing NA #1 out. NA #1 stated she reached for Resident #1 but did not touch him because she was pulled back and was taken down the hall. She went outside where she tried to calm herself down. The statement said it was the third time he had cussed her out and stood up on her like he wanted to hit her. When he stood up, he pushed her and then sat back down. On 10/10/17 at 12:29 PM, a telephone interview was conducted with NA #1. She stated she was on 200 hall showing someone who to get up and Resident #1 was giving the girls instructions on who to get up. One of the residents on 400 hall fell and she went back to help. NA #1 said he heard Resident #1 say if NA #1 had been on 400 hall, the resident would not have fallen. NA #2 had told NA #1 to go to 200 hall. NA #1 said, as she was coming up the hall, she heard Resident #1 at the top of 200 hall cursing NA #2. NA #1 said she passed NA #2 and went on 200 hall. Resident #1 began cursing and hollering at NA #1. NA #1 said she got upset and Resident #1 stood up like he wanted to hit her. Staff were telling her to calm down and they took her outside. NA #1 said she calmed down and returned into the building. Resident #1 was in the hallway talking to Nurse #1. NA #1 stated she was walking past and paying Resident #1 no attention. Resident #1 said something to her and kept saying stuff to her. NA #1 said that was when she tried to get at him. NA #1 said Resident #1 said she hit him but she denied that she hit him. NA #1 said NA #2, NA #3 and Nurse #3 grabbed her and took her outside of the building. NA #1 said the police came to the building but, the first time, she had left the building and had gone to the police station. When she went to the police station, they said there had been no charges filed. NA #1 stated she went back to the facility to the smoking area across the street so her cousin could get her belongings. The police came back a second time, put her in handcuffs and took her to the police station but no charges were filed. NA #1 stated she had reached her breaking point and again stated she did not make any physical contact with Resident #1. A statement from NA #2 stated she was sitting in her office at about 7:20 AM when resident #1 came to the door and told her he wanted NA #1 off his hall and that she wasn ' t supposed to be on that hall anyway. NA #2 told him NA #1 was not supposed to be in his room. He said he didn ' t give a (profanity), he wanted her off the hall. NA #2 went down the hall and switched NA #1 from 400 to 200 hall. As NA #2 was talking to Nurse #2 about what was going on with Resident #1, Resident #1 came up behind NA #2 and asked her why the (profanity) was she telling his business. N A#2 told him that she was telling her business since he had told it to her. Then he started getting upset going on and on. As he was fussing, NA #1 walked up 200 hall and he said something to her and called her a (profanity). NA #1 got upset and told him she was tired of his (profanity). Resident #1 then stood up and told her to come on. NA #1 went towards him, she was grabbed by staff and taken down the hall. Resident #1 was still cursing and carrying on. NA #2 took NA #1 outside to calm down. When they re-entered the building, NA #1, Nurse #3 and NA #2 walked towards the nursing station. Resident #1 was in the hall between the Director of Nurse ' s office and the Minimum Data Set (MDS) office talking to Nurse #1. Resident #1 said something to NA #1 as she was walking by. NA #1 then said she was so (profanity) tired of resident #1. She went to swing but Nurse #3 grabbed her and NA #1 ' s hand barely hit Resident #1 ' s left shoulder. On 10/10/17 at 10:25 AM, an interview was conducted with NA #2. She said she was in her office around 7:15 AM and Resident #1 came into her office and stated he wanted NA #1 off that (profanity) hall. NA #2 told him NA #1 was allowed to work the hall and just not allowed to come in his room. NA #2 said she was going to wait to talk to the Director of Nursing about the situation and then decided she would handle the situation herself. NA #2 went to NA #1 and told her to switch with the nursing assistant who was on 200 hall. NA #1 went from 400 to 200 hall. NA #2 was talking to Nurse #2 telling her what she was doing as far as switching the staff on the halls because Nurse #2 was the only administrative nurse in the building at the time. Resident #1 came up behind NA #2 and asked her why she was telling his business. She said she told him once he brought it to her, he made it her business and she had to let Nurse #2 know what she was doing. NA #1 was coming up 200 hall and when resident #1 saw her, he said that (profanity) right there. NA #1 told Resident #1 she was tired of him. NA #2, Nurse #3 and maybe two other people grabbed NA #1. Resident #1 jumped out of his chair, stood up and said to NA #1 come on. Nurse #3 took NA #1 outside and Resident #1 went on to the dining room to eat breakfast. NA #2 stated she went outside and stayed with NA #1 to calm her down. She said she told NA #1 that the Director of Nursing was probably going to cancel her and she wasn ' t going to be allowed to be at the facility anymore. NA #2 told NA #1 to get her stuff together. They came back in the door and Resident #1 was talking to Nurse #1 about what happened. NA #2 stated she could not remember Resident #1 ' s exact words but he said something and NA #1 went to swing at him. Nurse #3 grabbed NA #1. NA #1 did make contact to Resident #1 ' s left shoulder. NA #1 was hollering and screaming. Resident #1 stood up from his wheelchair. Nurse #3 took NA #1 out the door and she did not come back in the building at all. NA #2 stated as soon as NA #1 ' s hand touched him, Resident #1 said call the police and Nurse #2 called the police. A statement from Nurse #2 dated 10/6/17 stated a code green was called to 400 hall, As Nurse #2 started in the room where the resident had fallen, Resident #1 came up the hall saying NA #1 let him fall. The door to the resident room was closed immediately. When Nurse #2 came out of the room, Nurse #2 met NA #2 at the 200 hall medication cart and NA #2 was telling Nurse #2 about a the statement that Resident #1 had said when he went to NA #2 ' s office. Resident #1 came up behind NA #2 and started telling her not to be telling nothing about him. NA #2 tried to explain to Nurse #2 what had been said. About that time, NA #1 came up and the explosion happened, cussing from both. Nurse #3 and NA #2 took NA #1 down 200 hall. On 10/10/17 at 10:49 AM, an interview was conducted with Nurse #2. She stated she had assisted with a resident who had fallen in one of the rooms on 400 hall. When she came out of the room, she went to 200 hall and was at the medication cart. She met NA #2 and NA #2 was telling her about Resident #1 and the conversation regarding NA #1. Resident #1 came up behind NA #2 and was yelling at her not to tell his business. NA #2 told him she had to tell Nurse #2 because she was the only administrative staff in the building at the time. NA #2 didn ' t get a chance to tell Nurse #2 what she wanted to tell her because he had come up behind NA #2 and was screaming. Before NA #2 could finish talking, NA #1 came up the hallway. When NA #1 got to the end where 400 and 200 hall meet near the nursing station, NA #1 and Resident #1 both started yelling at each other. By that time, Nurse #3 came up behind NA #1 and grabbed her to keep her away from Resident #1. Nurse #3 took NA #1 down the hallway. Nurse #2 stated she thought they took NA #1 out of the building. Nurse #2 stated she then saw Nurse #1 and Resident #1 talking near the time clock. Then Nurse #2 saw NA #1 come in the side door and Nurse #1 began yelling and screaming and said to call 911. Nurse #2 called 911 to get the police to the facility because Resident #1 and NA #1 were yelling and screaming again. The situation escalated at that time. They took NA#1 out of the building and, to her knowledge, she did not come back in the building. Resident #1 was in his wheelchair near the Director of Nursing office. Nurse #2 stated she saw Resident #1 stand up the first time at the nursing station and that was the only time she remembered him standing up from his wheelchair. A statement from Nurse #3 dated 10/6/17 stated she was counting the cart with the night nurse and heard arguing on the top of 200 hall. She looked up and saw Resident #1 yelling and cursing at the scheduler (NA #2) stating she should not spread his business around the facility. NA #2 stated she was not spreading his business. She continued to talk to Nurse #2 and Resident #1 got louder and angrier. When NA #1 walked by, he began cursing her and saying how sorry she was. NA #1 began to argue back with Resident #1 and he proceeded to stand up and threaten NA #1 while pointing at her. At that point Nurse #3 went over and grabbed NA #1 holding her to calm her down. Nurse #3 escorted NA #1 out the door. Upon returning to the building, NA #2, NA #1, NA #3 and Nurse #3 walked into the building not knowing Nurse #1 and Resident #1 were in the hallway. As they walked past, Resident #1 argued with NA #1. Resident #1 stood up and the verbal back and forth started again. Nurse #3 again escorted NA #1 out of the building. On 10/10/17 at 11:05 AM, an interview was conducted with Nurse #3. She stated she was at the nursing station counting narcotics with Nurse #5 around 7:15 AM. One of the aides came and asked them to call a code green because one of the residents was on the floor (400 hall). When she walked down the hall, she saw Resident #1 coming down 400 hall towards the nursing station saying if the aides were on the hall, he wouldn ' t have fallen. It was their fault that he fell . Nurse #3 stated she heard the comment in passing but didn ' t take much stock of it because the nursing staff had been on the hall at the time the resident fell . She went back to the medication cart to finish counting narcotics. As they were counting narcotics, Nurse #3 remembered seeing Resident #1 come across the nursing station to 200 hall where NA #2 was talking to Nurse #2. Nurse #3 heard arguing between NA #2 and Resident #1. Resident #1 got louder and cursing and told NA #2 she did not know what she was doing as he pointed at her. NA #2 began to ignore him and resumed talking to the person she was talking to. Resident #1 continued to curse at NA #2. Nurse #3 stated she did not see NA #1 walk in resident #1 ' s direction. When Nurse #3 looked back up, she heard Resident #1 call NA #1 a (profanity). By that time, both NA #1 and Resident #1 were yelling and cursing at each other. NA #1 was telling Resident #1 she was not on his hall and she was not bothering him. They started calling each other profane names and NA #1 told Resident #1 she was not messing with his (profanity). Resident #1 stood up and he was pointing at her and they were yelling at each other. When he stood up, NA #1 went towards him. Nurse #3 stated she went towards NA #1 because NA #1 was shaking other staff off her with her arms saying get off of me. Nurse #3 said she grabbed NA #1 from the front and she was trying to get Nurse #3 away from her. Nurse #3 then bear hugged NA #1 and tried to calm her down because they were related she thought she could calm her down. All this happened at top of 200 hall. Nurse #3 walked NA #1 down 200 hall and around the corner to calm her down. She was visually upset, saying she was getting tired of this, talking junk to us, threatening us and could not take it anymore. Nurse #3 suggested she go outside to calm down. Nurse #3 took her out and then came back in to the building to complete counting narcotics. One of the shower aides came to Nurse #3 and told her that Resident #1 had said he was going to get rid of NA #1 one way or the other. She said she told somebody else but not NA #2. Nurse #3 went outside to tell NA #2 about the conversation and NA #1 seemed calmer at that time. Nurse #3 said she came back inside but did tell NA #1 and NA #2 that Resident #1 was talking to Nurse #1. They were near the nursing station. NA #2, NA#1 and Nurse #3 were going to get NA #1 ' s belongings. Nurse #3 stated she did not visualize the next blow up. They were fussing again. This time, Nurse #3 grabbed NA #1 and pulled her out of the doors. Nurse #3 stated she did not see any physical contact on either party. A statement from NA #3 dated 10/6/17 stated she and Resident #1 were in the shower room and he said he was going to do everything to get NA #1 out of the building. NA #1 didn ' t say anything to him until he called her a (profanity) and (profanity). NA #1 swung at him and NA #3 grabbed NA #1 and Resident #1 stood up. On 10/10/17 at 12:16 PM, an interview was conducted with NA #3. She stated she was giving Resident #1 a shower around 6:45 AM and he said he was going to get that (profanity) out of this building. By the time he got out of the shower, NA #3 was picking up towels form the shower room and had not seen anybody up front to tell then what Resident #1 had said. NA #3 was in the shower room on 200 hall when she heard a commotion but was unable to see what happened because she had someone in the shower at the time. When NA #3 came out of the shower, breakfast trays were out so she went to get a cup of coffee. NA #3 went to the smoking area and NA #1 and NA #2 were there also. All three came back into the building together. Resident #1 and Nurse #1 were in the hallway. When NA #1, NA #2 and NA #3 passed them in the hall near the Director of Nursing office, Resident #1 called NA #1 a black (profanity) and NA #1 swung at Resident #1. NA #3 said she grabbed NA #1 and somebody took NA #1 from her and took her out of the building. NA #3 stated she didn ' t know if NA #1 made direct contact or not. A statement from Nurse #4 stated she was at the nurse ' s station. Resident #1 was talking loudly to NA #2 (scheduler) and Nurse #2. When NA #1 walked by, they started arguing and NA #1 walked toward Resident #1. NA #2 and Nurse #3 walked NA #1 walked KS outside. Around 20 minutes later, Resident #1 was talking to Nurse #1. NA #1 walked around the corner and they started arguing and cursing. Resident #1 stood up and NA #1 walked past him and out the door. On 10/11/17 at 7:57 AM, an interview was conducted with Nurse #4. She stated she was counting narcotics with Nurse #5 on 10/6/17. They were on the 100 hall side of the nurse ' s station. She heard Resident #1 talking loudly to NA #2 and Nurse #2. Resident #1 was talking loudly and yelling, cursing at NA #2. She stated she was not sure which side NA #1 came from and did not know who said what to each other first. Resident #1 and NA #1 began yelling and cursing back and forth and she was walking towards Resident #1. There were other people who grabbed NA #1 and took her outside. Nurse #4 stated she did not remember if Resident #1 stood up from his wheelchair at that time. Nurse #4 stated they began counting narcotics again and she remembered Nurse 1 was talking to Resident #1 near the Director of Nursing office. NA #1 came around the corner and they started yelling and cursing again. Resident #1 stood up that time. She stated she did not observe any physical contact because she was not in direct view of the altercation. A statement from Nurse #5 dated 10/6/17 (no time) stated she was counting and heard loud noises, turned toward 200 hall and saw NA #2 and Nurse #2 talking. Resident #1 was sitting in his chair yelling and cussing and calling NA #2 names loudly. NA #2 responded that she was talking with an administrative nurse and she would be with him in a minute. He continued cursing and yelling. Nurse #5 stated she resumed counting narcotics and heard even more commotion. Resident #1 was standing up yelling threats at NA #1. Then staff removed NA #1 from the hall. On 10/11/17 at 10:05 AM, attempts were made twice to contact Nurse #5. The phone number was no longer valid. On 10/10/17 at 8:44 AM, an interview was conducted with Resident #1. He stated it was Friday morning around 7:30-8:00 AM. He had found out that NA#1 was working on his hall for the 3rd or 4th time. Resident #1 stated she could not work on his side when the other aide took a break or was not on the schedule because he and NA#1 could not work together. They had a problem previously and she had been taken off his assignment. Resident #1 said he went to NA#2 and told her he didn ' t want NA#1 on his hall. NA#1 wasn ' t on his assignment but was working the opposite side of the hall so would have been working with him when the other nursing assistant took breaks. Resident #1 stated he went to his room and grabbed some change to get a drink in the lounge area at the front door. He said he saw NA#2 at the nurse ' s station top of 200 hall talking to Nurse #2. She was talking to her about Resident #1 wanting to get NA #1 off his hall and how much trouble it was causing. Resident #1 asked her to please stop talking about him in front of other patients and stuff. NA #2 stated she was talking to management and Resident #1 said he told her that was fine but not to talk about him in front of a bunch of people. NA #2 turned her back to Resident #1 and he got mad. He raised his voice to NA #2. About that time, NA #1 came around the corner and Resident #1 stated he did not know what he said but he was still talking to NA #2. NA #1 got in the conversation and he told her to stay out of it. Resident #1 and NA #1 had words with both of them shouting, name calling and cursing at each other. Resident #1 stated the next thing he knew, she became a windmill swinging her arms and kicking her feet trying to get to him. He said she did not make physical contact but was saying she was going to (profanity) me up. She was about 3 feet away from him at the time. NA#1 was crying and screaming. Staff took her to a room down 200 hall on the left hand side of the hall. Then NA #1 tried to come back out talking junk and Resident #1 was talking junk too. NA #1 tried to hit Resident #1 again. Staff took her down the hall again. He thought she remained in the building. Resident #1 stated he was talking to Nurse #1 in the hallway near the Director of Nurse ' s office around 9:00 AM (not sure of time) and was telling her what happened. Nurse #1 said she would call the Director of Nursing. NA #1 came around the corner from the dining room with mean look on her face and her fists balled. She kind of cut her eyes at resident #1 and he told her not to cut her eyes at him. NA #1 hit Resident #1 in the head, shoulders, arms, legs and chair. Resident #1 stated Nurse #1 was a witness to the event. He said he didn ' t say anything else to her except she was going to jail. Resident #1 said he only got a long scratch on his left upper arm. He said he had no other physical injuries On 10/10/17 at 3:01 PM, an interview was conducted with the Director of Nursing (DON) and the Administrator. She stated she received a phone call between 7:47 AM and 7:57 AM from Nurse #1 and was informed that a staff member had struck a resident. She told me there was someone on the phone calling 911. The DON said she asked if the staff member had been removed from the building and she was told yes and the resident was ok. The DON stated she called the Administrator immediately after getting off the phone and told her that a staff member had struck a resident and that the staff member had been removed from the building and the resident was ok. The Administrator added that she was called while she was enroute to the facility and was informed the police were at the building. The DON stated the police were at the facility when she arrived. She was told the staff member who had assaulted the resident had borrowed someone ' s car and she had left the premises. The DON stated around 9:00 AM, both she and the Administrator went to Resident #1 and assessed him for injuries. No injuries were noted and Resident #1 did not complain of any pain at the time of the assessment. Resident #1 explained to them that both of them (resident #1, NA #1) got into verbal altercations and went at each other meaning verbal arguing and cursing at each other. He did state his left knee would probably start hurting because he stood up at the time of the altercation. The DON asked him if he needed to go to the hospital and he declined. The DON stated she called the physician at 9:22 AM and began the investigation. The DON continued to state what happened next: At 8:50 AM, they received several statements and gave them to Administrator. At 9:00 AM, the Administrator and DON assessed Resident #1. At 9:22 AM, the facility spoke to the Medical Director and conducted an interview with Resident #1 ' s roommate. At 9:35 AM, the facility called the agency that employed NA #1 and informed them of the situation that had occurred between Resident #1 and NA #1. On 10/11/17 at 8:30 AM, a telephone interview was conducted with the police officer from the (name) Police Department who responded to the call 10/6/17. He stated he and another police officer responded to a 911 call that an assault had occurred at Richmond Pines. He stated, when they arrived, the female aggressor had left the facility. He spoke to Resident #1 and spoke to Nurse #1. Nurse #1 stated the nursing assistant (NA #1) and Resident #1 got into an argument in the hallway and NA #1 had hit Resident #1. The police officer stated Resident #1 had a few surface scratches on his left upper arm. During the interview, Resident #1 was agitated and appeared angry-was not yelling but, by the way he was talking to the officer, he was upset over the situation. The police officer stated NA #1 was arrested when she returned to the facility area later in the morning but no charges were filed. He stated both parties were going to file warrants out against each other. The Magistrate talked to both parties and it was decided on both parties that no charges would be filed. The corrective action for past non-compliance dated 10/7/17 was as follows: On 09/17/17, nursing assistants reported to the charge nurse that Resident #1 was using profanity towards the accused agency nursing assistant and one other agency nursing assistant. Resident #1 stated the nursing assistants should stay on the hall. Resident #1 has ongoing behavioral issues, is care planned for demonstrating behaviors, and treated by the physician and psychiatric services for behaviors. The two agency nursing assistants did not engage Resident #1 and instead the staff nurse intervened. The staff nurse re-assigned another nursing assistant to Resident #1 for the duration of the shift. On 10/06/17, the accused agency staff employee was walking in the hall and had a verbal interaction with Resident #1. Resident #1 stood up and made a statement and used profanity towards the accused agency staff. The accused agency staff used profanity in return towards Resident #1. The agency licensed practical nurse removed the accused agency staff immediately from the facility. The agency licensed practical nurse and facility scheduler escorted the accused agency nursing assistant back into the facility to speak with the director of nursing (DON), not knowing the director of nursing was not at the facility. Instead, the quality improvement (QI) nurse was entering the f(TRUNCATED)

Based on medical record review, resident and staff interviews, it was determined that the facility failed to follow their abuse policy and procedures for abuse prohibition for protecting a resident after a verbal altercation between a resident and a staff member. After the verbal altercation, NA #1 was allowed to come back into the building and a second altercation between Resident #1 and NA #1 resulted in NA #1 making physical contact with Resident #1. The findings included: The facility ' s abuse, neglect or misappropriation of resident property policy last revised 3/10/17 was reviewed. The policy under Prevention read in part The facility will provide supervision to staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care or directing residents who need toileting assistance to urine or defecate in bed. The policy under Protection read in part The facility shall take whatever steps are necessary to prevent further acts of abuse, neglect, misappropriation of property, drug diversion, or fraud while the investigation is in progress. Employees accused of being directly involved in allegations of abuse, neglect, exploitation, or misappropriation of property will be suspended immediately from duty pending the outcome of the investigation. Resident #1 was admitted to the facility 5/10/16. Cumulative [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact. No behaviors were noted on the assessment. Resident #1 required supervision with bed mobility, transfers, ambulation in the room, ambulation in the corridor only occurred one or two times, supervision with locomotion on and off the unit, extensive assistance with toilet , personal hygiene and total dependence with bathing, Balance was impaired but resident #1 was able to stabilize without staff assistance for moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfers. No impairment with range of motion for upper and/or lower extremities. An Incident/ Investigation Report from the (name) Police Department dated 10/6/17 at 7:51 AM stated the crime/ incident was simple assault, assault and battery by striking the victim causing physical injury. Weapon used was hand. Victim was Resident #1. Offender was nursing assistant (NA) #1. Narrative stated the following: On 10/6/2017 at 7:52 AM, (name) Police Department received a call in reference to an assault at the nursing home. Upon his arrival, he spoke to Nurse #1 (witness) who advised that NA #1 and Resident #1 had gotten into an altercation resulting in Resident #1 getting physically struck in the arm. At that time, the officer went inside and spoke with Resident #1 who advised that himself and the nursing assistant had gotten into several arguments and that the incident had started earlier that morning. Resident #1 stated that, after the initial argument, he went to the front hallway of the facility near the entrance. He stated that when NA #1 came back around into the front hallway, she gave him a mean look to which he told her to not look at him in that way. He then stated that she went crazy and began to swing at him and struck him in the top part of his left arm. Both his and the witness stories were consistent with each other in explaining the incident. Upon further investigation, it was determined the name of the CNA was (offender/ suspect) and that she was from an outside agency. She was working at the nursing home and had left prior to the officer ' s arrival. Warrants were advised to both parties involved and obtained on behalf of Resident #1 due to his inability to get into a vehicle to proceed to the magistrate ' s office. The police officer called the magistrate who advised that the officer could swear out the warrants on the behalf of Resident #1 due to the issue. Same were obtained in reference to the assault. A review of the emergency room record dated 10/6/17 stated Patient states that he feels anxious. Has altercation with CNA (certified nursing assistant) at Richmond Pines. Feels like they are out to get me. She jumped on me twice. Past medical history significant for anxiety, asthma, [MEDICAL CONDITION] disorder, depression. Resident #1 stated he got into an altercation with a CNA and she assaulted him but also stated he did not want to get into it. He provided very little information. He stated he tried to press charges but the law was against him. When asked if he sustained any injuries, he stated No and denied any injuries. Skin was noted as negative for rash. There was no documentation of any scratches on Resident #1 ' s body. He denied any trauma or injury from the incident that had occurred 10/6/17. A review of the 24 hour report dated 10/6/17 at 9:45 AM stated Resident #1 alleged NA #1 yelled and hit him. A statement dated 10/6/17 (no time noted) from NA #2 stated she was sitting in her office at about 7:20 AM when resident #1 came to the door and told her he wanted NA #1 off his hall and that she wasn ' t supposed to be on that hall anyway. NA #2 told him NA #1 was not supposed to be in his room. He said he didn ' t give a (profanity), he wanted her off the hall. NA #2 went down the hall and switched NA #1 from 400 to 200 hall. As NA #2 was talking to Nurse #2 about what was going on with Resident #1, Resident #1 came up behind NA #2 and asked her why the (profanity) was she telling his business. N A#2 told him that she was telling her business since he had told it to her. Then he started getting upset going on and on. As he was fussing, NA #1 walked up 200 hall and he said something to her and called her a (profanity). NA #1 got upset and told him she was tired of his (profanity). Resident #1 then stood up and told her to come on. NA #1 went towards him, she was grabbed by staff and taken down the hall. Resident #1 was still cursing and carrying on. NA #2 took NA #1 outside to calm down. When they re-entered the building, NA #1, Nurse #3 and NA #2 walked towards the nursing station. Resident #1 was in the hall between the Director of Nurse ' s office and the Minimum Data Set (MDS) office talking to Nurse #1. Resident #1 said something to NA #1 as she was walking by. NA #1 then said she was so (profanity) tired of resident #1. She went to swing but Nurse #3 grabbed her and NA #1 ' s hand barely hit Resident #1 ' s left shoulder. On 10/10/17 at 10:25 AM, an interview was conducted with NA #2. She said she was in her office around 7:15 AM and Resident #1 came into her office and stated he wanted NA #1 off that (profanity) hall. NA #2 told him NA #1 was allowed to work the hall and just not allowed to come in his room. NA #2 said she was going to wait to talk to the Director of Nursing about the situation and then decided she would handle the situation herself. NA #2 went to NA #1 and told her to switch with the nursing assistant who was on 200 hall. NA #1 went from 400 to 200 hall. NA #2 was talking to Nurse #2 telling her what she was doing as far as switching the staff on the halls because Nurse #2 was the only administrative nurse in the building at the time. Resident #1 came up behind NA #2 and asked her why she was telling his business. She said she told him once he brought it to her, he made it her business and she had to let Nurse #2 know what she was doing. NA #1 was coming up 200 hall and when resident #1 saw her, he said that (profanity) right there. NA #1 told Resident #1 she was tired of him. NA #2, Nurse #3 and maybe two other people grabbed NA #1. Resident #1 jumped out of his chair, stood up and said to NA #1 come on. Nurse #3 took NA #1 outside and Resident #1 went on to the dining room to eat breakfast. NA #2 stated she went outside and stayed with NA #1 to calm her down. She said she told NA #1 that the Director of Nursing was probably going to cancel her and she wasn ' t going to be allowed to be at the facility anymore. NA #2 told NA #1 to get her stuff together. They came back in the door and Resident #1 was talking to Nurse #1 about what happened. NA #2 stated she could not remember Resident #1 ' s exact words but he said something and NA #1 went to swing at him. Nurse #3 grabbed NA #1. NA #1 did make contact to Resident #1 ' s left shoulder. NA #1 was hollering and screaming. Resident #1 stood up from his wheelchair. Nurse #3 took NA #1 out the door and she did not come back in the building at all. NA #2 stated as soon as NA #1 ' s hand touched him, Resident #1 said call the police and Nurse #1 called the police. A statement from Nurse #1 dated 10/6/17 at 8:30 AM stated shortly after clocking in, Resident #1 approached her in his wheelchair. As he began reporting incidents of the earlier morning to Nurse #1 concerning NA #1, NA #1 and several other employees came walking down the hallway. Nurse #1 was facing Resident #1 with her back to the employees. She stated she did not remember whether the resident spoke first to NA #1 or the other way around but NA #1 swung around towards Resident #1 and called him a (profanity) and struck him on his upper arm. The two began yelling at each other. Employees were struggling with NA #1 to prevent her from engaging further with Resident #1. Nurse #1 stayed with the resident who was upset saying You ' re going to jail. Nurse #1 directed Nurse #2 to call 911 and have the employees remove NA #1 from the building. This interaction began at 7:50 AM. NA #1 was removed from the building by 7:55 AM. On 10/10/17 at 11:30 AM, an interview was conducted with Nurse #1. She stated she met Resident #1 at the time clock when she clocked in at 7:45 AM. He was facing towards the front door in his chair and Nurse #1 had her back to the front door. He pulled up and just looked at her not saying anything. She asked him if he was ok and he said no. He started to tell Nurse #1 what had happened before she got there/ He told her he had hurt his knee because a nursing assistant went to hit him or some threat had been made and he hurt his knee when he stood up. Resident #1 told Nurse #1 that NA #1 had cussed him out and called him a (profanity). The time was between 7:45 and 7:50AM. At that point, several staff members including NA #1 were walking towards the nursing station and the next thing Nurse #1 knew, NA #1 screams (profanity), swung with her left hand and hit Resident #1 on his left upper arm. Nurse #1 stated NA #1 ' s fingers were not open but not clenched in a fist. At that point, the staff grabbed her, Nurse #1 jumped in front of Resident #1 and yelled for Nurse #2 to call 911. Resident #1 had moved his chair closer to the nursing station telling NA #1 she was going to jail. Na #1 was still fighting, kicking, swinging and trying to get away from the staff holding her and trying to get to Resident #1 again. That was when Resident #1 stood up from his wheelchair. Nurse #1 told him he needed to sit down and he took ½ step with one foot, then sat back down. Staff pulled NA #1 out of the building. The whole episode lasted about 5 minutes. A statement from NA #1 dated 10/6/17 (no time noted) stated she was threatened and cussed out very badly that morning by Resident #1. He cussed her out as she was walking on to the 200 hall to start her work. He sat at the top of 200 hall and was cursing the scheduler out for telling his business to the supervisor in charge at the time and as NA #1 was passing by, Resident #1 started yelling and cursing at NA #1 crazy like and saying that she was supposed to be on a certain hall. He proceeded to stand up like he wanted to hit NA #1 so she left the hall and walked outside to calm down. When she came back in the building to go back to her hall, she stated she was looking straight ahead. Resident #1 said, while he was talking to the nurse why are you looking at me with the side eye. NA #1 stated she did not say anything. Resident #1 kept talking and cussing NA #1 out. NA #1 stated she reached for Resident #1 but did not touch him because she was pulled back and was taken down the hall. She went outside where she tried to calm herself down. The statement said it was the third time he had cussed her out and stood up on her like he wanted to hit her. When he stood up, he pushed her and then sat back down. On 10/10/17 at 12:29 PM, a telephone interview was conducted with NA #1. She stated she was on 200 hall showing someone who to get up and Resident #1 was giving the girls instructions on who to get up. One of the residents on 400 hall fell and she went back to help. NA #1 said he heard Resident #1 say if NA #1 had been on 400 hall, the resident would not have fallen. NA #2 had told NA #1 to go to 200 hall. NA #1 said, as she was coming up the hall, she heard Resident #1 at the top of 200 hall cursing NA #2. NA #1 said she passed NA #2 and went on 200 hall. Resident #1 began cursing and hollering at NA #1. NA #1 said she got upset and Resident #1 stood up like he wanted to hit her. Staff were telling her to calm down and they took her outside. NA #1 said she calmed down and returned into the building. Resident #1 was in the hallway talking to Nurse #1. NA #1 stated she was walking past and paying Resident #1 no attention. Resident #1 said something to her and kept saying stuff to her. NA #1 said that was when she tried to get at him. NA #1 said Resident #1 said she hit him but she denied that she hit him. NA #1 said NA #2, NA #3 and Nurse #3 grabbed her and took her outside of the building. NA #1 said the police came to the building but, the first time, she had left the building and had gone to the police station. When she went to the police station, they said there had been no charges filed. NA #1 stated she went back to the facility to the smoking area across the street so her cousin could get her belongings. The police came back a second time, put her in handcuffs and took her to the police station but no charges were filed. NA #1 stated she had reached her breaking point and again stated she did not make any physical contact with Resident #1. On 10/10/17 at 8:44 AM, an interview was conducted with Resident #1. He stated it was Friday morning around 7:30-8:00 AM. He had found out that NA#1 was working on his hall for the 3rd or 4th time. Resident #1 stated she could not work on his side when the other aide took a break or was not on the schedule because he and NA#1 could not work together. They had a problem previously and she had been taken off his assignment. Resident #1 said he went to NA#2 and told her he didn ' t want NA#1 on his hall. NA#1 wasn ' t on his assignment but was working the opposite side of the hall so would have been working with him when the other nursing assistant took breaks. Resident #1 stated he went to his room and grabbed some change to get a drink in the lounge area at the front door. He said he saw NA#2 at the nurse ' s station top of 200 hall talking to Nurse #2. She was talking to her about Resident #1 wanting to get NA #1 off his hall and how much trouble it was causing. Resident #1 asked her to please stop talking about him in front of other patients and stuff. NA #2 stated she was talking to management and Resident #1 said he told her that was fine but not to talk about him in front of a bunch of people. NA #2 turned her back to Resident #1 and he got mad. He raised his voice to NA #2. About that time, NA #1 came around the corner and Resident #1 stated he did not know what he said but he was still talking to NA #2. NA #1 got in the conversation and he told her to stay out of it. Resident #1 and NA #1 had words with both of them shouting, name calling and cursing at each other. Resident #1 stated the next thing he knew, she became a windmill swinging her arms and kicking her feet trying to get to him. He said she did not make physical contact but was saying she was going to (profanity) me up. She was about 3 feet away from him at the time. NA#1 was crying and screaming. Staff took her to a room down 200 hall on the left hand side of the hall. Then NA #1 tried to come back out talking junk and Resident #1 was talking junk too. NA #1 tried to hit Resident #1 again. Staff took her down the hall again. He thought she remained in the building. Resident #1 stated he was talking to Nurse #1 in the hallway near the Director of Nurse ' s office around 9:00 AM (not sure of time) and was telling her what happened. Nurse #1 said she would call the Director of Nursing. NA #1 came around the corner from the dining room with mean look on her face and her fists balled. She kind of cut her eyes at resident #1 and he told her not to cut her eyes at him. NA #1 hit Resident #1 in the head, shoulders, arms, legs and chair. Resident #1 stated Nurse #1 was a witness to the event. He said he didn ' t say anything else to her except she was going to jail. Resident #1 said he only got a long scratch on his left upper arm. He said he had no other physical injuries. A nursing note dated 10/6/17 at 9:01AM indicated Resident #1 was assessed for injury via head to toe assessment with no noted injury. On 10/10/17 at 11:05 AM, an interview was conducted with Nurse #3. She stated she was at the nursing station counting narcotics with Nurse #5 around 7:15 AM. One of the aides came and asked them to call a code green because one of the residents was on the floor (400 hall). When she walked down the hall, she saw Resident #1 coming down 400 hall towards the nursing station saying if the aides were on the hall, he wouldn ' t have fallen. It was their fault that he fell . Nurse #3 stated she heard the comment in passing but didn ' t take much stock of it because the nursing staff had been on the hall at the time the resident fell . She went back to the medication cart to finish counting narcotics. As they were counting narcotics, Nurse #3 remembered seeing Resident #1 come across the nursing station to 200 hall where NA #2 was talking to Nurse #2. Nurse #3 heard arguing between NA #2 and Resident #1. Resident #1 got louder and cursing and told NA #2 she did not know what she was doing as he pointed at her. Resident #1 was fussing at NA #2 because he did not want NA #1 anywhere on his hall in addition to making the statement that NA #1 let a resident fall. Na #2 began to ignore him and resumed talking to the person she was talking to. Resident #1 continued to curse at NA #2. Nurse #3 stated she did not see NA #1 walk in resident #1 ' s direction. When Nurse #3 looked back up, she heard Resident #1 call NA #1 a (profanity). By that time, both Na #1 and Resident #1 were yelling and cursing at each other. NA #1 was telling Resident #1 she was not on his hall and she was not bothering him. They started calling each other profane names and NA #1 told Resident #1 she was not messing with his (profanity). Resident #1 stood up and he was pointing at her and they were yelling at each other. When he stood up, NA #1 went towards him. Nurse #3 stated she went towards NA #1 because NA #1 was shaking other staff off her with her arms saying get off of me. Nurse #3 said she grabbed NA #1 from the front and she was trying to get Nurse #3 away from her. Nurse #3 then bear hugged NA #1 and tried to calm her down because they were related she thought she could calm her down. All this happened at top of 200 hall. Nurse #3 walked NA #1 down 200 hall and around the corner to calm her down. She was visually upset, saying she was getting tired of this, talking junk to us, threatening us and could not take it anymore. Nurse #3 suggested she go outside to calm down. Nurse #3 took her out and then came back in to the building to complete counting narcotics. One of the shower aides came to Nurse #3 and told her that Resident #1 had said he was going to get rid of NA #1 one way or the other. She said she told somebody else but not NA #2. Nurse #3 went outside to tell NA #2 about the conversation and NA #1 seemed calmer at that time. Nurse #3 said she came back inside but did tell NA #1 and NA #2 that Resident #1 was talking to Nurse #1. They were near the nursing station. NA #2, NA#1 and Nurse #3 were going to get NA #1 ' s belongings. Nurse #3 stated she did not visualize the next blow up. They were fussing again. This time, Nurse #3 grabbed NA #1 and pulled her out of the doors. Nurse #3 stated she did not see any physical contact on either party. On 10/10/17 at 3:01 PM, an interview was conducted with the Director of Nursing (DON) and the Administrator. She stated she received a phone call between 7:47 AM and 7:57 AM from Nurse #1 and was informed that a staff member had struck a resident. She told me there was someone on the phone calling 911. The DON said she asked if the staff member had been removed from the building and she was told yes and the resident was ok. The DON stated she called the Administrator immediately after getting off the phone and told her that a staff member had struck a resident and that the staff member had been removed from the building and the resident was ok. The Administrator added that she was called while she was enroute to the facility and was informed the police were at the building. The DON stated the police were at the facility when she arrived. She was told the staff member who had assaulted the resident had borrowed someone ' s car and she had left the premises. The DON stated around 9:00 AM, both she and the Administrator went to Resident #1 and assessed him for injuries. No injuries were noted and Resident #1 did not complain of any pain at the time of the assessment. Resident #1 explained to them that both of them (resident #1, NA #1) got into verbal altercations and went at each other meaning verbal arguing and cursing at each other. He did state his left knee would probably start hurting because he stood up at the time of the altercation. The DON asked him if he needed to go to the hospital and he declined. The DON stated she called the physician at 9:22 AM and began the investigation. The DON continued to state what happened next: At 8:50 AM, they received several statements and gave them to Administrator. At 9:00 AM, the Administrator and DON assessed Resident #1. At 9:22 AM, the facility spoke to the Medical Director and conducted an interview with Resident #1 ' s roommate. At 9:35 AM, the facility called the agency that employed NA #1 and informed them of the situation that had occurred between Resident #1 and NA #1. On 10/11/17 at 8:30 AM, a telephone interview was conducted with the police officer from the (name) Police Department who responded to the call 10/6/17. He stated he and another police officer responded to a 911 call that an assault had occurred at the nursing home. He stated, when they arrived, the female aggressor had left the facility. He spoke to Resident #1 and spoke to Nurse #1. Nurse #1 stated the nursing assistant (NA #1) and Resident #1 got into an argument in the hallway and NA #1 had hit Resident #1. The police officer stated Resident #1 had a few surface scratches on his left upper arm. During the interview, Resident #1 was agitated and appeared angry-was not yelling but, by the way he was talking to the officer, he was upset over the situation. The police officer stated NA #1 was arrested when she returned to the facility area later in the morning but no charges were filed. He stated both parties were going to file warrants out against each other. The Magistrate talked to both parties and it was decided on both parties that no charges would be filed. The corrective action for past non-compliance dated 10/7/17 was as follows: On 09/17/17, nursing assistants reported to the charge nurse that Resident #1 was using profanity towards the accused agency nursing assistant and one other agency nursing assistant. Resident #1 stated the nursing assistants should stay on the hall. Resident #1 has ongoing behavioral issues, is care planned for demonstrating behaviors, and treated by the physician and psychiatric services for behaviors. The two agency nursing assistants did not engage Resident #1 and instead the staff nurse intervened. The staff nurse re-assigned another nursing assistant to Resident #1 for the duration of the shift. On 10/06/17, the accused agency staff employee was walking in the hall and had a verbal interaction with Resident #1. Resident #1 stood up and made a statement and used profanity towards the accused agency staff. The accused agency staff used profanity in return towards Resident #1. The agency licensed practical nurse removed the accused agency staff immediately from the facility. The agency licensed practical nurse and facility scheduler escorted the accused agency nursing assistant back into the facility to speak with the director of nursing (DON), not knowing the director of nursing was not at the facility. Instead, the quality improvement (QI) nurse was entering the facility where Resident #1 met her on the administrative hall. Immediately upon the agency nursing assistant entering the administrative hall, Resident #1 used profanity towards the agency staff again. The accused agency staff walked by Resident #1, who was sitting in a wheelchair, and swung at Resident #1. The agency staff struck Resident #1 ' s upper left arm with an open hand. The accused agency staff was immediately removed from the facility a second time by the facility staff scheduler and agency staff nurse. The QI nurse notified the director of nursing (DON). The DON notified the administrator. The QI nurse was assessing the resident and facility treatment nurse called 911 at 8:00 AM. The city police responded and interviewed Resident #1. The accused agency staff left the facility to self-report to the county magistrate. The accused waited off campus and the city police returned and escorted the accused to the magistrate. On 10/06/17, the DON called and verbally notified via telephone Resident #1 ' s nurse practitioner. Later on 10/06/17, the DON spoke via telephone to Resident #1 ' s physician/facility medical director. No new orders were received from the nurse practitioner or physician. On 10/06/17 in the afternoon, the DON called the psychiatric nurse supervisor and within 30 minutes the psychiatric nurse practitioner was in the facility and assessed Resident #1 related to ongoing behaviors. On 10/06/17 at 9:57 AM, the administrator faxed a 24 hour report for allegation of abuse/suspicion of a crime to the North Carolina Health Care Personnel Registry. On 10/06/17, the DON assessed Resident #1 for physical injury with no signs of injury noted. As of 10/06/17, the plan to manage the resident behavior in the facility includes 1) the administrator and DON permanently removing the accused agency nursing assistant from the staffing roster, 2) the registered nurse/QI nurse ' s daily support through conversation and encouragement, 3) 1-to-1 staff assignment to assist Resident #1, 4) psychiatric services, 5) Master ' s in Social Work (MSW) social worker meetings to discuss feelings, 6) the DON will work with the physician to provide Resident #1 with tangible interventions for skin and pain relief. On 10/06/17 at approximately 7:55 AM, the accused agency staff was removed permanently from the Richmond Pines facility by the facility scheduler and agency licensed practical nurse while the QI nurse was assessing the resident and facility treatment nurse called 911. On 10/06/17 at approximately 8:16 AM, the DON, QI nurse, and corporate clinical director had identified the root cause of the problem: the agency nursing assistant should not have been allowed back into the facility after the first verbal interaction on 10/06/17. Why did the resident get hit? Because the agency nursing assistant hit the resident. Why did the agency nursing assistant hit the resident? Because the nursing assistant swung at the resident. Why was the agency nursing assistant swinging to hit the resident? Because the assistant was upset. Why was the agency nursing assistant upset? Because of a verbal interaction with the resident. Why was there a verbal interaction with the resident? Because the nursing assistant was being brought in for an interview. Why was the agency nursing assistant being brought in for an interview? Because there was an earlier verbal altercation. Because there was an earlier verbal altercation, the employee should not been allowed back into the facility. The facility staff thought the agency nursing assistant needed to be interviewed and drug tested . On 10/06/17 at approximately 9:37 AM, the facility administrator and DON notified the staffing agency that the accused agency staff would not be allowed to work at the facility. On 10/06/17 at 10:45 AM, the social worker initiated abuse interviews for all interviewable residents. The interviews were completed at 1:40 PM. The interviews resulted in no concerns expressed by interviewable residents. On 10/06/17, beginning at approximately 11:00 AM, the treatment nurse and floor nurses assessed all non-interviewable residents who are unable to communicate or who are disoriented. On 10/06/17, the body audits were completed. The 100% body audits of all non-interviewable residents resulted in no identified bodily signs of abuse. On 10/06/17, the DON completed a review of all nurse progress notes for the time period of 09/22/17 through 10/06/17 for any incidents of abuse/neglect. No incidents of abuse/neglect were identified during the progress note review by the DON. The processes that lead to the deficiency cited: To address the processes that lead to the deficiency cited and why it escalated to a physical altercation the facility performed at root cause analysis. The root cause analysis using 5 Whys determined: 1) the physical abuse would not have happened if the accused agency nursing assistant had not been allowed to re-enter the facility after the initial verbal altercation, 2) if the facility and agency staff would have recognized the initial verbal altercation as a problem with the potential to escalate, and 3) the importance of preventing abuse/neglect. It was determined that the facility needed to train staff on: abuse neglect policies and procedures, prevention of abuse/neglect, identification of abuse/neglect, protecting the resident from abuse/neglect, protecting the staff from burn out, and immediately reporting abuse/neglect. On 10/06/17, the regional vice president trained the department leaders regarding the policy for abuse/neglect, including reporting requirements. On 10/06/17, the staff facilitator initiated in-servicing for all staff on abuse/neglect. The training included the definition of abuse/neglect, the types of abuse/neglect, and reporting abuse/neglect immediately. The in-service was completed on 10/10/17 for all staff who have worked. No staff worked until they had received the abuse neglect in-service. On 10/06/17, the staff facilitator initiated in-servicing for all staff on burn-out. The training included what burn out is. The burn out in-service covered the signs and symptoms of burn out, what to do when feeling frustrated, to let the supervisor know when experiencing/feeling early signs of burn out, and to report to a supervisor when a co-worker shows signs and symptoms of burn out. The in-service was completed on 10/10/17 for all staff who have worked. No staff worked until they had received the burn-out in-service. On 10/06/17, the DON called a staff meeting with the nurses to knowing where the nursing assistants are at all times, about the abuse/neglect in-service, about the burn out in-service, and about correct staffing assignments. On 10/06/17, the DON called a nursing assistant meeting at the nurse station to review the in-services, offer clarification and support regarding the allegation of abuse/neglect. The DON encouraged the facility staff to communicate with management when they see something that is not right. The DON assured the staff the management team that talking about problems is healthy

Based on record review and staff, Nurse Practitioner and Physician interview, the facility failed to notify the physician when a cognitively impaired resident was entrapped between the mattress and the foot board causing a bruise to the back of the resident's neck. This was evident for 1 of 3 sampled residents reviewed for accidents (Resident #80). Immediate jeopardy began on 5/1/17 when Resident #80 was found entrapped between the mattress and the foot board and the facility did not notify the physician. The immediate Jeopardy is present and ongoing. Findings included: 1. Resident #80 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#80 had memory and decision making problems and needed extensive assistance with bed mobility. Resident #80 resided in the secured unit. Resident #80's incident report dated 5/1/17 at 4:42 AM was reviewed. The report revealed resident observed by writer facing the base board of their bed with their head wedged between the base board and the mattress. Writer, nurse, medication aide and Nursing aide (NA) helped remove resident's head from being wedged between base board and mattress by lifting resident's body and pulling mattress out from under resident to make room to slide resident's head out from under base board of their bed. Bruise noted to back of neck. (Name of physician) was notified. Responsible party (RP) notified. Resident #80's nurse's notes were reviewed. The notes dated 5/1/17 at 4:40 AM revealed resident observed by writer facing the base of their bed with their head wedged between the base board and the mattress. Write asked resident what are you doing? Resident stated trying to get up. Writer, nurse, medication aide and NA helped remove resident's head from being wedged between base board and the mattress by lifting resident's body and pulling the mattress out from under the resident to make room to slide resident's head out from under the base board. Bruise noted to back of neck. Physician notified and responsible party (RP) notified. No change in resident's base line, level of consciousness (LOC), pupils equal, round, reactive to light and accommodation (PERRLA). Able to move all extremities within resident's normal base line. Skin warm and dry to touch. Respiration even and unlabored. Lung sounds clear. No shortness of breath noted. Denies any pain or discomfort. No adverse reaction noted. Vital signs (VS) 126/66, 72, 18, 98.2. On 6/8/17 at 7:55 AM, Nurse #2 was interviewed. Nurse #2 was assigned to Resident #80 on 4/30/17 (night shift). Nurse #2 stated that she was checking the rooms and she found Resident#80's head stuck under the base board of the bed. She clarified that she meant the base board as foot board. The resident was facing the floor and his neck was under the base of the foot board and his head was hanging out. The resident's body was in bed on downward facing position. He was not talking but he was alert. Four staff members helped to get the resident's head out from the foot board by lifting his body up and pulling the mattress out under him. Nurse #2 stated that she called the attending physician of Resident #80 and not the on-call and left a message on his voice mail. She further stated that she was told to always call the resident's attending physician and not the after-hours access line. Nurse #2 further stated she was not aware that the attending physician of Resident #80 was on vacation at that time. Interview with the DON was conducted on 6/8/17 at 9:27 AM. She stated that she expected the nurses to follow their after-hours procedure in calling the physician. The DON also indicated she expected the nurses to call her if unable to reach the physician and to send the resident to the emergency room (ER). The DON indicated that the incident with Resident #80, the nurse should have sent the resident to ER if unable to reach the physician. Review of the doctor's progress notes from 5/1/17 through 5/7/17 was conducted. There were no notes which addressed the resident's entrapment. Interview with the Physician was conducted on 6/8/17 at 9:58 AM. He stated that he was not informed of the incident with Resident #80 which happened on 5/1/17. He stated that he was on vacation the last week of April and was back to work the morning of 5/1/17. He stated that he expected the nurse to call the Nurse Practitioner or the on call physician. At 4:40 PM, the Physician indicated that his work phone was showing that the facility had called on 5/1/17 at 4:15 AM and left a message on his voice mail. He stated that he was unable to retrieve the message on his voice mail. Interview with the Nurse Practitioner (NP) was conducted on 6/8/17 at 10:50 AM. The NP stated that she was scheduled to come to the facility every Tuesday and Thursday and at times on Friday and the Physician came every Monday between 8 AM to 5 PM. She stated that she was not informed of the incident with Resident #80. The NP added that she expected the nurses to call her or the physician during office hours Monday through Friday between 8 AM to 5 PM and to call the on call number during after- hours and on the weekends. A follow up interview with the DON was conducted on 6/8/17 at 1:10 PM. The DON stated that she expected the nurses to notify the physician of any incidents/accidents with or without injury. She indicated that she also expected the nurses to call her if unable to reach the physician and she would try to call the physician. She added that if they were unable to reach the physician, the resident should be sent to the ER. The administrator and the DON were notified of immediate jeopardy on 6/8/17 at 12:06 PM.

Based on record review, observation and staff interview, the facility utilized a device (foot board) in bed without considering it to be a restraint and without a medical symptom. Resident #80's head was caught between the bed's mattress and the foot board causing a bruise to the back of the resident's neck. This was evident for 1 of 3 sampled residents whose beds had a gap of 4 inches or more between the mattress and the foot board in the facility's secured unit (Resident #80). Immediate jeopardy began on 5/1/17 when Resident #80 was found with his head entrapped between the mattress and the foot board causing a bruise to the back of the resident's neck. The immediate jeopardy is present and ongoing. Findings included: 1. Resident #80 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#80 had memory and decision making problems and needed extensive assistance with bed mobility. The assessment further indicated that the resident was not using any physical restraint in bed and in the chair. Resident #80 resided in the facility's secured unit. Resident #80's care plan dated 4/25/17 was reviewed. The care plan problem was resident was at risk for falls and the goal was the resident will be free of falls through the next review. The approaches included to assist during transfer and mobility, ensure environment free of clutter, administer medications as ordered and have commonly used articles within easy reach. Resident #80's incident report dated 5/1/17 at 4:42 AM was reviewed. The report revealed, Resident observed by writer facing the base board of their bed with their head wedged between the base board and the mattress. Writer, nurse, medication aide and nursing side (NA) helped remove resident's head from being wedged between base board and mattress by lifting resident's body and pulling mattress out from under resident to make room to slide resident's head out from under base board of their bed. Bruise noted to back of neck. Resident #80's nurse's notes were reviewed. The notes dated 5/1/17 at 4:40 AM revealed resident observed by writer facing the base of their bed with their head wedged between the base board and the mattress. Writer asked resident, What are you doing? Resident stated trying to get up. Writer, nurse, medication aide and NA helped remove resident's head from being wedged between base board and the mattress by lifting resident's body and pulling the mattress out from under the resident to make room to slide resident's head out from under the base board. Bruise noted to back of neck. This note was written by Nurse #2. Resident #3 was observed up in wheelchair in his room on 6/5/17 at 4:20 PM. His bed had a ¼ side rail, a foot board and a head board. His bed had no gap between the mattress, foot board and head board. Interview with Nurse Aide (NA) #3 (assigned to Resident #80) was conducted on 6/7/17 at 5:40 PM. NA #3 stated that that the resident was independent with bed mobility, transfer and ambulation but he needed constant reminder due to his confusion. On 6/8/17 at 7:55 AM, Nurse #2 was interviewed. Nurse #2 was assigned to Resident #80 on 4/30/17 (night shift). Nurse #2 stated that she was checking the rooms and she found Resident #80's head stuck under the base board of the bed. She clarified that she meant the base board as foot board. The resident was facing the floor and his neck was under the base of the foot board and his head was hanging out. The resident's body was in bed in the downward facing position. He was not talking but he was alert. Four staff members helped to get the resident's head out from the foot board by lifting his body up and pulling the mattress out from under him. Interview with the Maintenance Director was conducted on 6/8/17 at 8:15 AM. He stated that he didn't know that he had to check the gaps between the mattress, foot board, head board and side rails and he was not told to check them. An interview with the Director of Nurses (DON) was conducted on 6/8/17 at 9:27 AM. The DON stated that nobody was checking the gaps between the mattress and the foot board even after the incident with Resident #80 on 5/1/17. She further stated nothing had been done after the resident's entrapment. The resident was moved to another room per family request and not related to the resident's entrapment. Interview with the Administrator was conducted on 6/8/17 at 9:37 AM. She indicated that she expected the maintenance director to check the gaps between the mattress and the foot board at least monthly but she didn't know if the maintenance director was doing it or not. Interview with the Quality Assurance (QA) Nurse was conducted on 6/9/17 at 3:35 PM. The QA Nurse stated that she didn't consider the foot board as a restraint. Interview with MDS Nurse #2 was conducted on 6/9/17 at 3:36 PM. She stated that she didn't consider the foot board as a restraint. The Regional Vice President and the Administrator were notified of the immediate jeopardy on 6/9/17 at 3:30 PM.

Based on record review, observation and staff interview, the facility neglected to supervise a cognitively impaired resident who was identified as a wanderer which resulted in an unsupervised exit from the facility for 1 of 3 sampled residents reviewed for accidents (Resident #3). Resident #3 was found a few feet to the road heading towards a busy highway. Resident #3 had to go through a parking lot to get to the road. Immediate jeopardy began on 3/4/17 when Resident #3 exited the building unsupervised. Immediate jeopardy is present and ongoing. Findings included: The facility's wandering risk potential protocol dated 1/16/16 was reviewed. The protocol read in part the purpose of this protocol is to implement guidelines to identify a resident's risk for inappropriate wandering within or outside the facility and to ensure a resident's safety in regards to the identified behavior. To identify this behavior and to ensure a resident's safety, utilization of the wandering risk potential protocol should occur as indicated. These guidelines apply to all residents within the facility including this residents who may reside on secured dementia units. The purpose of the protocol were to prevent the resident's unsupervised exit and to plan for the resident's safety and well-being within the facility. The procedure included implement preventative interventions up to or including the application of an alarm bracelet, monitoring the care plan, etcetera (etc.). 1. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#3 had moderate cognitive impairment and was independent with locomotion on and off unit. The assessment also indicated that the resident needed extensive assistance with transfer and was using a wheelchair for mobility. The assessment further indicated that the resident had not exhibited a wandering behavior during the assessment period. Resident #3's wandering risk evaluations were reviewed. The risk evaluation form indicated that a resident with a score of greater than 5 was at risk for wandering. The wandering risk evaluation form dated 10/7/16 revealed that Resident #3 was at risk for wandering with a score of 16. The form indicated that the resident has had one or more attempts to leave home/facility and or wander in the past 3 months. The form also indicated that the resident had made verbal statement of desire or intent to leave the facility. The wandering risk evaluation form dated 3/23/17 and 5/18/17 revealed that Resident #3 was at risk for wandering with a score of 19. The form indicated that the resident has had one or more attempts to leave home/facility and or wander in the past 3 months. The form also indicated that the resident had made verbal statement of desire or intent to leave the facility. Resident #3's care plan for wandering was reviewed. The wandering care plan was initiated on 8/9/16 and was reviewed on 3/28/17. One of the care plan problems was wandering and or at risk for unsupervised exits from facility related to: attempts to leave unit/building. The goal was the resident will have no episode of unsupervised exits from facility through next review. The approaches included to allow resident to wander on units, to check daily to ensure resident has an alarm bracelet on and it is functioning properly, documents episodes of wandering per facility protocol, ensure identification (ID) bracelet is in place, ensure resident's picture and name are on the wandering resident board, ensure that alarm exits are functional, provide 1:1 staff monitoring as necessary, provide supervision during recreational programs, and provide resident with opportunities to attend group activities of choice. All of these care plan approaches were initiated/started on 8/9/16. There were no new interventions added after 8/9/2016. The nurse's notes dated 3/4/17 at 7:45 PM revealed alarm sounding at front door. Upon investigating, visitor said that he had let resident (Resident #3) out of door because resident asked him to. Upon going outside, this nurse noted (name of Resident#3) in his chair within a few feet of roadway. This nurse could not get resident return to building. He was yelling I'm not going back in the building, I'm going home. This nurse continued to hold chair to prevent resident from entering roadway and turned on her cell phone and phoned facility. Advised staff of situation and 3 staff members came and assisted writer to get resident back into building. The notes indicated that the resident had no injuries from the incident. The nurse's notes dated 4/11/17 at 4:47 PM revealed late entry for 4/10/17 at 5:30 PM, Director of Nursing (DON) and Social Worker (SW) spoke with wife to inform her that the resident had an unsupervised exit and that the team needed to meet with her and the family to discuss the move to sparks (secured unit) unit. She stated that we could go ahead and plan a meeting and she would make sure the family was present. The nurse's notes dated 4/14/17 at 1:59 PM revealed resident at front door yelling trying to get out. Redirected to lunch with good results. Returned to door, loudly yelling for his wife and son. The nurse's notes dated 4/14/17 at 3:02 PM revealed that at 2:05 PM, Resident #3 was still wanting to leave the facility. The nurse's notes dated 5/15/17 at 4:26 PM revealed that DON was notified that resident was allowed to leave the building by a family member visiting another resident. The nurse asked the visitor not to let the resident out but they did it anyway. The resident made it out the door but not off the porch and supervised by the nurse the entire time. The nurse's notes dated 5/16/17 at 4:40 PM revealed resident propelling self-up and down halls in wheelchair yelling and screaming for someone to pay him and that he needs a ride home. Resident repeatedly asking visitors to let him out so he can find a ride home. The nurse's notes dated 5/23/17 at 3:37 PM revealed wife notified that the resident has been trying to exit building all day. The wife stated that she knows that he will not come back if he is allowed to exit facility. The nurse's notes dated 5/24/17 at 1:53 PM revealed that the resident attempts to leave facility to vacate the premises. Is cognitively impaired and cannot make good decision to protect himself from danger. The nurse's notes dated 6/4/17 at 10:20 PM revealed resident sitting in wheelchair propelling self about facility. Third shift reports that resident didn't sleep last night, he has been up all night wandering about facility in his wheelchair. Resident #3 was observed up in wheelchair in his room on 6/5/17 at 4:20 PM. A wander guard was observed attached to his wheelchair. Interview with NA #1 (assigned to Resident #3 on first shift) was conducted on 6/6/17 at 12:05 PM. NA #1 stated that Resident #3 was independent with locomotion using a wheelchair. She stated that the resident was always out of bed around 10 in the morning and he propelled his wheelchair around facility talking to other residents. NA #1 revealed that the resident was a wanderer and she heard that he had wandered outside during the second shift but she didn't know the date of the incident. NA #1 stated that she was the only NA on the hall. An interview with Nurse #1 was conducted on 6/6/17 at 2:10 PM. Nurse #1 stated that she worked second shift. She indicated that she heard and responded to a front door alarm twice (didn't remember the dates). She indicated that a family member had let Resident #3 out the door. Nurse #1 didn't remember the exact time but it was late in the evening. She found the resident on the road towards the highway (highway 177) in his wheelchair. The resident refused to come back. She had to use her cell phone to call the facility to get help because the resident would not return back to facility. The nurse claimed that she didn't know how long the resident was outside and how long the alarm was sounding before she answered it. She indicated that she completed the incident report and informed the physician, responsible party, DON and Administrator of the incident. Nurse #1 further revealed that she had responded also to another front door alarm and found the resident on the porch. She stated that a family member had let the resident out. Nurse #1 claimed that she didn't know how long the resident was outside on the porch. She also indicated that she didn't remember the dates and times of the incidents. Nurse #1 also claimed that she didn't remember if she was assigned to the resident on the days Resident #3 was found outside. The location where Resident #3 was found on 3/4/17 was measured by the maintenance director and it was 236 feet (78 yards) away from the facility's front door. The weather underground report revealed that the temperature in the area where Resident #3 was found was on the low 40's degree Fahrenheit (F) on 3/4/17 between 7:30 PM and 7:45 PM. An interview with the DON was conducted on 6/6/17 at 2:50 PM. She indicated that she had asked the resident's family member to move Resident #3 to the secured unit but the family member had refused. She stated that she posted a sign on the door reminding visitors not to let any resident out, but this didn't work. She also stated that the resident had a wander guard. Interview with NA #2 was conducted on 6/6/17 at 3:40 PM. NA #2 was assigned to Resident #3 on 3/4/17 and 4/10/17 on the second shift. NA #2 stated that she had known Resident #3 as a wanderer. NA #2 revealed that she was the only NA on the hall that day. Interview with the Administrator was conducted on 6/6/17 at 4:46 PM. The Administrator stated that this was the time of the day that Resident #3's behavior was worst, trying to leave the facility. She stated that she had met with the family who gave her permission to move the resident to the secured unit if it was necessary but she felt that the resident was safe if only the staff were monitoring him and responding to the door alarm immediately. The Administrator further stated that there was a staff member (receptionist) in the lobby until 9 PM every day who could monitor the front door. The Administrator further indicated that incident reports were reviewed during the morning meeting and interventions were discussed and the MDS Nurse was responsible to update the care plan. She acknowledged that completion of incident report was an issue as evidenced by Resident #3's wandering incidents on 3/4/17 and 4/10/17 had no incident report completed. The administrator and the DON were notified of immediate jeopardy on 6/7/17 at 1:23 PM.

Based on record review and staff interview, the facility failed to revise the care plan for wandering for a cognitively impaired resident who was identified at risk for elopement, which resulted in an unsupervised exit from the facility's front door for 1 of 3 sampled residents reviewed for accidents (Resident #3.) The facility also failed to revise the care plan of a cognitively impaired resident who had repeated falls for 1 of 3 sampled residents (Resident #3) at a scope and severity of D. The facility failed to involve alert and oriented residents in the care planning process for 2 (Residents #82 & #74) of 3 sampled residents. This was at a scope and severity of D. Immediate jeopardy began on 3/4/17 when Resident #3 exited the facility unsupervised and facility failed to update the care plan. The immediate jeopardy is present and ongoing. Findings included: 1a. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#3 had moderate cognitive impairment and was independent with locomotion on and off unit. The assessment also indicated that the resident needed extensive assistance with transfer and was using a wheelchair for mobility. The assessment further indicated that the resident had not exhibited a wandering behavior during the assessment period. Resident #3's care plan for wandering was reviewed. The wandering care plan was initiated on 8/9/16 and was reviewed on 3/28/17. One of the care plan problems described the resident at risk for wandering and for unsupervised exits from the facility related to: attempts to leave unit/building. The goal was the resident will have no episode of unsupervised exits from facility through next review. The approaches included to allow resident to wander on units, to check daily to ensure resident has an alarm bracelet on and it is functioning properly, documents episodes of wandering per facility protocol, ensure identification (ID) bracelet is in place, ensure resident's picture and name are on the wandering resident board, ensure that alarm exits are functional, provide 1:1 staff monitoring as necessary, provide supervision during recreational programs, and provide resident with opportunities to attend group activities of choice. All of these care plan approaches were initiated/started on 8/9/16. There were no revisions to the care plan approaches after 8/9/16 or after 3/4/17 when the resident had exited the facility unsupervised. The nurse's notes dated 3/4/17 at 7:45 PM revealed alarm sounding at front door. Upon investigating, visitor said that he had let resident (Resident #3) out of door because resident asked him to. Upon going outside, this nurse noted (name of Resident#3) in his chair within a few feet of roadway. This nurse could not get resident return to building. He was yelling I'm not going back in the building, I'm going home. This nurse continued to hold chair to prevent resident from entering roadway and turned on her cell phone and phoned facility. Advised staff of situation and 3 staff members came and assisted writer to get resident back into building. The notes indicated that the resident had no injuries from the incident. Nurse #1 was the author of this note. The nurse's notes dated 4/11/17 at 4:47 PM revealed late entry for 4/10/17 at 5:30 PM, Director of Nursing (DON) and Social Worker (SW) spoke with wife to inform her that the resident had an unsupervised exit and that the team needed to meet with her and the family to discuss the move to sparks unit (secured unit). She stated that we could go ahead and plan a meeting and she would make sure the family was present. The DON was the author of this note. The nurse's notes dated 4/14/17 at 1:59 PM revealed resident at front door yelling trying to get out. Redirected to lunch with good results. Returned to door, loudly yelling for his wife and son. The Quality Assurance (QA) Nurse was the author of this note. The nurse's notes dated 4/14/17 at 3:02 PM revealed that at 2:05 PM, Resident #3 was still wanting to leave the facility. The QA Nurse was the author of this note. The nurse's notes dated 5/15/17 at 4:26 PM revealed that DON (Director of Nursing) was notified that resident was allowed to leave the building by a family member visiting another resident. The nurse asked the visitor not to let the resident out but they did it anyway. The resident made it out the door but not off the porch and supervised by the nurse the entire time. The DON was the author of this note. The nurse's notes dated 5/16/17 at 4:40 PM revealed resident propelling self-up and down halls in wheelchair yelling and screaming for someone to pay him and that he needs a ride home. Resident repeatedly asking visitors to let him out so he can find a ride home. The MDS Nurse #2 was the author of this note. The nurse's notes dated 5/23/17 at 3:37 PM revealed wife notified that the resident has been trying to exit building all day. The wife stated that she knows that he will not come back if he is allowed to exit facility. The DON was the author of this note. The nurse's notes dated 5/24/17 at 1:53 PM revealed that the resident attempts to leave facility to vacate the premises. Is cognitively impaired and cannot make good decision to protect himself from danger. The QA Nurse was the author of this note. The nurse's notes dated 6/4/17 at 10:20 PM revealed resident sitting in wheelchair propelling self about facility. Third shift reports that resident didn't sleep last night, he has been up all night wandering about facility in his wheelchair. Nurse #7 was the author of this note. Interview with the MDS Coordinator #1 was conducted on 6/6/17 at 3:45 PM. The MDS Coordinator stated that she started as MDS Nurse in March 2017. She stated she had no MDS experience in the past and she had received MDS training from the corporate consultant and not from the state MDS training. The MDS Nurse indicated they discussed the incident reports during their morning meeting. She stated she was aware of Resident #3's wandering episodes. The MDS Nurse had reviewed the resident's electronic care plan for wandering and stated that there were no revisions to the care plan approaches since 8/9/16. Interview with the DON on 6/8/17 at 2:15 PM was conducted. The DON stated she expected the MDS Nurse to revise the care plan after every fall or unsupervised exit. The Administrator and the DON were notified of immediate jeopardy on 6/7/17 at 1:23 PM. b. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#3 had moderate cognitive impairment and was independent with locomotion on and off unit. The assessment also indicated that the resident needed extensive assistance with transfer and was using a wheelchair for mobility. The assessment further indicated that the resident had falls since admission or prior assessment with no injury. Resident #3's care plan for falls was reviewed. The falls care plan was initiated on 8/9/16 and was reviewed on 3/28/17. The care plan problem was risk for falls characterized by history of falls related to: weakness, back surgery. The goal was resident will be free of falls through next review. The approaches included assist during transfer and mobility, bed in lowest position, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, fall risk protocol, have commonly used articles within easy reach, keep assistive ambulation devise (wheelchair) within reach of the resident and keep call light within reach and answer timely. All of these approaches were initiated/started on 8/9/2016. There were no revisions to the care plan approaches after 8/9/2016 and after the incidents of falls. Resident #3's incident reports were reviewed. The resident had 10 falls from 10/2016 through 05/2017. The dates of the falls were 10/17/16, 11/11/16, 11/17/16, 12/7/16, 12/19/16, 1/4/17, 2/7/17, 4/23/17, 4/29/17 and 5/30/17. Interview with the MDS Coordinator #1 was conducted on 6/6/17 at 3:45 PM. The MDS Coordinator stated that she started as MDS Nurse in March 2017. She stated that she had no MDS experience in the past and she had received MDS training from the corporate consultant and not from the state MDS training. The MDS Nurse indicated the incident reports were discussed during morning meeting. She stated that she was aware of Resident #3's repeated falls. The MDS Nurse had reviewed the resident's electronic care plan for falls and stated that there were no revisions to the care plan approaches since 8/2016. Interview with the DON on 6/8/17 at 2:15 PM was conducted. The DON stated that she expected the MDS Nurse to revise the care plan after every fall or unsupervised exit. 2. Resident #82 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] indicated that Resident #82 had moderate cognitive impairment. The assessment also indicated that the resident had no behavior, she has clear speech, she had clear comprehension and she was able to make self - understood. On 6/5/17 at 10:02 AM and on 6/7/17 at 12:43 PM, Resident #82 was interviewed. She stated that she didn't feel included and had not been involved in the care planning process. The Social service progress notes were reviewed from 6/1/16 through 6/7/17. There were no notes of any care planning process held for Resident #82. Interview with the Social Worker (SW) was conducted on 6/7/17 at 3:12 PM. The SW stated she was responsible for inviting residents and responsible party (RP) to the care plan meeting. She stated that she documented electronically when the care plan meeting was held and if the RP or the resident had attended the meeting. The SW provided additional information and stated that she could not find any documentation that a care plan meeting was held for Resident #82. Interview with the DON was conducted on 6/8/17 at 2:15 PM. The DON stated that she expected the residents and the RP to be involved in the care planning process. Interview with the MDS Nurse #2 was conducted on 6/8/17 at 3:20 PM. MDS Nurse #2 indicated that it has been an issue for over a year now that the interdisciplinary team (IDT) didn't meet for the care planning process. The SW was responsible for inviting residents and RP to the meeting but that was not happening. MDS Nurse #2 further stated that there were no meetings held with the facility's staff, residents and RPs to discuss the care planning process for over a year now. She indicated that administration was aware of this issue. 3. Resident #74 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #3's medical record revealed his most recent care plan meeting was held on 10/18/16. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74's cognition was intact. An interview was conducted with Resident #74 on 6/5/17 at 10:17 AM. He stated he had not felt like he was included in decisions about his medicine, therapy, or other treatments. He indicated his last care plan meeting was over 6 months ago. An interview was conducted with the Director of Nursing (DON) on 6/6/17 at 12:34 PM. She indicated the facility utilized care plan meetings to incorporate the resident and/or Responsible Party (RP) in the care planning process. She stated her expectation was for a care plan meeting to be held quarterly with the resident and/or the RP and as needed if an issue arose. She indicated the Social Worker (SW) was responsible for scheduling care plan meetings and for inviting the resident and/or RP. The DON revealed the facility had an ongoing problem with the timeliness of care plan meetings. An interview was conducted with the SW on 6/7/17 at 12:53 PM. She indicated care plan meetings were utilized to include the resident and/or RP in the care planning process. She stated care plan meetings were held quarterly and as needed if an issue arose. She reported she was responsible for scheduling the care plan meetings and for inviting the resident and/or RPs. The SW indicated she was familiar with Resident #74. She stated he was his own RP and he was to be included in all of his care plan meetings. She reported she was unsure of when Resident #74's last care plan meeting was held. She reported she needed to review her records. A follow up interview was conducted with the SW on 6/7/17 at 3:12 PM. She revealed Resident #74's last care plan meeting was held on 10/18/16. She indicated there should have been a care plan meeting held with Resident #74 since that time. She stated she was unable to explain why Resident #74 had not had a care plan meeting since 10/18/16. An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 6/8/17 at 3:21 PM. MDS Nurse #1 and MDS Nurse #2 reported that care plan meetings were utilized to incorporate the resident and/or RP in the care planning process. They both indicated care plan meetings were supposed to be held quarterly. The MDS Nurses revealed that quarterly care plan meetings were not occurring consistently. MDS Nurse #2 stated she had been in her position at the facility for about a year and this was an ongoing problem for that entire length of time.

Based on record review, observation and staff interview, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised (Resident #3) and also failed to prevent a cognitively impaired resident from bed entrapment between the mattress and the foot board (Resident #80). The facility also failed to reassess and to intervene to prevent repeated falls (Resident #3) at a scope and severity of D. These were evident for 2 (Residents #3 and #80) of 3 sampled residents reviewed for accidents. Immediate jeopardy began on 3/4/17 when Resident #3 exited the building unsupervised. Immediate jeopardy began on 5/1/17 when Resident #80's head was found caught between the foot board and the mattress causing a bruise to the back of neck. Immediate jeopardy is present and ongoing. Findings included: 1. Resident #80 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#80 had memory and decision making problems and needed extensive assistance with bed mobility. Resident #80 resided in the secured unit. Resident #80's care plan dated 4/25/17 was reviewed. The care plan problem was resident was at risk for falls and the goal was the resident will be free of falls through the next review. The approaches included to assist during transfer and mobility, ensure environment free of clutter, administer medications as ordered and have commonly used articles within easy reach. The care plan did not address the resident's bed mobility. Resident #80's incident report dated 5/1/17 at 4:42 AM was reviewed. The report revealed resident observed by writer facing the base board of their bed with their head wedged between the base board and the mattress. Writer, nurse, medication aide and Nursing aide (NA) helped remove resident's head from being wedged between base board and mattress by lifting resident's body and pulling mattress out from under resident to make room to slide resident's head out from under base board of their bed. Bruise noted to back of neck. (Name of physician) was notified. RP notified. The incident report revealed that Resident #80 resided in room 413 B on 5/1/17. Resident #80's nurse's notes were reviewed. The notes dated 5/1/17 at 4:40 AM revealed resident observed by writer facing the base of their bed with their head wedged between the base board and the mattress. Write asked resident what are you doing? Resident stated trying to get up. Writer, nurse, medication aide and NA helped remove resident's head from being wedged between base board and the mattress by lifting resident's body and pulling the mattress out from under the resident to make room to slide resident's head out from under the base board. Bruise noted to back of neck. Physician notified and responsible party (RP) notified. No change in resident's base line, level of consciousness (LOC), pupils equal, round, reactive to light and accommodation (PERRLA). Able to move all extremities within resident's normal base line. Skin warm and dry to touch. Respiration even and unlabored. Lung sounds clear. No shortness of breath noted. Denies any pain or discomfort. No adverse reaction noted. Vital signs (VS) 126/66, 72, 18, 98.2. The nurse's notes dated 5/3/17 at 10:39 PM revealed that swelling noted to right (R) check and R lip. Physician and RP notified. Interview with NA #3 (assigned to Resident #80) was conducted on 6/7/17 at 5:40 PM. NA #3 stated that that the resident was independent with bed mobility, transfer and ambulation but he needed constant reminder due to his confusion. Interview with the Director of Nursing (DON) was conducted on 6/7/17 at 5:50 PM. The DON stated that she was not aware of an incident with Resident #80 on 5/1/17. The DON was asked to read the electronic nurse's notes dated 5/1/17. The DON read the nurse's notes loudly with the Administrator and Corporate staff member in the room. The DON and the Administrator stated that they were not aware of the 5/1/17 incident. On 6/8/17 at 7:55 AM, Nurse #2 was interviewed. Nurse #2 was assigned to Resident #80 on 4/30/17 (night shift). Nurse #2 stated that she was checking the rooms and she found Resident#80's head stuck under the base board of the bed. She clarified that she meant the base board as foot board. The resident was facing the floor and his neck was under the base of the foot board and his head was hanging out. The resident's body was in bed in downward facing position. He was not talking but he was alert. Four staff members helped to get the resident's head out from the foot board by lifting his body up and pulling the mattress out under him. Nurse #2 stated that she called the attending physician of Resident #80 and not the on-call and left a message on his voice mail. She further stated that she was told to always call the resident's attending physician and not the after-hours access line. Nurse #2 further stated she was not aware that the attending physician of Resident #80 was on vacation at that time. Interview with the Physician was conducted on 6/8/17 at 9:58 AM. He stated that he was not informed of the incident with Resident #80 which happened on 5/1/17. He stated that he was on vacation the last week of April and was back to work the morning of 5/1/17. He stated that he expected the nurse to call the Nurse Practitioner or the on call physician. At 4:40 PM, the Physician indicated that his work phone was showing that the facility had called on 5/1/17 at 4:15 AM and left a message on his voice mail. He stated that he was unable to retrieve the message on his voice mail. On 6/8/17 at 8:08 AM, room 413 B (the room where Resident #80 resided on 5/1/17) was observed to measure the gap between the mattress and the foot board but the bed was already removed from the room. Nurse #2 had identified the same bed Resident #80 was using during the 5/1/17 incident. The bed mattress was small for the bed and there was a big gap between the bed frame (under the mattress) and the foot board. The nurse demonstrated how she found the resident in bed. Interview with the Maintenance director was conducted on 6/8/17 at 8:15 AM. He stated that he didn't know the incident with Resident #80 until yesterday 6/7/18. He indicate that he didn't know what kind of bed he was on but he thought he was on a hospice bed. The Maintenance director claimed that he didn't know who removed the bed from room 413 B. He added that he didn't know that he had to check the gaps between mattress, foot board, head board and side rails and he was not told to check them. On 6/8/17 at 8:25 AM, the beds in the secured unit were observed with the Maintenance director. In room 418 A, the foot board was loose, two screws were missing. In room 421 A, the hospice bed had a gap of 5 inches from the mattress to the foot board. In room 423 B, a regular bed had a gap of 4 inches between the mattress and the foot board. The distance between the bed frame (under the mattress) and the foot board was 7 and ¼ inches. A follow up interview with the DON was conducted on 6/8/17 at 9:27 AM. The DON stated she was not informed of the incident with Resident #80 that occurred on 5/1/17. She indicated that she had signed off the incident report dated 5/1/17 but she didn't think it was that bad but when she read the nurse's notes yesterday (6/7/17), she said oh my God. The DON further indicated as far as she knew nothing had been done after the incident. She further stated that she didn't know what kind of bed the resident was on. The DON revealed that the resident was moved to another room per the family request but she was not sure of this. The DON stated that nobody was checking the gaps between the mattress and the foot board. Interview with the Administrator was conducted on 6/8/17 at 9:37 AM. The Administrator stated that she didn't read the incident report dated 5/1/17 because the DON and the QA (Quality Assurance) nurse had already signed it off. She indicated that she expected the maintenance director to check the gaps between the mattress and the foot board at least monthly but she didn't know if the maintenance director was doing it or not. The facility's wandering risk potential protocol dated 1/16/16 was reviewed. The protocol read in part the purpose of this protocol is to implement guidelines to identify a resident's risk for inappropriate wandering within or outside the facility and to ensure a resident's safety in regards to the identified behavior. To identify this behavior and to ensure a resident's safety, utilization of the wandering risk potential protocol should occur as indicated. These guidelines apply to all residents within the facility including this residents who may reside on secured dementia units. The purpose of the protocol were to prevent the resident's unsupervised exit and to plan for the resident's safety and well-being within the facility. The procedure included implement preventative interventions up to or including the application of an alarm bracelet, monitoring the care plan, etcetera (etc.). 2 a. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#3 had moderate cognitive impairment and was independent with locomotion on and off unit. The assessment also indicated that the resident needed extensive assistance with transfer and was using a wheelchair for mobility. The assessment further indicated that the resident had not exhibited a wandering behavior during the assessment period. Resident #3's wandering risk evaluations were reviewed. The risk evaluation form indicated that a resident with a score of greater than 5 was at risk for wandering. The wandering risk evaluation form dated 10/7/17 revealed that Resident #3 was at risk for wandering with a score of 16. The form indicated that the resident has had one or more attempts to leave home/facility and or wander in the past 3 months. The form also indicated that the resident had made verbal statement of desire or intent to leave the facility. The wandering risk evaluation form dated 3/23/17 and 5/18/17 revealed that Resident #3 was at risk for wandering with a score of 19. The form indicated that the resident has had one or more attempts to leave home/facility and or wander in the past 3 months. The form also indicated that the resident had made verbal statement of desire or intent to leave the facility. Resident #3's care plan for wandering was reviewed. The wandering care plan was initiated on 8/9/16 and was reviewed on 3/28/17. One of the care plan problems was wandering and or at risk for unsupervised exits from facility related to: attempts to leave unit/had building. The goal was the resident will have no episode of unsupervised exits from facility through next review. The approaches included to allow resident to wander on units, to check daily to ensure resident has an alarm bracelet on and it is functioning properly, documents episodes of wandering per facility protocol, ensure identification (ID) bracelet is in place, ensure resident's picture and name are on the wandering resident board, ensure that alarm exits are functional, provide 1:1 staff monitoring as necessary, provide supervision during recreational programs, and provide resident with opportunities to attend group activities of choice. All of these care plan approaches were initiated/started on 8/9/16. There were no revisions to the approaches as of 6/9/17. The nurse's notes dated 3/4/17 at 7:45 PM revealed alarm sounding at front door. Upon investigating, visitor said that he had let resident (Resident #3) out of door because resident asked him to. Upon going outside, this nurse noted (name of Resident#3) in his chair within a few feet of roadway. This nurse could not get resident return to building. He was yelling I'm not going back in the building, I'm going home. This nurse continued to hold chair to prevent resident from entering roadway and turned on her cell phone and phoned facility. Advised staff of situation and 3 staff members came and assisted writer to get resident back into building. The notes indicated that the resident had no injuries from the incident. The nurse's notes dated 4/11/17 at 4:47 PM revealed late entry for 4/10/17 at 5:30 PM, Director of Nursing (DON) and Social Worker (SW) spoke with wife to inform her that the resident had an unsupervised exit and that the team needed to meet with her and the family to discuss the move to sparks unit. She stated that we could go ahead and plan a meeting and she would make sure the family was present. The nurse's notes dated 4/14/17 at 1:59 PM revealed resident at front door yelling trying to get out. Redirected to lunch with good results. Returned to door, loudly yelling for his wife and son. The nurse's notes dated 4/14/17 at 3:02 PM revealed that at 2:05 PM, Resident #3 was still wanting to leave the facility. The nurse's notes dated 5/15/17 at 4:26 PM revealed that DON was notified that resident was allowed to leave the building by a family member visiting another resident. The nurse asked the visitor not to let the resident out but they did it anyway. The resident made it out the door but not off the porch and supervised by the nurse the entire time. The nurse's notes dated 5/16/17 at 4:40 PM revealed resident propelling self-up and down halls in wheelchair yelling and screaming for someone to pay him and that he needs a ride home. Resident repeatedly asking visitors to let him out so he can find a ride home. The nurse's notes dated 5/23/17 at 3:37 PM revealed wife notified that the resident has been trying to exit building all day. The wife stated that she knows that he will not come back if he is allowed to exit facility. The nurse's notes dated 5/24/17 at 1:53 PM revealed that the resident attempts to leave facility to vacate the premises. Is cognitively impaired and cannot make good decision to protect himself from danger. The nurse's notes dated 6/4/17 at 10:20 PM revealed resident sitting in wheelchair propelling self about facility. Third shift reports that resident didn't sleep last night, he has been up all night wandering about facility in his wheelchair. The incident reports were reviewed. There was no incident report completed for the incidents that occurred on 3/4/17 and 4/10/17. The daily staffing sheets were reviewed. The staffing sheets revealed that there was one NA assigned on the hall where Resident #3 resided on 3/4/17 and 5/14/17 on the second shift. A family member of Resident #3 was interviewed on 6/5/17 at 4:15 PM. The family member indicated that the resident had exited the facility 4 times but the family member was unable to remember the exact dates. The family member stated that the facility indicated that a visitor, other resident and or the emergency medical services (EMS) had opened the front door for the resident to go out. Resident #3 was observed up in wheelchair in his room on 6/5/17 at 4:20 PM. A wander guard was observed attached to his wheelchair. Interview with the Social Worker (SW) was conducted on 6/6/17 at 11:55 AM. The SW stated that she had known Resident #3 as a wanderer and had wandered outside 2-3 times. She indicated that the family of the resident had refused to move him to the secured unit. She had scheduled a meeting with the family but they kept rescheduling or canceling the meeting. The SW claimed that most of his wandering incidents occurred during the weekends. Interview with NA #1 (assigned to Resident #3 on first shift) on 6/6/17 at 12:05 PM was conducted. NA #1 stated that Resident #3 was independent with locomotion using a wheelchair. She stated that the resident was always out of bed around 10 in the morning and he propelled his wheelchair around facility talking to other residents. NA #1 revealed that the resident was a wanderer and she heard that he had wandered outside during the second shift but she didn't know the date of the incident. NA #1 stated that she was the only NA on the hall. An interview with Nurse #1 was conducted on 6/6/17 at 2:10 PM. Nurse #1 stated that she worked second shift. She indicated that she heard and responded to a front door alarm twice (didn't remember the dates). She indicated that a family member had let Resident #3 out the door. Nurse #1 didn't remember the exact time but it was late in the evening. She found the resident on the road towards the highway (highway 177) in his wheelchair. The resident refused to come back. She had to use her cell phone to call the facility to get help because the resident would not return back to facility. The nurse stated that she didn't know how long the resident was outside and how long the alarm was sounding before she answered it. Nurse #1 further revealed that she had responded also to another front door alarm and found the resident on the porch. She stated that a family member had let the resident out. Nurse #1 stated that she didn't know how long the resident was outside on the porch. She also indicated that she didn't remember the dates and times of the incidents. Nurse #1 also stated that she didn't remember if she was assigned to the resident on the days Resident #3 was found outside. An interview with the Director of Nursing (DON) was conducted on 6/6/17 at 2:50 PM. The DON stated that Resident #3 had went out the door 4 times (didn't remember the exact dates). She indicated that she had asked the resident's family member to move him to the secured unit but the family member had refused. She reviewed the electronic nurse's notes and indicated that the resident had exited the front door on 3/4/17, 4/10/17 and 5/14/17. The DON indicated that out of the 3 wandering episodes, she had only one incident report dated 5/14/17. She indicated that there was no incident report for the wandering incidents on 3/4/17 and 4/10/17 and she didn't know how the resident had exited the front door. She stated that she posted a sign on the door reminding visitors not to let any resident out, but this didn't work. She also stated that the resident had a wander guard. Interview with NA #2 was conducted on 6/6/17 at 3:40 PM. NA #2 was assigned to Resident #3 on 3/4/17 and 4/10/17 on the second shift. NA #2 stated that she had known Resident #3 as a wanderer. She stated that the resident propelled his wheelchair around facility. She indicated that she observed the resident propelled his wheelchair to the front door all the time. She stated that she had heard him out of the facility twice but she had never witnessed him going out. NA #2 stated that on 3/4/17, she saw the resident last at the nurse's station but she could not remember the time. NA #2 revealed that she was the only NA on the hall that day. Interview with the Administrator was conducted on 6/6/17 at 4:46 PM. The Administrator stated that this was the time of the day that Resident #3's behavior was worst, trying to leave the facility. She stated that she had met with the family who gave her permission to move the resident to the secured unit if it was necessary but she felt that the resident was safe if only the staff were monitoring him and responding to the door alarm immediately. The Administrator further stated that there was a staff member (receptionist) in the lobby until 9 PM every day who could monitor the front door. The Administrator stated that she expected the staff to complete an incident report when an incident happened so the incident could be investigated. The administrator and the DON were notified of immediate jeopardy on 6/7/17 at 1:23 PM for Resident #3 and on 6/8/17 at 12:06 PM for Resident #80. b. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#3 had moderate cognitive impairment and was independent with locomotion on and off unit. The assessment also indicated that the resident needed extensive assistance with transfer and was using a wheelchair for mobility. The assessment further indicated that the resident had falls since admission or prior assessment with no injury. Resident #3's care plan for falls was reviewed. The falls care plan was initiated on 8/9/16 and was reviewed on 3/28/17. The care plan problem was risk for falls characterized by history of falls related to: weakness, back surgery. The goal was resident will be free of falls through next review. The approached included assist during transfer and mobility, bed in lowest position, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, fall risk protocol, have commonly used articles within easy reach, keep assistive ambulation devise (wheelchair) within reach of the resident and keep call light within reach and answer timely. All of these approaches were initiated/started on 8/9/2016 and there were no revisions as of 6/9/17. Resident #3's incident reports were reviewed. The resident had 10 falls in the last 6 months. The report dated 10/17/16 revealed that the resident was found on the floor on the side of his bed and wheelchair. The resident stated that he slid off the bed. Immediate action taken the resident was assessed with [REDACTED]. The report dated 11/11/16 at 2:17 PM revealed that the resident was found on the floor in his bathroom. There was no injury noted. The immediate action taken the resident assessed for injuries and none noted. The resident was lifted off floor and placed on commode. The report dated 11/17/16 at 3:04 PM revealed that resident was observed on the floor in the bathroom in front of wheelchair. Immediate action taken the resident was assessed and no injuries notes and resident was placed back into wheelchair. Wheelchair alarm in wheelchair. The report dated 12/7/116 at 9:01 PM revealed that the resident was found on floor in front of chair with small skin tear to front of head. Immediate action taken was to clean area on forehead and apply dry dressing and did neuro check. The report dated 12/19/16 at 10:07 PM revealed that resident was found lying on the floor in front of wheelchair. Resident stated that he slid out the wheelchair. Immediate action taken resident was assessed with [REDACTED]. The report dated 1/4/17 at 8:16 PM revealed that the resident was found on the floor beside the bed and the wheelchair. Immediate action taken the resident was assessed with [REDACTED]. The report dated 2/7/17 at 1:17 AM revealed that resident was found on the floor beside the bed and in front of the wheelchair. The resident stated the he slid out of the wheelchair. Immediate action taken was resident was assessment with no injuries and the resident was put back to bed. The report dated 4/23/17 at 10:27 PM revealed that at approximately 10:20 PM, the alarm sounded and the resident was found sitting on the floor. The resident stated that he slid off the bed. Immediate action taken the resident was assessed and no injuries noted. The report dated 4/29/17 at 8:06 PM revealed the resident was found on floor between his wheelchair and stationary chair. Immediate action taken the resident was assessed and no injuries noted. The report dated 5/30/17 at 8:00 PM revealed that the resident was found on the floor in front of his wheelchair. Resident #3 was observed up in wheelchair in his room on 6/5/17 at 4:20 PM. A wander guard was observed attached to his wheelchair and a family member was in the room with him. Interview with the MDS Nurse #1 was conducted on 6/6/17 at 3:40 PM. The MDS Nurse stated that she started as MDS Nurse in March 2017. She stated that she had no MDS experience in the past and she had received MDS training from the corporate consultant and not from the state MDS training. The MDS Nurse indicated that they discussed the incident reports on their morning meeting. She stated that she was aware of Resident #3's repeated falls. The MDS Nurse had reviewed the resident's electronic care plan for falls and stated that there were no revisions on the care plan approaches since 8/2016. Interview with the Quality Assurance (QA) Nurse was conducted on 6/8/17 at 2:40 PM. The QA Nurse indicated that she started as QA Nurse in March 2017. She stated that she had no guidance or training regarding QA but she was learning. She added that she had no monitoring tool to monitor the resident's falls. She also indicated that they (department heads) reviewed the incident reports on their morning meeting but she didn't remember what happened after that. Interview with the Administrator was conducted on 6/8/17 at 3:05 PM. The Administrator stated that the QA Nurse and the DON were responsible for the incident/accident reports.

Based on record review, observation and resident, staff, Nurse Practitioner and Physician interview, the facility administration failed to provide the leadership and management necessary to ensure resident's needs were met. Immediate jeopardy began on 3/4/17 when Resident #3, a cognitively impaired resident and was identified as a wanderer, had exited the facility unsupervised. Immediate jeopardy began on 5/1/17 when Resident #80 was caught between the bed's mattress and the foot board causing a bruise to the back of his neck. The immediate jeopardy is present and ongoing. Findings included: This tag is cross referred to: 1. F157 - Based on record review and staff, Nurse Practitioner and Physician interview, the facility failed to notify the physician when a cognitively impaired resident was entrapped between the mattress and the foot board causing a bruise to the back of the resident's neck. This was evident for 1 of 3 sampled residents reviewed for accidents (Resident #80). Immediate jeopardy began on 5/1/17 when Resident #80 was found entrapped between the mattress and the foot board and the facility did not notify the physician. The immediate Jeopardy is present and ongoing. 2. F221 -Based on record review, observation and staff interview, the facility utilized a device (foot board) in bed without considering it to be a restraint and without a medical symptom. Resident #80's head was caught between the bed's mattress and the foot board causing a bruise to the back of the resident's neck. This was evident for 1 of 3 sampled residents reviewed for accidents (Resident #80). Immediate jeopardy began on 5/1/17 when Resident #80 was found with his head entrapped between the mattress and the foot board causing a bruise to the back of the resident's neck. The immediate Jeopardy is present and ongoing. 3. F224- Based on record review, observation and staff interview, the facility neglected to supervise a cognitively impaired resident who was identified as a wanderer which resulted in an unsupervised exit from the facility for 1 of 3 sampled residents reviewed for accidents (Resident #3). Resident #3 was found a few feet to the road heading towards a busy highway. Resident #3 had to go through a parking lot to get to the road. Immediate jeopardy began on 3/4/17 when Resident #3 exited the building unsupervised. Immediate jeopardy is present and ongoing. 4. F280 - Based on record review and staff interview, the facility failed to revise the care plan for wandering for a cognitively impaired resident who was identified at risk for elopement, which resulted in an unsupervised exit from the facility's front door for 1 of 3 sampled residents reviewed for accidents (Resident #3.) The facility also failed to revise the care plan of a cognitively impaired resident who had repeated falls for 1 of 3 sampled residents (Resident #3) at a scope and severity of D. The facility failed to involve alert and oriented residents in the care planning process for 2 (Residents #82 & #74) of 3 sampled residents. This was at a scope and severity of D. Immediate jeopardy began on 3/4/17 when Resident #3 exited the facility unsupervised and the facility failed to update the care plan. Resident #3 had an unsupervised exit on 3/4/17 and had several attempts of leaving the facility after the 3/4/17 incident and the care plan for wandering was not revised since 8/9/2016. The immediate jeopardy is present and ongoing. 5. F323 - Based on record review, observation and staff interview, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised (Resident #3) and also failed to prevent a cognitively impaired resident from bed entrapment between the mattress and the foot board (Resident #80). The facility also failed to reassess and to intervene to prevent repeated falls (Resident #3) at a scope and severity of D. These were evident for 2 (Residents #3 and #80) of 3 sampled residents reviewed for accidents. Immediate jeopardy began on 3/4/17 when Resident #3 exited the facility unsupervised. Immediate jeopardy began on 5/1/17, when Resident #80 was caught between the foot board and the mattress causing a bruise to the back of his neck. Immediate jeopardy is present and ongoing.

Based on record review, observation and staff interview, the facility's Quality Assessment and Assurance Committee failed to determine a root cause analysis in relation to elopement and bed entrapment. Resident #3 exited the facility unsupervised on 3/4/17 and the facility failed to investigate the root cause and to develop plan of action to prevent further unsupervised exits. Resident #80 was observed with his head entrapped between the bed's mattress and the foot board and the facility failed to investigate the root cause and to develop plan of action to prevent further bed entrapment. This was evident for 2 of 3 sampled residents reviewed for accidents (Resident #3 and Resident #80.) Immediate jeopardy began on 3/4/17 when Resident #3 exited the facility unsupervised and was found by Nurse #1 few feet away from a road. Immediate jeopardy began on 5/1/17 when Resident #80 was found in bed with his head entrapped between the mattress and the foot board resulting in a bruise to the back of his neck. The immediate Jeopardy is present and ongoing. This tag is cross referenced to: 1. F323 - Based on record review, observation and staff interview, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised (Resident #3) and also failed to prevent a cognitively impaired resident from bed entrapment between the mattress and the foot board (Resident #80.) These were evident for 2 (Resident #3 and Resident #80) of 3 sampled residents reviewed for accidents. Immediate jeopardy began on 3/4/17 when Resident #3 exited the building unsupervised. Immediate jeopardy began on 5/1/17 when Resident #80's head was found caught between the foot board and the mattress causing a bruise to the back of neck. Immediate jeopardy is present and ongoing. 2. F224 - Based on record review, observation and staff interview, the facility neglected to supervise a cognitively impaired resident who was identified as a wanderer which resulted in an unsupervised exit from the facility for 1 of 3 sampled residents reviewed for accidents (Resident #3). Resident #3 was found a few feet to the road heading towards a busy highway. Resident #3 had to go through a parking lot to get to the road. Immediate jeopardy began on 3/4/17 when Resident #3 exited the building unsupervised. Immediate jeopardy is present and ongoing. 3. F221 - Based on record review, observation and staff interview, the facility utilized a device (foot board) in bed without considering it to be a restraint and without a medical symptom. Resident #80's head was caught between the bed's mattress and the foot board causing a bruise to the back of the resident's neck. This was evident for 1 of 3 sampled residents reviewed for accidents. (Resident #80). Immediate jeopardy began on 5/1/17 when Resident #80 was found with his head entrapped between the mattress and the foot board causing a bruise to the back of the resident's neck. The immediate Jeopardy is present and ongoing. Interview with the Quality Assurance (QA) Nurse was conducted on 6/8/17 at 2:40 PM. She stated that she started as a QA Nurse in March 2017. She stated that she had no guidance or training regarding QA but she was learning. She stated that she had not identified the use of the foot board as a restraint or accident hazard. She added she didn't have any monitoring tools to monitor falls or elopement. She further indicated that they discussed incident report during the morning meeting but she didn't remember what happened after that. The administrator and the DON were notified of immediate jeopardy on 6/7/17 at 1:23 PM for Resident #3 and on 6/8/17 at 12:06 PM for Resident #80. 3. The facility failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey 6/2/16 in the area of resident Assessment at F278. In the area of Quality of Care, F312 was recited and in the area of Nursing Services, F353 pattern of the facility ' s inability to sustain an effective Quality Assessment and Assurance program. Findings included: This tag is cross referenced to: 1. F278-D: Based on record review, observations, and staff interview and resident interview, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of dental and [DIAGNOSES REDACTED].#71 and Resident #100) 22 MDS ' s reviewed for accuracy. During the recertification survey of June 2016 the facility was cited for F278 for failing to accurately code catheter use, bed mobility, toilet use, eating status, and restraint use for sampled residents. On the current survey the facility was recited for failure to accurately code areas of dental care and [DIAGNOSES REDACTED]. 2. F312-D: Based on observations, staff and resident interviews and record review, the facility failed to provide resident showers as scheduled for 1 (Resident #37) of 5 residents who required staff assistance with bathing and reviewed for activities of daily living (ADLs.) During the recertification survey of June 2016 the facility was cited for failure to provide nail care to a resident. On the current survey the facility was recited for failure to provide showers to a dependent resident. 3. F353-D: Based on observations, resident interview, staff interviews and record review, the facility failed to provide sufficient staff to provide showers as scheduled for residents who required staff assistance with bathing for 1 (Resident #37) of 5 residents reviewed for activities of daily living (ADLs.) During the recertification survey of June 2016 the facility was cited for failure to provide sufficient nursing staff to meet the needs of resident in the area of restorative nursing. On the current survey the facility was recited for failure to provide sufficient staff to complete showers for a dependent resident. In an interview on 6/8/17 at 3:05 PM, the Administrator stated her expectation was for the Quality Assurance Nurse to have focused on the areas identified on the last survey of record, monitored for effectiveness if the implemented interventions, and notified her if there was evidence on continued noncompliance in those areas. In an interview on 6/9/17 at 12:30 PM, the Quality Assurance Nurse stated the committee met based on needed actions and they had no tool to identify and problems. She stated she was new to her position and she was not aware of any focus on the previously cited tags at F278, F312 and F353.

Based on observations, staff, resident, responsible party (RP), physician interviews and record review, the facility failed to follow manufacturer instructions for the facility van securement system by not securing the over the retractable shoulder belt and remove the lift sling from the wheelchair for 1 of 1 alert and oriented resident (Resident #1) resulting in a fall on the transportation van, a fracture of the left hip and fractures of the right tibia and fibula. Immediate Jeopardy began on 11/23/15 at the time of the fall when Resident #1 was not properly secured in the facility ' s transportation van. The facility provided a Creditable Allegation on 12/10/15 at 12:45 PM. The immediate jeopardy is lowered to scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure implementation of permanent change in the process of ensuring the safety of residents while on transports. Findings included: A review of the manufacturer instructions regarding the use of the retractable shoulder belt for facility ' s transport van (name of company and identifier of product series) read in part, Bring the triangular fitting of the shoulder belt over the shoulder across the chest of the occupant and connect it to the pin of the lap belt latch plate. Pull on the shoulder belt to ensure that it is properly attached. The retractor will automatically adjust the tension. The document included the following caution: Always ensure that the shoulder belt is properly extended over the shoulder and across the chest area of the occupant when connecting it to the lap belt. In an observation on 12/8/15 at 12:05 PM of the internal safety mechanisms inside the facility ' s transport van, it was noted to be equipped with a 4 point tie down mechanism, lap belt and a retractable shoulder strap. Resident #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She required total assistance with all transfers and non-ambulatory according to the assessment. A review of Resident #1 ' s care plan revised on 10/21/15 included a fall risk care plan with intervention to remove the lift sling after the Resident #1 was placed in her wheelchair with the initiation date for this intervention as 10/8/15. In an interview on 12/8/15 at 12:00 PM, Resident #1 recalled falling from her wheelchair in the facility van on 11/23/15 while on a transport. She recalled that the transportation aide (TA) #1 did not secure the van ' s shoulder belt to her prior to transporting her in the van and she slid out of the wheelchair falling onto the leg rest of the wheelchair. Resident #1 stated the aide who got her up for the appointment did not remove the lift sling from her wheelchair once she was placed in the wheelchair. Resident #1 stated she rode in the van with TA #1 in the recent past and she never recalled TA #1 securing the van ' s shoulder belt to her. She stated she was uncomfortable with riding on the van since the incident but rode with TA #1 again on 11/24/15 and 11/25/15 to go to her chemotherapy and radiation treatments. An observation of Resident #1 revealed an elastic wrap around her right lower extremity. Resident #1 stated she voiced pain after the fall and she was treated with Tylenol. She recalled it helped some but the pain became so bad the Tylenol didn ' t work to control her pain after a few days. Resident #1 stated she did not recall anyone coming to assess her legs after the fall on 11/23/15 and it was not until the Friday after Thanksgiving that she had an x-ray done and then was sent to the hospital on [DATE]. In a telephone interview on 12/9/15 at 11:10 AM, Nursing Assistant (NA) #7 confirmed she worked first shift on 11/23/15 with Resident #1. She stated she was unable to recall if she removed the lift sling out from under Resident #1 after she got her up to the wheelchair to go out to her appointment. She recalled the RP assisted her with getting Resident #1 out of the bed that day. NA #7 stated she was aware that the lift sling was not to be left under Resident #1 because she had trouble sitting up in the wheelchair due to her leg contractures and she had fallen in the past. A review of the incident report dated 11/27/15 read as follows: According to TA #1 on 11/23/15, Resident #1 had an appointment at the cancer center with her RP present at the time. Upon leaving her appointment, Resident #1 was placed in the transport van and secured. When asked was she ok, Resident #1 stated yes . While driving back to facility, Resident #1 stated I ' m sliding out of my chair. Before TA # 1 could stop, Resident #1 slid out of her chair onto the pedals of her wheelchair. TA #1 pulled over and with the assistance of Resident #1 ' s RP, they were able to get Resident #1 back into her wheelchair. TA #1 stated she asked Resident #1 if she was ok, she stated yes . TA #1 proceeded to drive back to the facility where she reported the incident to Resident #1 ' s assigned nurse and the director of nursing (DON). In a telephone interview on 12/8/15 at 2:30 PM, TA #1 recalled transporting Resident #1 to the cancer center in the facility ' s van on 11/23/15. She stated the resident ' s RP rode in the van ' s front passenger seat while Resident #1 rode in the back of the van in her wheelchair. TA #1 recalled using the motorized ramp to raise Resident #1 in her wheelchair up to be rolled into the back of the van where TA #1 strapped the wheelchair into place using the 4 point tie downs. She then recalled securing the lap belt around Resident #1 ' s waist allowing for 2 finger widths of space for comfort. She stated she then proceeded to drive back to the facility. On questioning, TA #1 stated she did not secure Resident #1 with the van ' s shoulder belt prior to transporting Resident #1 back to the facility and she normally never used the shoulder strap during resident transports. TA #1 stated she had been doing resident transports since July 2015 and the previous quality assurance (QA) nurse trained her on transporting residents. She did not recall being trained to use the van ' s shoulder strap during transports. TA #1 recalled when transporting Resident #1 in the facility van on 11/23/15 she was merging onto highway 74 when she heard Resident #1 state she was sliding. TA #1 stated she pulled over and with the assistance of the RP, they lifted Resident #1 off the wheelchair foot pedals using the lift sling straps and returned her to the wheelchair. She then proceeded to transport the resident back to the facility. She stated she did not call the facility or call 911 for assistance because Resident #1 stated she was ok. Once she arrived back at the facility, she notified the DON who told her to write a statement and informed Resident #1 ' s nurse. TA #1 confirmed she transported Resident #1 again to the cancer center on 11/24/15 and 11/25/15, but she was off Thanksgiving and the following day. She stated she received a call on 11/27/15 from the administrator and she met him at the facility on 11/28/15 to go over all of her transports for October 2015 and November 2015. On 11/30/15 she stated the administrator called her again and told her to come to the facility. She was asked to reenact how she put Resident #1 into the van. It was at this time, the administrator told her he would be in touch with her after he concluded his investigation. TA #1 stated she went to the facility to get her paycheck on 12/3/15 and waited to see the administrator who was busy at that time. She left and called back to the facility and spoke with the DON who informed her she was suspended. In an interview on 12/8/15 at 4:35 PM, the RP recalled riding in the facility ' s transportation van in the front passenger seat to take Resident #1 to the cancer center on 11/23/15. He stated TA #1 loaded Resident #1 into the van. The RP stated TA #1 secured the resident ' s wheelchair to the van and the lap belt to the resident. The RP stated TA #1 did not secure the van ' s shoulder belt nor had he ever seen observed her use it on Resident #1 in the past. The RP recalled during the transport TA #1 was waiting to turn onto highway 74. She approached the turn yielding to oncoming traffic and at the first chance, she accelerated to turn and merge onto the highway. He stated he felt TA #1 may have slowed to 45 miles per hour. He recalled commenting to TA #1 that she almost threw him from his seat when he heard Resident #1 say I ' m fixing to slide out of my wheelchair. He stated TA #1 pulled over and he got behind Resident #1 while the TA #1 remained in the front of the van. He stated the lift sling was under Resident #1 and he thought it was not to be under her because it caused her to slide from her wheelchair in the recent past. The RP stated they used the lift sling straps to lift Resident #1 off the wheelchair foot pedals and move her back into the wheelchair. He recalled Resident #1 seemed scared but she did not complain of pain at that time. He stated TA #1 tightened the lap belt back on Resident #1 because he stated it was too loose. TA #1 did not apply the shoulder strap to Resident #1 but he sat in the back with Resident #1 and held onto her to ease her anxiety. The RP stated TA #1 never offered to call 911 or call the facility put rather proceeded to drive back to the facility. He stated she told him she would complete a report about what happened. The RP recalled that once he and Resident #1 returned to her room, the staff was attempting to get her back into the bed using the mechanical lift and Resident #1 was complaining pain in her legs then. He stated he was not aware that the staff ever contacted the physician at any time until he insisted on something be done on 11/27/15. The RP stated that on 11/24/15 he again observed Resident #1 being transported by TA #1 in the facility van without the resident being secured by the van ' s shoulder strap during the transport. The RP stated he was not able to go with her on 11/25/15 but she did go in the van and TA #1 transported her again according to Resident #1. He said he visited Resident #1 on 11/27/15 and when she raised her head to take a drink of water she screamed out in pain. The RP stated he informed staff at this time something had to be done. In an interview on 12/8/15 at 12:21 PM, the DON recalled TA #1 reported to her that Resident #1 slipped in the van on 11/23/15. TA #1 stated Resident #1 ' s RP was present in the van and caught her and she was alright. The DON stated she was unsure if it was an actual fall at that time. She told TA #1 to write a statement and inform Resident #1 ' s nurse to complete an incident report but the DON did not go and assess Resident #1 for any injures or discuss the circumstances of the fall with her or the RP. In an interview on 12/8/15 at 1:02 PM, Nurse #1 confirmed she was assigned Resident #1 on 11/23/15 when she returned from her appointment. She recalled TA #1 reporting to her Resident #1 fell in the van. Nurse #1 stated it was around shift change so she was busy. She recalled TA #1 told her Resident #1 slid from her wheelchair but she was fine. Nurse #1 stated she worked a double shift that day so after shift change she went and spoke to Resident #1 who was already back in the bed. Nurse #1 stated she did not assess Resident #1 or attempt any range of motion because Resident #1 did not complain of any pain at that time and her RP was no longer present. Nurse #1 stated she did not ask Resident #1 what happened in the van at the time of the fall and she did not complete an incident report because the fall did not happened at the facility. Nurse #1 stated she did not document the fall in the medical record nor did she recall passing the incident along to the next shift during shift report. Nurse #1 stated if Resident #1 had acted differently or acted like she was in pain, she would have gotten an x-ray that day. In an another interview on 12/8/15 at 3:00 PM, the DON stated she asked TA #1 if she had Resident #1 secured properly in the van and she verbalized she did. The DON confirmed she asked TA #1 to write a statement but the DON stated she forgot to tell the administrator. The DON stated if Resident #1 had been injured, she would have informed the administrator. The DON confirmed she did not perform a physical assessment on Resident #1 but rather instructed Nurse #1 to complete it. She stated she did not follow up with Resident #1 at any point after 11/23/15. The DON stated she was off on 11/27/15 when she got a call from the administrator asking about the incident. The DON stated the administrator stated the RP was at the facility upset insisting Resident #1 be evaluated due her continued complaints of pain. In an interview on 12/8/15 at 3:28 PM, NA # 5 confirmed she worked second shift on 11/23/15 with Resident #1. NA #5 stated she put Resident #1 in the bed after she returned from the appointment the day she fell . She stated the lift sling was under Resident #1 in the wheel chair when she returned and she was not supposed to have it under her when she was up in her wheelchair because she had been known to slide out of her wheelchair off the sling. In an interview on 12/8/15 at 3:17 PM, NA #4 confirmed she worked second shift on 11/25/15 with Resident #1. NA #4 recalled she and NA #3 assisted Resident #1 back into the bed using the mechanical lift after she returned from the cancer center. NA #4 confirmed the lift sling was under Resident #1 in the wheel chair on her return from the cancer center on 11/25/15. In an interview on 12/8/15 at 2:20 PM, the administrator stated he did not become aware of Resident #1 falling in the facility ' s transport van until 11/27/15 and he immediately stopped all transports. He confirmed TA #1 continued to transport Resident #1 and other residents on 11/24/15 and 11/25/15. He stated he started an investigation when he became aware and so far, he felt TA #1 did not have the shoulder belt in use when Resident #1 fell . He recalled speaking to TA #1 and suspended her effective 11/30/15 pending the outcome of his investigation. He stated there was no transports on 11/26/15 or 11/27/15 due to the Thanksgiving holiday. The administrator verified he or the previous QA nurse were the staff who trained TA #1 and TA #2. In an interview on 12/8/15 at 1:43 PM, the maintenance director stated he was not aware of the fall Resident #1 experienced in the facility transport van on 11/23/15, but on 11/30/15, the administrator asked him to inspect the lap straps, shoulder straps and tie downs on the van. He stated he was not responsible for training the transportation aides on proper use of the equipment. But rather the administrator was responsible for the training. He stated he was responsible for a monthly safety inspection of the van. A review of the monthly check off van inspection form included the condition of the seat belt and the consistent use of the seat belt by the staff and residents. He stated he had checked those off on the monthly inspections provided but he was unsure who verified the staff use using the straps properly. He provided evidence of a monthly inspections for 9/29/15, 11/3/15 and 12/8/15. He stated he did not complete a monthly inspection in October 2015. He stated he did not perform any observations of the TA ' s securing the residents in the van. In an interview on 12/9/15 at 8:45 AM, TA #2 stated she was trained by the Quality Assurance (QA) nurse and the previous transporter on how to transport residents in the facility ' s transport van. TA #2 stated she served as the backup transporter for over one year. She stated she was checked off for safety before she was allowed to transport residents. She stated she always used the lap belt and the shoulder belt to secure the resident in the wheelchair during transport. TA #2 stated the administrator recently retrained her and stressed to her that the shoulder strap was the most important strap. TA #2 stated she had not had any issues with falls during her transports but if she did, she would call 911 and not move the resident. TA #2 confirmed that the lift sling was to be removed from underneath Resident #1 whenever she was up in her wheelchair. TA #2 stated Resident #1 had trouble sitting up in her wheelchair due to her bilateral leg contractures and the lift sling was slippery and had resulted in her falling in the past. TA #2 also stated she always had a co-worker present during all resident transports for safety. She stated she had never been told she had to transport alone but rather administration knew she always had another staff member with her on her transports. In an interview on 12/9/15 at 10:45 AM, the QA nurse confirmed he added the care plan intervention to remove the lift sling from under Resident #1 when she fell from her wheelchair on 10/8/15. The QA nurse also confirmed he did the training on mechanical lift operation, securing the wheelchair with tie downs, how to apply safety belts to include the lap and shoulder belts and driving of the transportation van for TA #1 and TA #2 with the assistance of the administrator. He was able to provide training evidence for TA #2 dated 11/12/14 and provided a typed statement that he trained TA #1 on 7/13/15 through 7/15/15 on transporting residents in the facility van. He stated he trained TA #1 to use the shoulder strap during every resident transport for safety. A review of Resident #1 ' s nursing notes indicated a note dated 11/27/15 documenting the events that occurred on 11/23/15. This nursing note indicated the physician was made aware on 11/27/15 of Resident #1 ' s fall that occurred Monday 11/23/15 while she was on the facility transportation van. The physician ordered a series of x-rays. When the physician was notified of the x-ray results, orders were received to send Resident #1 to the hospital for an evaluation on 11/27/15 due an acute impacted left hip fracture of the left femoral neck and posttraumatic deformities of the distal tibia and fibula of the right ankle. In a telephone interview on 12/8/15 at 4:02 PM, the physician stated he was not notified of any incident involving a fall on the van with Resident #1 until 11/27/15 when the RP was at the facility very upset stating Resident #1 was in severe pain and something had to be done. He stated he ordered x-rays and that was when he discovered the fractures. The physician stated his expectation was to be notified immediately when an incident like the one involving Resident #1 occurred so proper assessment and treatment would not be delayed and his expectation would be that anytime a resident was placed in the transportation van, the resident would be properly secured for safety. A review of the hospital records dated 11/27/15 indicated Resident was being transported in a van 5 days ago in her wheelchair when she slipped from the wheelchair onto her left hip when her right leg under her. She has been complaining of some pain in the area since that time. The pain was reported mostly to her left proximal femur and her right ankle which showed evidence of bruising and swelling. A splint was applied to her right lower extremity for immobilization and the orthopedic consult recommended no surgical intervention due to Resident #1 ' s bed bound status and severe MS with contractures. Pain management was recommended and she was diagnosed with [REDACTED]. Richmond Pines was placed into Immediate Jeopardy at 6:18 PM, on December 8, 2015, related to an incident that took place on a facility van on November 23, 2015. Immediately a plan was put in place to complete a Credible Allegation. A. How the corrective action will be accomplished for those residents found to have been affected by deficient practice? Outcome? · On 11/27/15, the administrator stopped all facility transports with facility van. · On 11/30/15, the maintenance director completed an inspection of the van tie downs, tracks, and seatbelts and all were found to be in proper working order. · On 12/1/15, the administrator educated the director of nursing, the assistant director of nursing and the scheduler on how to properly secure a resident in the facility van with the appropriate tie down straps, waist belt, and shoulder harness per the manufacturer recommendations/instructions. The director of nursing, the assistant director of nursing, and the scheduler all provided correct return demonstrations per the manufacturer recommendations/instructions. · On 12/1/15, the administrator personally conducted training and successful return demonstration with the scheduler, assistant director of nursing, and the director of nursing. The administrator used, as a reference document, the QRT Max Work book for trainees. (The manufacturer ' s recommendation/instruction regarding the application of the wheelchair restraint system.) The administrator included in the training and return demonstration, wheelchair positioning, appropriate placement of wheelchair tie downs, appropriate positioning and fastening of lap and shoulder belts. · On 12/1/15, transportation resumed with the facility van after training and return demonstration. · On 12/9/15, the MDS nurse updated the resident ' s care plan to include resident will not be transported with lift pad under her. · On 12/9/15, an in-service was initiated for 100% of LPN ' s, RN ' s, and CNA ' s relating to following the care guide for lift pad removal for when the resident is in the wheelchair or when the resident is being transported in the facility van. No RN ' s, LPN ' s, and CNA ' s will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/9/15, the director of nursing initiated an in-service for all nursing staff, RN ' s, LPN ' s, CNA ' s, medication aides, restorative aides, and transportation aides, including staff involved with care from 11/23/15 through 11/27/15. The following was covered; All nursing staff must follow the resident care guide, posted in the resident ' s closet. Please especially pay attention to the handling and movement directions on the care guide. For example, the care guide may instruct you to remove the resident ' s lift pad after transferring the resident from the bed to the chair as well as it may include the removal of the lift pad when being transferred in the company van. If you have any comments or questions please see the director of nursing. All nursing staff, RN ' s, LPN ' s, CNA ' s, medication aides, restorative aides, and transportation aides will complete this in-service prior to completing their shift. This in-service will be incorporated into new employee orientation. · On 12/9/15, resident number 1 ' s care plan was updated to include resident number 1 will not be transported in the facility van with a lift pad under her. · On 12/9/15 scheduler/backup van driver, assistant director of nursing, and the director of nursing successfully completed a Transportation Skill Checklist and return demonstration prior to initiation of transports by company van. This was verified by the administrator. Included but not limited to appropriate placement of the tie down straps and application of the van seat belts. · Effective 12/9/15, the scheduler, assistant director of nursing, and the director of nursing completed the Resident Transport Checklist tool ensuring each step of properly securing a resident has been completed appropriately during the securing process each transport. B. How did the facility identify other residents having the potential to be affected by the same deficient practice? · On 11/27/15, the administrator stopped all facility transports with facility van. · On 12/1/15, the administrator educated the director of nursing, the assistant director of nursing and the scheduler on how to properly secure a resident in the facility van with the appropriate tie down straps, waist belt, and shoulder harness per the manufacturer recommendations. The director of nursing, the assistant director of nursing, and the scheduler all provided correct return demonstrations. · On 12/1/15, the administrator personally conducted training and successful return demonstration with the scheduler, assistant director of nursing, and the director of nursing. The administrator used, as a reference document, the QRT Max Work book for trainees. The administrator included in the training and return demonstration, wheelchair positioning, appropriate placement of wheelchair tie downs, appropriate positioning and fastening of lap and shoulder belts. · Transporting with facility van resumed on 12/1/15. · On 11/27/15, the administrator conducted interviews with alert and oriented residents that had received van transport regarding seat belt use during transport and overall wellbeing and safety with no negative findings. Residents that were interviewed were transported between the dates of 11/23/15 to 11/27/15. · On 11/27/15, the administrator interviewed resident number 1 involved in the incident regarding seat belt use during transport. The resident was unable to recall if the seatbelt was properly in place. · On 11/28/15, the administrator obtained the transportation driver ' s statement relating to her recall of the van incident. The transportation driver was drug tested and remains suspended. · On 11/30/15, the maintenance director completed an inspection of the van tie downs, tracks, and seatbelts and all were found to be in proper working order. · On 12/9/15, the MDS coordinator reviewed all residents using sling lift pads for safety while in wheelchair. The MDS coordinator assessed the residents that utilize the sling lift and updated the residents ' care plans and care guides to reflect if the sling lift pad needs to be removed for safe transport in the facility van. Determination for having the lift pad removed will be based upon resident preference, resident upper body, strength, coordination, and balance (ability to sit up straight independently). · On 12/9/15, the director of nursing initiated an in-service for all nursing staff, RN ' s, LPN ' s, CNA ' s, medication aides, restorative aides, and transportation aides, including staff involved with care from 11/23/15 through 11/27/15. The following was covered; All nursing staff must follow the resident care guide, posted in the resident ' s closet. Please especially pay attention to the handling and movement directions on the care guide. For example, the care guide may instruct you to remove the resident ' s lift pad after transferring the resident from the bed to the chair as well as it may include the removal of the lift pad when being transferred in the company van. If you have any comments or questions please see the director of nursing. All nursing staff, RN ' s, LPN ' s, CNA ' s, medication aides, restorative aides, and transportation aides will complete this in-service prior to completing their shift. This in-service will be incorporated into new employee orientation. · On 12/9/15 scheduler/backup van driver, assistant director of nursing, and the director of nursing successfully completed a Transportation Skill Checklist and return demonstration prior to initiation of transports by company van. This was verified by the administrator. · Effective 12/9/15, the scheduler, assistant director of nursing, and the director of nursing completed the Resident Transport Checklist tool ensuring each step of properly securing a resident has been completed appropriately during the securing process each transport. C. Give specific dates of the corrective actions. · On 11/27/15, the administrator stopped all facility transports with facility van. · On 11/30/15, the maintenance director inspected the facility van wheelchair tie down equipment. · On 12/1/15, administrator educated the director of nursing, the assistant director of nursing, and the scheduler regarding wheelchair tie downs. · On 12/1/15, transportation resumed with the facility van after training and return demonstration. · On 12/9/15, the MDS nurse updated the care plans regarding the placement of the lift pad. · On 12/9/15, an in-service was conducted by the DON regarding care guides. · On 12/9/15, the scheduler, the assistant director of nursing, and the director of nursing completed a transportation skills checklist and the resident transportation checklist tool. The Credible Allegation (CA) was verified 12/10/15 at 12:45 PM by observation of TA #2 proper usage of shoulder belt, lap belt and the 4 point tie down system while securing a resident in the van for transport. The administrator verified no resident has been transported in the van since 11/27/15 and TA #1 was suspended 11/30/15. The CA was further verified by observation of residents and interviews of staff regarding the removal of the lift pads from underneath identified residents while up in their wheelchairs. The CA was verified for in-servicing of staff regarding the reporting of incidents to the physician, documenting incidents and assessments of residents after a reported incidents.

Based on staff, resident, responsible party (RP), and physician interviews and record review, the facility failed to notify the physician of a fall sustained during transportation in the facility van on 11/23/15 which resulted in a [MEDICAL CONDITION] hip and multiple fractures of the right lower leg for 1 of 5 residents reviewed for supervision to prevent accidents (Resident #1). Immediate Jeopardy began on 11/23/15 when the facility did not notify Resident #1 ' s physician of a fall sustained on the transportation van resulting in multiple fractures. The facility was notified of the immediate jeopardy on 12/16/15 at 4:41 PM. Immediate jeopardy was removed on 12/18/15 at 11:45 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective. Findings included: Resident #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #1 was also coded as requiring total assistance with all transfers, non-ambulatory, and without pain during this MDS assessment. Resident #1 was further coded as not having received any scheduled or as needed pain medication. A review of the hospital records dated 11/27/15 indicated Resident was being transported in a van 5 days ago in her wheelchair when she slipped from the wheelchair onto her left hip with her right leg under her. She has been complaining of some pain in the area since that time. The pain was reported mostly to her left proximal femur and her right ankle which showed evidence of bruising and swelling. A splint was applied to her right lower extremity for immobilization and the orthopedic consult recommended no surgical intervention due to Resident #1 ' s bed bound status and severe MS with contractures. Pain management was recommended. Resident #1 was discharged back to the facility on [DATE] with pain medication orders In an interview on 12/8/15 at 12:00 PM, Resident #1 recalled falling from the wheelchair in the van on 11/23/15 while on a transport. Resident #1 stated she did not recall anyone coming to assess her legs after the fall on 11/23/15 and it was not until the Friday after Thanksgiving that she had a x-ray done and then was sent to the hospital on [DATE]. In a telephone interview on 12/8/15 at 2:30 PM, Transportation Aide (TA) #1 recalled taking Resident #1 to [MEDICAL CONDITION] center on 11/23/15. She recalled Resident #1 stated she was sliding from her wheelchair so she pulled over and with the assistance of the RP, they lifted Resident #1 and returned her to the wheelchair. She then proceeded to return to the facility. She stated she did not call the facility or call 911 for assistance because Resident #1 stated she was ok. Once she arrived back at the facility, she notified the Director of Nursing (DON) who told her to write a statement and inform Resident #1 ' s nurse. In an interview on 12/8/15 at 12:21 PM, the DON recalled TA #1 reporting to her that Resident #1 slipped in the van. The DON explained TA #1 stated Resident #1 ' s RP was present in the van and caught her and she was alright. The DON stated she was unsure if it was an actual fall at that time. She told the TA #1 to write a statement and inform Resident #1 ' s nurse to complete an incident report. The DON stated she did not go and assess Resident #1 for any injures or discuss the circumstances of the fall with her or the RP. She stated she did not recall instructing the nurse to notify the physician. In an interview on 12/8/15 at 4:35 PM, the RP recalled riding in the front passenger seat of the facility van to take Resident #1 to [MEDICAL CONDITION] center on 11/23/15. On their return to the facility, he recalled Resident #1 say I ' m fixing to slide out of my wheelchair. He explained Resident #1 had slid from her wheelchair and landed on the foot pedal of the wheelchair. He stated he was not aware that the staff never contacted the physician at any time until he insisted on something be done on 11/27/15 due to Resident #1 ' s reported pain. In an interview on 12/8/15 at 1:02 PM, Nurse #1 confirmed she was assigned Resident #1 on 11/23/15 when she returned from her appointment. She recalled TA #1 reporting to her Resident #1 fell in the van. Nurse #1 stated it was around shift change so she was busy. She recalled TA #1 told her Resident #1 slid from her wheelchair but she was fine. Nurse #1 stated she worked a double shift that day so after shift change she went and spoke to Resident #1 who was already back in the bed. Nurse #1 confirmed she did not notify the physician of the fall that occurred on 11/23/15. In an interview on 12/8/15 at 3:25 PM, Nurse #3 confirmed she worked second shift on 11/24/15 with Resident #1. Did Nurse #3 receive a report regarding the fall from the Nurse she relieved? No, but the fall happened the day before She stated Resident #1 did not report any pain to her and the assigned aide did not report any pain to her. She recalled also working second shift on 11/27/15 with Resident #1 and she contacted the physician about Resident #1 ' s leg pain and obtained orders for x-rays. Nurse #3 stated the x-rays returned positive for fractures to her left hip and right leg and she sent her to the hospital for an evaluation as ordered by the physician. In a telephone interview on 12/8/15 at 4:02 PM, the physician stated he was not notified of any incident involving a fall on the van with Resident #1 until 11/27/15 when the RP was at the facility stating Resident #1 was in severe pain and something had to be done. He stated he ordered x-rays and that was when he discovered the fractures. The physician stated his expectation was to be notified immediately when an incident like the one involving Resident #1 occurred and Resident #1 should have been assessed sooner in the hospital and her pain treated properly. A review of Resident #1 ' s nursing notes indicated a note dated 11/27/15 documenting the events that occurred on 11/23/15. This nursing note indicated the physician was made aware on 11/27/15 of Resident #1 ' s fall that occurred Monday 11/23/15 while she was on the facility transportation van. The physician ordered a series of x-rays. When the physician was notified of the x-ray results, orders were received to send Resident #1 to the hospital for an evaluation on 11/27/15 due multiple lower extremity fractures. The facility was notified of being placed into Immediate Jeopardy at approximately 4:45 PM, on December 16, 2015, related to an incident that took place on a facility van on November 23, 2015. Immediately a plan was put in place to complete a Credible Allegation. A. How the corrective action will be accomplished for those residents found to have been affected by deficient practice? Outcome? · On 11/27/15, the second shift 200 hall staff nurse notified resident number 1's physician regarding the incident that took place on 11/23/15. · On 11/27/15, the second shift 200 hall staff nurse assessed resident number 1 during medication administration and completed a head-to-toe skin assessment. The second shift 200 hall nurse notified the physician of her assessment which included bruising to the left foot and ankle. The second shift 200 hall staff nurse also notified the physician of resident number 1's complaints of pain to the left foot and ankle and the right hip. The physician gave an order for [REDACTED].>· On 11/27/15, X-rays were completed on resident number 1, of resident number 1 ' s left foot and ankle and right hip. The results of the x-ray were communicated to the physician, resident number 1, and resident number 1 ' s family member or RP by the second shift 200 hall staff nurse. · On 11/27/15, the physician gave an order to the second shift 200 hall staff nurse to send resident number 1 to the emergency room . Resident number 1 was discharged to the local hospital emergency room for further evaluation. · On 11/27/15, the second shift 200 hall staff nurse initiated an incident/accident report, as directed by the administrator, on behalf of the first shift 200 hall nurse who failed to initiate an incident/accident report on 11/23/15 for resident number 1. · On 12/17/15 the director of nursing received additional in-service training, from the administrator, regarding promptly notifying the resident ' s physician regarding an incident or accident. · On 12/17/15 the director of nursing administered additional in-service training, for the involved nurse from 11/23/15, regarding promptly notifying the resident ' s physician regarding an incident or accident. · How did the facility identify other residents having the potential to be affected by the same deficient practice? · On 12/9/15, the director of nursing initiated an in-service for all LPN's and RN's including all nurses working from 11/23/15 to 11/27/15 regarding the expectation that the nurse promptly notifies the physician post incident/accident. No LPN or RN will be allowed to complete a shift until they have completed and signed the in-service. This in-service will be incorporated into new employee orientation. · On 12/17/15, all incident/accident reports from 11/23/15 through 12/17/15 were reviewed by the director of nursing and the assistant director of nursing to ensure physician notification. · On 12/16/15, an in-service was initiated by the director of nursing for all certified nursing assistants, including all nursing assistants that worked from 11/23/15 through 11/27/15, stating it is the responsibility of the CNA to seek immediate guidance for residents presenting a change in condition or resident incident including but not limited to: calling code green (resident fall) if inside facility or on facility grounds, calling 911 if outside facility grounds, and calling the facility directly to obtain professional guidance by a licensed nurse and/or administration if outside of the facility grounds. This in-service will be incorporated into new employee orientation. B. Give specific dates of the corrective actions. · On 11/27/15 resident number 1's physician was notified of the incident. · On 11/27/15 resident number 1's physician was notified of the X-ray results. · On 11/27/15 resident number 1's physician directed that the resident be sent to the emergency room . · On 12/17 the director of nursing received additional training regarding incident and accident notification. · On 12/9/15 the director of nursing initiated an in-service for all LPN's and RN's, including all nurses working from 11/23/15 to 11/27/15, regarding the expectation that the physician is made aware of all incident and accidents. · On 12/17/15, all incident/accident reports from 11/23/15 through 12/17/15 were reviewed to ensure physician notification. The Credible Allegation (CA) was verified on 12/18/15 at 11:45 AM by observation of Resident #1 resting comfortably on 12/18/15 and no reports of pain. Resident #1 verified staff were assessing her pain frequently. The CA was verified on interview in-servicing of nurses regarding the notification of the physician incidents and accidents involving any resident.

Based on staff, resident, responsible party (RP), physician interviews and record review, the facility transportation aide (TA) #1 returned Resident #1 to her the wheelchair after sustaining a fall on 11/23/15 while on the facility transportation van and neglected to provide notification, assessment or guidance of emergency medical services or a licensed professional for 1 of 1 (Resident #1). The TA #1 transported Resident #1 back to her room and using the mechanical lift and lift sling with the assistance of Nursing Assistant (NA) #5, transferred Resident #1 back into her bed on 11/23/15 without seeking guidance or assessment by a nurse before moving Resident #1. The facility staff nelgected to perform a physical assessment and neglected to seek medical attention for 1 of 1 alert and oriented resident (Resident #1) who sustained a fall resulting in a [MEDICAL CONDITION] hip and fractures of the right tibia and fibula on 11/23/15. Immediate Jeopardy began on 11/23/15 when Resident #1 was not assessed and moved after a fall on the transportation van, not assessed and moved upon return to the facility after sustaining a fall on the transportation van on 11/23/15 and the facility staff failed to seek medical attention for Resident #1 who sustained a fall on the transportation van on 11/23/15 resulting in multiple fractures. The facility provided and implemented a credible allegation on 12/18/15 at 11:45 AM. The immediate jeopardy is lowered to scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure implementation of permanent change in the process of providing education and training regarding neglect and mistreatment of [REDACTED]. Findings included: Resident #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was coded as requiring total assistance with all transfers and non-ambulatory. Resident #1 was coded as not having received any scheduled or as needed pain medication and was coded as reporting no pain on the MDS assessment. A review of Resident #1 ' s care plan dated as revised 10/21/15 included a pain risk care plan related to a patella fracture in [DATE] with intervention to include administrating pain medication as needed, reassessing the effectiveness of the pain medications and pain assessment for establish the effectiveness of the pain management system. A review of the October Medication Administration Record [REDACTED]. A review of the 24 hour Report form indicated Resident #1 received Tylenol on 11/23/15 at 10:30 PM and again on 11/24/15 at 5:00 AM. A review of the November MAR indicated [REDACTED]. In an interview on 12/8/15 at 12:00 PM, Resident #1 recalled falling from the wheelchair in the van on 11/23/15 while on a transport. An observation of Resident #1 revealed no evidence of surgical intervention to her left hip and an elastic wrap was observed around her right lower extremity. There was observed contractures to both lower extremities. Resident #1 stated she voiced pain after the fall and she was treated with Tylenol. She recalled it helped some but the pain became so bad the Tylenol didn ' t work to control her pain after a few days. Resident #1 stated she did not recall anyone coming to assess her legs after the fall on 11/23/15 and it was not until the Friday after Thanksgiving that she had a x-ray done and then was sent to the hospital on [DATE]. She stated the nurse had recently given her a pain pill that was stronger than Tylenol and it was helping control the pain. She stated she had to ask for the pain medication when she started to hurt. In a telephone interview on 12/8/15 at 2:30 PM, TA #1 recalled taking Resident #1 to [MEDICAL CONDITION] center on 11/23/15. She recalled Resident #1 stated she was sliding from her wheelchair so she pulled over and with the assistance of the RP, they lifted Resident #1 and returned her to the wheelchair. She then proceeded to return to the facility. She stated she did not call the facility or call 911 for assistance because Resident #1 stated she was ok. Once she arrived back at the facility, she notified the director of nursing (DON) who told her to write a statement and informed Resident #1 ' s nurse. In an interview on 12/8/15 at 12:21 PM. the director of nursing (DON) recalled transportation aide (TA) #1 reporting to her that Resident #1 slipped in the van. TA #1 stated Resident #1 ' s RP was present in the van and caught her and she was alright. The DON stated she was unsure if it was an actual fall at that time. She told the TA #1 to write a statement and inform Resident #1 ' s nurse to complete an incident report but the DON neglected to go and assess Resident #1 for any injures or discuss the circumstances of the fall with her or the RP. In an interview on 12/8/15 at 4:35 PM, the RP recalled riding in the front passenger seat to take Resident #1 to [MEDICAL CONDITION] center on 11/23/15. On their return to the facility, he recalled Resident #1 say I ' m fixing to slide out of my wheelchair. Resident #1 had slid from her wheelchair and landed of the foot pedal of the wheelchair. The RP stated Resident #1 seemed scared and she did not complain of pain at that time. The RP recalled that once he and Resident #1 returned to her room, the staff was attempting to get her back into the bed using the mechanical lift and Resident #1 was complaining pain in her legs then. He stated he was not aware that the staff never contacted the physician at any time until he insisted on something be done on 11/27/15. He said he visited Resident #1 on 11/27/15 and when she raised her head to take a drink of water she screamed out in pain. He said he told him then something had better be done. In an interview on 12/8/15 at 1:02 PM, Nurse #1 confirmed she was assigned Resident #1 on 11/23/15 when she returned from her appointment. She recalled TA #1 reporting to her Resident #1 fell in the van. Nurse #1 stated it was around shift change so she was busy. She recalled TA #1 told her Resident #1 slid from her wheelchair but she was fine. Nurse #1 stated she worked a double shift that day so after shift change she went and spoke to Resident #1 who was already back in the bed. Nurse #1 stated she did not assess Resident #1 or attempt any range of motion because Resident #1 did not complain of any pain at that time and her RP was no longer present. Nurse #1 stated if Resident #1 had acted differently or acted like she was in pain, she would have gotten an x-ray that day. In an interview on 12/8/15 at 3:28 PM, NA # 5 confirmed she worked second shift on 11/23/15 with Resident #1 and assisted TA #1 in putting her back into the back after she returned from her appointment the day she fell . NA #5 stated Resident #1 complained of pain in both legs. She recalled reporting the pain to the nurse because she had never complained of pain in her legs before. NA #5 stated Resident #1 refused her activities of daily living (ADL) care until around 10:00 PM. NA #5 stated Resident #1 was almost crying because she was in so much pain and the nurse gave her two Tylenol. NA #5 elaborated to say she had facial grimacing commonly associated with pain and was moaning when lying still in bed. In an interview on 12/8/15 at 2:10 PM, Nurse #2 confirmed she worked with Resident #1 on 11/24/15 first shift. She recalled Resident #1 complaining of pain all over but nothing directly related to her legs. Nurse #2 stated she thought the pain was related to the [MEDICAL CONDITION] and [MEDICAL CONDITION] she started the day before. She stated she was not aware that Resident #1 had a fall in the van. In an interview on 12/9/15 at 12:10 PM, NA #8 confirmed she worked first shift on 11/24/15 and 11/26/15 with Resident #1. She stated Resident #1 complained of pain on one of those days and said she was sore from the fall. NA #8 stated she did not report the voiced soreness to the nurse because she said the nurse already knew. NA #8 stated Resident #1 allowed her to complete her ADLs and she did not notice her legs looking any differently. NA #8 stated she observed no bruising or swelling to either leg. In an interview on 12/8/15 at 3:15 PM, NA #3 confirmed she worked second shift on 11/24/15 with Resident #1. NA #3 stated Resident #1 complained of pain in both legs due a fall on the van. NA #3 stated she reported it to the nurse but she was unsure of she medicated Resident #1. NA #3 stated Resident #1 refused incontinence care later in the her shift and she had never refused incontinence care before. In an interview on 12/8/15 at 3:25 PM, Nurse #3 confirmed she worked second shift on 11/24/15 with Resident #1. She stated Resident #1 did not report any pain to her and the assigned aide did not report any pain to her. She recalled also working second shift on 11/27/15 with Resident #1 and she contacted the physician about Resident #1 ' s leg pain and obtained orders for x-rays. She recalled Resident #1 ' s right foot appeared swollen but stated she did not assess her legs on 11/24/15 since she did not report any pain to her. Nurse #3 stated the x-rays returned positive for fractures to her left hip and right leg and she sent her to the hospital for an evaluation as ordered by the physician. In an interview on 12/8/15 at 3:10 PM, NA #1 confirmed she worked first shift on 11/25/15 with Resident #1. NA #1 stated Resident #1 complained of both legs hurting and could not turn over for incontinence care due to the pain. NA #1 stated she reported the complaints of leg pain to the nurse. She stated she was not aware of Resident #1 was ever medicated but she continued to complain of pain the entire shift. In a telephone interview on 12/9/15 at 11:25 AM, Nurse #5 confirmed she worked first shift on 11/25/15 and 11/26/15 with Resident #1. She stated Resident #1 never complained of pain and never asked for anything for pain. She stated she did not do a physical assessment of Resident #1 because she was not aware of the fall and she did not complain of leg pain. In an interview on 12/8/15 at 3:17 PM, NA #4 confirmed she worked second shift on 11/25/15 with Resident #1. NA #4 recalled Resident #1 complaining of pain in her legs when she and NA #3 were assisting Resident #1 back into the bed using the mechanical lift after she returned from [MEDICAL CONDITION] center. NA #4 stated Resident #1 was complaining of leg pain but she thought the pain was due to her contractures and not related the fall on Monday. NA #4 recalled telling the nurse about Resident #1 ' s pain. In an interview on 12/8/15 at 6:02 PM, Nurse #4 confirmed she worked second shift on 11/25/15. She stated Resident #1 did not complain of any pain and nobody reported any problems to her. Nurse #4 stated she was not aware Resident #1 had a fall on the van until 11/27/15. She stated the only thing Resident #1 ever complained about was an occasional headache. In an interview on 12/8/15 at 3:12 PM, NA #2 confirmed she worked second shift on 11/26/15 with Resident #1. NA #2 stated Resident #1 did complain of pain during her shift but she did not recall if the pain was in her legs. NA #2 stated that when she provided incontinence care on Resident #1 she groaned some and not was not normal for her. NA #2 stated Resident #1 very seldom complained of pain except for a headache on occasion. In an interview on 12/9/15 at 10:18 AM, NA #6 confirmed she worked third shift with Resident #1 on 11/23/15, 11/24/15, 11/25/15 and 11/26/15. She recalled Resident #1 telling her that she was sore from slipping out of the wheelchair and NA #5 reported it to the nurse who worked nights but NA #6 was unsure which night it was that Resident #1 complained. NA #5 stated Resident #1 allowed her to perform ADLs and never directly complained of leg pain. In a telephone interview on 12/9/15 at 11:40 AM, Nurse #6 confirmed she worked night shift 11/23/15, 11/24/15, 11/25/15 and 11/26/15 with Resident #1. Nurse #6 stated she was not aware of a fall on the van but the aide told her that Resident #1 was sore on 11/23/15 but she thought it was due to the [MEDICAL CONDITION]. Nurse #6 stated she failed to assess Resident #1 because she did not complain of pain specifically to her legs. Nurse #6 stated she became aware of the fall on 11/24/15 but again she did not assess Resident #1 because she did not complain of pain to her. In another telephone interview on 12/9/15 at 3:22 PM, NA #7 confirmed she also worked first shift on 11/27/15 with Resident #1. She stated Resident #1 complained of pain all over on Friday and would not let her do any ADLs. She would not let her turn her and she even asked the nurse to help her because Resident #1 was hurting so bad. NA #7 stated before the fall on 11/23/15, Resident #1 could turn onto her left side without any complaints of pain. She stated Resident #1 ' s pain was different but she wasn ' t crying. She did not want anyone to touch her. And that was unusual. In an interview on 12/10/15 at 9:00 AM, the medical records director recalled the RP approaching her Friday 11/27/15 late in the afternoon stated he needed to talk to someone about getting help for Resident #1 ' s pain from the fall on the van. She stated she was not aware of a fall but she reported what the RP told her to talk to the administrator. She told the RP to report the pain to Resident #1 ' s nurse and he stated the nurse was aware of her pain and had not done anything. In a telephone interview on 12/8/15 at 4:02 PM, the physician stated he was not notified of any incident involving a fall on the van with Resident #1 until 11/27/15 when the RP was at the facility stating Resident #1 was in severe pain and something had to be done. He stated he ordered x-rays and that was when he discovered the fractures. The physician stated his expectation was to be notified immediately when an incident like the one involving Resident #1 occurred and Resident #1 should have assessed sooner in the hospital and her pain treated properly. A review of Resident #1 ' s nursing notes indicated a note dated 11/27/15 documenting the events that occurred on 11/23/15. This nursing note indicated the physician was made aware on 11/27/15 of Resident #1 ' s fall that occurred Monday 11/23/15 while she was on the facility transportation van. The physician ordered a series of x-rays. When the physician was notified of the x-ray results, orders were received to send Resident #1 to the hospital for an evaluation on 11/27/15 due multiple lower extremity fractures. A review of the hospital records dated 11/27/15 indicated Resident was being transported in a van 5 days ago in her wheelchair when she slipped from the wheelchair onto her left hip when her right leg under her. She has been complaining of some pain in the area since that time. The pain was reported mostly to her left proximal femur and her right ankle which showed evidence of bruising and swelling. A splint was applied to her right lower extremity for immobilization and the orthopedic consult recommended no surgical intervention due to Resident #1 ' s bed bound status and severe MS with contractures. Pain management was recommended. Resident #1 was discharged back to the facility on [DATE] with orders for [MEDICATION NAME]-[MEDICATION NAME] 5 milligrams (mg)-325 mg (narcotic [MEDICATION NAME]) one tablet every 4hours for a pain score of 4-6. A review of the electronic medical record indicated no pain assessment completed in 2015 until 12/4/15 upon return from the hospital after the fall in the van that resulted in a left [MEDICAL CONDITION] and a right tibia and fibula fracture. The administrator was notified of the immediate jeopardy at F224 on 12/16/15 at 4:41 PM Immediately a plan was put in place to complete a Credible Allegation. A. How the corrective action will be accomplished for those residents found to have been affected by deficient practice? Outcome? · On 11/23/15, resident number 1 ' s family member/responsible party was aware of the incident as he was present on the van when the incident occurred. · On 11/23/15, the transportation aide reported the incident to the director of nursing and the second shift 200 hall nurse upon entering the facility. · On 11/23/15, the director of nursing asked resident number 1 if the resident was okay and if she had any pain. Resident number 1 stated she did not have any pain. · On 11/23/15, according to the second shift 200 hall nurses statement, although there is no documentation, she assessed resident number 1 during medication administration. According to the second shift 200 hall nurse ' s statement, she assessed resident number 1 ' s level of discomfort and pain. The second shift 200 hall nurse stated she determined that resident number 1 was at her baseline. The second shift 200 hall nurse stated she pulled back the covers and assessed the lower extremities for redness, pain, swelling, and bruising. There was no bruising, swelling, redness, or pain. The second shift 200 hall nurse reported she did not assess range of motion due to the resident number 1 ' s discomfort related to [MEDICAL CONDITION] and lower extremity contractures. According to the nurses ' written statement. The resident had no complaint of pain and exhibited normal behavior and activity. · On 11/27/15, the second shift 200 hall nurse assessed resident number 1 during medication administration and completed a head-to-toe skin assessment. On 11/27/15, the second shift 200 hall nurse made the initial notification of the incident to the physician. · On 11/27/15, X-rays were completed by MMDS x-ray provider, in the facility, of the resident ' s left ankle and foot and right hip. On 11/27/15, the results of the x-ray were communicated to the physician, the resident, and resident number 1 ' s family member/responsible party. Resident number 1 was discharged to the local hospital for further evaluation per physician order. · On 11/27/15, the second shift 200 hall nurse initiated an incident/accident report for the 11/23/15 incident/accident. · On 12/3/15, resident number 1 was returned to facility. While at the hospital resident number 1 received no surgical intervention. · On 12/8/15, the MDS nurse reviewed and updated resident number 1 ' s care plan and care guide to reflect fracture related pain. On 12/8/15, the MDS nurse also performed an updated pain assessment. · On 12/9/15, the director of nursing initiated an in-service for all LPN ' s and RN ' s, including all LPN ' s and RN ' s that worked from 11/23/15 to 11/27/15. The in-service covered assessing the resident post incident/accident. Assessment will include pain, swelling, redness, or other changes in condition. The in-service also covered the requirement to document the assessment in the electronic medical record. No nursing staff will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/9/15, the director of nursing initiated an in-service for LPN ' s, RN ' s and Medication Aides, including all LPN ' s, RN ' s, and Medication Aides that worked from 11/23/15 to 11/27/15, reinforcing communication during shift reports of incident/accidents, pain, changes in condition, or potential problems. No nursing staff will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/9/15, the director of nursing initiated an in-service for all LPN ' s, RN ' s, and Medication Aides, including all LPN ' s, RN ' s, and medication aides that worked from 11/23/15 to 11/27/15, stating that during shift report it is imperative nurses communicate any incident/accident, pain, changes in condition, or potential problems to ensure thorough and appropriate follow up care is provided. It is also a strong recommendation to note any of the above on your 24 hour nurse report. Make sure any of the above is also noted in the electronic medical record. This in-service will be incorporated into new employee orientation. · On 12/2/15 the director of nursing was in-serviced by the administrator that all incidents must be entered into the electronic medical record. · On 12/17/15 the director of nursing was in-serviced by the administrator that the resident ' s physician must be promptly made aware of all incidents and accidents. · On 12/16/15, the director of nursing initiated an in-service on abuse and neglect for 100% of staff including all staff that worked from 11/23/15 to 11/27/15. No nursing staff will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/17/15 the director of nursing was in-serviced by the administrator that the resident ' s physician must be promptly made aware of all incidents and accidents. · On 12/17/15, the administrator in-serviced the director of nursing regarding abuse and neglect. B. How did the facility identify other residents having the potential to be affected by the same deficient practice? · On 11/27/15, the administrator conducted interviews with alert and oriented residents that had received van transport regarding seat belt use during transport and overall wellbeing and safety with no negative findings. Residents that were interviewed were transported between the dates of 11/23/15 to 11/27/15. · On 11/27/15, the assistant director of nursing/staff initiated an in-service for all licensed nurses. The in-service covered the requirement for licensed nurses, to include all of the nurses that worked from 11/23/15 through 11/27/15, to initiate an incident accident report in a timely manner in the electronic medical record when a resident is involved in an incident/accident. On 12/9/15, 100% of licensed nurses have completed the in-service. This in-service will be incorporated into new employee orientation. · On 12/8/15 the hall nurses started assessing pain levels on residents every shift and documenting it on the Medication Administration Record, [REDACTED] · On 12/16/15, an in-service was initiated by the director of nursing for all certified nursing assistants, including all nursing assistants that worked from 11/23/15 through 11/27/15, stating it is the responsibility of the CNA to seek immediate guidance for residents presenting a change in condition or resident incident including but not limited to: calling code green (resident fall) if inside facility or on facility grounds, calling 911 if outside facility grounds, and calling the facility directly to obtain professional guidance by a licensed nurse and/or administration if outside of the facility grounds. Any certified nursing assistant will not be able complete their shift without completing the in-service. This in-service will be incorporated into new employee orientation. · On 12/16/15, the director of nursing initiated an in-service on abuse and neglect for 100% of staff including all staff that worked from 11/23/15 to 11/27/15. No nursing staff will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/17/15 the director of nursing was in-serviced by the administrator that the resident ' s physician must be promptly made aware of all incidents and accidents. · On 12/17/15, the administrator in-serviced the director of nursing regarding abuse and neglect. C. Give specific dates of the corrective actions. · On 11/23/15, resident number 1 ' s family member/responsible party was aware. · On 11/23/15, resident number 1 was assessed for pain, bruising, swelling, and redness by the second shift 200 hall nurse. · On 11/27/15, resident number 1 was assessed from head to toe by the second shift 200 hall nurse. · On 11/27/15, resident number 1's physician was notified of the incident. · On 11/27/15, resident number 1's physician was notified of the X-ray results. · On 11/27/15, resident number 1's physician directed that the resident be sent to the emergency room . · On 11/27/15, the incident accident report for resident number was initiated for the incident/accident that took place on 11/23/15. · On 11/27/15, the assistant director of nursing initiated an in-service. · On 12/4/15, therapy evaluation was completed on resident number 1, after resident number 1 returned from the hospital on [DATE]. · On 12/8/15, resident number 1 ' s care guide and care plan was updated regarding pain. A new pain assessment was completed. · On 12/8/15 the DON directed each nurse to ask each resident on their assignment about pain/discomfort. · On 12/9/15, the director of nursing initiated an in-service on communication during shift report for all LPN ' s, RN ' s, and medication aides. · On 12/9/15, the director of nursing initiated an in-service on performing physical assessment post incident or accident for LPN ' s and RN ' s. · On 12/16/15, the director of nursing initiated an in-service for all CNA ' s on calling code green (resident fall) or calling 911in the event of an accident or incident. To seek guidance from a licensed professional. Any certified nursing assistant will not be able complete their shift without completing the in-service. This in-service will be incorporated into new employee orientation. · On 12/9/15 the director of nursing initiated an in-service for all LPN's and RN's regarding the expectation that the physician is made aware of all incident and accidents. · On 12/16/15, the director of nursing initiated an in-service for all CNA ' s on calling code green (resident fall) or calling 911in the event of an accident or incident. To seek guidance from a licensed professional. · On 12/17/15 the director of nursing was in-serviced by the administrator that the resident ' s physician must be promptly made aware of all incidents and accidents. · On 12/17/15, the administrator in-serviced the director of nursing regarding abuse. The Credible Allegation (CA) was verified on 12/18/15 at 11:45 AM by observation of Resident #1 resting comfortably on 12/18/15 and no reports of pain. Resident #1 verified staff were assessing her pain frequently. The CA was verified by staff interviews for in-servicing of nurses, aides, the DON on abuse and neglect

Based on observations, staff, resident, responsible party (RP), interviews and record review, the facility failed to follow the care plan and remove the lift sling from the wheelchair for 1 of 1 alert and oriented resident (Resident #1) resulting in a fall on the transportation van resulting in a [MEDICAL CONDITION] hip and multiple fractures of the right lower leg. Immediate Jeopardy began on 11/23/15 when the facility failed to follow established care plan interventions resulting in a fall while on the facility transportation van with resulting multiple fractures and was removed at 11:45 AM on 12/18/15 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the implementation of their corrective action in the process of following care plan interventions. Findings included: Resident #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was coded as cognitively intact and exhibited no behavioral problems and coded as requiring total assistance with all transfers, and non-ambulatory. A review of Resident #1 ' s care plan revised on 10/21/15 included a fall risk care plan with an intervention to remove the lift sling after placing Resident #1 in her wheelchair with the initiation date for this intervention as 10/8/15. In an interview on 12/8/15 at 12:00 PM, Resident #1 recalled falling from the wheelchair in the van on 11/23/15 while on a transport. Resident #1 stated the aide who got her up for the appointment did not remove the lift sling from her wheelchair once she was placed in the wheelchair. An observation of Resident #1 revealed an elastic wrap around her right lower extremity A review of the incident report dated 11/27/15 revealed the following: According to transportation aide (TA) #1 on 11/23/15, Resident #1 had an appointment at [MEDICAL CONDITION] center with her Responsible Party (RP) present at the time. Upon leaving her appointment, Resident #1 was placed in the transport van and secured. While riding back to facility, Resident #1 stated I ' m sliding out of my chair. Before TA # 1 could stop the van, Resident #1 slid out of her chair onto the pedals of her wheelchair. TA #1 pulled over and with the assistance of Resident #1 ' s RP, they were able to get Resident #1 back into her wheelchair. TA #1 stated she asked Resident #1 if she was ok, the resident stated yes . TA #1 proceeded to drive back to the facility where she reported the incident to Resident #1 ' s assigned nurse and the Director of Nursing (DON). She stated the DON asked her to write a statement which she did and gave it to the DON. A review of Resident #1 ' s nursing notes indicated a note dated 11/27/15 documenting the events that occurred on 11/23/15. This nursing note indicated the physician was made aware on 11/27/15 of Resident #1 ' s fall that occurred Monday 11/23/15 while she was on the facility transportation van. The physician ordered a series of x-rays. When the physician was notified of the x-ray results, orders were received to send Resident #1 to the hospital for an evaluation on 11/27/15 due multiple lower extremity fractures. In a telephone interview on 12/9/15 at 11:10 AM, NA #7 confirmed she worked first shift on 11/23/15 with Resident #1 and got her up out of bed and placed her in her wheelchair the morning of 11/23/15. She stated she was unable to recall if she removed the lift sling out from under Resident #1 after she got her up to the wheelchair to go out to her appointment. She recalled the RP assisted her with getting Resident #1 up out of the bed that day. NA #7 stated she was aware that the lift sling was not to be left under Resident #1 because she had trouble sitting up in the wheelchair due to her leg contractures and she had fallen in the past. In a telephone interview on 12/8/15 at 2:30 PM, TA #1 recalled taking Resident #1 to [MEDICAL CONDITION] center on 11/23/15. On the way back to the facility she heard Resident #1 saying she was sliding, TA #1 stated she pulled over and with the assistance of the RP, they lifted Resident #1 off the wheelchair foot pedals using the lift sling and returned her to the wheelchair. She then proceeded to return to the facility. She stated she did not call the facility or call 911 for assistance because Resident #1 stated she was ok. Once she arrived back at the facility, she notified the DON who told her to write a statement and inform Resident #1 ' s nurse of the incident. TA #1 stated Resident #1 was already up in her wheelchair when she went to get her to put her on the van. She did not notice the lift sling was still under Resident #1 until she used it to pull her back up into the wheelchair when she slid onto the foot pedals. In an interview on 12/8/15 at 4:35 PM, the RP recalled riding in the transportation van in the front passenger seat to take Resident #1 to [MEDICAL CONDITION] center on 11/23/15. The RP recalled hearing Resident #1 say I ' m fixing to slide out of my wheelchair. He stated TA #1 pulled over and he got behind Resident #1 while TA #1 remained in the front of the van. He stated the lift sling was under Resident #1 and he thought it was not to be under her because it caused her to slide from her wheelchair in the recent past. The RP stated he and TA #1 used the lift sling straps to lift Resident #1 off the wheelchair foot pedals and move her back into the wheelchair. He stated TA #1 told him she would complete a report about what happened. The RP recalled that once he and Resident #1 returned to her room, the staff was attempting to get her back into the bed using the mechanical lift and Resident #1 was complaining of pain in her legs then. In an interview on 12/8/15 at 12:21 PM. the DON recalled TA #1 reported to her that Resident #1 slipped in the van. TA #1 stated Resident #1 ' s RP was present in the van and caught her and she was alright. The DON stated she was unsure if it was an actual fall at that time. She told TA #1 to write a statement and inform Resident #1 ' s nurse to complete an incident report but the DON did not discuss the circumstances of the fall with TA #1 or the RP. In an interview on 12/8/15 at 2:20 PM, the Administrator stated he did not become aware of the incident until 11/27/15 when he immediately stopped all transports. He stated he started an investigation when he became aware and so far, he felt TA #1 did not have the shoulder belt in use. The administrator stated he was not aware that the lift sling was not removed from the wheelchair after the resident was placed in the wheelchair. The Administrator was not aware that Resident #1 ' s care plan included an interventions to remove the lift sling after placing the resident in a wheelchair. In an interview on 12/8/15 at 3:28 PM, Nursing Assistant (NA) # 5 confirmed she worked second shift on 11/23/15 with Resident #1. NA #5 stated she put Resident #1 in the bed after she returned from the appointment the day she fell . She stated the lift sling was under Resident #1 when she returned and she was not supposed to have it under her when she was up in her wheelchair because she has been known to slide out of her wheelchair off the sling In an interview on 12/9/15 at 8:45 AM, TA #2 stated she was trained by the Quality Assurance (QA) nurse and the previous transporter. TA #2 stated she served as the backup transporter for over one year. TA #2 confirmed that the lift sling was to be removed from underneath Resident #1 whenever she was up in her wheelchair. TA #2 stated Resident #1 had trouble sitting up in her wheelchair due to contractures in both legs and the lift sling was slippery and had resulted in her falling in the past. In an interview on 12/9/15 at 10:40 AM, the MDS nurse stated she completed the quarterly MDS on Resident #1 and updated her care plan on 10/21/15. She explained the QA nurse added the intervention to remove the lift sling from underneath Resident #1 since it was determined to be the cause of a fall dated 10/8/15. She stated whenever the care plan was updated with a new intervention, it should be added to the resident care guide located in Resident #1 ' s closet. A review at this time of Resident #1 ' s care guide dated as printed 12/8/15 did not include the intervention to remove the lift sling from underneath Resident #1. The MDS nurse stated it should have been added and it was an oversight. In an interview on 12/9/15 at 10:45 AM, the QA nurse confirmed he added the care plan intervention to remove the lift sling from under Resident #1 after she fell from her wheelchair on 10/8/15. The QA nurse stated he neglected to add it to Resident #1 ' s care guide at the time of the fall. The Administrator was notified on 12/8/15 at 6:18 PM of the immediate jeopardy related to Resident #1 ' s fall during van transport from an appointment to the facility on [DATE]. The Administrator provided the following credible allegation of compliance on 12/9/15 at 5:00 PM: Immediately a plan was put in place to complete a Credible Allegation. A. How the corrective action will be accomplished for those residents found to have been affected by deficient practice? Outcome? · On 12/8/15, the MDS nurse reviewed and updated the resident ' s care plan and care guide, in response to the incident report, to reflect fracture related pain. · On 12/9/15, the MDS nurse updated resident 1 ' s care plan/care guide to include resident 1 will not be transported with lift pad under her in the facility van. · On 12/9/15, the director of nursing initiated an in-service for all nursing staff, RN ' s, LPN ' s, CNA ' s, medication aides, restorative aides, and transportation aides, including staff involved with care from 11/23/15 through 11/27/15. The following was covered; All nursing staff must follow the resident care guide, posted in the resident ' s closet. Please especially pay attention to the handling and movement directions on the care guide. For example, the care guide may instruct you to remove the resident ' s lift pad after transferring the resident from the bed to the chair as well as it may include the removal of the lift pad when being transferred in the company van. If you have any comments or questions please see the director of nursing. All nursing staff, RN ' s, LPN ' s, CNA ' s, medication aides, restorative aides, and transportation aides will complete this in-service prior to completing their shift. This in-service will be incorporated into new employee orientation. · On 12/17/15, the administrator in-serviced the MDS coordinator, director of nursing, and assistant director of nursing to review incident accident interventions and ensure interventions are appropriately reflected on the resident care plan including the resident care guide. B. How did the facility identify other residents having the potential to be affected by the same deficient practice? · On 12/9/15, the MDS coordinator reviewed all residents using sling lift pads for safety while in wheelchair. The MDS coordinator assessed the residents that utilize the sling lift and updated the residents ' care plans and care guides to reflect if the sling lift pad needs to be removed for safe transport in the facility van. · On 12/9/15, an in-service was initiated by the director of nursing, for 100% of nursing staff, including the nurses that worked from 11/23/15 through 11/27/15, relating to following the care guide for lift pad removal for when the resident is in the wheelchair or when the resident is being transported in the facility van. In-services for department heads was initiated on 12/17/15. Nursing staff and department heads will be required to complete this in-service prior to completing their shift. This in-service will be incorporated into new employee orientation. C. Give specific dates of the corrective actions. · On 12/9/15, resident number 1 ' s care guide/care plan updated. · On 12/9/15, the director of nursing initiated an in-service for nursing staff on following the care guide and care plan. · On 12/9/15, the MDS coordinator reviewed all residents using sling lift pads. · On 12/9/15, the director of nursing initiated an in-service for all nursing staff regarding following the care guide for if the lift pad should be removed. · On 12/17/15, the administrator in-service the MDS coordinator, DON, and ADON to review incidents and accidents for appropriate interventions. The Credible Allegation (CA) was verified 12/18/15 at 11:45 AM by observations and interviews of other alert and oriented Residents care planned to have the lift sling removed from underneath them while up in their wheelchairs. Resident #1 was not observed up out of her bed in her wheelchair but she verified she was not to have the lift sling under her when she was up sitting in her wheelchair. The MDS nurse verified she updated all the care plans and care guide for residents identified a fall risk to remove the lift sling from the wheelchair when in use. The CA was also verified for in-servicing of nurses and nursing assistants staff through interviews to remove the lift sling from resident identified a fall risk and to review the resident care guide prior to rendering care.

Based on observations, staff, resident, responsible party (RP), physician interviews and record review, the facility transportation aide (TA) #1 returned Resident #1 to her the wheelchair after sustaining a fall on 11/23/15 while on the facility transportation van without notification, assessment or guidance of emergency medical services or a licensed professional for 1 of 1 (Resident #1). The TA #1 transported Resident #1 back to her room and using the mechanical lift and lift sling with the assistance of Nursing Assistant (NA) #5, transferred Resident #1 back into her bed on 11/23/15 without seeking guidance or assessment by a nurse before moving Resident #1. The facility staff failed to perform a physical assessment and seek medical attention for 1 of 1 alert and oriented resident (Resident #1) who sustained a fall resulting in a [MEDICAL CONDITION] hip and fractures of the right tibia and fibula on 11/23/15. Immediate Jeopardy began on 11/23/15 when Resident #1 was not assessed and moved after a fall on the transportation van, not assessed and moved upon return to the facility after sustaining a fall on the transportation van on 11/23/15 and the facility staff failed to seek medical attention for Resident #1 who sustained a fall on the transportation van on 11/23/15 resulting in multiple fractures. The facility provided and implemented a credible allegation on 12/18/15 at 11:45 AM. The immediate jeopardy is lowered to scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure implementation of permanent change in the process of assessment and treatment of [REDACTED]. Findings included: Resident #1 ' s quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. She was coded as requiring total assistance with all transfers and non-ambulatory. Resident #1 was coded as not having received any scheduled or as needed pain medication and was coded as reporting no pain on the MDS assessment. A review of Resident #1 ' s care plan dated as revised 10/21/15 included a pain risk care plan related to a patella fracture in [DATE] with intervention to include administrating pain medication as needed, reassessing the effectiveness of the pain medications and pain assessment for establish the effectiveness of the pain management system. A review of the October Medication Administration Record [REDACTED]. A review of the 24 hour Report form indicated Resident #1 received Tylenol on 11/23/15 at 10:30 PM and again on 11/24/15 at 5:00 AM. A review of the November MAR indicated [REDACTED]. In an interview on 12/8/15 at 12:00 PM, Resident #1 recalled falling from the wheelchair in the van on 11/23/15 while on a transport. An observation of Resident #1 revealed no evidence of surgical intervention to her left hip and an elastic wrap was observed around her right lower extremity. There was observed contractures to both lower extremities. Resident #1 stated she voiced pain after the fall and she was treated with Tylenol. She recalled it helped some but the pain became so bad the Tylenol didn ' t work to control her pain after a few days. Resident #1 stated she did not recall anyone coming to assess her legs after the fall on 11/23/15 and it was not until the Friday after Thanksgiving that she had a x-ray done and then was sent to the hospital on [DATE]. She stated the nurse had recently given her a pain pill that was stronger than Tylenol and it was helping control the pain. She stated she had to ask for the pain medication when she started to hurt. In a telephone interview on 12/8/15 at 2:30 PM, TA #1 recalled taking Resident #1 to [MEDICAL CONDITION] center on 11/23/15. She recalled Resident #1 stated she was sliding from her wheelchair so she pulled over and with the assistance of the RP, they lifted Resident #1 and returned her to the wheelchair. She then proceeded to return to the facility. She stated she did not call the facility or call 911 for assistance because Resident #1 stated she was ok. Once she arrived back at the facility, she notified the director of nursing (DON) who told her to write a statement and informed Resident #1 ' s nurse. In an interview on 12/8/15 at 12:21 PM. the DON recalled transportation aide (TA) #1 reporting to her that Resident #1 slipped in the van. TA #1 stated Resident #1 ' s RP was present in the van and caught her and she was alright. The DON stated she was unsure if it was an actual fall at that time. She told the TA #1 to write a statement and inform Resident #1 ' s nurse to complete an incident report but the DON did not go and assess Resident #1 for any injures or discuss the circumstances of the fall with her or the RP. In an interview on 12/8/15 at 4:35 PM, the RP recalled riding in the front passenger seat to take Resident #1 to [MEDICAL CONDITION] center on 11/23/15. On their return to the facility, he recalled Resident #1 say I ' m fixing to slide out of my wheelchair. Resident #1 had slid from her wheelchair and landed of the foot pedal of the wheelchair. The RP stated Resident #1 seemed scared and she did not complain of pain at that time. The RP recalled that once he and Resident #1 returned to her room, the staff was attempting to get her back into the bed using the mechanical lift and Resident #1 was complaining pain in her legs then. He stated he was not aware that the staff never contacted the physician at any time until he insisted on something be done on 11/27/15. He said he visited Resident #1 on 11/27/15 and when she raised her head to take a drink of water she screamed out in pain. He said he told him then something had better be done. In an interview on 12/8/15 at 1:02 PM, Nurse #1 confirmed she was assigned Resident #1 on 11/23/15 when she returned from her appointment. She recalled TA #1 reporting to her Resident #1 fell in the van. Nurse #1 stated it was around shift change so she was busy. She recalled TA #1 told her Resident #1 slid from her wheelchair but she was fine. Nurse #1 stated she worked a double shift that day so after shift change she went and spoke to Resident #1 who was already back in the bed. Nurse #1 stated she did not assess Resident #1 or attempt any range of motion because Resident #1 did not complain of any pain at that time and her RP was no longer present. Nurse #1 stated if Resident #1 had acted differently or acted like she was in pain, she would have gotten an x-ray that day. In an interview on 12/8/15 at 3:28 PM, NA # 5 confirmed she worked second shift on 11/23/15 with Resident #1 and assisted TA #1 in putting her back into the back after she returned from her appointment the day she fell . NA #5 stated Resident #1 complained of pain in both legs. She recalled reporting the pain to the nurse because she had never complained of pain in her legs before. NA #5 stated Resident #1 refused her activities of daily living (ADL) care until around 10:00 PM. NA #5 stated Resident #1 was almost crying because she was in so much pain and the nurse gave her two Tylenol. NA #5 elaborated to say she had facial grimacing commonly associated with pain and was moaning when lying still in bed. In an interview on 12/8/15 at 2:10 PM, Nurse #2 confirmed she worked with Resident #1 on 11/24/15 first shift. She recalled Resident #1 complaining of pain all over but nothing directly related to her legs. Nurse #2 stated she thought the pain was related to the [MEDICAL CONDITION] and [MEDICAL CONDITION] she started the day before. She stated she was not aware that Resident #1 had a fall in the van. In an interview on 12/9/15 at 12:10 PM, NA #8 confirmed she worked first shift on 11/24/15 and 11/26/15 with Resident #1. She stated Resident #1 complained of pain on one of those days and said she was sore from the fall. NA #8 stated she did not report the voiced soreness to the nurse because she said the nurse already knew. NA #8 stated Resident #1 allowed her to complete her ADLs and she did not notice her legs looking any differently. NA #8 stated she observed no bruising or swelling to either leg. In an interview on 12/8/15 at 3:15 PM, NA #3 confirmed she worked second shift on 11/24/15 with Resident #1. NA #3 stated Resident #1 complained of pain in both legs due a fall on the van. NA #3 stated she reported it to the nurse but she was unsure of she medicated Resident #1. NA #3 stated Resident #1 refused incontinence care later in the her shift and she had never refused incontinence care before. In an interview on 12/8/15 at 3:25 PM, Nurse #3 confirmed she worked second shift on 11/24/15 with Resident #1. She stated Resident #1 did not report any pain to her and the assigned aide did not report any pain to her. She recalled also working second shift on 11/27/15 with Resident #1 and she contacted the physician about Resident #1 ' s leg pain and obtained orders for x-rays. She recalled Resident #1 ' s right foot appeared swollen but stated she did not assess her legs on 11/24/15 since she did not report any pain to her. Nurse #3 stated the x-rays returned positive for fractures to her left hip and right leg and she sent her to the hospital for an evaluation as ordered by the physician. In an interview on 12/8/15 at 3:10 PM, NA #1 confirmed she worked first shift on 11/25/15 with Resident #1. NA #1 stated Resident #1 complained of both legs hurting and could not turn over for incontinence care due to the pain. NA #1 stated she reported the complaints of leg pain to the nurse. She stated she was not aware of Resident #1 was ever medicated but she continued to complain of pain the entire shift. In a telephone interview on 12/9/15 at 11:25 AM, Nurse #5 confirmed she worked first shift on 11/25/15 and 11/26/15 with Resident #1. She stated Resident #1 never complained of pain and never asked for anything for pain. She stated she did not do a physical assessment of Resident #1 because she was not aware of the fall and she did not complain of leg pain. In an interview on 12/8/15 at 3:17 PM, NA #4 confirmed she worked second shift on 11/25/15 with Resident #1. NA #4 recalled Resident #1 complaining of pain in her legs when she and NA #3 were assisting Resident #1 back into the bed using the mechanical lift after she returned from [MEDICAL CONDITION] center. NA #4 stated Resident #1 was complaining of leg pain but she thought the pain was due to her contractures and not related the fall on Monday. NA #4 recalled telling the nurse about Resident #1 ' s pain. In an interview on 12/8/15 at 6:02 PM, Nurse #4 confirmed she worked second shift on 11/25/15. She stated Resident #1 did not complain of any pain and nobody reported any problems to her. Nurse #4 stated she was not aware Resident #1 had a fall on the van until 11/27/15. She stated the only thing Resident #1 ever complained about was an occasional headache. In an interview on 12/8/15 at 3:12 PM, NA #2 confirmed she worked second shift on 11/26/15 with Resident #1. NA #2 stated Resident #1 did complain of pain during her shift but she did not recall if the pain was in her legs. NA #2 stated that when she provided incontinence care on Resident #1 she groaned some and not was not normal for her. NA #2 stated Resident #1 very seldom complained of pain except for a headache on occasion. In an interview on 12/9/15 at 10:18 AM, NA #6 confirmed she worked third shift with Resident #1 on 11/23/15, 11/24/15, 11/25/15 and 11/26/15. She recalled Resident #1 telling her that she was sore from slipping out of the wheelchair and NA #5 reported it to the nurse who worked nights but NA #6 was unsure which night it was that Resident #1 complained. NA #5 stated Resident #1 allowed her to perform ADLs and never directly complained of leg pain. In a telephone interview on 12/9/15 at 11:40 AM, Nurse #6 confirmed she worked night shift 11/23/15, 11/24/15, 11/25/15 and 11/26/15 with Resident #1. Nurse #6 stated she was not aware of a fall on the van but the aide told her that Resident #1 was sore on 11/23/15 but she thought it was due to the [MEDICAL CONDITION]. Nurse #6 stated she did not assess Resident #1 because she did not complain of pain specifically to her legs. Nurse #6 stated she became aware of the fall on 11/24/15 but again she did not assess Resident #1 because she did not complain of pain to her. In another telephone interview on 12/9/15 at 3:22 PM, NA #7 confirmed she also worked first shift on 11/27/15 with Resident #1. She stated Resident #1 complained of pain all over on Friday and would not let her do any ADLs. She would not let her turn her and she even asked the nurse to help her because Resident #1 was hurting so bad. NA #7 stated before the fall on 11/23/15, Resident #1 could turn onto her left side without any complaints of pain. She stated Resident #1 ' s pain was different but she wasn ' t crying. She did not want anyone to touch her. And that was unusual. In an interview on 12/10/15 at 9:00 AM, the medical records director recalled the RP approaching her Friday 11/27/15 late in the afternoon stated he needed to talk to someone about getting help for Resident #1 ' s pain from the fall on the van. She stated she was not aware of a fall but she reported what the RP told her to the administrator. She told the RP to report the pain to Resident #1 ' s nurse and he stated the nurse was aware of her pain and had not done anything. In a telephone interview on 12/8/15 at 4:02 PM, the physician stated he was not notified of any incident involving a fall on the van with Resident #1 until 11/27/15 when the RP was at the facility stating Resident #1 was in severe pain and something had to be done. He stated he ordered x-rays and that was when he discovered the fractures. The physician stated his expectation was to be notified immediately when an incident like the one involving Resident #1 occurred and Resident #1 should have assessed sooner in the hospital and her pain treated properly. A review of Resident #1 ' s nursing notes indicated a note dated 11/27/15 documenting the events that occurred on 11/23/15. This nursing note indicated the physician was made aware on 11/27/15 of Resident #1 ' s fall that occurred Monday 11/23/15 while she was on the facility transportation van. The physician ordered a series of x-rays. When the physician was notified of the x-ray results, orders were received to send Resident #1 to the hospital for an evaluation on 11/27/15 due multiple lower extremity fractures. A review of the hospital records dated 11/27/15 indicated Resident was being transported in a van 5 days ago in her wheelchair when she slipped from the wheelchair onto her left hip when her right leg under her. She has been complaining of some pain in the area since that time. The pain was reported mostly to her left proximal femur and her right ankle which showed evidence of bruising and swelling. A splint was applied to her right lower extremity for immobilization and the orthopedic consult recommended no surgical intervention due to Resident #1 ' s bed bound status and severe MS with contractures. Pain management was recommended. Resident #1 was discharged back to the facility on [DATE] with orders for [MEDICATION NAME]-[MEDICATION NAME] 5 milligrams (mg)-325 mg (narcotic [MEDICATION NAME]) one tablet every 4 hours for a pain score of 4-6. A review of the electronic medical record indicated no pain assessment completed in 2015 until 12/4/15 upon return from the hospital after the fall in the van that resulted in a left [MEDICAL CONDITION] and a right tibia and fibula fracture. Richmond Pines was placed into Immediate Jeopardy at 6:18 PM, on December 8, 2015, related to an incident that took place on a facility van on November 23, 2015. Immediately a plan was put in place to complete a Credible Allegation. A. How the corrective action will be accomplished for those residents found to have been affected by deficient practice? Outcome? · On 11/23/15, resident number 1 ' s family member/responsible party was aware of the incident as he was present on the van when the incident occurred. · On 11/23/15, the transportation aide reported the incident to the director of nursing and the second shift 200 hall nurse upon entering the facility. · On 11/23/15, the director of nursing asked resident number 1 if the resident was okay and if she had any pain. Resident number 1 stated she did not have any pain. · On 11/23/15, according to the second shift 200 hall nurses statement, although there is no documentation, she assessed resident number 1 during medication administration. According to the second shift 200 hall nurse ' s statement, she assessed resident number 1 ' s level of discomfort and pain. The second shift 200 hall nurse stated she determined that resident number 1 was at her baseline. The second shift 200 hall nurse stated she pulled back the covers and assessed the lower extremities for redness, pain, swelling, and bruising. There was no bruising, swelling, redness, or pain. The second shift 200 hall nurse reported she did not assess range of motion due to the resident number 1 ' s discomfort related to [MEDICAL CONDITION] and lower extremity contractures. According to the nurses ' written statement. The resident had no complaint of pain and exhibited normal behavior and activity. · On 11/27/15, the second shift 200 hall nurse assessed resident number 1 during medication administration and completed a head-to-toe skin assessment. On 11/27/15, the second shift 200 hall nurse made the initial notification of the incident to the physician. · On 11/27/15, X-rays were completed by MMDS x-ray provider, in the facility, of the resident ' s left ankle and foot and right hip. On 11/27/15, the results of the x-ray were communicated to the physician, the resident, and resident number 1 ' s family member/responsible party. Resident number 1 was discharged to the local hospital for further evaluation per physician order. · On 11/27/15, the second shift 200 hall nurse initiated an incident/accident report for the 11/23/15 incident/accident. · On 12/3/15, resident number 1 was returned to facility. While at the hospital resident number 1 received no surgical intervention. · On 12/8/15, the MDS nurse reviewed and updated resident number 1 ' s care plan and care guide to reflect fracture related pain. On 12/8/15, the MDS nurse also performed an updated pain assessment. · On 12/9/15, the director of nursing initiated an in-service for all LPN ' s and RN ' s, including all LPN ' s and RN ' s that worked from 11/23/15 to 11/27/15. The in-service covered assessing the resident post incident/accident. Assessment will include pain, swelling, redness, or other changes in condition. The in-service also covered the requirement to document the assessment in the electronic medical record. No nursing staff will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/9/15, the director of nursing initiated an in-service for LPN ' s, RN ' s and Medication Aides, including all LPN ' s, RN ' s, and Medication Aides that worked from 11/23/15 to 11/27/15, reinforcing communication during shift reports of incident/accidents, pain, changes in condition, or potential problems. No nursing staff will be allowed to complete a work shift until this in-service is completed. This in-service will be incorporated into new employee orientation. · On 12/9/15, the director of nursing initiated an in-service for all LPN ' s, RN ' s, and Medication Aides, including all LPN ' s, RN ' s, and medication aides that worked from 11/23/15 to 11/27/15, stating that during shift report it is imperative nurses communicate any incident/accident, pain, changes in condition, or potential problems to ensure thorough and appropriate follow up care is provided. It is also a strong recommendation to note any of the above on your 24 hour nurse report. Make sure any of the above is also noted in the electronic medical record. This in-service will be incorporated into new employee orientation. · On 12/2/15 the director of nursing was in-serviced by the administrator that all incidents must be entered into the electronic medical record. · On 12/17/15 the director of nursing was in-serviced by the administrator that the resident ' s physician must be promptly made aware of all incidents and accidents. B. How did the facility identify other residents having the potential to be affected by the same deficient practice? · On 11/27/15, the administrator conducted interviews with alert and oriented residents that had received van transport regarding seat belt use during transport and overall wellbeing and safety with no negative findings. Residents that were interviewed were transported between the dates of 11/23/15 to 11/27/15. · On 11/27/15, the assistant director of nursing/staff initiated an in-service for all licensed nurses. The in-service covered the requirement for licensed nurses, to include all of the nurses that worked from 11/23/15 through 11/27/15, to initiate an incident accident report in a timely manner in the electronic medical record when a resident is involved in an incident/accident. On 12/9/15, 100% of licensed nurses have completed the in-service. This in-service will be incorporated into new employee orientation. · On 12/8/15 the hall nurses started assessing pain levels on residents every shift and documenting it on the Medication Administration Record, [REDACTED] · On 12/16/15, an in-service was initiated by the director of nursing for all certified nursing assistants, including all nursing assistants that worked from 11/23/15 through 11/27/15, stating it is the responsibility of the CNA to seek immediate guidance for residents presenting a change in condition or resident incident including but not limited to: calling code green (resident fall) if inside facility or on facility grounds, calling 911 if outside facility grounds, and calling the facility directly to obtain professional guidance by a licensed nurse and/or administration if outside of the facility grounds. Any certified nursing assistant will not be able complete their shift without completing the in-service. This in-service will be incorporated into new employee orientation. C. Give specific dates of the corrective actions. · On 11/23/15, resident number 1 ' s family member/responsible party was aware. · On 11/23/15, resident number 1 was assessed for pain, bruising, swelling, and redness by the second shift 200 hall nurse. · On 11/27/15, resident number 1 was assessed from head to toe by the second shift 200 hall nurse. · On 11/27/15, resident number 1's physician was notified of the incident. · On 11/27/15, resident number 1's physician was notified of the X-ray results. · On 11/27/15, resident number 1's physician directed that the resident be sent to the emergency room . · On 11/27/15, the incident accident report for resident number was initiated for the incident/accident that took place on 11/23/15. · On 11/27/15, the assistant director of nursing initiated an in-service. · On 12/4/15, therapy evaluation was completed on resident number 1, after resident number 1 returned from the hospital on [DATE]. · On 12/8/15, resident number 1 ' s care guide and care plan was updated regarding pain. A new pain assessment was completed. · On 12/8/15 the DON directed each nurse to ask each resident on their assignment about pain/discomfort. · On 12/9/15, the director of nursing initiated an in-service on communication during shift report for all LPN ' s, RN ' s, and medication aides. · On 12/9/15, the director of nursing initiated an in-service on performing physical assessment post incident or accident for LPN ' s and RN ' s. · On 12/16/15, the director of nursing initiated an in-service for all CNA ' s on calling code green (resident fall) or calling 911in the event of an accident or incident. To seek guidance from a licensed professional. Any certified nursing assistant will not be able complete their shift without completing the in-service. This in-service will be incorporated into new employee orientation. · On 12/9/15 the director of nursing initiated an in-service for all LPN's and RN's regarding the expectation that the physician is made aware of all incident and accidents. The Credible Allegation (CA) was verified on 12/18/15 at 11:45 AM by observation of Resident #1 resting comfortably on 12/18/15 and no reports of pain. Resident #1 verified staff were assessing her pain frequently. The CA was verified for in-servicing of staff regarding the assessment of pain every shift, assessment for a resident after a reported fall and reporting any voiced pain to the physician.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan to address 1 of 1 resident (Resident #5) protective of his personal space and failed to address behaviors of 2 of 2 sampled residents (Resident #4 and Resident #2) who wandered and would lie down in other resident ' s beds resulting in injury to Resident #4 and Resident #2. The Immediate Jeopardy began on 3/9/13 at 8:00 PM and was identified on 04/10/13 at 2:10 PM. The Immediate Jeopardy was removed on 04/11/13 at 5:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be in-serviced. The facility will then implement monitoring of its corrective action. The findings include: 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Resident ' s Annual Minimum Data Set (MDS) assessment dated [DATE] revealed no behavioral symptoms or mood issues therefore a Care Area Assessment was not done. The assessment revealed that the Resident received [MEDICAL CONDITION] medications 7 out of 7 days during the assessment period and would be care planned. The Resident ' s current Care Plan dated 1/4/13 revealed that the Resident had verbal and physical aggression related to anger, cognitive impairment and depression. The interventions included the following: Do not argue or condemn Resident. Document summary of each episode. Note cause and successful interventions, include frequency and duration. Medication/Treatment as prescribed by physician in a timely manner. Monitor and document behavior per facility protocol. Remove Resident from public area when behavior is disruptive and unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. Remove to a quiet area; reassure Resident of personal safety and stay with Resident during periods of anger if appropriate or if resident wishes. Try not to reason with Resident, as Resident no longer has the ability to think logically. The care plan did not include information regarding the Resident ' s aggression when other resident ' s got in his personal space. The Care Plan for Psychoactive Medications showed that the Resident received drugs that had the potential of having an altering effect of the mind. The Care Plan showed that the Resident was taking the medications due to anxiety, depression and a decline in mood and behaviors. The interventions included monitoring of the Resident ' s mood and behaviors with documentation per facility policy and to notify the physician of any significant changes. The Care Plan revealed no new interventions until 3/13/13. The most recent MDS (Quarterly) dated 1/11/13 revealed that the Resident was severely cognitively impaired and had behaviors of threatening others, screaming and cursing at others during 1 to 3 days of the 7 day assessment period. The MDS showed that the Resident was ambulatory with the supervision of 1 person and received antianxiety and antipsychotic medications. A nursing progress note dated 12/4/12 at 11:10 PM revealed that Resident #5 was standing in the doorway of the dining room and Resident #4 started to go in and Resident #5 balled up his fist and started yelling at Resident #4 stating that he would hit him. It was noted that this happened x (times) 2. A nursing progress note dated 12/20/12 at 11:34 PM revealed that Resident #5 knocked down Resident #4 after Resident #4 pulled his chair from behind him. No injuries were noted. A nursing progress note dated 2/20/13 at 9:42 PM revealed that the Resident yelled out x 3 at other residents. When asked why he was yelling at them he stated: " I don ' t want them to touch me. " The Resident yelled at another resident that was in his room. A facility incident report dated 3/9/13 revealed that at 8:00 PM Resident #5 hit Resident #4 because the Resident was in his bed. Resident #4 had to have his eye removed due to trauma to the eye. A facility incident report dated 3/10/13 at 10:02 PM revealed that Resident #5 hit Resident #2 because the Resident was in his bed resulting in a [MEDICAL CONDITION] ' s nose. Nurse #1 stated in an interview on 3/25/13 at 2:52 PM that Resident #5 did not like to be touched and if anyone was in his room he would holler out and the staff would go to the room to see what was going on. An interview was conducted with NA #1 and NA #2 on 3/25/13 at 3:13 PM. NA #1 stated that Resident #4 and Resident #2 would wander around the unit and might get into any resident ' s bed. The NA stated that when this happened the staff would get them up and show them their bed. The Director of Nursing (DON) stated in an interview on 3/26/13 at 9:54 AM that the girls in the unit know Resident #5 and if someone bothers him, he will yell and the staff go see what is going on and redirects the resident. The Quality Improvement Nurse stated in an interview on 3/26/13 at 10:04 AM that Resident #5 had always been aggressive but did not hit people on a regular basis. The Nurse stated that it was a known fact that Resident #5 did not like anyone in his personal space and if the person did not move, the Resident would become aggressive. On 3/26/13 at 12:45 PM an interview was conducted with the Administrator, Director of Nursing and a Facility Consultant. The Facility Consultant stated that they had completed a Plan of Correction (POC) after the altercations on the weekend of 3/9-10/13. A review of the POC revealed no information regarding the care plan for Resident #5. The MDS Nurse stated in an interview on 3/28/13 at 3:30 PM that when updating care plans and coding the MDS she looked at the nurse ' s notes and behaviors documented by the staff. The Nurse stated that she was not aware that Resident #5 was protective of his personal space until the incidents on the weekend of 3/9-10/13. The Nurse stated that she was not aware of residents getting into other resident ' s beds on the Alzheimer ' s Unit. 2. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the nursing progress notes for Resident #4 showed a note dated 2/5/13 at 7:32 PM that the Resident was lying in another resident ' s bed. A nursing progress note dated 2/13/13 at 12:05 AM that the Resident was in and out of other resident ' s beds. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 2/17/13 showed that the Resident had short and long term memory loss and had poor decision making skills and required cues and supervision. The MDS showed that the Resident had behavior symptoms not directed toward others and was ambulatory with the supervision of one person. The Resident ' s current Care Plan last updated on 2/18/13 showed problematic manner in which Resident acts characterized by ineffective coping and repetitive actions related to cognitive impairment, shaking doors in the unit almost daily, wandering into other resident ' s rooms and getting into other resident ' s beds. The care plan was initiated by MDS Nurse #1 on 8/22/12. The interventions were as follows: Give Resident item or task in attempt to distract or break repetitive cycle. Monitor episodes of repetitive behavior and report to MD as indicated. Note frequency, duration, interventions and results. Pharmacy review of medications monthly and/or as needed. Praise/reward resident for demonstrating consistent desired/acceptable behavior. Redirect behavior (shaking doors). The care plan showed no interventions to prevent Resident #4 from getting into Resident #5's bed. A nursing progress note dated 2/18/13 at 11:16 PM showed that the Resident continued to get into roommates bed to rest. The Quality Improvement Nurse stated in an interview on 3/26/13 at 10:04 AM that Resident #5 had always been aggressive but did not hit people on a regular basis. The Nurse stated that it was a known fact that Resident #5 did not like anyone in his personal space and if the person did not move, the Resident would become aggressive. The MDS Nurse stated in an interview on 03/28/13 at 3:30 PM that when updating care plans and coding the MDS she looked at the nurse ' s notes and behaviors documented by the staff. The Nurse stated that she was not aware of residents getting in other resident ' s beds on the Alzheimer ' s Unit. 3. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A nursing progress note dated 1/22/13 at 10:54 AM revealed that Resident #2 wandered into the wrong rooms and beds and was found in a female ' s room in bed fast asleep. A nursing progress note dated 1/31/13 at 3:31 PM revealed that the Resident was in and out of other resident ' s rooms and beds. The Annual Minimum Data Set (MDS) Summary sheet for the Minimum Data Set (MDS) assessment dated [DATE] revealed that Behaviors triggered. There was not a Care Area Assessment for behaviors. The most recent MDS(Quarterly) dated 2/8/13 revealed that the Resident had no behaviors during the assessment period. The Resident ' s current Care Plan last updated on 1/6/13 showed no care plan for behaviors. There was a care plan that read: " Trauma Potential for Wandering. The Interventions were to check for whereabouts frequently. Insure (sic) that alarmed exits are functional. Preventive Intervention: (wanderguard). " There were no interventions to prevent the Resident #2 from getting into Resident #5's bed. A nursing progress note dated 3/10/13 at 10:20 PM showed that the Resident was observed with lacerations on his nose and left eye with reddened sclera. The note showed that Resident #5 stated that Resident #2 was in his bed so he hit him and that Resident #2 was placed in another room. An Eye Consultation report dated 3/11/13 showed subconjunctival hemorrhage left eye. An interview was conducted with NA #1 and NA #2 on 3/25/13 at 3:13 PM. NA #1 stated that Resident #4 was confused and wandered around the unit and might get into any resident ' s bed. NA #1 stated that the staff would get them up and show them their bed. The Quality Improvement Nurse stated in an interview on 3/26/13 at 10:04 AM that Resident #5 had always been aggressive but did not hit people on a regular basis. The Nurse stated that it was a known fact that Resident #5 did not like anyone in his personal space and if the person did not move, the Resident would become aggressive. On 3/26/13 at 12:45 PM an interview was conducted with the Administrator, Director of Nursing and Facility Consultant #1. The Facility Consultant stated that they had completed a Plan of Correction (POC) after the altercation on the weekend of 3/9-10/13. A review of the POC revealed no information regarding the care plan for Resident #2. The MDS Nurse stated in an interview on 3/28/13 at 3:30 PM that when updating the care plans and coding the MDS she looked at the nurse ' s notes and behaviors documented by the staff. The Nurse stated that she was not aware of residents getting in other resident ' s beds on the Alzheimer ' s Unit. The MDS Nurse stated in an interview on 4/2/13 that the only behavior for the 12/25/12 MDS assessment period was pacing and that this was not new behavior for Resident #2 therefore a Care Area Assessment was not done. The Administrator was notified of the Immediate Jeopardy on 4/10/13 at 2:10 PM. The facility provided a credible allegation of compliance on 04/11/13 at 5:55 PM. The allegation of compliance indicated: What measures the facility put in place for the resident affected: On 3-9-13 Resident #4 was assessed by Nurse #3 and attempt made to notify MD. XRay of eye area was completed on 3/9/13 at 10:30 pm with results of no fractures identified. On 3/11/13 the physician gave an order for [REDACTED]. On 3/14/13 Resident #4 had a procedure to remove the right eye and returned to the facility on [DATE]. On 3-10-13 Resident #2 was assessed by Nurse #4 and an attempt made to notify the physician. The family was notified on 3-10-13. On 3-10-13 Resident #2 was moved to another room. On 3-11-13 the physician gave an order for [REDACTED].#2 showing a non-displaced fracture of nose. The Responsible party was notified by the nurse on 3-9-13 and 3-10-13 or resident ' s behaviors. The MD was attempted to be notified by nurse of behavior on 3/9/13 and 3/10/13. On 3-10-13 at 7:00 am Resident #5 was placed on 15 minutes checks. On 3-11-13 first shift Resident #5 was placed on one to one staff monitoring. The Director of Nursing (DON) contacted the psychiatric nurse practitioner on 3-11-13 and psychiatric nurse practitioner arrived same day at 3:45 pm to see resident with recommendation to resume previous dosage of antipsychotic medications. Social Worker contacted outside psychiatric center on 3-11-2013 for potential placement due to resident behavior. On 3-11-2013 at 7:00 pm the outside psychiatric center contacted social worker and verified they would admit Resident #5 on the morning of 3-12-13. One to One staff monitoring continued with Resident #5 until he was discharged from facility. On 3-12-13, Resident #5 was transported to outside psychiatric center for admission and no longer resides at this facility. What measures were put in place for residents having the potential to be affected: On 3-11-13 at 5:45 pm the Regional Director in-serviced the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses and Administrative Nurses who take Nurse On Call responsibilities on assuring that interventions are immediately put in place with resident to resident incidents to include one to one staff monitoring when a resident strikes another resident until the situation is assessed further and appropriate interventions are decided to meet the resident ' s individualized needs to include care planning. When unsure about a situation, the Administrator and/or Director of Nursing should contact the Regional Director or Corporate Nurse Consultant for additional advisement. No Administrative Nurses worked until they received this in-servicing. On 4-3-13 the MDS Nurses started a 100 percent review of all Care Plans to assure individualization of the plan of care was completed for each resident to include behaviors of residents. On 4-10-2013 the MDS nurses completed a 100 percent audit of all residents on antipsychotic medications to assure that the plan of care addresses the use of antipsychotic medication and any current dose reduction or changes. Any areas identified were corrected by updating of the residents ' care plan. On 3-13-2013 to 3-15-2013 the pharmacy consultant completed a drug regimen review of all residents to include residents on psychoactive medications. Any recommendations made regarding possible antipsychotic medications will be reviewed by the Quality Improvement Antipsychotic Medication Committee. The Committee will review each resident medication(s) to include current dosage, whether there are documented behaviors since last review, verification that MD orders are correct, PRN Medications used are properly documented for the need and frequency, [DIAGNOSES REDACTED]. What systems were put in place to prevent the deficient practice from reoccurring: On 3-12-2013 the Administrator initiated a Quality Improvement Incident/Accidents Committee starting on 3-12-13 consisting of the Administrator, Director of Nursing (DON), Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses, Social Workers, and Therapy staff that will meet five times per week to review all incidents and accidents to assure nurse assessment of situation, intervention put in place, MD notified, RP notified, and Care Plan updated for changes and interventions. This review will be documented on a Quality Improvement Incident/Accident Review Committee QI Audit Tool. The facility Quality Improvement Antipsychotic Committee will meet monthly to review all residents that are on antipsychotic medications. The Committee will consist of the Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurses, Quality Improvement (QI) Nurses , Social Workers, and Pharmacy Consultant. The Committee will review each resident medication(s) to include current dosage, whether there are documented behaviors since last review, verification that MD orders are correct, PRN Medications used are properly documented for the need and frequency, [DIAGNOSES REDACTED]. Any recommendations made during the Committee Meeting will be referred to the Attending Physician for acceptance or decline of recommendation. If the physician agrees with the recommendation of change in medication, then the resident will be Care Planned for changes in antipsychotic medications with goal and approaches listed and the QI Nurse and/or DON will note the change in antipsychotic medication on the Resident Care Guide to prompt staff to watch for any changes in behavior or condition. On 4-10-13, the Staff Development Coordinator and DON initiated in-servicing at 6:15 pm for all nursing assistants and nurses that anytime a resident has a change in antipsychotic medications, the change will be noted on the Resident Care Guide located in each resident ' s closet and prompt nursing staff to observe for any changes in behaviors or medical condition. If a Nursing Assistant notices a change in resident behavior or condition they are to notify their nurse immediately. Anytime a Nurse is notified that there is a change in behavior or condition they are to immediately assess the resident, assure resident is safe and other residents are safe related to the behavior, and notify the QI Nurse and/or DON and/or the Nurse On-Call. If situation warrants, notify the physician and responsible party. The in-service included the reminder that the QI Nurse will also be routinely observing these residents while on an antipsychotic medication change as well and will also be asking Nursing Assistants and Nurses who work with resident if any observed changes in condition or behavior. How the facility will monitor systems put in place: The Administrator and/or DON will review the Quality Improvement Incident/Accident Committee QI Audit Tool five times per week to assure all areas are reviewed with appropriate intervention and notifications. The Administrator will review the QI Review of Nurses Notes three times a week for eight weeks starting 3-11-2013 the once per week ongoing thereafter to assure all notes were reviewed and that any areas with identified concerns were handled to meet the individual needs of the resident and situation. The Regional Director and/or Corporate Nurse Consultant will review the " Incident Notification Worksheet QI Audit tools, the Incident/Accident Committee QI Audits tools, and the QI Review of Nurses Notes monthly for six months starting April 2013 then quarterly thereafter to assure the facility is completing and interventions are in place and working to meet residents ' needs. The Quality Improvement Executive Committee which consists of the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurse, Social Workers, Bookkeeper, Activity Director, Dietary Director, Medical Records Director, and Maintenance Director will review the quality improvement audit tools to include the Incident Notification Worksheets, the Reviews of Nurses Notes for unreported incidents, the Incident/Accident Committee Reviews, and the Antipsychotic Medication Committee Meeting Minutes for monitoring, assessment and recommendation of needs to further monitor these systems, and to assure continued compliance in these areas. On 4/11/13 at 5:00 PM, the credible allegation was validated by reviewing the audits of resident ' s care plans and inservices conducted with the staff. Interviews were conducted with the MDS Nurses who were knowledgeable of the changes and updates to be made to the resident care plans and care guides. The Incident/Accident Committee QI Audit Tool was in place to be used to ensure that care plans address changes in a resident ' s psychoactive medications.

Based on record review, staff and physician interviews the facility failed to notify the physician that 1 of 1 sampled resident with aggressive behaviors (Resident #5) hit 2 of 3 (Resident #4 and Resident #5) sampled residents reviewed for accidents in the locked dementia unit. The facility also failed to notify the physician on 3/9/13 that Resident #4 had been hit in the eye and failed to notify the physician on 3/10/13 that Resident #2 had been hit in the face and nose. The Immediate Jeopardy began on 3/9/13 at 8:00 PM and was identified on 04/10/13 at 2:10 PM. The Immediate Jeopardy was removed on 04/11/13 at 5:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be in-serviced. The facility will then implement monitoring of its corrective action. The findings included: 1. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had short and long term memory problems and was moderately cognitively impaired requiring cues and supervision. The MDS revealed that the resident was ambulatory and had behavior symptoms not directed towards others. A facility incident report prepared by Nurse #3 on 3/9/13 at 11:19 PM revealed that the nurse was notified on 3/9/13 at 8:00 PM that 2 residents were fighting. The report revealed that the nurse observed Resident #5 standing over Resident #4 with a clenched fist and Resident #4 ' s eye was swollen and blood shot. The report read: ADON (Assistant Director of Nursing) notified via phone at 8:10 PM. (Name of physician) beeped via phone @ 8:20 PM x (times) 2. Have not gotten ret. (returned) call. Mobile X-ray called via phone @ 8:45 PM for X-ray of rt. (right) eye r/o (rule out) fracture. X-ray of rt. Eye done. " The report did not reveal that the physician returned the call or that the physician was notified of the incident. There was no documentation in the progress notes for Resident #4 of the incident or that the physician was notified. The nursing progress notes for Resident #4 revealed that Resident #4 was seen by an eye doctor on 3/11/13, 3/12/13 and 3/14/13. An Eye Consult dated 3/14/13 at 4:10 PM revealed the resident had trauma to right eye, had no light perception and a ruptured globe and that the treatment plan was enucleation (removal of) of the right eye. A Discharge Summary dated 3/15/13 revealed that Resident #4 had the right eye removed on 3/14/13. The Assistant Director of Nursing (ADON) stated in an interview on 3/26/13 at 10:30 AM that she was the nurse on call on the weekend of 3/9-10/13 and that she received a phone call from Nurse #3 on Saturday evening (3/9/13) that Resident #5 had hit Resident #4. The ADON stated that she told the nurse to keep the two residents separated and to go ahead and get a facial X-ray for Resident #4. The ADON stated that Nurse #3 was trying to reach the physician at that time and that she told the nurse to call her back if any further changes. Nurse #3 stated in an interview on 3/26/13 at 10:55 AM that she worked on the dementia unit on the 3PM-11PM shift on 3/9/13 (Saturday). The Nurse stated that she paged the physician on his beeper and called the Assistant Director of Nursing (ADON) who was on call for the weekend regarding the incident where Resident #5 hit Resident #4. The Nurse stated that she did not receive a response from the physician so she beeped the physician again. The Nurse stated that when she did not receive a response from the physician the second time she called the ADON and told her that she had not been able to reach the physician. The Nurse stated that the ADON told her to go ahead and get an X-ray of Resident 4 ' s eye. An interview was conducted with the Administrator, the Director of Nursing (DON) and Facility Consultant #1 on 3/26/13 at 12:45 PM. The DON stated that this was the first incident she was aware of that the staff was unable to get (name of physician). The DON stated that she tried to tell all the nurses to call the physician ' s cell phone and to call the hospital if they had trouble reaching him. The ADON was asked by the Facility Consultant to join the interview. The ADON stated that on 3/9/13 while on the phone with Nurse #3 she heard the telephone ringing in the background and Nurse #3 commented that the physician was probably calling back. The Facility Consultant stated that they had identified a problem with the nurses not documenting the response of calls made to physicians and had inserviced all the staff regarding this issue. The ADON stated in an interview on 3/26/13 at 1:07 PM that she called the physician on Monday (3/11/13) for an eye appointment for Resident #4 and the physician stated that he was aware of the situation and would see him on Wednesday (3/13/13) The Physician stated in an interview on 3/26/13 at 1:30 PM that he did not think that the staff called him over the weekend of 3/9-10/13 but really could not remember. The Physician stated that he did not remember when he was notified of the incident between Resident #5 and Resident #4 but he thought that he found out on Monday (3/11/13). The Physician stated that he was at home on the weekend and was available by cell phone and his home phone. On 4/10/13 at 1:25 PM an interview was conducted with the Optometrist that first saw Resident #4 on 3/11/13. The Physician stated that the resident ' s eye looked very bad so he sent him to the eye clinic. The Physician stated that he could not say that the eye could have been saved had the resident received treatment on the day that the trauma occurred. On 4/10/13 at 1:40 PM an interview was conducted with the Opthamologist that saw Resident #4 at the eye clinic on 3/11/13. The Physician stated that on the initial examination, the resident had a large laceration of the globe of the eye. The Physician stated that when this happens, the person did not regain their eyesight in the injured eye. The Physician stated that he could not say that resident #4 ' s eye could have been saved had the resident received emergency care on the night of the injury. Nurse #3 stated in an interview on 4/10/13 at 2:15 PM that on 3/9/13 (Saturday) she never did get the physician during her shift. The Nurse stated that she beeped the physician and that this was the only way she knew to reach the physician. The Nurse stated that she called the hospital to make sure that he was on call and was told that he was on call for himself that night. The Nurse stated that her shift was over at 11:00 PM and she told Nurse #4 in report that she had not been able to reach the physician. Nurse #4 stated in an interview on 4/11/13 at 11:45 AM that on 3/9/13 she worked the 11PM-7AM shift. The Nurse stated that she thought that the physician had been notified because there was an order for [REDACTED].#5 hit Resident #2 but was unable to reach him. The Nurse stated that she sent a fax to the physician ' s office on Monday morning about the incident. The Administrator stated in an interview on 4/11/13 at 12:43 PM that she would have expected the nurse to call the physician and that if the physician did not respond in a timely manner to call the on-call nurse or the DON for further instructions. The Administrator stated that it was her expectation that the staff notify her when they were unable to reach the physician; let her know that the DON had been notified and what the end result was. On 4/11/13 at 6:00 PM, Facility Consultant #2 stated that they were not able to determine when the physician was notified of the incident. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating that the resident was severely cognitively impaired. The MDS revealed that the resident had no behaviors and was ambulatory. A facility incident report prepared by Nurse #4 on 3/10/13 (Sunday) at 10:02 PM revealed that Resident #2 was observed to have a laceration on the nose and under the left eye with redness of the left eye. The report revealed that Resident #5 was standing at the foot of the bed and said that he hit Resident #2 for being in his bed. The report revealed that the physician was paged but there was no documentation that the physician was notified of the incident. There was a physician's order [REDACTED]. The Consultation report for Resident #2 revealed that the resident had a subconjunctival hemorrhage of the left eye with recommendations for cool compresses and an antibiotic ointment twice a day for 7 days. There was a physician's order [REDACTED]. The X-ray report dated 3/12/13 for Resident #2 revealed a non-displaced [MEDICAL CONDITION] nasal bone. Nurse #4 stated in an interview on 3/26/13 at 12:25 PM that she worked 7PM to 7AM on 3/10/13 (Sunday). The Nurse stated that Resident #5 hit Resident #2 and that she paged the physician but did not receive a response from the physician. An interview was conducted with the Administrator, the Director of Nursing (DON) and Facility Consultant #1 on 3/26/13 at 12:45 PM. The DON stated that this was the first incident she was aware of that the staff was unable to get (name of physician). The DON stated that she tried to tell all the nurses to call the physician ' s cell phone and to call the hospital if they had trouble reaching him. The Facility Consultant stated that they had identified a problem with the nurses not documenting the response of calls made to physicians and had inserviced all the staff regarding this issue. The Physician stated in an interview on 3/26/13 at 1:30 PM that he did not think that the staff called him over the weekend of 3/9-10/13 but really could not remember. The Physician stated that he did not remember when he was notified of the incident between Resident #5 and Resident #2 but he thought that he found out on Monday (3/11/13). The Physician stated that he was at home on the weekend and was available by cell phone and his home phone. Nurse #3 stated in an interview on 4/11/13 at 11:45 AM that she worked 7PM-7AM on 3/10/13 (Sunday) and attempted to notify the physician that night when Resident #5 hit Resident #2 but was unable to reach him. The Nurse stated that she called the Administrator about the incident but did not notify the Administrator that she could not reach the physician. The Nurse stated that she sent a fax to the doctor ' s office on Monday morning to let him know of the incident. The Administrator stated in an interview on 4/11/13 at 12:43 PM that she would have expected the nurse to call the physician and that if the physician did not respond in a timely manner to call the on-call nurse or the DON for further instructions. The Administrator stated that it was her expectation that the staff notify her when they were unable to reach the physician; let her know that the DON had been notified and what the end result was. On 4/11/13 at 6:00 PM, Facility Consultant #2 stated that they were not able to determine when the physician was notified of the incident. 3. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #5 resided on the locked dementia unit in the facility. A review of the most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 1/11/13 revealed that the Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 indicating that the resident was severely cognitively impaired. The MDS revealed that the resident had behaviors directed towards others such as threatening others, screaming and cursing at others 1-3 days during the 7 day assessment period. The MDS revealed that the Resident was on anti-anxiety and antipsychotic medications 7 of the 7 days of the assessment period. The resident ' s current Care Plan updated on 1/4/13 revealed that the resident had verbal and physical aggression related to anger, cognitive impairment and depression. Among the interventions were to monitor mental status/mood state changes when new medications were added and notify physician of any significant changes and to Observe and report any changes in behaviors and notify physician of significant changes as necessary. A review of the Resident ' s medical record revealed that on 2/7/13 there had been a gradual dose reduction of the Resident ' s psychoactive medications. a. A facility incident report dated 3/9/13 revealed that Nurse #3 was notified at 8:00 PM that two residents were fighting. The report revealed that upon entering the room the nurse observed Resident #5 standing over Resident #4 with a clenched fist and stated that he hit Resident #4 because the resident was in his bed. The report revealed that Resident #4 had swelling and redness of the eye. The report read: " (Name of physician) beeped via phone @ (at) 8:20PM x (times) 2. Have not gotten ret. (returned) call. The progress notes for Resident #5 revealed no documentation that Resident #5 had hit another resident or that the physician had been notified of the incident. The Assistant Director of Nursing (ADON) stated in an interview on 3/26/13 at 10:30 AM that she was the nurse on call on the weekend of 3/9-10/13 and that she received a phone call from Nurse #3 on Saturday evening (3/9/13) that Resident #5 had hit Resident #4. The ADON stated that she told the nurse to keep the two residents separated and to go ahead and get a facial X-ray for Resident #4. The ADON stated that Nurse #3 was trying to reach the physician at the time and she told the nurse to call her back for further changes. Nurse #3 stated in an interview on 3/26/13 at 10:55 AM that she worked on the dementia unit on the 3PM-11PM shift on 3/9/13 (Saturday). The Nurse stated that she paged the physician on his beeper and called the Assistant Director of Nursing (ADON) who was on call for the weekend regarding the incident where Resident #5 hit Resident #4. The Nurse stated that she did not receive a response from the physician so she beeped the physician again. The Nurse stated that when she did not receive a response from the physician the second time she called the ADON and told her that she had not been able to reach the physician. The Nurse stated that the ADON told her to go ahead and get an X-ray of Resident 4 ' s eye. An interview was conducted with the Administrator, the Director of Nursing (DON) and Facility Consultant #1 on 3/26/13 at 12:45 PM. The DON stated that this was the first incident she was aware of that the staff was unable to get (name of physician). The DON stated that she tried to tell all the nurses to call the physician ' s cell phone and to call the hospital if they have trouble reaching him. The ADON was asked by the Facility Consultant to join the interview. The ADON stated that on 3/9/13 while on the phone with Nurse #3 she heard the telephone ringing in the background and Nurse #3 commented that the physician was probably calling back. The ADON stated that she spoke with the physician on Wednesday (3/13/13) when he made rounds and the physician was aware of the incident. The Facility Consultant stated that they had identified a problem with the nurses not documenting the response of calls made to physicians and had inserviced all the staff regarding this issue. The Physician stated in an interview on 3/26/13 at 1:30 PM that he did not think that the staff called him over the weekend of 3/9-10/13 but really could not remember. The Physician stated that he did not remember when he was notified of the incident between Resident #5 and Resident #4 but he thought that he found out on Monday (3/11/13). The Physician stated that he was at home on the weekend and was available by cell phone and his home phone. Nurse #3 stated in an interview on 4/10/13 at 2:15 PM that on 3/9/13 (Saturday) she never did get the physician during her shift. The Nurse stated that she beeped the physician and that this was the only way she knew to reach the physician. The Nurse stated that she called the hospital to make sure that he was on call and was told that he was on call for himself that night. The Nurse stated that her shift was over at 11:00 PM and she told Nurse #4 in report that she had not been able to reach the physician. Nurse #4 stated in an interview on 4/11/13 at 11:45 AM that on 3/9/13 she worked the 11PM-7AM shift. The Nurse stated that she thought that the physician had been notified because there was an order for [REDACTED].#5 hit Resident #2 but was unable to reach him. The Nurse stated that she sent a fax to the physician ' s office on Monday morning about the incident. The Administrator stated in an interview on 4/11/13 at 12:43 PM that she would have expected the nurse to call the physician and that if the physician did not respond in a timely manner to call the on-call nurse or the DON for further instructions. The Administrator stated that it was her expectation that the staff notify her when they were unable to reach the physician; let her know that the DON had been notified and what the end result was. On 4/11/13 at 6:00 PM, Facility Consultant #2 stated that they were not able to determine when the physician was notified of the incident. b. A facility incident report for Resident #2 was prepared by Nurse #4 on 3/10/13 at 10:02 PM. The report revealed that Resident #5 had hit Resident #2 because the resident was in his bed and that Resident #2 had a laceration on the nose and under the left eye. The report revealed that the physician was paged but there was no documentation on the report that the physician was notified of the incident. The progress notes for Resident #5 revealed no documentation of the incident or that the physician was notified that Resident #5 had hit another resident. Nurse #4 stated in an interview on 3/26/13 at 12:25 PM that she worked 7PM to 7AM on 3/10/13 (Sunday). The Nurse stated that Resident #5 hit Resident #2 and that she paged the physician but did not receive a response from the physician. An interview was conducted with the Administrator, the Director of Nursing (DON) and Facility Consultant #1 on 3/26/13 at 12:45 PM. The DON stated that this was the first incident she was aware of that the staff was unable to get (name of physician). The DON stated that she tried to tell all the nurses to call the physician ' s cell phone and to call the hospital if they have trouble reaching him. The Facility Consultant stated that they had identified a problem with the nurses not documenting the response of calls made to physicians and had inserviced all the staff regarding this issue. The Physician stated in an interview on 3/26/13 at 1:30 PM that he did not think that the staff called him over the weekend of 3/9-10/13 but really could not remember. The Physician stated that he did not remember when he was notified of the incident between Resident #5 and Resident #2 but he thought that he found out on Monday (3/11/13). The Physician stated that he was at home on the weekend and was available by cell phone and his home phone. Nurse #4 stated in an interview on 4/11/13 at 11:45 AM that on Sunday night (3/10/13) she called the Administrator about the incident and tried to contact the physician but was unable to reach him. The Nurse stated that she did not notify the Administrator that she could not reach the physician and that she sent a fax to the doctor ' s office on Monday morning. The Administrator stated in an interview on 4/11/13 at 12:43 PM that she would have expected the nurse to call the physician and that if the physician did not respond in a timely manner to call the on-call nurse or the DON for further instructions. The Administrator stated that it was her expectation that the staff notify her when they were unable to reach the physician; let her know that the DON had been notified and what the end result was. On 4/11/13 at 6:00 PM, Facility Consultant #2 stated that they were not able to determine when the physician was notified of the incident. The Administrator was notified of the Immediate Jeopardy on 4/10/13 at 2:10 PM. The facility provided a credible allegation of compliance on 04/11/13 at 5:55 PM. The allegation of compliance indicated: What measures the facility put in place for the resident affected: On 3-9-2013 resident (JD) was assessed by nurse (LD) and attempt made to notify MD. XRay of eye area was completed on 3-9-13 10:30 pm with results of no fractures identified. On 3-11-13 MD gave order for resident to see eye physician and resident (JD) was seen by eye physician on 3-11-13, with additional eye physician visits on 3-12-13 with order to start antibiotic therapy and a return visit scheduled for 3-13-2013. On 3-14-13 resident had procedure to remove right eye and returned to the facility from procedure on 3-15-13. On 3-10-13 resident (RH) was assessed by nurse (RG) and attempt made to notify MD. Family notified on 3-10-13. On 3-10-13 resident (RH) was moved to another room. On 3-11-13 MD gave order for resident to see eye physician and resident was seen by eye physician on 3-11-13 with orders for cold compress and antibiotic ointment to be applied. On 3-12-13 facility obtained X-Ray of resident nasal bones and received X-Ray results on 3-12-13 for resident (RH) showing non-displaced fracture of nose. RP was notified by nurse on 3-9-13 and 3-10-13 of resident ' s behaviors. MD was attempted to be notified by nurse of behavior on 3-9-13 and 3-10-13. On 3-10-13 at 7:00 am resident was placed on 15 minutes checks. On 3-11-13 first shift resident was placed on one to one staff monitoring. DON contacted psychiatric nurse practitioner on 3-11-13 and psychiatric nurse practitioner arrived same day at 3:45 pm to see resident with recommendation to resume previous dosage of antipsychotic medications. Social Worker contacted outside psychiatric center on 3-11-2013 for potential placement due to resident behavior. On 3-11-2013 at 7:00 pm the outside psychiatric center contacted social worker and verified they would admit resident (WM) on the morning of 3-12-13. One to One staff monitoring continued with resident until he was discharged from facility. On 3-12-13, resident (WM) was transported to outside psychiatric center for admission and no longer resides at this facility. What measures were put in place for residents having the potential to be affected: The Corporate Nurse Consultants completed a 100 percent audit of resident nurses notes starting on 3-11-13 and completed on 3-12-13 for the time period of documentation from 12-1-2012 to present 3-11-2013, to assure there were no nursing documentation of resident to resident episodes that may not have been previously identified in incident reporting to include notification of MD with no negative outcomes identified. On 3-12-13, the Corporate Nurse Consultant (PG) completed a review of resident to resident altercations from 9-1-12 to 3-11-12 to assure interventions for resident to resident incidents were in place and/or still appropriate to include notification of MD with no new concerns identified. What systems were put in place to prevent the deficient practice from reoccurring: On 3-12-2013 the Administrator initiated a Quality Improvement Incident/Accidents Committee starting on 3-12-13 consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses, Social Workers, and Therapy staff that will meet five times per week to review all incidents and accidents to assure nurse assessment of situation, intervention put in place, MD notified, RP notified, and Care Plan updated for changes and interventions. This review will be documented on a Quality Improvement Incident/Accident Review Committee QI Audit Tool. On 3-12-2013 the Staff Development Coordinator initiated in-servicing for all Licensed Nurses on Notification of Physician for Changes in Resident ' s Condition that emphasized when to notify the MD and that if a nurse is unable to reach the Attending MD, to notify the On-Call MD. The in-service continues that if a nurse is unable to reach the attending or on-call MD to notify the facility Medical Director. On 4-11-2013 the Corporate Nurse Consultant and Staff Development Coordinator initiated an additional in-service for all Licensed Nurses on MD Notification that included when contacting the MD for notification of a situation and the MD does not respond, contact the physician who has been designated to take on-call for this physician. If there is a question as to who is taking on-call for an attending MD, then contact the hospital and request the on-call physician for the MD you are attempting to contact. Nurses can also notify the Medical Director. Anytime a nurse feels that a resident needs physician medical evaluation and the physician has not returned call or on-call status of the MD cannot be verified, then send resident to the emergency room as a precautionary measure for their needs. On 4-10-13, the Staff Development Coordinator and DON initiated in-servicing at 6:15 pm for all nursing assistants and nurses that anytime a resident has a change in antipsychotic medications, the change will be noted on the Resident Care Guide located in each resident ' s closet and prompt nursing staff to observe for any changes in behaviors or medical condition. If a Nursing Assistant notices a change in resident behavior or condition they are to notify their nurse immediately. Anytime a Nurse is notified that there is a change in behavior or condition they are to immediately assess the resident, assure resident is safe and other residents are safe related to the behavior, and notify the QI Nurse and/or DON and/or the Nurse On-Call. If situation warrants, notify the MD and RP. The in-service included the reminder that the QI Nurse will also be routinely observing these residents while on an antipsychotic medication change as well and will also be asking Nursing Assistants and Nurses who work with resident if any observed changes in condition or behavior. How the facility will monitor systems put in place: The Administrator and/or DON will review the Quality Improvement Incident/Accident Committee QI Audit Tool five times per week to assure all areas are reviewed with appropriate intervention and notifications to MD. The Regional Director and/or Corporate Nurse Consultant will review the Incident/Accident Committee QI Audits tools monthly for six months starting April 2013 then quarterly thereafter to assure the facility is completing and that MD notifications are made for all facility incidents/accidents. The Quality Improvement Executive Committee which consists of the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurse, Social Workers, Bookkeeper, Activity Director, Dietary Director, Medical Records Director, and Maintenance Director will review the quality improvement audit tools to include the Incident/Accident Committee Reviews for monitoring, assessment and recommendation of needs to further monitor these systems, and to assure continued compliance in these areas. On 4/11/13 at 5:00 PM the credible allegation was validated by reviewing the audits conducted on the dementia unit and the general floors for signs of injury or other signs of resident to resident abuse. Interviews were conducted with the administrative staff and the managers that are on call after business hours and on weekends to assure that interventions are immediately put in place with resident to resident incidents. An " On-call Incident Management " form had been developed for the administrative and on-call staff to take home to document calls regarding incidents and accidents in the facility after business hours and on weekends. This form included the notification of the physician. The staff was knowledgeable of the form and its use. A QI Worksheet had been developed for the staff that rotate nurse on-call duties to document interventions for incidents/accidents that occur after business hours. Interviews were conducted with the nurses and the nursing assistants on the locked dementia unit and on the general floors. It was confirmed that staff had received inservices regarding the new systems put in place.

Based on record review and staff interviews the facility ' s Quality Improvement Committee failed to develop and implement a plan of action to monitor 1 of 1 sampled resident ' s (Resident #5) behaviors after a reduction of the Resident ' s psychoactive medications. This failure resulted in injury to 2 of 2 sampled residents (Resident #4 and Resident #2) known to get into other resident ' s beds. The facility also failed to develop and implement a plan of action to monitor the behaviors of other residents whose psychoactive medications could potentially be reduced after the 2 residents were injured. The Immediate Jeopardy began on 3/9/13 at 8:00 PM and was identified on 04/10/13 at 2:10 PM. The Immediate Jeopardy was removed on 04/11/13 at 5:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff could be in-serviced. The facility will then implement monitoring of its corrective action. The findings included: The facility ' s Quality Improvement Policy dated 1/11 read as follows: "The Quality Improvement Executive Committee directs and supervises the Quality Improvement Program in the facility. This committee meets quarterly or as designated by the administrator to review information concerning resident care. The Quality Improvement Program reviews trends noted from Action Team meetings and rounds made by facility staff. The committee should then determine if changes in plans of action are required to improve outcomes. The Quality Improvement Executive Committee should decide if an Action Team needs to be formed or modified, if further staff education is required and if increased monitoring is required in resident care. The Executive Committee should then direct the Quality Improvement Coordinator or responsible department head to initiate any changes or retraining of staff as required." Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident resided on the locked dementia unit in the facility. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 1/11/13 revealed that Resident #5 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3. The MDS revealed that the Resident had behaviors directed towards others such as threatening others, screaming and cursing at others for 1-3 days during the 7 day assessment period. The MDS showed that the Resident was ambulatory with the supervision of 1 person and was on anti-anxiety and antipsychotic medications for 7 of 7 days of the assessment period. A physician's order [REDACTED]. An entry in the Resident ' s progress notes by the QI Nurse dated 2/12/13 read: " Quality Improvement - Antipsychotic Medication. Data: Resident received [MEDICATION NAME] 300 MG, [MEDICATION NAME] 1 MG, [MEDICATION NAME] 15 MG and [MEDICATION NAME] 50 MG with [DIAGNOSES REDACTED]. Behaviors include yelling, cursing and screaming. No GDR (gradual dose reduction) noted for any meds. Action: Recommend decreasing [MEDICATION NAME] 200 mg daily, decreasing [MEDICATION NAME] 0.5 mg, decreasing [MEDICATION NAME] 7.5mg, decreasing [MEDICATION NAME] 2.5mg. No changes recommended to [MEDICATION NAME] at this time, continue to monitor for behaviors. Response: MD (medical doctor) and RP (responsible party) aware, MD agrees with recommendations. " There were no QI progress notes on the resident ' s clinical record after the 2/12/13 entry. A facility Incident Report dated 2/17/13 revealed that Resident #5 hit Resident #7 in the face while in the dining room. There were no injuries noted to Resident #7. A facility Incident Report dated 3/9/13 revealed that Resident #5 hit Resident #4 in the face resulting in Resident #4 losing his right eye. A facility Incident Report dated 3/10/13 revealed that Resident #5 hit Resident #2 in the face resulting in Resident #2 having a non-displaced [MEDICAL CONDITION] and [MEDICAL CONDITION] of the left eye. Resident #5 was discharged from the facility on 3/12/13. The QI Nurse stated in an interview on 3/25/13 at 1:15 PM that the facility had established a new committee to look at residents on antipsychotic medications with the goal of reducing these medications. The QI Nurse stated that on 2/6/13 the psychiatric nurse saw Resident #5 and reviewed the recommendations of the QI committee regarding the GDR (gradual dose reduction) of the psychoactive medications for Resident #5. The QI Nurse stated that the psychiatric nurse agreed to the recommendations and the physician signed for the recommendations to be initiated. On 3/25/13 at 2:52 PM, Nurse #1 stated in an interview that she noticed a difference in Resident #5 after his medications had been cut. The Nurse stated that prior to the reduction in his medications, Resident #5 was easier to re-direct. The Nurse stated that after his medications were reduced, Resident #5 ' s aggressive behaviors were worse and Resident #5 hit a female resident in the dining room. The Nurse stated that Resident #5 would usually call the nurse if someone was in his space but it was not like him to just hit someone. Nurse #1 stated in an interview on 3/26/13 at 9:40 AM that the nurse ' s document resident ' s behaviors in the nurse ' s notes and the nursing assistants address behaviors in their documentation in the Point of Care (POC) computer program. The Nurse stated that she did not monitor the documentation of resident ' s behaviors and that the information went to administration. The Director of Nursing (DON) stated in an interview on 3/26/13 at 9:54 AM that the nurses document resident ' s behaviors in the nurse ' s notes. The DON stated that the Antipsychotic Committee monitors the resident after a medication dose reduction by talking with the nurses. On 4/10/13 at 11:15 AM an interview was conducted with the Administrator, the Director of Nursing (DON) and the QI Nurse. The Administrator stated that during the QI meeting on February 13, 2013 they discussed the need for medication dose reductions for all residents on psychoactive medications. The Administrator stated that resident ' s behaviors were to be monitored on every shift like they normally do for any medication changes. The Administrator stated that during the QI meeting on March 13, 2013 there was no discussion regarding dose reductions for specific residents but there was a general discussion regarding dose reductions for residents on psychoactive medications. The Administrator stated in an interview on 4/11/13 at 10:30 AM that there were various action teams and that the teams met separately and would bring their information to the monthly QI meeting. The Administrator stated that the QI Committee met on February 13, 2013 and there was no specific information in the meeting minutes about the dose reduction of medications for Resident #5 but they did talk in general about reducing psychoactive medications in the facility. The QI Nurse stated in an interview on 4/11/13 at 10:49 AM that during the February 13, 2013 QI meeting they had a brief discussion about the new regulations and guidelines on psychoactive medications. The QI Nurse stated that there was no discussion on the reduction of Resident #5 ' s psychoactive medications and no change in the plan for monitoring resident ' s behaviors after a reduction of psychoactive medications. The Administrator was notified of the Immediate Jeopardy on 4/10/13 at 2:10 PM. The facility provided a credible allegation of compliance on 04/11/13 at 5:55 PM. The allegation of compliance indicated: What measures the facility put in place for the resident affected: On 3-9-13 Resident #4 was assessed by Nurse #3 and attempt made to notify MD. XRay of eye area was completed on 3/9/13 at 10:30 pm with results of no fractures identified. On 3/11/13 the physician gave an order for [REDACTED]. On 3/14/13 Resident #4 had a procedure to remove the right eye and returned to the facility on [DATE]. On 3-10-13 Resident #2 was assessed by Nurse #4 and an attempt made to notify the physician. The family was notified on 3-10-13. On 3-10-13 Resident #2 was moved to another room. On 3-11-13 the physician gave an order for [REDACTED].#2 showing a non-displaced fracture of nose. The Responsible party was notified by the nurse on 3-9-13 and 3-10-13 or resident ' s behaviors. The MD was attempted to be notified by nurse of behavior on 3/9/13 and 3/10/13. On 3-10-13 at 7:00 am Resident #5 was placed on 15 minutes checks. On 3-11-13 first shift Resident #5 was placed on one to one staff monitoring. The Director of Nursing (DON) contacted the psychiatric nurse practitioner on 3-11-13 and psychiatric nurse practitioner arrived same day at 3:45 pm to see resident with recommendation to resume previous dosage of antipsychotic medications. Social Worker contacted outside psychiatric center on 3-11-2013 for potential placement due to resident behavior. On 3-11-2013 at 7:00 pm the outside psychiatric center contacted social worker and verified they would admit Resident #5 on the morning of 3-12-13. One to One staff monitoring continued with Resident #5 until he was discharged from facility. On 3-12-13, Resident #5 was transported to outside psychiatric center for admission and no longer resides at this facility. What measures were put in place for residents having the potential to be affected: On 3-11-13 at 7:00 pm a 100 percent audit was completed by the ADON on all residents residing in the locked dementia unit to check for any signs of injury or suspicious signs of resident to resident abuse. No negative outcomes were identified in this audit. On 3-12-13 the audit was expanded by the floor nurses to the remaining residents residing in the nursing facility as an additional precautionary intervention to check for any signs of injury or resident to resident abuse. No negative outcomes were identified from this audit. The Corporate Nurse Consultants completed a 100 percent audit of resident nurses notes starting on 3-11-13 and completed on 3-12-13 for the time period of documentation from 12-1-2012 to present 3-11-2013, to assure there were no nursing documentation of resident to resident episodes that may not have been previously identified in incident reporting with no negative outcomes identified. On 3-12-13, the Corporate Nurse Consultant (PG) completed a review of resident to resident altercations from 9-1-12 to 3-11-12 to assure interventions for resident to resident incidents were in place and/or still appropriate with no new concerns identified. On 3-11-13 at 5:45 pm the Regional Director in-serviced the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses and Administrative Nurses who take Nurse On Call responsibilities on assuring that interventions are immediately put in place with resident to resident incidents to include one to one staff monitoring when a resident strikes another resident until the situation is assessed further and appropriate interventions are decided to meet the resident ' s individualized needs to include care planning. When unsure about a situation, the Administrator and/or Director of Nursing should contact the Regional Director or Corporate Nurse Consultant for additional advisement. No Administrative Nurses worked until they received this in-servicing. On 3-12-13, the Regional Director in-serviced the Administrator and all Administrative Nurses who take Nurse On Call to include the Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, and Minimum Data Set Nurses on " On-Call Incident Management; steps to look at when called about an incident that outlined data to collect about situation including answers to WHO, WHAT, WHEN, WHERE, HOW, and INTERVENTION to be put in place. On 3-15-13 the Administrator expanded the " On-Call Incident Management " in-service to all staff members who rotate weekend Administrative Call Rounds including the Housekeeping Director, Medical Records Director, Social Workers, Business Office staff, Dietary Manager, Activity Director, and Maintenance Director. On 3-11-13 at 7:10 pm the Staff Development Coordinator initiated in-servicing for all facility staff to include nurses, nursing assistant, nursing support staff, dietary staff, housekeeping staff, maintenance staff, activities staff, office staff, and therapy staff on Resident to Resident Abuse to include when episodes are observed that safety is provided immediately, charge nurses are notified immediately for appropriate interventions. No staff was allowed to work until they received this in-service. On 4-3-13 the MDS Nurses started a 100 percent review of all Care Plans to assure individualization of the plan of care was completed for each resident to include behaviors of residents. On 4-10-2013 the MDS nurses completed a 100 percent audit of all residents on antipsychotic medications to assure that the plan of care addresses the use of antipsychotic medication and any current dose reduction or changes. Any areas identified were corrected by updating of the residents ' care plan. On 3-13-2013 to 3-15-2013 the pharmacy consultant completed a drug regimen review of all residents to include residents on psychoactive medications. Any recommendations made regarding possible antipsychotic medications will be reviewed by the Quality Improvement Antipsychotic Medication Committee. The Committee will review each resident medication(s) to include current dosage, whether there are documented behaviors since last review, verification that MD orders are correct, PRN Medications used are properly documented for the need and frequency, [DIAGNOSES REDACTED]. What systems were put in place to prevent the deficient practice from reoccurring: On 3-12-2013 a QI worksheet guide was implemented to be used by the Administrator, Director of Nursing, and all Administrative Nurses that rotate Nurse On-Call duties for non-business hours, weekends, and nights to assist in gathering information to make decisions about interventions for incidents to include resident to resident incidents utilizing a " On-Call Incident Management " Worksheet QI Audit Tool. This audit tool will be utilized when calls are received and forwarded to the Administrator for review. On 3-12-2013 the Administrator initiated a Quality Improvement Incident/Accidents Committee starting on 3-12-13 consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses, Social Workers, and Therapy staff that will meet five times per week to review all incidents and accidents to assure nurse assessment of situation, intervention put in place, MD notified, RP notified, and Care Plan updated for changes and interventions. This review will be documented on a Quality Improvement Incident/Accident Review Committee QI Audit Tool. Administrative Nurses will review all resident nurses notes three times per week for eight weeks starting week of 3-11-2013 and then once per week ongoing thereafter to assure there are no resident to resident episodes that may have occurred that were not identified by incident reporting. On 4-10-2013 the Staff Development Coordinator initiated in-servicing at 1:17 pm for nurses and nursing assistants regarding monitoring of residents that in the daily monitoring of our residents staff should routinely monitor their whereabouts. If a dementia resident is identified as being in another resident ' s space or bed to redirect the resident to the common care areas of the unit and that if the resident is resistive to the redirection to stay with the resident to assure no resident to resident conflicts occur until the resident is able to be redirected. The facility Quality Improvement Antipsychotic Committee will meet monthly to review all residents that are on antipsychotic medications. The Committee will consist of the Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurses, Quality Improvement Nurses, Social Workers, and Pharmacy Consultant. The Committee will review each resident medication(s) to include current dosage, whether there are documented behaviors since last review, verification that MD orders are correct, PRN Medications used are properly documented for the need and frequency, [DIAGNOSES REDACTED]. Any recommendations made during the Committee Meeting will be referred to the Attending Physician for acceptance or decline of recommendation. If the physician agrees with the recommendation of change in medication, then the resident will be Care Planned for changes in antipsychotic medications with goal and approaches listed and the QI Nurse and/or DON will note the change in antipsychotic medication on the Resident Care Guide to prompt staff to watch for any changes in behavior or condition. On 4-10-13, the Staff Development Coordinator and DON initiated in-servicing at 6:15 pm for all nursing assistants and nurses that anytime a resident has a change in antipsychotic medications, the change will be noted on the Resident Care Guide located in each resident ' s closet and prompt nursing staff to observe for any changes in behaviors or medical condition. If a Nursing Assistant notices a change in resident behavior or condition they are to notify their nurse immediately. Anytime a Nurse is notified that there is a change in behavior or condition they are to immediately assess the resident, assure resident is safe and other residents are safe related to the behavior, and notify the QI Nurse and/or DON and/or the Nurse On-Call. If situation warrants, notify the MD and RP. The in-service included the reminder that the QI Nurse will also be routinely observing these residents while on an antipsychotic medication change as well and will also be asking Nursing Assistants and Nurses who work with resident if any observed changes in condition or behavior. Starting the week of 4-8-13, the QI Nurse will two times a week observe residents who are currently under a antipsychotic medication change and question staff who work with the resident to assess if there are any changes in behaviors or condition related to the change in the medication that have not already been reported by other staff observations utilizing a QI Audit Tool. Any changes in behavior or condition will be assessed and referred to the MD for any further changes needed in medications for the resident. Any changes identified and actions taken by nursing and/or MD will be reported to the Antipsychotic Medication QI Committee on their next review. How the facility will monitor systems put in place: The Administrator will review the " Incident Notification Worksheet QI Audit Tools " daily as they are completed to include nights and weekends as incidents occur. The Administrator and/or DON will review the Quality Improvement Incident/Accident Committee QI Audit Tool five times per week to assure all areas are reviewed with appropriate intervention and notifications. The Administrator will review the QI Review of Nurses Notes three times a week for eight weeks starting 3-11-2013 the once per week ongoing thereafter to assure all notes were reviewed and that any areas with identified concerns were handled to meet the individual needs of the resident and situation. The Regional Director and/or Corporate Nurse Consultant will review the " Incident Notification Worksheet QI Audit tools, the Incident/Accident Committee QI Audits tools, and the QI Review of Nurses Notes monthly for six months starting April 2013 then quarterly thereafter to assure the facility is completing and interventions are in place and working to meet residents ' needs. The Administrative Nurses and/or Corporate Nurse Consultant will randomly administer written quiz forms with the employees to verify knowledge from the in-service given on resident to resident abuse and On-Call Incident Management. The quizzes will be completed with staff on all shifts and at varying times of the day to verify continued knowledge of this information. Quizzes on Resident to Resident abuse were started on 3-13-2013 and will continue for six months, and then quarterly ongoing. New employees hired will receive this in-servicing and quiz as a part of their general orientation to the facility. The Quality Improvement Executive Committee which consists of the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurse, Social Workers, Bookkeeper, Activity Director, Dietary Director, Medical Records Director, and Maintenance Director will review the quality improvement audit tools to include the Incident Notification Worksheets, the Reviews of Nurses Notes for unreported incidents, the Incident/Accident Committee Reviews, and the Antipsychotic Medication Committee Meeting Minutes for monitoring, assessment and recommendation of needs to further monitor these systems, and to assure continued compliance in these areas. On 4/11/13 at 5:00 PM the credible allegation was validated by reviewing the audits conducted on the dementia unit and the general floors for signs of injury or other signs of resident to resident abuse. Interviews were conducted with the administrative staff and the managers that are on call after business hours and on weekends to assure that interventions are immediately put in place with resident to resident incidents. An " On-call Incident Management " form had been developed for the administrative and on-call staff to take home to document calls regarding incidents and accidents in the facility after business hours and on weekends. The staff was knowledgeable of the form and its use. A QI Worksheet had been developed for the staff that rotate nurse on-call duties to document interventions for incidents/accidents that occur after business hours. Interviews were conducted with the nurses and the nursing assistants on the locked dementia unit and on the general floors. It was confirmed that staff had received inservices on monitoring behaviors and were knowledgeable of the interventions put into place for monitoring residents with behaviors and residents whose medications had been changed.

Based on record review and staff interviews the facility failed to identify an increase in behaviors for 1 of 1 sampled resident (Resident #5) after a reduction of the resident ' s psychoactive medications resulting in injury to 2 of 2 sampled residents (Resident #4 and Resident #2) that were known to get into other resident ' s beds. The Immediate Jeopardy began on 3/9/13 at 8:00 PM and was identified on 04/10/13 at 2:10 PM. The Immediate Jeopardy was removed on 04/11/13 at 5:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be in-serviced. The facility will then implement monitoring of its corrective action. The findings include: Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the Resident had no mood issues or behavioral symptoms during the 7 day assessment period. The MDS revealed that the Resident was on antipsychotic and antidepressant medications and would be addressed in the care plan. A progress note by the Quality Improvement (QI) Nurse dated 12/27/12 revealed that Resident #5 was aggressive at times with multiple behavioral issues and that staff continued to redirect the resident when having behaviors and was aggressive with other residents. The resident ' s Care Plan updated on 1/4/13 revealed that the resident had verbal and physical aggression related to anger, cognitive impairment and depression. The interventions included the following: Do not argue or condemn Resident. Document summary of each episode. Note cause and successful interventions, include frequency and duration. Medication/Treatment as prescribed by physician in a timely manner. Monitor and document behavior per facility protocol. Remove Resident from public area when behavior is disruptive and unacceptable. Talk with Resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. Remove to a quiet area; reassure Resident of personal safety and stay with Resident during periods of anger if appropriate or if Resident wishes. Try not to reason with Resident, as Resident no longer has the ability to think logically. The Resident ' s Care Plan showed that the Resident had feelings of sadness, emptiness, anxiety, uneasiness and depression characterized by ineffective copying, low self esteem, tearfulness, motor agitation, withdrawal from care/activities related to brain deterioration. Among the interventions were as follows: Monitor mental status/mood state changes when new medication is added and notify physician of any significant changes. Observe and report any changes in mental status, mood or behaviors and notify physician of significant changes as necessary. The Care Plan revealed that the Resident was using drugs that had an altering effect of the mind with the potential for side effects including a decline in mood and behaviors. The interventions included to monitor the Resident ' s mood and behaviors with documentation per facility policy and to notify the physician of any significant changes. A physician ' s progress note dated 1/2/13 revealed that Resident #5 was okay as long as everybody left him alone. The note revealed that the resident was very protective of his space and did not like anyone to crowd his space. A nursing progress note dated 1/9/13 at 10:06 PM revealed that Resident #5 yelled out at other residents at intervals if they were getting too close to him or touching him. A nursing progress note dated 1/10/13 at 3:26 PM revealed that Resident #5 was yelling at another resident for being in his space and touching him. A nursing progress note dated 1/10/13 at 11:39 PM revealed that Resident #5 was yelling out at other residents walking close to him. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 01/11/13 revealed that Resident #5 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3. The MDS revealed that the Resident had behaviors directed towards others that included threatening others, screaming at others and cursing at others that occurred 1-3 days during the 7 day assessment period. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] in a non-benzodiazepine medication used to treat generalized anxiety. [MEDICATION NAME] is a benzodiazepine medication used to treat anxiety. [MEDICATION NAME] is a medication used to treat depression and [MEDICATION NAME] is an antipsychotic medication used in the treatment of [REDACTED]. A review of the physician's order [REDACTED]. Decrease [MEDICATION NAME] to 0.5mg every day. Decrease [MEDICATION NAME] to 7.5mg every day and decrease [MEDICATION NAME] to 2.5mg every night at bedtime. A review of the MAR indicated [REDACTED]. The other medications were given at the reduced dosage beginning 2/7/13. An incident report dated 2/17/13 at 4:20 PM revealed that Resident #5 and Resident #7 were in the dining room. The report revealed that Nurse #2 responded when she heard yelling and Resident #7 stated that Resident #5 had hit her on the left side of her face. The report revealed that no visible injuries were noted. A nursing progress note dated 2/17/13 at 11:31PM (late entry) revealed that Resident #5 was standing at the sink in the dining room and Resident #7 was in the dining room in a wheelchair. The note revealed that Resident #5 hit Resident #7 on the right side of the face. The note revealed that Resident #5 was asked if he hit Resident #7 and Resident #5 stated that he did because Resident #7 was fussing at him about standing at the sink and that it belonged to her and he hit her. Under " Other info " revealed that Resident #5 had a history of [REDACTED]. A nursing progress note for Resident #7 revealed that a nursing assessment revealed no visible injuries and that the Administrator was made aware and that the physician and responsible parties for both residents was notified. A nursing progress note dated 2/18/13 at 11:35 PM revealed that Resident #5 yelled out several times during the evening at residents if they came into his room while he was resting in bed. The note revealed that when asked why he was yelling so loud he replied that they did not belong in his room. A nursing progress note dated 2/19/13 at 9:46 PM revealed that Resident #5 yelled a few times at other resident ' s being too close to him. A nursing progress note dated 2/20/13 at 9:42 PM revealed that Resident #5 yelled out three times this evening at other residents. When asked why he was yelling he stated: " I don ' t want them to touch me. " The note revealed that Resident #5 yelled at Resident #7 for entering his room. A nursing progress note dated 3/3/13 at 7:59 AM revealed that Resident #5 was yelling and trying to hit at the nursing assistants when they went in the room to provide care for his roommate. A nursing progress note dated 3/5/13 at 9:34 PM revealed that Resident #5 had been very vocal and cursing at other residents and staff. A review of the behavior monitoring documentation for Resident #5 revealed that from 1/1/13 to 2/8/13 (psychoactive medications reduced on 2/7/13), 20 episodes of yelling/screaming were documented. There were no other behaviors documented on the behavior monitoring sheets during that time. The monitoring sheets revealed that from 2/9/13 to 3/8/13 there were 22 episodes of yelling/screaming, one episode of agitation without harm to self or others, one clear threat of violence towards others, three episodes of hitting (the incident on 2/27/13 when Resident #5 hit Resident #7 was not documented on the behavior monitoring sheet), and one episode of swinging at others. An incident report for Resident #4 revealed that on 3/9/13 Nurse #3 was called to Resident 5 ' s room at 8:00 PM due to two residents fighting. The report revealed that Resident #5 was standing over Resident #4 with a clenched fist and stated: " I told him to leave me alone and get out of my bed. " The report revealed that Resident #4 had swelling and redness of the right eye and that an X-ray was done that showed no fracture. A review of the nursing progress notes for Resident #4 revealed that the resident was seen by an eye doctor on 3/11/13 and a consultation report dated 3/14/13 revealed that Resident #4 had a ruptured globe, had a blind, painful eye and the right eye was removed on 3/14/13. An incident report for Resident #2 dated 3/10/13 at 11:02 PM revealed that Nurse #4 observed Resident #2 to have a laceration on his nose and under the left eye with redness of the left eye. The report revealed that Resident #5 said he hit Resident #2 for being in his bed. An eye consult dated 3/11/13 revealed that Resident #2 had subconjunctival hemorrhage of the left eye related to trauma and an antibiotic ointment for the eye was ordered. There was a physician's order [REDACTED]. The X-ray report for Resident #2 dated 3/12/13 revealed a nondisplaced [MEDICAL CONDITION] nasal bone. A physician ' s progress note for Resident #2 dated 3/12/13 revealed that the resident had a nondisplaced [MEDICAL CONDITION] and ecchymosis of the left eye. The note revealed that Resident #2 was hit by another resident on the unit and had some [MEDICAL CONDITION] from the injury. Nurse #1 stated in an interview on 3/25/13 at 2:52 PM that after Resident #5 ' s medications were reduced the resident would say that he stayed up all night cleaning. The Nurse stated that Resident #5 was easier to redirect prior to the reduction in his medications and that his aggressive behaviors were worse after reducing his meds. The Nurse stated that Resident #5 would usually call the nurse if someone was in his space but it was not like him to just hit someone. Nurse #1 stated in an interview on 3/26/13 at 9:40 AM that the nurses document behaviors in the progress notes and the nursing assistants address behaviors in their documentation in the computer. The Nurse stated that the nurses can also document behaviors in the computer. The Nurse stated that she did not monitor the behavior documentation because the information was reviewed by administration. The Director of Nursing (DON) stated in an interview on 3/26/13 at 9:54 AM that after a dose reduction of a resident ' s psychoactive medications, the Antipsychotic Medication Committee monitored the resident ' s behaviors by talking with the nurses. The Quality Improvement (QI) Nurse stated in an interview on 3/26/13 at 10:04 AM that the nurses document any resident behaviors in the nurse ' s notes and the nursing assistants document behaviors in the computer. The QI Nurse stated that the system will flag a change in condition that had occurred in the past 24 hours. The Nurse stated that nothing unusual happened with Resident #5 after his medications were changed. The Nurse stated that Resident #5 had always been aggressive but did not hit people on a regular basis. The QI Nurse stated that Resident #7 had [MEDICAL CONDITION] and Resident #5 admitted that he hit Resident #7. The QI Nurse stated that it was a known fact that Resident #5 did not like anyone in his personal space and if the person did not move, Resident #5 would become aggressive. The QI Nurse stated that Resident #5 ' s behaviors did not change after his dose reduction. The QI Nurse stated that the staff was being educated regarding the documentation of behaviors during this time and that all residents with behaviors showed an increase in documentation of behaviors. The DON stated in an interview on 3/26/13 at 1:03 PM that in the morning meetings on Monday through Friday they review the 24 hour reports for any changes in a resident ' s behaviors. The DON stated that the administrative staff reviewed the nurse ' s notes for changes in behaviors and the QI Nurse and the Assistant Director of Nursing reviewed the documentation by the nursing assistants for behavior monitoring in the computer system. The DON was observed to review the behavior monitoring sheets for January 1, 2013 through March 8, 2013 and stated that there was a slight change in Resident #5 ' s behaviors after his psychoactive medications were reduced. On 4/10/13 at 10:00 AM Nurse #1 stated in an interview that Resident #5 and Resident #2 were roommates. The Nurse stated that prior to the reduction in his psychoactive medications, Resident #5 would yell for Resident #2 to get out of his bed and staff would go down and get Resident #2 out of Resident #5 ' s bed. The Nurse stated Resident #5 never hit anyone for being in his bed until after his medications were reduced. An interview was conducted with the Administrator, DON and the QI Nurse on 4/10/13 at 11:15 AM. The QI Nurse stated that he did not see any documented changes in Resident #5 ' s behaviors. The Nurse stated that the computer system flags if there is a behavior change in a 24 hour period. Stated that he would be looking for extreme behaviors that had not occurred before; something that would indicate a change in condition that he would need to follow up on. The Nurse stated that he did not usually print out the behavior monitoring sheets to look at the behaviors. The Nurse was observed to review a print out of the behaviors for Resident #5 from January 1, 2013 to March 8, 2013. The Nurse stated that there was a slight increase in the resident ' s behaviors but did not see any difference in his behaviors that were alarming or that would indicate that the resident would do what he did on March 9 and 10, 2013 (hit Resident #4 and Resident #2). The Nurse stated that if anything needed to be done about Resident #5 ' s behaviors the staff would have come to them and told them and it would have been addressed. The Administrator was notified of the Immediate Jeopardy on 4/10/13 at 2:10 PM. The facility provided a credible allegation of compliance on 04/11/13 at 5:55 PM. The allegation of compliance indicated: What measures the facility put in place for the resident affected: On 3-9-13 Resident #4 was assessed by Nurse #3 and attempt made to notify MD. XRay of eye area was completed on 3/9/13 at 10:30 pm with results of no fractures identified. On 3/11/13 the physician gave an order for [REDACTED]. On 3/14/13 Resident #4 had a procedure to remove the right eye and returned to the facility on [DATE]. On 3-10-13 Resident #2 was assessed by Nurse #4 and an attempt made to notify the physician. The family was notified on 3-10-13. On 3-10-13 Resident #2 was moved to another room. On 3-11-13 the physician gave an order for [REDACTED].#2 showing a non-displaced fracture of nose. The Responsible party was notified by the nurse on 3-9-13 and 3-10-13 or resident ' s behaviors. The MD was attempted to be notified by nurse of behavior on 3/9/13 and 3/10/13. On 3-10-13 at 7:00 am Resident #5 was placed on 15 minutes checks. On 3-11-13 first shift Resident #5 was placed on one to one staff monitoring. The Director of Nursing (DON) contacted the psychiatric nurse practitioner on 3-11-13 and psychiatric nurse practitioner arrived same day at 3:45 pm to see resident with recommendation to resume previous dosage of antipsychotic medications. Social Worker contacted outside psychiatric center on 3-11-2013 for potential placement due to resident behavior. On 3-11-2013 at 7:00 pm the outside psychiatric center contacted social worker and verified they would admit Resident #5 on the morning of 3-12-13. One to One staff monitoring continued with Resident #5 until he was discharged from facility. On 3-12-13, Resident #5 was transported to outside psychiatric center for admission and no longer resides at this facility. What measures were put in place for residents having the potential to be affected: On 3-11-13 at 7:00 pm a 100 percent audit was completed by the ADON on all residents residing in the locked dementia unit to check for any signs of injury or suspicious signs of resident to resident abuse. No negative outcomes were identified in this audit. On 3-12-13 the audit was expanded by the floor nurses to the remaining residents residing in the nursing facility as an additional precautionary intervention to check for any signs of injury or resident to resident abuse. No negative outcomes were identified from this audit. The Corporate Nurse Consultants completed a 100 percent audit of resident nurses notes starting on 3-11-13 and completed on 3-12-13 for the time period of documentation from 12-1-2012 to present 3-11-2013, to assure there were no nursing documentation of resident to resident episodes that may not have been previously identified in incident reporting with no negative outcomes identified. On 3-12-13, the Corporate Nurse Consultant (PG) completed a review of resident to resident altercations from 9-1-12 to 3-11-12 to assure interventions for resident to resident incidents were in place and/or still appropriate with no new concerns identified. On 3-11-13 at 5:45 pm the Regional Director in-serviced the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses and Administrative Nurses who take Nurse On Call responsibilities on assuring that interventions are immediately put in place with resident to resident incidents to include one to one staff monitoring when a resident strikes another resident until the situation is assessed further and appropriate interventions are decided to meet the resident ' s individualized needs to include care planning. When unsure about a situation, the Administrator and/or Director of Nursing should contact the Regional Director or Corporate Nurse Consultant for additional advisement. No Administrative Nurses worked until they received this in-servicing. On 3-12-13, the Regional Director in-serviced the Administrator and all Administrative Nurses who take Nurse On Call to include the Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, and Minimum Data Set Nurses on " On-Call Incident Management; steps to look at when called about an incident that outlined data to collect about situation including answers to WHO, WHAT, WHEN, WHERE, HOW, and INTERVENTION to be put in place. On 3-15-13 the Administrator expanded the " On-Call Incident Management " in-service to all staff members who rotate weekend Administrative Call Rounds including the Housekeeping Director, Medical Records Director, Social Workers, Business Office staff, Dietary Manager, Activity Director, and Maintenance Director. On 3-11-13 at 7:10 pm the Staff Development Coordinator initiated in-servicing for all facility staff to include nurses, nursing assistant, nursing support staff, dietary staff, housekeeping staff, maintenance staff, activities staff, office staff, and therapy staff on Resident to Resident Abuse to include when episodes are observed that safety is provided immediately, charge nurses are notified immediately for appropriate interventions. No staff was allowed to work until they received this in-service. On 4-3-13 the MDS Nurses started a 100 percent review of all Care Plans to assure individualization of the plan of care was completed for each resident to include behaviors of residents. On 4-10-2013 the MDS nurses completed a 100 percent audit of all residents on antipsychotic medications to assure that the plan of care addresses the use of antipsychotic medication and any current dose reduction or changes. Any areas identified were corrected by updating of the residents ' care plan. On 3-13-2013 to 3-15-2013 the pharmacy consultant completed a drug regimen review of all residents to include residents on psychoactive medications. Any recommendations made regarding possible antipsychotic medications will be reviewed by the Quality Improvement Antipsychotic Medication Committee. The Committee will review each resident medication(s) to include current dosage, whether there are documented behaviors since last review, verification that MD orders are correct, PRN Medications used are properly documented for the need and frequency, [DIAGNOSES REDACTED]. What systems were put in place to prevent the deficient practice from reoccurring: On 3-12-2013 a QI worksheet guide was implemented to be used by the Administrator, Director of Nursing, and all Administrative Nurses that rotate Nurse On-Call duties for non-business hours, weekends, and nights to assist in gathering information to make decisions about interventions for incidents to include resident to resident incidents utilizing a " On-Call Incident Management " Worksheet QI Audit Tool. This audit tool will be utilized when calls are received and forwarded to the Administrator for review. On 3-12-2013 the Administrator initiated a Quality Improvement Incident/Accidents Committee starting on 3-12-13 consisting of the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurses, Social Workers, and Therapy staff that will meet five times per week to review all incidents and accidents to assure nurse assessment of situation, intervention put in place, MD notified, RP notified, and Care Plan updated for changes and interventions. This review will be documented on a Quality Improvement Incident/Accident Review Committee QI Audit Tool. Administrative Nurses will review all resident nurses notes three times per week for eight weeks starting week of 3-11-2013 and then once per week ongoing thereafter to assure there are no resident to resident episodes that may have occurred that were not identified by incident reporting. On 4-10-2013 the Staff Development Coordinator initiated in-servicing at 1:17 pm for nurses and nursing assistants regarding monitoring of residents that in the daily monitoring of our residents staff should routinely monitor their whereabouts. If a dementia resident is identified as being in another resident ' s space or bed to redirect the resident to the common care areas of the unit and that if the resident is resistive to the redirection to stay with the resident to assure no resident to resident conflicts occur until the resident is able to be redirected. The facility Quality Improvement Antipsychotic Committee will meet monthly to review all residents that are on antipsychotic medications. The Committee will consist of the Administrator, Director of Nursing, Assistant Director of Nursing, Minimum Data Set Nurses, Quality Improvement Nurses, Social Workers, and Pharmacy Consultant. The Committee will review each resident medication(s) to include current dosage, whether there are documented behaviors since last review, verification that MD orders are correct, PRN Medications used are properly documented for the need and frequency, [DIAGNOSES REDACTED]. Any recommendations made during the Committee Meeting will be referred to the Attending Physician for acceptance or decline of recommendation. If the physician agrees with the recommendation of change in medication, then the resident will be Care Planned for changes in antipsychotic medications with goal and approaches listed and the QI Nurse and/or DON will note the change in antipsychotic medication on the Resident Care Guide to prompt staff to watch for any changes in behavior or condition. On 4-10-13, the Staff Development Coordinator and DON initiated in-servicing at 6:15 pm for all nursing assistants and nurses that anytime a resident has a change in antipsychotic medications, the change will be noted on the Resident Care Guide located in each resident ' s closet and prompt nursing staff to observe for any changes in behaviors or medical condition. If a Nursing Assistant notices a change in resident behavior or condition they are to notify their nurse immediately. Anytime a Nurse is notified that there is a change in behavior or condition they are to immediately assess the resident, assure resident is safe and other residents are safe related to the behavior, and notify the QI Nurse and/or DON and/or the Nurse On-Call. If situation warrants, notify the MD and RP. The in-service included the reminder that the QI Nurse will also be routinely observing these residents while on an antipsychotic medication change as well and will also be asking Nursing Assistants and Nurses who work with resident if any observed changes in condition or behavior. Starting the week of 4-8-13, the QI Nurse will two times a week observe residents who are currently under a antipsychotic medication change and question staff who work with the resident to assess if there are any changes in behaviors or condition related to the change in the medication that have not already been reported by other staff observations utilizing a QI Audit Tool. Any changes in behavior or condition will be assessed and referred to the MD for any further changes needed in medications for the resident. Any changes identified and actions taken by nursing and/or MD will be reported to the Antipsychotic Medication QI Committee on their next review. How the facility will monitor systems put in place: The Administrator will review the " Incident Notification Worksheet QI Audit Tools " daily as they are completed to include nights and weekends as incidents occur. The Administrator and/or DON will review the Quality Improvement Incident/Accident Committee QI Audit Tool five times per week to assure all areas are reviewed with appropriate intervention and notifications. The Administrator will review the QI Review of Nurses Notes three times a week for eight weeks starting 3-11-2013 the once per week ongoing thereafter to assure all notes were reviewed and that any areas with identified concerns were handled to meet the individual needs of the resident and situation. The Regional Director and/or Corporate Nurse Consultant will review the " Incident Notification Worksheet QI Audit tools, the Incident/Accident Committee QI Audits tools, and the QI Review of Nurses Notes monthly for six months starting April 2013 then quarterly thereafter to assure the facility is completing and interventions are in place and working to meet residents ' needs. The Administrative Nurses and/or Corporate Nurse Consultant will randomly administer written quiz forms with the employees to verify knowledge from the in-service given on resident to resident abuse and On-Call Incident Management. The quizzes will be completed with staff on all shifts and at varying times of the day to verify continued knowledge of this information. Quizzes on Resident to Resident abuse were started on 3-13-2013 and will continue for six months, and then quarterly ongoing. New employees hired will receive this in-servicing and quiz as a part of their general orientation to the facility. The Quality Improvement Executive Committee which consists of the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Quality Improvement Nurse, Minimum Data Set Nurse, Social Workers, Bookkeeper, Activity Director, Dietary Director, Medical Records Director, and Maintenance Director will review the quality improvement audit tools to include the Incident Notification Worksheets, the Reviews of Nurses Notes for unreported incidents, the Incident/Accident Committee Reviews, and the Antipsychotic Medication Committee Meeting Minutes for monitoring, assessment and recommendation of needs to further monitor these systems, and to assure continued compliance in these areas. On 4/11/13 at 5:00 PM the credible allegation was validated by reviewing the audits conducted on the dementia unit and the general floors for signs of injury or other signs of resident to resident abuse. Interviews were conducted with the administrative staff and the managers that are on call after business hours and on weekends to assure that interventions are immediately put in place with resident to resident incidents. An " On-call Incident Management " form had been developed for the administrative and on-call staff to take home to document calls regarding incidents and accidents in the facility after business hours and on weekends. The staff was knowledgeable of the form and its use. A QI Worksheet had been developed for the staff that rotate nurse on-call duties to document interventions for incidents/accidents that occur after business hours. Interviews were conducted with the nurses and the nursing assistants on the locked dementia unit and on the general floors. It was confirmed that staff had received inservices on monitoring behaviors and were knowledgeable of the interventions put into place for monitoring residents with behaviors and residents whose medications had been changed.

Based on record review and staff interviews, the facility failed to supervise 2 of 2 sampled residents (Resident #4 and #2) in the locked dementia unit who wandered into other resident ' s rooms resulting in physical injury to 2 of 2 sampled Residents (#4 and #2). The facility failed to implement interventions for 1 of 1 sampled resident (Resident #5) who was protective of his personal space resulting in physical aggression toward two other residents (Resident #4 and #2). The Immediate Jeopardy began on 3/9/13 at 8:00 PM and was identified on 04/10/13 at 2:10 PM. The Immediate Jeopardy was removed on 04/11/13 at 5:55 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be inserviced. The facility will then implement monitoring of its corrective action. The findings included: 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the Resident had no mood issues or behavioral symptoms during the 7 day assessment period. The MDS revealed that the resident was on an antipsychotic medication and an antidepressant medication and would be addressed in the care plan. A nursing progress note dated 11/14/12 at 6:47 PM revealed that Resident #5 yelled out when another resident got too close or was in his way. A nursing progress note dated 12/4/12 at 11:10 PM revealed that Resident #5 was standing in the doorway of the dining room and Resident #4 started to go in and Resident #5 balled up his fist and started yelling at the Resident that he would hit him. The note revealed that both Residents were redirected. A progress note by the Quality Improvement (QI) Nurse dated 12/27/12 revealed that Resident #5 was aggressive at times with multiple behavioral issues and that staff continued to redirect the Resident when having behaviors and being aggressive with other residents. A physician ' s progress note dated 1/4/12 revealed that Resident #5 had a problem with anger management and that the Resident had severe dementia. The note revealed that the Resident was not combative as long as he was left alone. The Resident ' s Care Plan initiated on 7/18/13 and updated on 1/4/13 revealed that the Resident had verbal and physical aggression related to anger, cognitive impairment and depression. The interventions included the following: Do not argue or condemn Resident. Document summary of each episode. Note cause and successful interventions, include frequency and duration. Medication/Treatment as prescribed by physician in a timely manner. Monitor and document behavior per facility protocol. Remove Resident from public area when behavior is disruptive and unacceptable. Talk with Resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. Remove to a quiet area; reassure Resident of personal safety and stay with Resident during periods of anger if appropriate or if Resident wishes. Try not to reason with Resident, as Resident no longer has the ability to think logically. The Care Plan revealed that the Resident received drugs that had the potential to have an altering effect on the mind and had problems that included anxiety, depression and decline in mood and behaviors. Among the interventions were to monitor the Resident ' s mood and behaviors with documentation per facility policy and to notify the physician of any significant changes. The Care Plan revealed no new interventions since 7/18/12. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 01/11/13 revealed that Resident #5 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3. The MDS revealed that the Resident had behaviors directed towards others that included threatening others, screaming at others and cursing at others that occurred 1-3 days during the 7 day assessment period. A review of the physician's order [REDACTED].#5 ' s psychoactive medications as follows: Reduce Buspar from 300mg (milligrams) to 200mg daily. Reduce Ativan from 1mg to 0.5mg every morning, Reduce Remeron from 15mg to 7.5mg at bedtime and reduce Zyprexa from 5mg to 2.5mg at bedtime. A nursing progress note dated 2/17/13 at 11:31 PM revealed that Resident #5 was standing at the sink in the dining room and Resident #7 was in the dining room in a wheelchair and was fussing at Resident #5 about leaving her stove alone and that this was her house and he needed to leave. The note revealed that Resident #5 hit Resident #7 on the side of the face after yelling at her. The note revealed that no injury had occurred and both Residents were redirected and separated. The note revealed that Resident #5 was asked if he hit Resident #7 and he said " Yes, she told me to get out of her house and this is not her house. " The note revealed that the physician and the administrator were made aware. A nursing progress note dated 2/18/13 at 11:35 PM revealed that Resident #5 yelled out several times at residents if they came into his room while he was resting in bed and stated that these residents did not belong in his room. A nursing progress note dated 2/20/13 revealed that Resident #5 yelled out three times at other residents and when asked why he was yelling stated: " I don ' t want them to touch me. " The note revealed that he yelled at another resident for entering into his room and the resident was removed from the room and reminded that it was not her room. A facility Incident Report revealed that on 3/9/13 at 8:00 PM Nurse #3 was called to Resident #5 ' s room due to two residents fighting. The report showed that Resident #5 was standing over Resident #4 with a clenched fist and stated: " I told him to leave me alone and get out of my bed. " The report revealed that Resident #4 ' s eye was swollen and blood shot. The report revealed that the Responsible Party for Resident #4 was notified. A review of the clinical record for Resident #4 revealed a nursing progress note dated 3/10/13 at 11:03 AM that Resident #4 had peri-orbital swelling and ecchymosis of the right eye. A nursing progress note dated 3/11/13 at 3:10 PM revealed that Resident #4 was transported to the doctor ' s office for a right eye consult. A nursing progress note dated 3/12/13 at 12:22 PM revealed that Resident #4 was taken to an eye specialist. An eye consultation report dated 3/14/13 revealed the following: Trauma to right eye. No light perception. Ruptured globe. Impression: Blind painful eye. Plan of treatment: Enucleation (removal of) right eye. A Discharge Summary dated 3/15/13 showed that Resident #4 had surgery to remove the right eye on 3/14/13. Record review revealed that Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] revealed that Resident #4 had short and long term memory loss and was moderately cognitively impaired with poor decision making skills and required cues and supervision. A review of Resident #4 ' s Care Plan updated on 2/18/13 revealed that the resident wandered into other resident ' s rooms and would get into other resident ' s beds. The nursing progress notes revealed that Resident #4 was lying in another resident ' s bed on 2/5/13, was in and out of other resident ' s beds on 2/13/13 and continued to get into roommate ' s bed to rest on 2/18/13. On 3/25/13 at 2:52 PM an interview was conducted with Nurse #1 (7AM-3PM) and Nurse #2 (3PM-11PM). The Nurses stated that they were not working on the weekend of the altercation between Resident #5 and Resident #4. Nurse #1 stated that during the evening, Resident #5 would keep to himself and did not like to be touched. The Nurse stated that if anyone was in his room he would holler out for the nurse and they would go down to see what was going on. Nurse #1 stated that there were altercations with 2 different residents the same weekend and Resident #4 had his eye taken out. On 3/25/13 at 3:13 PM an interview was conducted with the 2 nursing assistants (NAs) working on 3/9/13 when the altercation occurred between Resident #5 and Resident #4. NA #1 stated that on Saturday night (3/9/13) they were doing patient care and heard a resident yell that they were fighting. NA #1 stated she went to the room and observed Resident #4 lying in Resident #5 ' s bed bleeding. The NA stated that she asked Resident #5 if he hit Resident #4 and he said that he did. The NA stated that she took Resident #4 to the bench in the hallway and Resident #5 stayed in his room. NA #1 stated that on Sunday when starting her shift at 3:00 PM, Resident #5 was on 15 minute checks which meant that they had to check on the resident and document his location every 15 minutes. The NAs stated that Resident #4 would wander around the unit and might get in any resident ' s bed and staff would get him up and show him his bed. An interview was conducted with the Administrator and the Director of Nursing on 3/25/13 at 4:50 PM. The Administrator stated that the Assistant Director of Nursing (ADON) was the on duty manager on Saturday (3/9/13) when the incident with Resident #5 and Resident #4 occurred and had already left for the day but was the nurse on-call for the weekend. The Administrator stated that the Medical Records Manager was the manager on duty on Sunday (3/10/13). The Administrator stated that on Sunday AM she received a call from the Medical Records Manager who told her of the incident with Resident #5 and Resident #4. The Administrator stated that the Manager had put into place every 15 minute checks on Resident #5 meaning the staff was to check his whereabouts every 15 minutes. The Administrator stated that after a second altercation between Resident #5 and another resident on Sunday night, Resident #5 was put on 1 to 1 observation until he was transferred out of the facility on 3/12/13. The Medical Records Manager stated in an interview on 3/25/13 at 5:02 PM that she was the in-house manager on 3/9/13 but was not in the facility at the time of the altercation between Resident #5 and Resident #4. The Manager stated that when she came in on Sunday morning (3/10/13) she was making her rounds and a nursing assistant told her that Resident #5 had hit Resident #4 and that she needed to go and look at his eye. The Manager stated that the nurse had already called the physician and the Responsible Party, an X-ray had been done and the nurse was doing neurochecks on Resident #4. The Manager stated that she instructed the nurse on the Alzheimer ' s Unit to start 15 minute checks on Resident #5 and she called the Administrator to let her know what had been done. On 3/26/13 The DON stated in an interview that the girls in the back know Resident #5 and usually know where he is and that if someone bothers the Resident, he will yell and the staff go to see what is going on and re-directs the Resident. The Quality Improvement Nurse stated in an interview on 3/26/13 at 10:04 AM that Resident #5 had always been aggressive but did not hit people on a regular basis. The Nurse stated that it was a known fact that Resident #5 did not like anyone in his personal space and if the person did not move Resident #5 would become aggressive. The ADON stated in an interview on 3/26/13 at 10:30 AM that she was the nurse on-call on 3/9/13 and that she received a phone call from the nurse on the Alzheimer ' s Unit on Saturday evening (3/9/13) saying that Resident #5 had hit Resident #4. The ADON stated that she told the nurse to keep them separated and to call back if any further changes. The ADON stated that up to that point she was not aware of Resident #5 ever hitting another resident. On 3/26/13 at 10:55 AM an interview was conducted with Nurse #3 who was working on the Alzheimer ' s Unit on 3/9/13 on the 3PM-11PM shift. The Nurse stated that she was at the nurse ' s station and the NAs were making their rounds. The Nurse stated that a resident came to the nurse ' s station and said that two residents were fighting. The Nurse stated that she went to Resident #5 ' s room and the 2 NAs arrived about the same time. The Nurse stated that Resident #4 was in Resident 5 ' s bed and Resident #5 was standing over Resident #4. The Nurse stated that she noticed that Resident #4 ' s eye was bloodshot and swollen. The Nurse stated that Resident #4 was put in a wheelchair and taken to the nurse ' s station. The Nurse stated that an X-ray was done of Resident #4 ' s eye and the report was faxed back to her around 11:00 PM that there was no fracture. On 3/26/13 at 12:25 PM an interview was conducted with Nurse #4 who worked 11PM-7AM on Saturday night 3/9/13. The Nurse stated that Resident #5 stayed in his room and had no further problems. On 3/26/13 at 12:45 PM an interview was conducted with the Administrator, Director of Nursing and Facility Consultant #1. The Facility Consultant stated that they had completed a Plan of Correction (POC) after the altercations on the weekend of 3/9-10/13. A review of the POC showed that all administrative staff was inserviced on assuring that interventions were immediately put in place with resident to resident incidents to include one on one when a resident strikes another resident until the appropriate intervention can be determined. The POC did not address interventions to prevent Resident #4 from getting in other resident ' s beds and personal space. NA #3 stated in an interview on 4/10/13 at 10:34 AM that Resident #5 was the one you had to supervise. The NA stated Resident #5 would sit in the dining room until staff would tell him to go to the bathroom. The NA stated that when Resident #5 would start getting loud, staff would go to see what was going on. The NA stated that Resident #4 was easily directed. The ADON stated in an interview on 4/10/13 at 10:43 AM that Resident #4 was up and about the facility and Resident #5 stayed in one spot. The ADON stated that on 3/9/13 when the incident occurred between Resident #5 and Resident #4 she told the staff to keep the 2 Residents separated. The ADON stated that this meant for the staff to keep a constant eye on Resident #5 and keep him away from Resident #4. When asked how she intended to protect the other residents the ADON stated that she put an intervention in place to protect Resident #4 from Resident #5 and at the time was concerned about the situation with these 2 residents. Nurse #3 stated in an interview on 4/10/13 at 2:15 PM that she worked 3PM-11PM on 3/9/13 (Saturday). The Nurse stated that they kept an eye on Resident #5 as much as possible. The Nurse stated that the resident ' s tend to gather in the hall near the nurse ' s station and one NA sits on the bench and talks with the residents and can observe the hall. The Nurse stated that there were windows around the TV room and the dining room and that the residents in those areas could be observed from the hall. The Nurse stated that Resident #5 had a routine and after eating supper would go outside to smoke and then go to his room. The Nurse stated that she was getting ready to do a medication pass when Resident #5 hit Resident #4. The Nurse stated that Resident #4 was taken to the nurse ' s station where he stayed the rest of the night. The Nurse stated that they checked on Resident #5 and Resident #2 who were roommates periodically during the evening and they both stayed in their beds the rest of her shift. The Nurse stated that most of the residents knew to stay out of Resident #5 ' s way. 2. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the Resident had no mood issues or behavioral symptoms during the 7 day assessment period. The MDS revealed that the Resident was on antipsychotic and antidepressant medications and would be addressed in the care plan. A Progress note by the QI (Quality Improvement) Nurse dated 12/27/12 revealed that the Resident was aggressive at times with multiple behavioral issues and that staff continued to redirect the Resident when having behaviors and being aggressive with other residents. A physician ' s progress note dated 1/4/12 revealed that Resident #5 had a problem with anger management and that the resident had severe dementia. The note revealed that the resident was not combative as long as he was left alone. A nursing progress note dated 1/3/13 revealed that Resident #5 continued to yell out at residents if they get too close to him. The Resident ' s Care Plan updated on 1/4/13 revealed that the Resident had verbal and physical aggression related to anger, cognitive impairment and depression. The interventions included the following: Do not argue or condemn Resident. Document summary of each episode. Note cause and successful interventions, include frequency and duration. Medication/Treatment as prescribed by physician in a timely manner. Monitor and document behavior per facility protocol. Remove Resident from public area when behavior is disruptive and unacceptable. Talk with Resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. Remove to a quiet area; reassure Resident of personal safety and stay with Resident during periods of anger if appropriate or if Resident wishes. Try not to reason with Resident, as Resident no longer has the ability to think logically. The Care Plan revealed that the Resident received drugs that had the potential to have an altering effect on the mind and had problems that included anxiety, depression and decline in mood and behaviors. Among the interventions were to monitor the Resident ' s mood and behaviors with documentation per facility policy and to notify the physician of any significant changes. The Care Plan revealed no new interventions since the 7/18/12 assessment. A nursing progress note dated 1/9/13 at 10:06 PM revealed that Resident #5 yelled out at other residents at intervals if they were getting too close to him or touching him. A nursing progress note dated 1/10/13 at 3:26 PM revealed that Resident #5 was yelling at another resident for him being in his space and touching him. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 01/11/13 revealed that Resident #5 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3. The MDS revealed that the Resident had behaviors directed towards others that included threatening others, screaming at others and cursing at others that occurred 1-3 days during the 7 day assessment period. A nursing progress note dated 2/17/13 at 11:31 PM revealed that Resident #5 was standing at the sink in the dining room and Resident #7 was in the dining room in a wheelchair and was fussing at Resident #5 about leaving her stove alone and that this was her house and he needed to leave. The note revealed that Resident #5 it Resident #7 on the side of the face after yelling at her and both residents were redirected and separated. The note revealed that Resident #5 was asked if he hit Resident #7 he said " Yes, that she told me to get out of her house and this is not her house. " The note revealed that the physician and the administrator were made aware. A nursing progress note dated 2/18/13 at 11:35 PM revealed that Resident #5 yelled out several times at residents if they came into his room while he was resting in bed and stated that these residents did not belong in his room. A nursing progress note dated 2/19/13 at 9:46 PM revealed that Resident #5 yelled a few times at other residents being too close to him and that there had been no physical altercations between him with other residents. A nursing progress note dated 2/20/13 revealed that Resident #5 yelled out three times at other residents and when asked why he was yelling stated: " I don ' t want them to touch me. " The note revealed that he yelled at another resident for entering into his room and the resident was removed from the room and reminded that it was not her room. A nursing progress note dated 3/5/13 revealed that the Resident had been very vocal and cussing at other residents and staff. A facility Incident Report dated 03/10/13 at 10:02 PM revealed that Resident #2 was observed to have a laceration on the nose and under the left eye with redness in the left eye. The report revealed that Resident #5 was standing at the foot of the bed who stated that he hit Resident #2 because he was in his bed. The report revealed that Resident #2 was moved to another room. There was a physician's order [REDACTED]. A Consultation Report dated 3/11/13 showed subconjunctival hemorrhage of the left eye. The recommendations were cool compresses to the left eye and an antibiotic ointment to the left eye twice a day for 7 days. An X-ray report of the nasal bones for Resident #2 revealed a nondisplaced fracture of the right nasal bone and that the orbital rims were intact. A physician ' s progress note dated 3/13/13 revealed that Resident #2 had a nondisplaced fracture of the nose and ecchymosis of the left eye. The note revealed that the Resident was hit by another resident in the unit and his vision was okay in his left eye even though he did have some conjunctivitis from the trauma. Record review revealed that Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] revealed that the Resident ' s Care Plan updated on 12/26/12 showed a potential for trauma due to wandering but did not address the issue of the resident getting in other resident ' s beds. The nursing progress notes for Resident #2 revealed that the Resident was found in a female ' s room in bed fast asleep on 1/22/13, was in and out of other ' s rooms and beds on 1/31/13 and in and out of resident ' s rooms and in and out of resident ' s beds on 2/15/13. On 3/25/13 at 2:52 PM an interview was conducted with Nurse #1 (7AM-3PM) and Nurse #2 (3PM-11PM). The Nurses stated that they were not working on the weekend of the altercation between Resident #5 and Resident #2. Nurse #1 stated that during the evening, Resident #5 would keep to himself and did not like to be touched. The Nurse stated that if anyone was in his room he would holler out for the nurse and they would go to see what was going on. Nurse #1 stated that there were altercations with 2 different residents on the same weekend and Resident #4 had his eye taken out and Resident #2 had a broken nose. The Nurse stated that Resident #2 was likely to get into any resident ' s bed. The Nurse stated that Resident #5 and Resident #2 were roommates. On 3/25/13 at 3:13 PM an interview was conducted with the 2 nursing assistants (NAs) working on 3/9/13 when the altercation occurred between Resident #5 and Resident #2. NA #1 stated that when she came to work on Sunday (3/10/13) at 3:00 PM, Resident #5 was on q (every) 15 minute documentation checks meaning that they had to write down every 15 minutes where he was. NA #1 stated that NA #2 had just checked on him and was leaving the unit to go to the main nurse ' s station to get snacks for the residents. NA #2 stated that as she was leaving to go get the snacks she heard the alarm go off and entered the room and Resident #2 was out of bed and she asked him where he was going but he did not say anything. NA #2 stated that when she left the room, Resident #2 was behind her and she left to go get the snacks. NA #1 stated that she heard yelling and ran to the room and saw Resident #2 in Resident #5 ' s bed bleeding. NA #1 stated that she took Resident #2 to the bench near the nurse ' s station and then put him in the room with Resident #4. NA #1 stated that Resident #2 was confused and wandered around the unit and might get in any resident ' s bed. The NA stated that the staff would get him up and show him his bed. An interview was conducted with the Administrator and the Director of Nursing on 3/25/13 at 4:50 PM. The Administrator stated that on Sunday 3/10/13 the NA heard yelling and when she went into the room she found Resident #2 in Resident #5 ' s bed. The Administrator stated that Resident #5 had hit Resident #2. The Administrator stated that Resident #2 was moved to another room and assessed by the nurse. The Administrator stated that Resident #5 was put on 1 to 1 observation and was seen by the psychiatric nurse on 3/11/13. The Administrator stated that the psychiatric hospital could not take the resident on 3/11/13 but was moved to the psychiatric hospital on [DATE]. The Administrator stated that Resident #5 remained on 1 on 1 observation until discharged from the facility. The Administrator stated that they got the X-ray report for Resident #2 on 3/12/13 showing a nondisplaced fracture of the nose. The Director of Nursing (DON) stated in an interview on 3/26/13 at 9:54 AM that the girls in the unit know Resident #5 and usually know where he is and that if someone bothers the Resident he would yell and staff would go to see what was going on and re-direct the Resident. The QI Nurse stated in an interview on 3/26/13 at 10:04 AM that Resident #5 had always been aggressive but did not hit people on a regular basis. The Nurse stated that it was a known fact that Resident #5 did not like anyone in his personal space and if the person did not move, Resident #5 would become aggressive. On 3/26/13 at 12:25 PM an interview was conducted with Nurse #4 that worked 7PM to 7AM on 03/10/13 when the altercation occurred between Resident #5 and Resident #2. The Nurse stated that Resident #5 was on q15 minute checks. The Nurse stated that Resident #5 yelled at female resident ' s that were at his door and she re-directed the resident ' s so Resident #5 could go in his room and went back to the nurse ' s station. The Nurse stated that she heard yelling and the NA called her to the room. The Nurse stated that she observed Resident #2 in Resident #5 ' s bed and Resident #5 told her that Resident #2 was in his bed so he hit him. The Nurse stated that Resident #2 was taken down to the bench near the nurse ' s station and put him in another room. On 3/26/13 at 12:45 PM an interview was conducted with the Administrator, Director of Nursing and Facility consultant #1. The Facility Consultant stated that they had completed a Plan of Correction (POC) after the altercations on the weekend of 3/9-10/13. A review of the POC showed that all administrative staff was inserviced on assuring that interventions were immediately put in place with resident to resident incidents to include one on one when a resident strikes another resident until the appropriate intervention can be determined. The POC did not address interventions to prevent Resident #2 from getting in other resident ' s beds and personal space. NA #3 stated in an interview on 4/10/13 at 10:34 AM that Resident #5 was the one you had to supervise. The NA stated Resident #5 would sit in the dining room until staff would tell him to go to the bathroom. The NA stated that when Resident #5 would start getting loud, staff would go to see what was going on. The ADON stated in an interview on 4/10/13 at 10:43 AM that Resident #4 was up and about the facility and Resident #5 stayed in one spot. Stated that on 3/9/13 when the incident occurred between Resident #5 and Resident #4 she told the staff to keep the 2 residents separated. The ADON stated that this meant for the staff to keep a constant eye on Resident #5 and keep him away from Resident #4. When asked how she intended to protect the other residents the ADON stated that she put an intervention in place to protect Resident #4 from Resident #5 and at the time was concerned about the situation with these 2 Residents. Nurse #4 stated in an interview on 4/10/13 at 12:13 PM that she worked 7PM-7AM on 3/10/13 (Sunday night). The Nurse stated that at the time of the altercation between Resident #5 and Resident #2 she was at the nurse ' s station. The Nurse stated that one NA was at the desk charting and the other NA had left the unit to go to the main nurse ' s station to get snacks for the residents. NA #2 stated in an interview on 4/10/13 at 1:45 PM that she had to leave the unit to go to the main nurse ' s station to pick up the snacks. The NA stated that on the way she heard an alarm and went into the room and Resident #2 was getting out of his bed that was closest to the door of the room. The NA stated that Resident #5 ' s bed was next to the window and the curtain was pulled and she could not see Resident #5 ' s bed. The NA stated that she did not know where Resident #5 was at that time. The NA stated that she turned off the alarm because Resident #2 was out of bed and he followed her out of the room. The Administrator was notified of the Immediate Jeopardy on 4/10/13 at 2:10 PM. The facility provided a credible allegation of compliance on 04/11/13 at 5:55 PM. The allegation of compliance indicated: What measures the facility put in place for the resident affected: On 3-9-13 Resident #4 was assessed by Nurse #3 and attempt made to notify MD. XRay of eye area was completed on 3/9/13 at 10:30 pm with results of no fractures identified. On 3/11/13 the physician gave an order for [REDACTED]. Resident #4 was seen by an eye physician on 3/11/13, with additional eye physician visits on 3/12/13 with order to start antibiotic therapy and a return visit scheduled for 3/13/13. On 3/14/13 Resident #4 had a procedure to remove the right eye and returned to the facility on [DATE]. On 3-10-13 Resident #2 was assessed by Nurse #4 and an attempt made to notify the physician. The family was notified on 3-10-13. On 3-10-13 Resident #2 was moved to another room. On 3-11-13 the physician gave an order for [REDACTED]. On 3-12-13 the facility obtained X-Ray of resident nasal bones and received X-Ray results on 3-12-13 for Resident #2 showing a non-displaced fracture of nose. The Responsible party was notified by the nurse on 3-9-13 and 3-10-13 or resident ' s behaviors. The MD was attempted to be notified by nurse of behavior on 3/9/13 and 3/10/13. On 3-10-13 at 7:00 am Resident #5 was placed on 15 minutes checks. On 3-11-13 first shift Resident #5 was placed on one to one staff monitoring. The Director of Nursing (DON) contacted the psychiatric nurse practitioner on 3-11-13 and psychiatric nurse practitioner arrived same day at 3:45 pm to see resident with recommendation to resume previous dosage of antipsychotic medications. Social Worker contacted outside psychiatric center on 3-11-2013 for potential placement due to resident behavior. On 3-11-2013 at 7:00 pm the outside psychiatric center contacted social worker and verified they would admit Resident #5 on the morning of 3-12-13. One to One staff monitoring continued with Resident #5 until he was discharged from facility. On 3-12-13, Resident #5 was transported to outside psychiatric center for admission and no longer resides at this facility. What measures were put in place for residents having the potential to be affected: On 3-11-13 at 7:00 pm a 100 percent audit was completed by the ADON on all residents residing in the locked dementia unit to check for any signs of injury or suspicious signs of resident to resident abuse. No negative outcomes were identified in this audit. On 3-12-13 the audit was expanded by the floor nurses to the remaining residents residing in the nursing facility as an additional precautionary intervention to check for any signs of injury or resident to resident abuse. No negative outcomes were identified from this audit. The Corporate Nurse Consultants completed a 100 percent audit of resident nurses notes starting on 3-11-13 and completed on 3-12-13 for the time period of documentation from 12-1-2012 to present 3-11-2013, to assure there were no nursing documentation of resident to resident episodes that may not have been previously identified in incident reporting with no negative o