Every finding on record at Ridgewood Living & Rehabilitation Center

Based on observations, record review, and resident, staff and physician interviews, the facility failed to provide care in a safe manner when Resident #74 a) rolled out of bed during care sustaining a left front scalp hematoma (an injury with swelling caused by blood pooling under the skin) requiring evaluation in the emergency room and b) rolled out of bed during care sustaining a 15 centimeter scalp laceration (cut) requiring evaluation in the emergency room and wound closure with 9 sutures (stiches) and 7 staples. This was for 1 of 5 residents reviewed for accidents (Resident #74).Findings included:1a. Resident #74 was admitted to the facility on [DATE] with a diagnosis of muscle weakness.Resident #74's physician's orders revealed she was not receiving any anti-coagulant (blood thinning) medication.A nursing progress note for Resident #74 dated 7/12/24 at 12:30 PM written by Nurse #2 revealed he had been called to Resident #74's room. Resident #74 was on the floor with a bump on her head. Resident #74 told Nurse #2 she fell out of bed stating, I just kept rolling. Nurse Aide (NA) #2 reported that while she was providing care to Resident #74, Resident #74 rolled off the bed. Resident #74 was sent to the hospital.On 9/5/25 at 12:29 PM a telephone interview with Nurse #2 indicated he was caring for Resident #74 on 7/12/24 on the 7AM-3PM shift. He stated NA #2 reported to him she had been assisting Resident #74 with her bath that morning, had rolled Resident #74 away from herself when providing the care and Resident #74 kept rolling off her bed. Nurse #2 stated when he entered Resident #74's room, he observed Resident #74 on her back on the floor beside her bed. He reported the bed was elevated about 2 feet off the floor. He indicated Resident #74 had not been complaining of pain but had a knot on the side of her head. He stated Resident #74 had been sent to the hospital for an evaluation.The hospital emergency room record for Resident #74 dated 7/12/24 revealed she was being evaluated after a fall in the facility. She had no open wound. She was complaining of right arm pain and a headache. She had a left frontal scalp hematoma with no fractures or brain bleeding.A Teachable Moment statement dated 7/12/24 signed by NA #2 revealed the issue was Resident #74 rolled off her bed when NA #2 was bathing her. NA #2 was instructed post-incident to roll residents towards herself when providing care or to obtain the assistance of a second person when providing care.NA #2 no longer worked at the facility. She was not available for interview.Resident #74's current comprehensive care plan revealed a focus area for Activities of Daily Living (ADL) care. The goal was for Resident #74 to allow care to be provided through the next review. An intervention dated last revised on 7/12/24 was Resident #74 preferred bed baths and required total assistance of 2 staff for this.Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She had no behaviors or rejection of care. She had functional limitation in range of motion on one side of her upper extremities, and both sides of her lower extremities. She was dependent to roll left to right in bed and for bathing. Resident #74 had no pain in the last 5 days. She had one fall with injury since her last MDS assessment.In an interview on 9/2/25 at 3:13 PM Resident #74 stated she did recall falling once and hurting her left side. She reported she did not recall what happened. She indicated that she felt safe during care.On 9/5/25 at 9:06 AM in an interview the Director of Nursing stated she did not recall much about Resident #74's fall on 7/12/24. She reported she did recall doing some audits and updating resident's care guides.On 9/5/25 at 11:14 AM in an interview the Administrator stated she participated in the investigation and the corrective action plan for Resident #74's fall from bed on 7/12/24. She reported NA #2 had rolled Resident #74 away from herself instead of towards herself and turned to grab a towel. She stated Resident #74 slid off the side of the bed. The Administrator reported at the time of the incident on 7/12/24 Resident #74's assessed level of bed mobility was one person dependent assistance. She stated this was updated to 2 person dependent assistance after the incident. She went on to say Resident #74 should not have experienced a fall during the provision of care.On 9/5/25 at 12:17 PM a telephone interview with the Medical Director indicated Resident #74 should not have experienced a fall during the provision of care.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 07/12/2024, during Activities of Daily Living (ADLs) care, Nursing Assistant (NA) #2 turned the Resident #74 away from her; when NA #2 turned to grab a towel, the resident slid off the side of the bed.On 07/12/2024 Nurse #2 assessed the resident post-fall; edema to the forehead was noted. Nurse #3 notified the physician, obtained an order for Emergency Department (ED) evaluation, and the resident was sent to the ED. The Responsible Party (RP) was notified by nursing staff. The Director of Nursing (DON) completed immediate 1:1 education with NA #2 on proper bed-mobility and transfer technique, including log-rolling the resident toward the caregiver and proper repositioning techniques. The DON validated NA #2's competency to provide assistance with bed mobility using proper technique. The unit manager updated the electronic plan of care with the intervention: two-person assist for bed mobility, and reinforced use of proper technique during bed mobility and transfers.Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents who require assistance with bed mobility are at risk.On 07/12/2024 the DON/Assistant DON (ADON)/unit manager audited all residents' electronic plans of care to confirm that bed-mobility and transfer instructions emphasized proper technique. Audit results: 8 care plans were updated to ensure they reflected the appropriate level of care and emphasized proper technique for bed mobility and transfers.On 7/12/24 the administrator (or clinical designee) audited all incident reports for the prior 30 days for falls from bed; no additional concerns were identified.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 7/12/24 the DON initiated education for all staff nurses and Certified Nursing Assistants (CNAs) together on bed mobility and transfers, with emphasis on log-rolling toward the caregiver and proper repositioning techniques; competency validation was performed. No staff were permitted to work after 07/12/2024 without completing the education. On 7/12/24 the DON added this content to orientation for newly hired staff to be completed prior to assignment. Education/competency specifics: All staff nurses and CNAs completed the education by 07/12/2024; competency validations were completed 07/12/2024 and directly observed: Correctly accessing/reading the electronic plan of care to verify technique requirements for bed mobility and transfers Performing log-rolling toward the caregiver and proper repositioning techniques Safe technique/body mechanics during bed mobility/repositioning Clear handoff/communication of the resident's current technique requirementsIndicate how the facility plans to monitor its performance to make sure that solutions are sustained.The DON/ADON or designee will observe 10 bed-mobility/repositioning occurrences per week for 4 weeks, then 5 per week for 4 additional weeks, to verify that proper technique is used in alignment with the electronic plan of care, including residents requiring two-person assist. The decision to observe occurrences of bed mobility on all shifts was made on 7-12-24.The DON and/or administrator will review observation/audit results to identify trends and adjust the plan as needed to sustain compliance.Findings will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI); continued audits will occur at the discretion of the QAPI committee.The facility's corrective action plan was validated on 9/5/25. This validation included a reviews of the facility's initial audits, the facility's in-service education record and sign in sheets titled Bed Mobility and Transfers which including the educational materials for log rolling residents and repositioning, the facility's orientation competency checklist for which included repositioning and log rolling technique, checking the resident's care plan and communication system to determine the resident's specific needs and the number of staff required to complete the procedure, the facility's follow up audits and QAPI, interviews with Nurses and NAs regarding education and knowledge of repositioning and log rolling technique, checking the resident's care plan and communication system to determine the resident's specific needs daily and the number of staff required to complete the procedure and observations of NA's using the log rolling technique to turn resident's towards themselves when providing care with 1 person assistance.b) Resident #74's current comprehensive care plan revealed a focus area for Activities of Daily Living (ADL) care. The goal was for Resident #74 to allow care to be provided through the next review. An intervention dated last revised on 7/12/24 was bed mobility total dependence on 2 staff.Resident #74's physician's orders revealed she was not receiving any anti-coagulant (blood thinning) medication.Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She had no behaviors or rejection of care. She was dependent for toileting hygiene and for rolling left to right in bed. She was always incontinent of bowel and bladder. She had no falls since the prior assessment.A Nursing Progress note for Resident #74 dated 7/19/25 at 7:27 PM written by Nurse #1 revealed Nurse #1 was called to Resident #74's room by Nurse Aide (NA) #1. Resident #74 was lying on the floor, with a large area on her forehead that was opened wide, and an area on the back of her head which was bleeding. She was sent to the hospital.On 9/3/25 at 5:35 PM an interview with NA #1 indicated when she went in to provide incontinence care to Resident #74 on 7/19/25 on the 3PM-11PM shift, she had not asked anyone for help. She reported she had not seen anyone in the hall to ask. She stated although she had known how to and could access resident's care plans and Kardex since coming back to work at the facility in December of 2024, she had not checked Resident #74's prior to providing care to her. She indicated she did not know why. She stated Resident #74 had a large bowel movement and she wanted to get her cleaned up right away. NA #1 stated she pulled Resident #74 closer to herself using the draw sheet and when she went to turn Resident #74 to remove Resident #74's incontinence brief, Resident #74 rolled off the bed onto the floor. NA #1 stated that she could see that Resident #74 had a cut on the right side of her forehead and there was a lot of blood. She stated Resident #74 was quiet and she kept apologizing to Resident #74. NA #1 reported she called for the nurse, the nurse came and cleaned and bandaged Resident #74's wound. NA #1 stated she felt if she had asked someone to assist her with providing care to Resident #74 on 7/19/25, someone would have helped her. In a follow up interview with NA #1 on 09/04/2025 at 3:33 PM she indicated she and NA #3 usually worked together on the 3PM-11PM shift providing care to Resident #74, but on 7/19/25 NA #3 had been late coming to work.On 9/3/25 at 5:19 PM a telephone interview with Nurse #1 indicated she was in the hallway near Resident #74's room on 7/19/25 when NA #1 came out to say she needed help. Nurse #1 stated when she entered Resident #74's room she observed Resident #74 lying on the floor on her back. She indicated Resident #74's bed was elevated about 3 feet from the floor. She reported Resident #74 had a large gash on her forehead which was bleeding. She stated she could also see there was blood coming from the back of Resident #74's head. Nurse #1 indicated Resident #74 was complaining of pain to the right side of her body. She reported Resident #74 was sent to the hospital for an evaluation. She indicated she was familiar with Resident #74, and at the time of her fall on 7/19/25, 2 person assistance with bed mobility was listed on her Kardex which is the care guide NAs had access to. She stated when she asked NA #1 why she had not used a second person to provide care to Resident #74, NA #1 told her Resident #74 had a large bowel movement, and she wanted to get her cleaned up right away. Nurse #1 reported NA #1 had not asked her for help with providing care to Resident #74, or she would have assisted her.Resident #74's hospital record dated 7/19/25 revealed she was being seen after a fall from bed at the facility. She was unable to provide any history other than that she fell, and her head went boom. She had a significant scalp laceration which measured 15 centimeters in length. She was complaining of pain in her head. Her laceration was repaired using 7 staples and 9 sutures (stiches). She had no fractures or brain bleeding. She returned to the facility on 7/19/25.In an interview on 9/2/25 at 3:13 PM Resident #74 stated she did recall falling once and hurting her left side. She reported she did not recall what happened. She indicated that she felt safe during care.On 9/3/25 at 4:09 PM an observation of incontinence care was conducted for Resident #74 with NA #1 and NA #4. Both NAs confirmed access to Resident #74's Kardex and her need for 2 person assistance with bed mobility and ADL care prior to the provision of this care.On 9/5/25 at 7:55 AM an interview with the Medical Director indicated Resident #74 should have been provided with the appropriate level of staff assistance in accordance with her assessed need and her plan of care. He stated she should not have experienced a fall during the provision of care. He reported Resident #74's laceration had healed well, and she had not suffered any lasting harm from the incident.On 9/4/25 at 2:44 PM an interview with the Administrator indicated on 7/19/25, NA #1 was providing incontinence care to Resident #74 by herself. She reported this would not have been in accordance with Resident #74's plan of care or the information NA #1 would have had access to on Resident #74's Kardex at the time. The Administrator indicated although there were other staff available, NA #1 had not asked anyone else to assist her. She stated as a result, Resident #74 had experienced a fall from bed. She reported she felt if NA #1 had used the level of assistance indicated on Resident #74's Kardex, this fall could have been avoided.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 7/19/25 Resident #74 fell during staff-assisted repositioning; Nurse Aide (NA) #1 did not ensure the required level of assistance per Kardex.On 07/19/2025, a licensed nurse (Nurse #1) assessed the resident post-fall for injury; a laceration from the top of the head extending to the back of the head was noted.On 07/19/2025, the practitioner/MD was notified by the licensed nurse, and the resident was sent to the Emergency Department (ED) for treatment. On 07/19/2025, the responsible party was notified by the licensed nurse. On 07/19/2025, the involved Nursing Aide (NA #1) was re-educated by the unit manager on the resident's bed-mobility status and appropriate electronic plan of care use; the unit manager completed skill validation with the NA on safe assistance with bed mobility. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents who require two-person assistance with repositioning are at risk of being affected. On 07/20/2025, the unit manager/designee audited all residents' electronic plan of care entries to ensure the correct level of staff assistance was noted. Twenty-five Kardex's were updated by the MDS nurse on 7/21/2025 to reflect appropriate bed-mobility required assistance. The administrator reviewed risk reports involving staff assist with bed mobility for the prior three months; no other incidents were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 07/19/2025, Administrator, Director of Nursing, and Unit Managers conducted targeted education for staff on (a) confirming Activities of Daily Living (ADL) status and required assistance in the electronic plan of care before providing care and (b) using the correct number of staff for bed mobility/repositioning per electronic plan of care. All direct-care staff completed education by 07/22/2025. 26 licensed nurses and 62 NAs were educated, as verified by signed attendance logs. No staff were permitted to work after 07/22/2025 without completing the education. Staff returning from leave/orientation are required to complete the same education prior to receiving an assignment. The facility completed competency validation for all licensed nurses and NAs. Competencies directly observed: Correctly accessing and reading the electronic plan of care to verify ADL status and assistance level. Selecting and using the correct number of staff for all ADL care and in-bed repositioning per electronic plan of care. Safe technique and body mechanics during bed mobility/repositioning. Clear handoff/communication that reinforces the resident's current assist level.Education for newly hired NAs (and licensed nurses, as applicable) will be provided by the Director of Nursing (DON)/Assistant Director of Nursing (ADON)/nurse manager or charge nurse upon hire and prior to receiving an assignment. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The DON/ADON or designee will observe 5 occurrences of bed-mobility/repositioning weekly for 8 weeks to verify that the method used matches the electronic plan of care. These observations will include residents requiring two-person assist. The decision to observe occurrences of bed mobility on all shifts was made on 7-19-25. The DON and/or Administrator will review audits/observations to identify patterns/trends and will adjust the plan as necessary for continued compliance. The DON and/or Administrator will review the plan and findings during monthly Quality Assurance and Performance Improvement (QAPI); continued audits will occur at the discretion of the QAPI committee.Completion date 7/23/25The facility's corrective action plan was validated on 9/5/25. This validation included a reviews of the facility's initial audits, the facility's in-service education record and sign in sheet titled Accessing Kardex/ADL Status/Assist Required, the facility's orientation competency checklist for which included repositioning and log rolling technique, checking the resident's care plan and communication system daily to determine the resident's specific needs and the number of staff required to complete the procedure, the facility's follow up audits and QAPI, interviews with Nurses and NAs regarding education and knowledge of checking the resident's care plan and communication system daily to determine the resident's specific needs and the number of staff required to complete the procedure and observations of NA's accessing resident's Kardex and the provision of care with the number of staff and level of assistance specified.The facility's completion date of 7/23/25 for the corrective action plan was validated.

Based on record review and resident, staff and physician interviews the facility 1) failed to provide education regarding the benefits and possible side effects of a COVID-19 vaccination, offer a COVID-19 vaccination, and then document either a refusal or the administration of a COVID-19 vaccination in the past 14 months in the resident's medical record for 2 of 5 residents (Resident #54 and Resident #71) and 2) failed to maintain documentation that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine and were offered the COVID-19 vaccine or information on obtaining a COVID-19 vaccine in the past 14 months for 156 of 156 facility staff reviewed for COVID-19 immunization.Findings included:A review of the facility's policy titled COVID-19 Vaccine dated 12/28/21 revealed in part the following: COVID-19 Vaccine Education for Staff and Resident 1. COVID-19 vaccinations shall be offered to all staff and residents (or applicable POA [Power of Attorney]/Guardian) . per CDC [Centers for Disease Control and Prevention] guidance . 2. All staff and residents (applicable POA/Guardian) shall receive education regarding COVID-19 vaccine in a manner they can understand including information on the benefits and risk consistent with the CDC and/or FDA [Food and Drug Administration] information. The education, at a minimum shall include the FDA, EUA [Emergency Use Authorization] Fact Sheet or VIS [Vaccine Information Statement] for the vaccine being offered.A review of the CDC document titled Staying Up to Date with COVID-19 Vaccines dated 6/6/25 revealed in part the following: CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older.The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. Vaccine protection decreases over time.Getting the 2024-2025 COVID-19 vaccine is especially important if you: never received a COVID-19 vaccine, are ages 65 years and older.are living in a long-term care facility.1a. Resident #54 was admitted to the facility on [DATE] with a diagnosis of depression.Her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was [AGE] years old. She was cognitively intact. Her COVID-19 vaccine was not up to date.Resident #54's medical record did not reveal any documentation indicating she had been provided education regarding the benefits and possible side effects of a COVID-19 vaccination, offered a COVID-19 vaccination or a refusal or the administration of a COVID-19 vaccination in the past 14 months.On 9/4/25 at 12:42 PM an interview with Resident #54 indicated she thought she recalled being offered a COVID-19 vaccine in the facility after being educated on the risks versus the benefits of the vaccine recently, and she gave her consent. She stated she had not received the vaccine yet but thought she might in the next month or two.b. Resident #71 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD).Resident #71's annual MDS assessment dated [DATE] revealed she was [AGE] years old. She was cognitively intact. Her COVID-19 vaccine was not up to date.Resident #71''s medical record did not reveal any documentation indicating she had been provided education regarding the benefits and possible side effects of a COVID-19 vaccination, offered a COVID-19 vaccination or documentation of either a refusal or the administration of a COVID-19 vaccination in the past 14 months.On 9/4/25 at 10:25 AM an interview with Resident #54 indicated she thought she recalled being offered a COVID-19 vaccine in the facility in the last year. She stated she recalled she refused, because the last 2 times she received a COVID-19 vaccine she got sick with COVID-19.On 9/4/25 at 12:51 PM an interview with the Infection Preventionist indicated she was not sure what the current CDC recommendation was for the COVID-19 vaccine. She stated she was not aware of any education or offer of the COVID-19 vaccine since the last round of boosters for residents which was in October of 2024. She reported the facility did have access to the COVID-19 vaccine and could get it from the pharmacy.In an interview on 9/4/25 at 1:11 PM the Director of Nursing (DON) stated the facility had access to the COVID-19 vaccine and had provided this to some residents in October of 2024. She indicated Resident #54, and Resident #71 should have documentation of education regarding the benefits and possible side effects of a COVID-19 vaccination, an offer of a COVID-19 vaccination, and then documentation of either a refusal or the administration of a COVID-19 vaccine in the past 14 months in their medical record.In an interview on 9/4/25 at 1:13 PM the facility's Regional Director of Clinical Operations stated the COVID-19 vaccine should be offered annually.On 9/4/25 at 2:44 PM an interview with the Administrator indicated she was not sure what the current CDC recommendation was for the COVID-19 vaccine but she though it was recommended annually. She reported there should be documentation in resident's medical record that they received education regarding the benefits and possible side effects of a COVID-19 vaccination, an offer a COVID-19 vaccination, and then documentation of either a refusal or the administration of a COVID-19 in the past 14 months.On 9/05/2025 at 7:51AM in an interview the Medical Director stated there had been a new COVID-19 vaccine available in October 2024. He reported based on the new guidelines the facility would need to look into what the current COVID-19 vaccine recommendation was. He indicated the facility had 7 residents test positive for COVID in January 2025. He stated 2 roommates of positive residents had been vaccinated and had not tested positive.2. In an interview on 9/4/25 at 12:51 PM the Infection Preventionist stated she was not sure what the current CDC recommendation was for the COVID-19 vaccine. She indicated she was not aware of any education or offer of the COVID-19 vaccine for staff in the past 14 months.An interview on 9/4/25 at 1:11 PM with the Director of Nursing (DON) indicated she thought the facility had done education for staff in the past 14 months regarding the benefits and potential risks associated with the COVID-19 vaccine and were offered the COVID-19 vaccine or information on obtaining a COVID-19 vaccine, but she could not find any documentation.In an interview on 9/4/25 at 1:13 PM the facility's Regional Director of Clinical Operations stated the COVID-19 vaccine should be offered annually.On 9/4/25 at 2:44 PM an interview with the Administrator indicated she was not sure what the current CDC recommendation was for the COVID-19 vaccine, but she thought it was recommended annually. She reported she was not aware of any education regarding the benefits and possible side effects of a COVID-19 vaccination, an offer a COVID-19 vaccination or information on obtaining one for staff in the past 14 months. In a follow-up interview on 9/5/25 at 3:37 PM the Administrator stated the facility had 156 regular and contract staff.

Based on record review and staff interviews the facility failed to ensure nurse aides (NAs) received 12 hours of in-service training annually which included abuse and dementia training. This was for 3 of 5 NA files reviewed (NA#5, NA #6, and NA #7).Findings included: 1a. A review of the employee file and training information for NA #5 indicated a hire date of 2/1/24. There was no dated training to provide evidence NA #2 received 12 hours of in-service training including abuse and dementia training in the previous 12 months.b. A review of the employee file and training information for NA #6 indicated a hire date of 7/11/24. There was no dated training to provide evidence NA #6 received in-service training on abuse and dementia training in the previous 12 months.c. A review of employee file and training information for NA #7 indicated a hire date of 6/20/24. There was no dated training to provide evidence NA #7 received abuse training in the previous 12 months.On 09/5/2025 at 1:06 PM an interview with the Staff Development Coordinator (SDC) indicated she was responsible for tracking NAs in-service training. She reported all training for NAs was done in person. She stated she was not aware that 12 hours of in-service training annually to include abuse and dementia training was mandatory for NAs.On 9/5/25 at 2:45 PM an interview with the Director of Nursing indicated she was not aware NAs needed to have 12 hours of in-service education annually that included abuse and dementia training.In an interview on 09/05/2025 at 2:55 PM the Administrator stated that she knew the facility was lacking in the required education for NAs. She reported that the facility had some turnover in the SDC position, and now hopefully would get back on track with this.

Based on observations, record reviews, and interviews with staff, pharmacy consultant, pharmacy accounts receivable clerk, and Medical Director, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 6 residents reviewed for medications (Resident #22).The findings included:A review of the facility's policy titled Abuse and Neglect Protocol dated 9/24/18 and last revised on 6/13/21 revealed in part Misappropriation of resident property is defined as the deliberated misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Resident #22 was admitted to the facility on [DATE].A physician ordered dated 9/25/24 written by the Medical Director read Oxycodone (controlled pain medication used to treat moderate to severe pain) 5mg (milligram tablet). Take one tablet by mouth every 4 hours as needed.A physician ordered dated 9/25/24 written by the Medical Director revealed Buspirone (a medication used to treat anxiety) 5mg tablets. Give 1 tablet by mouth two times a day for mild neurocognitive disorder. This order was discontinued on 7/1/25.A delivery slip from the pharmacy dated 6/13/25 revealed 30 Oxycodone 5mg tablets were delivered to the facility on 6/13/25.A review of the Medication Administration Record (MAR) dated June 1, 2025-June 30,2025 revealed Nurse #8 was the last to sign off as administering the Oxycodone on 6/19/25 at 10:06 PM. Attempts to reach Nurse # 8 who last signed out the oxycodone were unsuccessful.The facility reported incident dated 6/23/25 revealed the Director of Nursing (DON) and Administrator were notified by Nurse #7 that the back of a controlled narcotic card had been taped. The reporting hall nurse observed that six pills in the card had been replaced with similar looking pills and taped closed. The resident did not miss any doses of the prescribed pain medication. Review of the facility reported investigation dated 6/30/25 and signed by the DON and Administrator read in part the facility did not substantiate abuse and or neglect. A telephone interview was conducted with Nurse #7 on 9/4/25 at 10:00 AM. She revealed Resident #22 called out for a pain pill on 6/22/25, when she went to get Resident #22's oxycodone card she noticed the size and shape of the pill did not look like an oxycodone. Nurse #7 then used her cellphone to look up the pill in the card and it was Buspirone. Nurse #7 then looked at the back of the narcotic card and noticed 7 oxycodone pills had been removed and replaced with Buspirone. There was a small incision in the foil like covering on the back of the card covered up by tape. She then reported what she found to Nurse #5. She went on to say Resident #22 rarely asks for her Oxycodone medication and did not feel Resident #22 experienced pain due to this issue as it was an as needed medication and Resident #22 had plenty. Nurse #7 did say when she began this shift, she and Nurse #10 did complete a narcotic count and neither one of them noticed the pills were different or the tape on the back of the card. Nurse #7 added that typically a nurse would not look at the back of the narcotic card when counting. She did not remember what happened to the Buspirone that was diverted into the oxycodone card. Attempts to reach Nurse #10 who counted the narcotics with Nurse #7 were unsuccessful.An interview with Nurse #5 was conducted on 9/4/25 at 10:30 AM. She stated Nurse #7 called her on her mobile phone and she came to the facility. Nurse #7 told her the oxycodone had been replaced with Buspirone. She revealed Nurses were documenting that Resident #22 often refused her Buspirone, she did not know how many had been replaced. Resident #22 did have more Buspirone available to her in the medication cart. An interview with the DON was held on 9/4/25 at 11:10 AM. She revealed she did not remember who notified her of the incident. After notification she went to the facility and spoke with Nurse #7. Nurse #7 told her the Oxycodone had been replaced with Buspirone and taped closed with medical tape. The DON then reported it to the Administrator. Drug tests were administered to everyone that had worked on that medication cart. The DON also stated she did not feel the resident was ever in pain or had anxiety due to the pills being taken. She said Nurse #5 and herself wasted the 7 Buspirone pills. The DON notified the pharmacy about the missing Oxycodone and wasted Buspirone. A delivery slip from the pharmacy dated 6/28/25 revealed 7 oxycodone 5 mg tablets were delivered on 6/28/25.An interview was held with the Pharmacy Director on 9/4/25 at 11:20 AM. She stated she did not see any notes that the incident had been reported but did see on 6/28/25, 7 oxycodone pills were dispersed to the facility for Resident #22. She could not tell me who requested the pills or paid for them.An interview with the Pharmacy Accounts receivable clerk on 9/4/25 at 11:35 AM revealed on 6/28/25, 7 oxycodone pills were dispersed for Resident #22. Resident #22's insurance was billed and paid for the medication. There were no Buspirone ordered or sent out for Resident #22 in the month of June 2025.An interview with Resident #22 was conducted on 9/4/25 at 11:50 AM, she was lying in bed in her room. She stated that if she was in pain she asks for pain medication, she also said when she asks for pain medication the nurses did give it to her.An interview was conducted with the Administrator on 9/4/25 at 2:00 PM. She stated she was notified by the DON and Nurse #5 of the missing pills. Local law enforcement was notified. She also stated the facility paid to replace the oxycodone. When asked, she stated she was not aware Resident #22's oxycodone was billed to and paid for by Resident #22's insurance. She also stated education, and systems had been put into place to keep the incident from recurring. The Administrator and DON completed the investigation including drug tests for Nurse #7 and Nurse #8 both of which were positive for Oxycodone. The facility did not substantiate abuse or neglect. An interview with the Medical Director was held on 9/5/25 at 8:00 AM. He stated he was made aware of the incident of drug diversion. He also stated he did not feel the resident was adversely affected by the drug diversion.A follow up interview with the Pharmacy Director on 9/5/25 at 10:30 AM revealed she vaguely remembered the situation but felt there was a conversation with someone at the facility around payment of the oxycodone and the billing of Resident #22's insurance was a pharmacy error as the facility should have been billed.A review of the email to the Administrator from the Pharmacy Director dated 9/4/25 at 2:35 PM, revealed the pharmacy reversed the charges to Resident #22's insurance and billed the facility.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls. This was for 1 of 5 residents (Resident #74) reviewed for accidents.Findings included:Resident #74 was admitted to the facility on [DATE].Resident #74's hospital record dated 7/19/25 revealed she was being seen after a fall from bed at the facility. She had a significant scalp laceration which measured 15 centimeters in length. Her laceration was repaired using 7 staples and 9 sutures (stiches).Resident #74's annual MDS assessment dated [DATE] revealed she had one fall with no injury and one fall with injury since her prior MDS assessment.Resident #74's medical record revealed no other falls since her prior MDS assessment dated [DATE].On 09/05/2025 at 8:03 AM an interview with MDS Nurse #1 indicated she coded the falls section of Resident #74's MDS assessment dated [DATE]. She reported on 7/19/25 Resident #74 had one fall with injury. She stated her coding on Resident #74's MDS assessment dated [DATE] that Resident #74 also had one fall with no injury was an error. MDS Nurse #1 stated when she reviewed Resident #74's incident reports prior to coding her 7/25/25 MDS assessment, there was one for a fall dated 7/12/24 directly above the one for her fall with injury on 7/19/25, and she looked at the date wrong.On 9/5/25 at 2:37 PM an interview with the Director of Nursing indicated that resident's MDS assessments should be coded accurately.On 9/5/25 at 2:55 PM an interview with the Administrator indicated MDS assessments should be accurately coded.

Based on observation, record review and staff interviews, the facility failed to develop an individualized, person-centered comprehensive care plan to include the use of side rails for 1 of 2 residents reviewed for side rails (Resident #5).Findings included: 1.Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 5 and generalized muscle weakness. Review of Resident #5's electronic record revealed an assessment titled bed rail/assist device dated 8/24/24 and completed by Nurse #9 that indicated Resident #5 did not need or use side rails. A care plan with the latest review date of 9/9/24 revealed no reference to use of side rails for Resident #5. A quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #5 was cognitively intact. The MDS indicated Resident #5 required partial to moderate assistance with bed mobility, substantial/maximal assistance with lying to sitting on the side of the bed and was non-ambulatory. The MDS revealed Resident #5 had no impairment to her upper or lower extremities. The MDS indicated Resident #5's siderails were not used as a restraint. An observation and interview were conducted on 9/3/25 at 3:56 PM. Resident #5 was observed lying in bed with bilateral grab bars in the up position on the bed. Resident #5 indicated she used the grab bars to help her roll over in bed during care. The grab bars were approximately 12 inches x 12 inches square.An interview with MDS Nurse #2 was conducted on 9/3/25 at 4:19 PM. MDS Nurse #2 stated she was responsible for updating care plans with information she received from the nursing assessments or verbal directive given to her by nursing. In an interview with the Director of Nursing (DON) on 9/5/25 at 10:08 AM she stated the MDS Nurse was responsible for updating the care plan to include side rail usage. In an interview with the Administrator on 9/5/25 at 10:10 AM she stated side rail usage should be included in the resident's care plan.

Based on observation, record review, staff and Medical Director interviews, the facility failed to maintain the sterility of tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) care when Nurse #4 failed to perform hand hygiene and don (put on) sterile gloves after touching and disposing of a soiled split gauze pad and inner cannula and before placing the new sterile inner cannula and clean split gauze as well as donning sterile gloves over soiled gloves prior to suctioning. This was for 1 of 1 resident reviewed for tracheostomy care (Resident #9). Findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses that included persistive vegetative state and tracheostomy status. Resident #9's care plan last revised on 7/12/24 revealed him to have a tracheostomy. Resident #9's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was unable to be assessed for cognition due to comatose state. He was documented to receive tracheostomy care in the facility. A continuous observation of tracheostomy care was observed on 9/3/25 at 11:53 AM with Nurse #4. At 11:53 AM she performed hand hygiene and donned clean gloves retrieved from her pocket. She poured normal saline onto clean gauze. Nurse #4 then removed the trach cap (sits on the end of the inner cannula) and soiled gauze from behind the tracheostomy flange, picked up clean gauze soaked with normal saline and cleaned around the stoma site behind the tracheostomy flange. Nurse #4 proceeded to change the tracheostomy tie that holds the flange in place and replaced the split gauze that sits behind the flange with a clean split gauze. Next, Nurse #4 removed the soiled inner cannula and inserted the sterile inner cannula. Nurse #4 then removed her gloves and washed her hands to prepare to suction Resident #9. Nurse #4 donned clean gloves taken from her pocket, opened a new container of normal saline, dated the bottle and poured some into a sterile cup. She then put the main suction tube under the resident's blanket at his chest and donned sterile gloves over the gloves she was already wearing. Nurse #4 then opened the sterile suction tubing, attached it to the main tubing that had been under the blanket and suctioned the resident. When finished, Nurse #4 removed both pairs of gloves, threw away the trash and washed her hands. In an interview with Nurse #4 on 9/3/25 at 12:18 PM she stated she should have removed the cap, soiled inner cannula and soiled split gauze, performed hand hygiene, donned sterile gloves and then handled the sterile inner cannula and clean split gauze. In an interview with the Director of Nursing (DON) on 9/3/25 at 12:25 PM, she stated Nurse #4 should have performed all tasks involving soiled items such as removing the used split gauze and used inner cannula and performed hand hygiene and donned sterile gloves before touching the sterile inner cannula and placing the clean gauze behind the flange. The DON indicated Nurse #4 should have removed her soiled gloves, performed hand hygiene and then donned sterile gloves before suctioning. An interview was conducted with the Administrator on 9/3/25 at 2:05 PM. She indicated Nurse #4 should not have touched the sterile inner cannula and clean gauze without performing hand hygiene and donning sterile gloves first. She stated bacteria could have been transferred from the soiled gloves to the sterile cannula and then to Resident #9's respiratory system potentially causing a respiratory infection. She further stated putting sterile gloves over soiled gloves was not acceptable. In an interview with the Infection Preventionist (IP) on 9/5/25 at 9:17 AM she stated that Nurse #4 should have removed the soiled gauze and soiled inner cannula, discarded them, performed hand hygiene and then donned sterile gloves before handling the sterile inner cannula and clean split gauze. The IP indicated keeping the procedure as sterile as possible was important to prevent the spread of bacteria to Resident #9's respiratory system. In an interview with the Medical Director on 9/5/25 at 8:05 AM he stated the respiratory tract was not a sterile space and he did not feel Nurse #4 put Resident #9 at risk by not following professional standards of practice and infection prevention measures.

Based on observations, staff interviews, and record review the facility failed to attempt alternatives prior to installing siderails, complete siderail assessments, assess entrapment risk, review the risks and benefits of siderails with the resident /resident representative and obtain informed consent prior to siderail use for 2 of 2 residents reviewed for siderails (Resident #5, Resident #4).Findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 5 and generalized muscle weakness. Review of Resident #5's information face sheet revealed she was her own Responsible Party. Review of Resident #5's electronic medical record revealed an assessment titled bed rail/assist device dated 8/24/24 and completed by Nurse #9. The response to the question, Bed rails/assist devices are indicated for the resident at this time? was no. In an interview with Nurse #9 on 9/5/25 at 10:29 AM he stated he completed the assessment in Resident #5's room on 8/24/24. Nurse #9 indicated the grab bars were on the bed when he completed Resident #5's bed rail/device assessment. Nurse #9 further stated he was unaware grab bars were considered side rails. He did not try alternatives to grab bars, did not assess for entrapment risk or review risks and benefits or obtain consent for grab bars from Resident #5. A care plan with the latest review date of 9/9/24 revealed no reference to use of grab bars for Resident #5. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. The MDS indicated Resident #5 required partial to moderate assistance with bed mobility, substantial/maximal assistance with lying to sitting on the side of the bed and was non-ambulatory. The MDS further revealed Resident #5 had no impairment to her upper or lower extremities. The MDS indicated Resident #5's grab bars were not used as a restraint. An observation and interview were conducted on 9/3/25 at 3:56 PM. Resident #5 was observed lying in bed with bilateral grab bars in the up position on the bed. Resident #5 indicated she used the grab bars to help her roll over in bed during care. The grab bars were approximately 12 inches x 12 inches square. In an interview with Nurse Aide (NA) #3 on 9/3/25 at 4:01 PM she indicated Resident #5 utilized the bilateral grab bars to assist with turning and repositioning. In an interview with the Unit Manager (UM) #1 on 9/3/25 at 4:15 PM, she indicated the admitting nurse completed the initial bed rail/assist device assessment and MDS completes a new one after that if needed. UM #1 stated they did not try alternatives before using side rails/grab bars and the assessment for entrapment was included in the bed rail/assist device assessment. UM #1 further stated the bed rail/assist device assessment had a place at the bottom for the nurse to sign that they reviewed the risks and benefits of grab bar usage with the resident or the resident representative. UM #1 revealed grab bars are kept on the beds between admissions but are strapped down with zip ties until it was determined if the resident needed them or not. UM #1 was unaware that Resident #5 had bilateral grab bars on her bed. A follow-up observation was conducted on 9/4/25 at 2:49 PM. Resident #5 was lying in bed with both grab bars raised. In an interview with the Director of Nursing (DON) on 9/5/25 at 10:08 AM she stated the admissions nurse completed the first bed rail/assist device assessment and MDS completed one quarterly and as needed, such as if therapy recommends grab bars or the resident or resident representative requests grab bars. The DON further stated entrapment risk was included in the bed rail assessment and the nurse reviews risks and benefits with the resident on the resident's family on a separate paper consent form. The DON indicated she was unaware that alternatives to grab bars needed to be tried and documented before using them and was also unaware that Resident #5 had bilateral grab bars on her bed. The DON revealed grab bars were left on the beds between admissions, but they are supposed to be zip tied down until it was decided if the resident needed them or not. An observation was conducted with the DON on 9/5/25 at 12:14 PM to locate the form that reviewed risks and benefits and gained consent for grab bars in the hard chart. The DON was unable to locate a consent form for the use of grab bars. In an interview with the Administrator on 9/5/25 at 10:10 AM she stated she was unaware alternatives to grab bars needed to be tried before they were used and was unaware grab bars were considered side rails. The Administrator indicated the paper consent form that reviews risks and benefits was probably kept in the hard charts behind the nurse's station. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus Type II and generalized muscle weakness. Review of Resident #4's care plan last revised 7/11/24 revealed an intervention of a right sided grab bar x 1 (side rail)/assist device to allow increased mobility, aid in repositioning and/or transfers. A review of Resident #4's electronic record revealed an assessment titled bed rail/assist device dated 6/23/25 and completed by Nurse #6 indicated Resident #4 did not need or use grab bars. The response to the question, Bed rails/assist devices are indicated for the resident at this time? was no. An interview with Nurse #6 was completed on 9/4/25 at 3:09 PM. Nurse #6 indicated she completed the bed rail/assist device assessment for Resident #4 on her most recent admission. Nurse #6 stated completed the assessment in Resident #4's room and she marked Resident #4 as not using or needing side rails as Resident #4 had what the facility called grab bars on her bed. She further stated alternatives to grab bars were not tried before a resident used them. Nurse #6 did not assess for entrapment risk or review risks and benefits and obtain consent for grab bars from Resident #4's Responsible Party as she was unaware grab bars were considered side rails. Review of Resident #4's quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed she was severely cognitively impaired. The MDS indicated Resident #4 required partial to moderate assistance with bed mobility, was dependent on staff for lying to sitting on the side of the bed and was non-ambulatory. The MDS revealed Resident #4 had impairment to both her upper and lower extremities. The MDS indicated Resident #4's grab bars were not used as a restraint. An observation of Resident #4 was conducted on 9/3/25 at 3:56 PM. Resident #4 was observed lying in bed with bilateral grab bars in the raised position. The grab bars were metal and approximately 6 inches wide and 18 inches tall. A follow-up observation was conducted on 9/4/25 at 2:48 PM. Resident #4 was observed lying in bed with bilateral grab bars in the raised position. Resident #4's Responsible Party was not available for interview. In an interview with Nurse Aide (NA) #3 on 9/4/25 at 2:52 PM she indicated Resident #4 used bilateral grab bars to help turn and reposition during care. In an interview with the Unit Manager (UM #1) on 9/3/25 at 4:15 PM, she indicated the admitting nurse completed the initial bed rail/assist device assessment and MDS completes a new one after that if needed. UM #1 stated they did not try alternatives before using grab bars and the assessment for entrapment was included in the bed rail/assist device assessment. UM #1 further stated the bed rail/assist device assessment had a place at the bottom for the nurse to sign that they reviewed the risks and benefits of grab bar usage with the resident or the resident representative. UM #1 revealed grab bars are kept on the beds between admissions but are strapped down with zip ties until it was determined if the resident needed them or not. UM #1 was unaware that Resident #4 had bilateral grab bars on her bed. In an interview with the Director of Nursing (DON) on 9/5/25 at 10:08 AM she stated the admissions nurse completed the first bed rail/assist device assessment and MDS completed one quarterly and as needed, such as if therapy recommends grab bars or the resident or resident representative requests grab bars. The DON further stated entrapment risk was included in the bed rail assessment and the nurse reviews risks and benefits with the resident on the resident's family on a separate paper consent form. The DON indicated she was unaware that alternatives to grab bars needed to be tried and documented before using them and was also unaware that Resident #4 had bilateral grab bars on her bed. The DON revealed grab bars were left on the beds between admissions, but they are supposed to be zip tied down until it was decided if the resident needed them or not. An observation was conducted with the DON on 9/5/25 at 12:14 PM to locate the form that reviewed risks and benefits and gained consent for grab bars in the hard chart. The DON was unable to locate a consent form for the use of grab bars. In an interview with the Administrator on 9/5/25 at 10:10 AM she stated she was unaware alternatives to grab bars needed to be tried before they were used and was unaware grab bars were considered side rails. The Administrator indicated the paper consent form that reviews risks and benefits was probably kept in the hard charts behind the nurse's station.

Based on observation, record review, staff and Medical Director interviews, the facility failed to follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a tracheostomy (a surgically created opening in the windpipe through the neck to provide an airway for breathing) when Nurse #4 provided tracheostomy care without wearing a gown. This was for 1 of 12 staff observed for infection control practices (Nurse #4).Findings included: The facility policy titled Enhanced Barrier Precautions (EBP) dated 4/24/24 stated in part: EBP's are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. Gloves and gowns are applied prior to performing high-contact resident care activities such as tracheostomy care. Observation of Resident #9's door on 9/3/25 at 11:53 AM revealed signage for EBP. The signage indicated that staff providing high contact care to Resident #9 were required to wear gowns and gloves. Further observation revealed a caddy hanging Resident #9's door that contained Personal Protective Equipment (PPE) including gowns and gloves. A continuous observation of tracheostomy care was observed on 9/3/25 at 11:53 AM with Nurse #4. At 11:53 AM she performed hand hygiene and donned clean gloves retrieved from her pocket. Nurse #4 did not don a gown. She proceeded to provide tracheostomy care and suctioning to the resident. In an interview with Nurse #4 on 9/3/25 at 12:18 PM she stated she never wore a gown while performing tracheostomy care as she thought EBP was only needed for incontinence care. Nurse #4 was observed reading the EBP sign located on Resident #9's door after which she stated she saw that she should have been wearing a gown while performing tracheostomy care. In an interview with the Infection Preventionist (IP) on 9/5/25 at 9:17 AM she stated that Nurse #4 should have worn a gown while providing tracheostomy care. The IP indicated following EBP policy was important to prevent the spread of bacteria to Resident #9's respiratory system. In an interview with the Director of Nursing (DON) on 9/3/25 at 12:25 PM, she stated Nurse #4 should have worn a gown and gloves while providing tracheostomy care to prevent the spread of infection from one resident to another. An interview was conducted with the Administrator on 9/3/25 at 2:05 PM. She indicated Nurse #4 should have followed the EBP policy and donned a gown in addition to the gloves before entering Resident #9's room to provide tracheostomy care. In an interview with the Medical Director on 9/5/25 at 8:05 AM he stated the respiratory tract was not a sterile space and he did not feel Nurse #4 put Resident #9 at risk by not following the EBP policy.

Based on record review and resident, Responsible Party (RP), staff and physician interview the facility failed to provide education regarding the benefits and possible side effects of a pneumococcal immunization, offer a pneumococcal immunization, and then document either a refusal or the administration of a pneumococcal immunization for 1 of 5 residents reviewed for immunizations (Resident #6).Findings included:The facility's undated policy titled Pneumococcal Vaccine revealed in part: All residents will be offered pneumococcal vaccines to aid in the preventing pneumonia/pneumococcal infections.7. Administration of the pneumococcal vaccines or vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination.The CDC document titled Summary of Risk-based Pneumococcal Vaccine Recommendations dated 5/24/2025 revealed in part the following: Adults aged 19-[AGE] years old; The following guidance applies to adults younger than [AGE] years old who have a risk condition [risk conditions listed included chronic lung disease including chronic obstructive pulmonary disease (COPD) and cigarette smoking]. Never received any pneumococcal vaccine; give one dose of PCV 15 (Pneumococcal 15-valent Conjugate Vaccine), PCV 20 (Pneumococcal 20-valent Conjugate Vaccine) or PCV 21 (Pneumococcal 21-valent Conjugate Vaccine).Resident #6 was admitted to the facility on [DATE] with a diagnosis of COPD.Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was [AGE] years old. She was moderately cognitively impaired. She was a current tobacco user. Her pneumococcal vaccine was not up to date.Resident #6's current comprehensive care plan revealed she was a supervised smoker.Resident #6's medical record did not reveal any documentation she had been educated on the benefits and possible side effects of a pneumococcal vaccine or refused the vaccine. Additionally, there was no documentation indicating a pneumococcal vaccine had ever been administered to her.On 9/4/25 at 9:29 AM a telephone interview with Resident #6's RP indicated he was not aware of Resident #6 ever having a pneumococcal vaccine. He stated he did not recall the facility ever providing him with education on the risks versus the benefits of the pneumococcal vaccine or offering a pneumococcal vaccine for Resident #6. He reported if the vaccine had been offered, he would have accepted it.On 9/4/25 at 10:39 AM an interview with Resident #6 indicated she did not recall ever receiving a pneumococcal vaccine. She stated if one was offered to her, she would want to have it.On 9/4/25 at 12:15 PM an interview with the facility's Infection Preventionist (IP) indicated she was aware there was an issue with some residents not being up to date with their pneumococcal vaccine. She stated she was trying to get it under control. She reported she had spoken to the pharmacy about some residents who had one step of pneumonia vaccine and had been instructed just to go ahead and use the PCV 20 because that would cover anyone. She reported she had started the process of getting residents up to date beginning with the new admissions because they were the easiest due to already having their consents with education. From there she was taking it chart by chart and was also using a report that showed her everyone's immunizations. She indicated she had not gotten to Resident #6 yet. The IP stated the process should include documentation of education on the risks versus the benefits of the vaccine, consent or refusal and if there was consent then documentation of administration of the vaccine.On 9/4/25 at 1:11 PM an interview with the Director of Nursing indicated she did not have any documentation Resident #6 had been educated on the benefits and possible side effects of a pneumococcal vaccine and refused the vaccine. She reported there was no documentation indicating a pneumococcal vaccine had ever been administered to Resident #6.In an interview on 9/5/25 at 7:51 AM the Medical Director stated that Resident #6's COPD was not oxygen dependent or really a significant risk factor. He reported it was a diagnosis she had, and she probably should have been offered a pneumococcal vaccine.On 9/5/25 at 2:55 PM an interview with the Administrator indicated there should be documentation Resident #6 had been educated on the benefits and possible side effects of a pneumococcal vaccine and refused the vaccine or documentation indicating a pneumococcal vaccine had been administered to her. She reported she thought because of Resident #6's age, this might have gotten missed.

Based on record review, observations, staff and pest control contractor interviews, the facility failed to maintain an effective pest control program to prevent brown crawling bugs in 1 of 1 laundry room. The findings included:A review of the Pest Control Service Agreement dated 4/16/25 revealed the company would provide pest control services monthly and every week on 2 out of the 4 halls. An observation was conducted of the facility laundry room on 9/5/25 at 8:40 AM. The area in which the 2 washing machines were located revealed water standing on the floor covered by a flattened cardboard box. There were also 2 brown crawling bugs on the laundry room wall between the laundry chute and the laundry bin that receives soiled laundry. The observation also revealed 3 brown crawling bugs on the floor near the washing machines.An interview with the Housekeeping and Laundry Director was held on 9/5/25 at 8:50 AM. She stated the flattened cardboard box covering the standing water on the floor draining from the washing machines was to prevent the staff from slipping. She also stated she sees pests often and reports it to the maintenance department. She also enters the requests into the electronic maintenance tracking system. She went on to say she thought pest control representative came every other Tuesday.An interview with the Maintenance Director on 9/5/25 at 9:30 AM revealed he was aware there were pests in the laundry room, both water bugs and roaches. He stated the pest control representative started coming every week in June 2025. He stated when someone reports a pest sighting to him, he notes it in a log and enters it into the electronic maintenance tracking system. He went on to say the common areas are treated weekly and thought the laundry room was part of the common areas.Review of the pest control logbook dated June 2025-August 2025 revealed no pest control service requests were logged for the laundry area.An interview was conducted with the pest control service representative on 9/5/25 at 10:00 AM, he revealed he went to the facility on a weekly basis and treated the halls, he treated the laundry area monthly. He did not have documentation to show what areas he treats. He went on to say the water draining from the washing machines onto the floor was sometimes covered with flattened cardboard, these items could harbor pests and encourage pest growth.An interview was conducted with the Administrator on 9/5/25 at 1:00 PM. She stated the Assistant Maintenance Director shadows the pest control person when they were onsite. She went on to say her expectation was that the laundry room be treated by pest control services every week.An interview with the Assistant Maintenance Director was held on 9/5/25 at 1:30 PM. He stated the pest control service comes every Monday. There were no records of which areas were treated. He added, pest control services had not treated the laundry room, only the laundry chute that carries the soiled linen from the 4th floor hallway down into the basement laundry room. He stated he goes to the laundry area a couple times a week and had not seen pests. He went on to say the standing water covered with flattened cardboard could cause the growth of pests.

Based on observations, staff interviews, resident interviews, physician interview, and a pest control supervisor interview the facility failed to maintain an effective pest control program that was free of German cockroaches for 4 (Resident #3, Resident #4, Resident #5, and Resident #6) of 4 residents reviewed for pest control services. Findings included: Documentation on the facility pest control company contract initiated on 6/27/2022 indicated that both interior and exterior pest control services, including cockroaches, were provided weekly to all rooms located on one wing of the facility. Pest control services rotated accordingly, so all wings and facility rooms were serviced at least once per quarter. Documentation on a pest control contract signed on 12/11/2024 revealed that a Roach Cleanout was negotiated for Rooms 409, 413, 415, 417, 419, and 421. Documentation on an unsigned pest control contract revealed a Roach Cleanout was being considered for Rooms 301, 302, 303, 305, 307, and 317. a. An observation was conducted of Resident #4 in room [ROOM NUMBER] and Housekeeper #1 on 1/16/2025 at 1:29 PM. Resident #4 was observed lying on her back in bed with the head of her bed slightly elevated. Resident #4 was still finishing her lunch meal which sat on a bedside table in front of her. A cockroach crawled out from under the mattress and started crawling across the sheet toward the head of Resident #4. Resident #4 became alarmed and spoke out requesting for the cockroach to be removed. Housekeeper #1, who was in the doorway of the room, came into the room. Housekeeper #1 responded and flicked the cockroach off the bed to the floor. Housekeeper #1 then left the room. Housekeeper #1 was interviewed on 1/16/2025 at 1:29 PM. Housekeeper #1 stated she just flicked the cockroaches off the bed when she saw them. Houskeeper #1 revealed she often saw cockroaches in the resident rooms while cleaning. Housekeeper #1 further revealed she did not tell anyone about the cockroaches because she was sure they knew. Resident #4 was interviewed on 1/16/2024 at 1:31 PM. Resident #4 stated cockroaches frequently crawled in her bed, on the walls, and around the television. She said everyone knew they were there. b. An observation was made of Resident #4 in room [ROOM NUMBER] and the Director of Housekeeping on 1/16/2025 at 1:34 PM. The Director of Housekeeping observed a cockroach crawling up the wall behind the bed of Resident #4 and he took a facial tissue and squashed the insect, ultimately depositing the insect in the garbage can. The Director of Housekeeping was interviewed on 1/16/2025 at 1:34 PM. The Director of Housekeeping knew that the facility had the pest control company super treat some of the rooms in the 400 hallway and that the pest control company sprayed the whole building once a week. The Director of Housekeeping stated the only thing that could be done was to kill the cockroaches when they saw them and sweep them up. c. The following observation was made of room [ROOM NUMBER] on 1/16/2025 at 1:50 PM. Twenty cockroaches of various sizes crawled around on the room floor and under the bed. Three cockroaches were crawling up the wall behind the bed. Seven cockroaches were crawling around the door frame of the closet next to the bed. Two cockroaches were on the resident's bedside table. Nurse #1 was interviewed on 1/16/2024 at 2:13 PM. Nurse #1 stated he wrote out a work order that morning for maintenance to spray for the cockroaches in room [ROOM NUMBER]. An observation was made of room [ROOM NUMBER] on 1/16/2025 at 5:47 PM. Five cockroaches were crawling around the door frame of the closet next to the bed. An additional observation was made of room [ROOM NUMBER] on 1/17/2025 at 9:48 AM. Three cockroaches were crawling along the door frame of the closet next to the bed. Resident #5 in room [ROOM NUMBER] was interviewed on 1/17/2025 at 9:48 AM. Resident #5 stated that at night, cockroaches crawled on the ceiling and came from behind his television on the wall. d. Resident #3 in room [ROOM NUMBER] was interviewed on 1/16/2025 at 11:55 AM. Resident #3 stated she saw cockroaches all the time in her room, and she had to call someone into the room to either help her or her roommate kill them. e. An interview was conducted with NA #2 on 1/16/2025 at 1:40 PM and the following information was provided. NA #2 stated that morning she was in the room of Resident #6 assisting him with morning care when she moved the bed slightly. NA #2 stated that 30 cockroaches came out of the wheel well on the bed, crawling in all directions across the floor. NA #2 explained there was a part underneath the bed frame which was a small cylinder for which insects could hide. NA #2 stated everyone knew cockroaches were everywhere. NA #2 explained that Resident #6 did not see the cockroaches and could not understand. The facility Administrator was interviewed on 1/16/2025 at 1:52 PM. The Administrator stated the facility determined the only effective way to get rid of the cockroaches was for the Pest Control company to provide a clean out which involved a two-step process of removing the residents from the rooms, treating the room for cockroaches, and then returning two weeks later to treat the rooms again. The Administrator stated the cleaning out process had already been performed for some of the rooms in the 400 hallway but getting rid of the cockroaches was a work in progress. A Supervisor with the pest control company was interviewed on 1/16/2024 at 2:43 PM and the following information was provided. The Supervisor has been out to the facility on three occasions in the last year to have meetings with the Administrator and the Director of Maintenance to discuss how to address the cockroaches in the facility. The Supervisor did not recall the dates of the meetings with the facility. The facility has German cockroaches. The German cockroaches are very invasive and the best way to handle an infestation is with the clean out process. The room needs to have all personal items removed, the resident removed for 4 to 5 hours, and the room needs to be cleaned. The pest control company then uses an aerosol spray, bait, and dust to kill the cockroaches in the room. The whole process was repeated after 2 weeks. It was proposed that every room in each hallway receive the clean out service, with one-half of the hallway completed at a time. In December 2024 six rooms were approved by the facility to receive the clean out service. There was another contract to perform the clean out service for rooms in the 300 hallway but it was not yet signed or agreed upon by the facility. If one German cockroach was visualized, there were likely a hundred cockroaches in the room. The German cockroach can multiply from two to two hundred in one month. The food, crumbs, and clutter exacerbate the problem of cockroaches. Certain respiratory issues or asthma can be exacerbated due to the pheromones and fecal matter of the German cockroach. The facility Administrator was interviewed again on 1/16/2024 at 4:12 PM. The Administrator revealed that room [ROOM NUMBER] and Resident #6's room had been added to the list of rooms to undergo the clean out service. The Administrator did not recall the dates of the meetings with the pest control company to discuss cockroaches but acknowledged that three meetings had been held. The Director of Maintenance was interviewed on 1/17/2025 at 10:42 AM. The Director of Maintenance stated he did not know the cause of the cockroaches in the facility. The Director of Maintenance explained the cockroach problem was significant at one time, but it seemed to get better after the 400 hall was treated by the pest control company. The Director of Maintenance revealed that the charger for the electric wheelchair in room [ROOM NUMBER] was full of cockroaches but was cleaned. The Director of Maintenance thought the facility residents and family needed to address the clutter and the snacks in the rooms, so the cockroaches did not have a food source. The Director of Maintenance stated the contract for the clean out service for some of the rooms in the 300 hallway had been signed and was to be completed the following week. The facility's Medical Director was interviewed on 1/17/2025 at 12:15 PM. The Medical Director stated he had not seen cockroaches while visiting the facility's residents and did not think cockroaches caused any medical harm or created any medical issues.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for oxygen for 4 of 28 residents reviewed for MDS assessments (Resident #3, Resident #75, Resident #121, and Resident #328). Findings include: a.Resident #3 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, oxygen dependence, and hypoxemia (low levels of oxygen in body tissues). Review of physician orders dated 5/5/22 revealed an order for Resident #3 to receive continuous oxygen three liters per minute via nasal cannula (oxygen delivery method) to maintain oxygen saturation (measurement of oxygen in the blood.) above 90%. Review of the annual MDS assessment dated [DATE] for Resident #3 revealed she was cognitively intact. Resident #3 had not been coded for oxygen use on the assessment. Review of Resident #3's June 2024 Medication Administration Record (MAR) revealed that she received continuous oxygen via nasal cannula delivered at 3 liters per minute. b.Resident #75 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, and diabetes. Review of physician orders dated 2/20/24 revealed an order for Resident #75 to receive oxygen two liters per minute via nasal cannula (oxygen delivery method) every bedtime and while napping to maintain oxygen saturation (measurement of oxygen in the blood.) above 90%. Review of the annual MDS assessment dated [DATE] for Resident #75 revealed she was cognitively intact. Resident #75 had not been coded for oxygen use on the assessment. Review of Resident #75's June 2024 Medication Administration Record (MAR) revealed that she received oxygen via nasal cannula delivered at 2 liters per minute at bedtime and when she napped. 48230 c. Resident #121 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of Resident #121's physician orders dated 4/28/24 revealed an order for oxygen at two liters per minute via nasal cannula (oxygen delivery method). Review of the five-day MDS assessment dated [DATE] for Resident #121 revealed he was moderately cognitively impaired. The Resident had not been coded for oxygen use on the assessment. Review of Resident #121's Medication Administration Record (MAR) dated June 2024 revealed he received continuous oxygen delivered at two liters per minute via nasal cannula. d. Resident #328 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur and asthma. Review of physician orders dated 5/22/24 revealed an order for Resident #328 to receive continuous oxygen at four liters per minute via nasal cannula (oxygen delivery). Review of the five-day MDS assessment dated [DATE] for Resident #328 revealed she was mildly cognitively impaired. Resident #328 had not been coded for oxygen use on the assessment. Review of Resident #328's Medication Administration Record (MAR) dated June 2024 revealed she received oxygen via nasal cannula delivered at four liters per minute continuously. In interviews with the MDS coordinator on 6/11/24 at 9:38 AM and 12:59 PM she stated that Resident #121, Resident #328, Resident #3, and Resident #75 were not coded for oxygen use because she did not code a resident for oxygen use unless the physician used the word hypoxia (low levels of oxygen in the blood) in the physician's order for oxygen. An interview with the Director of Nursing on 6/11/24 at 1:45 PM revealed all physician orders were reviewed by the MDS Coordinator and she coded based on the physician order. She stated that Resident #121, Resident #328, Resident #3, and Resident #75 should have been coded for oxygen by the MDS nurse. In interviews with the Administrator and the Director of Operations on 6/11/24 at 2:00 PM and 2:40 PM they stated that the MDS for Resident #121, Resident #328, Resident #3, and Resident #75 should have been coded for oxygen.

Based on observations, record review, and resident and staff interviews the facility failed to keep the call light within reach for 1 of 1 resident (Resident #54) reviewed for accommodation of needs. Findings included: Resident #54 was admitted to the facility on [DATE] with a diagnosis of intracerebral hemorrhage (bleeding in the brain). A review of Resident #54's care plan revealed in part a focus area initiated on 5/7/2019 of at risk for falls. The goal, last revised on 3/15/24, was for Resident #54 not to sustain any injuries related to falls through the next review. An intervention was to be sure Resident #54's call light was within reach and encourage Resident #54 to use it for assistance as needed as Resident #54 required prompt response to all requests for assistance. A review of Resident #54's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired. She had functional limitation in range of motion of her upper extremities on one side. On 6/10/24 at 1:22 PM Resident #54 was observed in her room seated in her recliner chair on the left side of her bed. Her call light was observed on the right side of her bed hanging from the headboard of her bed. Resident #54 was not able to reach her call light. An interview with Resident #54 at that time indicated she needed some assistance. Resident #54 stated she could not reach her call light, and she couldn't yell for help because her voice was not loud enough. She reported there had been other times when her call bell was left where she couldn't reach it, and she just had to wait for someone to come into her room to help her. She went on to say this was frustrating. On 6/10/24 at 1:55 PM Resident #54 was observed to be asleep in her recliner chair. Her call light was still observed to be out of reach. On 6/10/24 at 2:08 PM Resident #54 was observed to be asleep in her recliner chair. Her call light was still observed to be out of reach. On 6/10/24 at 2:47 PM an observation of Resident #54 with Nurse Aide (NA) #6 revealed Resident #54 was seated in her recliner chair with her call light out of her reach hanging on the right side of her bed from the headboard. An interview with NA #6 at that time indicated she was assigned to Resident #54. NA #6 reported Resident #54 could not reach her call light where it was now. She stated she had last been in Resident #54's room between 1:00 PM and 1:30 PM that day picking up lunch meal trays. She reported she had not made sure Resident #54 had her call bell in reach when she left Resident #54's room. NA #6 went on to say residents should have their call lights within reach at all times. She confirmed Resident #54 was able to use her call light. On 6/12/24 at 10:59 AM an interview with the Director of Nursing indicated Resident #54 was able to use her call light to obtain assistance. She reported residents should have their call light within their reach at all times. She stated when any staff member left a resident's room, they should always make sure the resident had their call light within their reach. On 6/12/24 at 11:13 AM an interview with the Administrator indicated the facility had longer call light cords if needed. She stated residents should have their call light within reach at all times. She went on to say before any staff member left a residents room, they should make sure that resident had their call light within reach.

Based on record review and staff interviews the facility failed to provide the opportunity to establish advanced directives and document this in the medical record for 1 of 2 residents (Resident #100) reviewed for advanced directives. Findings included: A review of the facility's policy titled Advanced Directives dated last revised September 2022 revealed, in part, the following: 1. If the resident or resident representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. A. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Resident #100 was admitted to the facility on [DATE] with a diagnosis of stroke (disrupted blood supply to the brain). A review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. On 6/9/24 at 4:05 PM an interview with Resident #100 indicated she understood that advanced directives included a living will and a power of attorney. She stated she did not have either of these things. She went on to say she did not recall ever being offered the opportunity or assistance with establishing them. Resident #100 stated she would like more information. On 6/11/24 a review of Resident 100's record did not reveal any evidence Resident #100 wanted to establish advanced directives or refused. On 6/11/24 at 2:31 PM an interview with Social Worker (SW) #2 indicated she was currently Resident #100's SW. She stated she started in this role in May 2023. She further indicated Resident #100 was her own representative. SW #2 reported she did not recall ever having a conversation with Resident #100 about whether or not she would like to establish advanced directives. On 6/11/24 at 3:23 PM an interview with the Admissions Director indicated she assisted residents with completing the admission paperwork. She reported she had been doing this when Resident #100 was first admitted to the facility. She stated she spoke with residents and/or their representatives regarding code status and asked if they had a living will and/or a power or attorney on admission. She went on to say if a resident had either of these things, a copy was requested to place in the resident's record. The Admissions Director reported if residents did not have these things, she did not ask if they would like to establish them or offer any assistance with doing this. On 6/12/24 at 8:42 AM an interview with SW #1 indicated he had been the SW at the facility from September 2022 through September of 2023. He stated he did not recall ever having a conversation with Resident #100 about whether or not she would like to establish advanced directives. On 6/12/24 at 10:00AM an interview with the Assistant Director of Nursing indicated there was no documentation in Resident #100's record that Resident #100 wanted to establish advanced directives or refused. On 6/12/24 at 10:59 AM an interview with the Director of Nursing indicated the Admissions Director asked residents whether or not they had advanced directives in a verbal conversation on admission. She reported regarding whether or not a resident or representative wished to establish advanced directives, there had not been any documentation of this in the record. On 6/12/24 at 11:13 AM an interview with the Administrator indicated she did not know why there was no documentation in Resident #100's record regarding whether or not she wanted to establish advanced directives.

Based on resident and staff interviews and record review the facility failed to have a quarterly interdisciplinary care plan meeting for 1 of 6 residents reviewed for care planning. (Resident #8) Findings included: Resident #8 was admitted to the facility on [DATE]. Her active diagnoses included hemiplegia affecting left nondominant side, diabetes mellitus, unsteadiness on feet, cerebrovascular disease, muscle weakness, hyperlipidemia, and hypertension. Review of Resident #8's minimum data set assessment dated [DATE] revealed she was assessed as cognitively intact. Review of Resident #8's medical record revealed her last care plan meeting was held on 2/13/24. During an interview on 6/9/24 at 10:37 AM Resident #8 stated she had not had a care plan meeting in a long time and could not remember the date of her last care plan meeting. During an interview on 6/11/24 at 9:28 AM Social Worker #2 stated the last care plan meeting for Resident #8 was on 2/13/24. She stated care plan meetings were supposed to be completed quarterly. She concluded she did not have a reason Resident #8 had not had another care plan meeting since 2/13/24. During an interview on 6/11/24 at 9:37 AM the Administrator stated care plan meetings were to be held quarterly for residents.

Based on observation, staff interviews, and record review the facility failed to apply a hand splint to a resident as ordered for 1 of 4 residents reviewed for positioning and mobility. (Resident #51) Findings included: Resident #51 was admitted to the facility on [DATE]. His active diagnoses included muscle weakness, unspecified sequelae (an aftereffect of a disease, condition, or injury) of cerebral infarction, pain in left shoulder, and flaccid hemiplegia affecting left nondominant side. Review of Resident #51's Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He was documented to have no rejection of evaluation or care. He had impairment on one side of his upper extremities. He required set-up or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. Review of an order dated 3/27/23 revealed Resident #51 was ordered for staff to apply left hand splint after breakfast and remove after supper for contracture prevention. Review of Resident #51's care plan dated 4/12/24 revealed he was care planned for activities of daily living self-care performance deficit related to flaccid hemiplegia of the left side, generalized weakness, and immobility. The interventions included applying his left-hand splint as directed for contracture prevention and left hemiplegia. During an interview on 6/9/24 at 11:38 AM Resident #51 stated he was supposed to get his splint applied to his left hand daily, but it was not on his left hand today. He concluded sometimes staff do not put his splint on him. During observation on 6/9/24 at 11:39 AM Resident #51 was observed to not have his splint on his left hand. During an interview on 6/10/24 at 8:54 AM Resident #51 stated he finished breakfast but had no one had put his left-hand splint on that morning. During observation on 6/10/24 at 8:54 AM Resident #51 was observed to not have his splint on his left hand. During an interview on 6/10/24 at 12:13 PM Resident #51 stated no staff had placed his splint on his left hand yet. During observation on 6/10/24 at 12:13 PM Resident #51 was observed to not have his splint on his left hand. During an interview on 6/10/24 at 12:56 PM Nurse #5 stated the nurse aides should place Resident #51's splint to his left hand in the mornings. Upon observing the resident, she concluded the splint was not placed on Resident #51's left hand and it should have been. Nurse #5 then retrieved the splint from Resident #51's dresser and placed it on the resident. During an interview on 6/10/24 at 12:59 PM Nurse Aide #4 stated she forgot to place Resident #51's splint on his left hand that morning. She stated she knew he was to get his splint on in the morning because the information was on the resident's care guide at the nurse aide's kiosk. During an interview on 6/10/24 at 1:18 PM the Director of Nursing stated if a resident is ordered to have a splint placed then staff should have put the splint on as ordered or documented a refusal.

Based on observations, record review, and staff interviews the facility failed to provide a nutritional supplement as ordered by the physician. This was for 1 of 1 residents (Resident #25) reviewed for nutrition. Findings included: Resident #25 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A care plan focus area initiated on 11/3/23 was at risk for nutritional problems related to poor oral intake. The goal, last revised on 4/22/24, was for Resident #25 to maintain stable weight through the next review. An intervention was to provide nutritional supplements as needed. A review of Resident #25's weight record revealed in part on 2/13/24 he weighed 188 pounds. On 6/11/24 Resident #25 weighed 196.4 pounds. A current active physician's order with a start date of 2/13/24 was for a nutritional shake three times a day with meals for weight loss prevention. A review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He rejected care on 4 to 6 days of the look back period for the assessment. He was 71 inches tall. Resident #25 weighed 191 pounds. He had no or unknown weight loss of 5 percent or more in one month or 10 percent or more in 6 months. On 6/11/24 at 8:53 AM the Unit Manager was observed to deliver Resident #25's breakfast meal tray to him and leave his room. Resident #25 began eating his toast. His meal tray ticket was observed to list a nutritional shake; however, no nutritional shake was present on his tray. On 6/11/24 at 9:09 AM Nurse Aide (NA) #5 was observed to remove Resident #25's breakfast tray. An interview with NA #5 at that time indicated Resident #25 did not receive a nutritional shake on his breakfast tray. She stated he was getting nutritional shakes at one time, but he had been refusing them. NA #5 reported she thought these had been discontinued. On 6/11/24 at 10:33 a review of Resident #25's Medication Administration Record (MAR) revealed in part documentation by Nurse #4 that Resident #25 took 50 percent of his nutritional shake with his breakfast meal. On 6/11/24 at 10:50 AM an interview with Nurse #4 indicated she was caring for Resident #25 on 6/11/24. She stated Resident #25 drank 50 percent of his nutritional shake this morning with his breakfast on 6/11/24. She reported she had not seen the shake, it came from the kitchen with his breakfast tray, but she asked NA #5 how much of it Resident #25 drank. On 6/11/24 at 1:09 PM in a follow-up interview NA #5 confirmed Resident #25 had not received a nutritional shake with his breakfast on 6/11/24. She stated she had not realized it was still listed on his meal ticket. She reported she was supposed to look at meal tickets and compare what was on the tray to what was on the meal ticket. NA #5 went on to say if an item was missing, she was supposed to call to the kitchen and get a replacement. She reported she had not done this for Resident #25's nutritional shake. NA #5 further indicated Nurse #4 had not asked her how much nutritional shake Resident #25 drank. On 6/11/24 at 1:29 PM an interview with the Unit Manager indicated she delivered Resident #25's breakfast meal tray on 6/11/24. She stated she had not seen a nutritional shake on Resident #25's breakfast tray, but she had not looked at the meal ticket either. She reported after she delivered Resident #25's breakfast, NA #5 had taken over. On 6/11/24 at 4:16 PM an interview with the Dietary Manager indicated the kitchen was not perfect. She stated Resident #25's nutritional shake was missing from his breakfast tray on 6/11/24. She reported as a safeguard the person who delivered Resident #25's breakfast tray should be calling the kitchen to obtain a replacement. On 6/12/24 at 10:59 AM an interview with the Director of Nursing (DON) indicated if a resident had a physician's order for a nutritional supplement, then the nurse should ensure that the resident received this as this was something the nurse needed to document on the MAR. The DON went on to say whoever delivered a resident's meal tray should be checking the tray to ensure all items listed on the meal ticket were present. She stated if an item was missing, a replacement should be obtained. On 6/12/24 at 11:13 AM an interview with the Administrator indicated the kitchen should be making sure that nutritional shakes were present on the meal tray for residents who had them listed on their meal tray tickets. She went on to say if the shake is missing from the tray, whoever delivered the tray should contact the kitchen for a replacement.

Based on observation, staff interviews, and record review the facility failed to clean and store a syringe for enteral feeding with the plunger separately to dry for 1 of 1 resident reviewed for tube feeding. (Resident #57) Findings included: Resident #57 was admitted to the facility on [DATE]. His active diagnoses included muscle weakness, persistent vegetative state, and anoxic brain damage. Review of Resident #57's Minimum Data Det assessment dated [DATE] revealed he was assessed as having a persistent vegetative state/no discernible consciousness. He was assessed to have a feeding tube in place and 51% or more of total calories the resident received through parenteral or tube feeding, and 501 cubic centimeters or more of fluid intake per day by IV or tube feeding. Review of Resident #57's care plan dated 4/8/24 revealed he was care planned to require tube feeding related to persistent vegetative state. The interventions included to keep the head of the bed elevated 45 degrees during and thirty minutes after tube feed, follow physician's orders for current feeding orders, check for tube placement and gastric contents/residual volume per facility protocol, and record, monitor, document, and report as needed any signs or symptoms of aspiration fever, shortness of breath, tube dislodged, infection at tube site, tube dysfunction or malfunction. During observation on 6/9/24 at 10:45 AM the enteral feeding syringe for Resident #57 was observed with the plunger stored in syringe and was in a plastic bag hanging beside the resident's bed and dated 6/9/24. [NAME] debris and liquid were observed at the base of plunger, inside of the syringe. During an interview on 6/9/24 at 10:46 AM Nurse #6 stated she stored the enteral feeding syringe for Resident #57 the way it was observed by the surveyor and reused it for medication pass. She further stated the white debris was left over medication and water from this morning when she gave his medication via feeding tube. During observation on 6/10/24 at 12:03 PM the enteral feeding syringe for Resident #57 was observed with the plunger stored in syringe and was in a plastic bag hanging beside the resident's bed and dated 6/10/24. [NAME] debris and liquid were observed at the base of plunger, inside of the syringe. During an interview on 6/10/24 at 12:08 PM Nurse #5 stated she used the enteral feeding syringe to check residual as well as provide medications that morning to Resident #57. The nurse stated after using it, she rinsed the syringe and plunger and then placed the plunger in the syringe and placed them in a bag hung next to the bed to dry and to be reused. Upon observing the syringe, she stated there was white debris and water must have been crushed medication remnants and water from the morning medication pass. During an interview on 6/11/24 at 7:58 AM the Director of Nursing stated the syringe, and the plunger were to be cleaned with soap and water and dried with a paper towel and then the plunger and the syringe were to remain separate as they dry hanging in the bag next to the resident's bed.

Based on observations, record review and staff interviews, the facility failed to honor residents' food preferences for 2 of 2 residents reviewed for food preferences (Resident #27, and Resident #117). Findings include: a.Resident #27 was admitted on [DATE] and readmitted on [DATE]. Review of the admission MDS assessment dated [DATE] for Resident #27 revealed she was cognitively intact. During an interview with Resident #27 on 6/9/24 at 11:39 am she stated that she did not like green beans or carrots but had been served green beans and carrots up to three times a week since her admission on 5/17/24. During an interview with Resident #27 on 6/9/24 at 12:21 pm she stated that she was served mixed vegetables that included large amounts of green beans and carrots. She indicated that she did not like carrots and green beans, and she wished the kitchen would stop sending them. Observation of Resident #27's meal tray on 6/9/24 at 12:21 pm a bowl of mixed vegetables that included green beans and carrots had been served to Resident #27. Review of Resident #27's meal ticket on her meal tray revealed that green beans and carrots were listed as disliked foods. During an interview on 6/10/24 at 12:57 pm Resident #27 stated that she got a bowl of carrots on her lunch tray. She further indicated that she was served a bowl of green beans with her dinner on 6/9/24. She stated that she had not spoken to anyone from the dietary department since she was readmitted on [DATE] because the dietary staff already had her dislikes from her prior admission on 5/17/24. She stated that her dislikes were listed on her meal ticket and the kitchen staff should honor what was on her meal ticket. Observation of Resident #27's meal tray on 6/10/24 at 12:57 pm a bowl of carrots had been served to Resident #27. Review of Resident #27's tray meal ticket dated 6/10/24 revealed her dislikes were listed. Her dislikes included carrots and green beans. b.Resident #117 was admitted on [DATE] with diagnoses that included heart failure and diabetes. Review of the annual MDS assessment dated [DATE] for Resident #117 revealed she was moderately cognitively impaired. In an interview with Resident #117 on 6/9/24 at 1:48 pm she stated that she did not like milk, eggs, or fish but was served eggs every few weeks, fish every Friday, and milk about once a month. Review of Resident #117's meal ticket on her tray revealed that her dislikes listed on the meal ticket included milk, scrambled eggs, and fish. Observation of Resident #117's meal tray on 6/10/24 at 7:45 am scrambled eggs had been served to Resident #117. Review of Resident #117's meal ticket on her tray revealed that her dislikes listed on the meal ticket included scrambled eggs. In an interview with Resident #117 on 6/11/24 at 9:30 am she stated that she received milk on her breakfast meal tray and before she could tell someone that she did not like or want milk it that it was opened, so it was wasted. During an interview with the Certified Dietary Manager (CDM) on 6/10/24 at 01:04 pm she stated that she meets with all residents after they were admitted and asked them about their food likes and dislikes and recorded the information in the computer system and when she printed out tray meal tickets dislikes were listed on the ticket. She stated that if a resident had a dislike that an alternative would have been provided to that resident and the disliked food would not have been placed on the meal tray to be served to the resident. The interview further revealed that the dietary aide viewed the meal tickets when meal plates were prepared and called out any disliked foods to the cook before the food was plated so the disliked food would not be placed on the resident's plate. The CDM stated that residents should not get food on their plate that was listed as a dislike on their meal ticket. She indicated that dietary staff were educated that diets must be followed and if there was a dislike listed on the meal ticket that the food should not be served to the resident. The CDM did not know why Resident #27 and #117 received disliked foods on their meal trays. During an interview with the [NAME] Aide on 6/10/24 at 1:15 pm she stated that she read the disliked foods listed on the meal ticket to the cook who plated the meal, and the cook would substitute the disliked food with an alternate food of the same food group. She further indicated that Resident #27 had a dislike of the alternate vegetable on 6/10/24 so she did not read the dislikes to the cook because she thought that a vegetable had to be served with the meal. She further indicated that she did not know why Resident #27 and Resident #112 received food that was listed on their meal ticket as disliked food on the other dates. In an interview with the Evening [NAME] on 6/10/24 at 1:22 pm she stated that she served the lunch meal every day after the morning cook prepared the food. She stated that the [NAME] Aide read the meal ticket to her and told her if a resident had a dislike and if they did, she would not put that food on the plate. She stated that if a resident had a dislike that she would serve an alternate food item and if a resident disliked the main and alternative food that she prepared and served a third option. The interview further revealed that the [NAME] did not look at the meal ticket and if the [NAME] Aide did not tell her of a disliked foods that she served the food that was on the menu. In an interview with the Director of Nursing on 6/10/24 at 1:53 pm she stated that if residents received food that was listed as disliked on their meal ticket that someone did not pay attention. She further stated that Resident #27 and #117 should not have received food that they disliked. In an interview with the Administrator on 6/10/24 at 3:36 pm she stated that Resident #27 and Resident # 117 should not have been served food that they disliked if it was marked on the meal ticket as disliked.

Based on CDC (Centers for Disease Control) guidance, facility policy, observations and staff interviews (1.) the facility failed to keep PPE (personal protective equipment) readily available on one (Covid-19 Unit B) out of two Covid-19 units. (2.) The facility failed to stop the meal service during a toilet overflow in the hallway on one (Covid-19 Unit A) of two Covid-19 units. (3.) The facility failed to do hand sanitation in one (Covid-19 Unit A) out of two Covid-19 units. Nurse aide (NA #2) failed to perform hand hygiene in-between residents during the meal service on Covid-19 Unit A. (4.) The facility failed to wear eye protection in two (Covid-19 Unit A and B) out of two Covid-19 units. Nurse aide (NA #1) and Housekeeper (HK #1) failed to wear eye protection on Covid-19 Units A and B. (5.) The facility failed to wear face masks the CDC (Centers for Disease Control) recommended number of times for 3 (Nurses #3, #4, and #6) of 3 nurses interviewed about mask use. (6.) The facility failed to store clean linens separately from the housekeeping cart on one (Covid-19 Unit A) of two Covid-19 units. (7.) In addition, the facility failed to keep resident room doors closed on one (Covid-19 Unit B) out of two Covid-19 units. This occurred during a Covid-19 pandemic and a Covid-19 outbreak in the facility. Twenty-one residents (Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23) were on Covid-19 Units A and B. Findings included: Immediate Jeopardy began on 10/1/20 when observations and staff interviews revealed numerous infection control breaches during a Covid-19 pandemic and outbreak in the facility. Observations revealed Covid-19 positive Unit B did not have PPE readily available per CDC guidelines. Staff were observed continuing a meal service while cleaning up a toilet overflow on the Covid-19 positive Unit A. A nurse aide was observed not performing hand hygiene prior to entering and exiting resident rooms on Covid-19 positive Unit A. Staff were not wearing eye protection in Covid-19 positive Units A and B. Staff were wearing face masks for more than the recommended number of times. Staff were storing clean linens next to the housekeeping cart on Covid-19 positive Unit A. Resident Room doors were open on Covid-19 positive Unit B. The Immediate Jeopardy was removed on 10/6/20 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. 1. CDC guidelines, dated 7/26/19, stated that PPE, including gowns and gloves are to be made available immediately outside of the resident room on enhanced barrier precautions. CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019(Covid-19) Pandemic, dated 7/15/20, stated in part, Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. The facility Covid-19 policy, dated 5/11/20, stated under Covid-19 Outbreak Precautions, Contact and droplet precautions are implemented during care of residents with suspected or confirmed cases, in addition to standard precautions used with all residents regardless of symptoms. Observations were made of Covid-19 Unit B on an initial tour on 10/1/20 from 10:17 AM to 10:30 AM. Covid-19 Unit B was located on the 300-hallway with a zippered plastic barrier with a sign titled Enhanced Barrier Precautions posted on the plastic barrier. On the sign were the instructions to wear a gown and gloves for high contact resident care activities. On the other side of the zippered plastic barrier to Covid-19 Unit B was an area in between another zippered plastic barrier. The area in between the zippered plastic barriers did not contain gowns, gloves, hand sanitizer, face masks, face shields, and/or goggles. The area in between did contain a plastic drawered bin which did not contain any PPE. On the other side of the second zippered plastic barrier were resident rooms with Covid-19 positive residents. The hallway within the Covid-19 unit contained one plastic drawered bin outside of room [ROOM NUMBER] (Covid-19 Unit B Nurses Station) that did not contain any PPE. Residents #3, #17, #18, #19, #20, #21, #22, #23 room doors were open. Loud coughing could be heard coming from the room of Resident #3, who resided across the hall from Resident #19. According to the annual Minimum data set assessment ((MDS) dated [DATE], Resident #19 had a feeding tube and received oxygen therapy, suctioning, and [MEDICAL CONDITION] care. The hallway had one hand sanitizer dispenser on the wall, but it was observed to be nonfunctional. An interview was conducted with Nurse #2 inside Covid-19 Unit B on 10/1/20 at 10:30 AM. Nurse #2 was observed at the time of the interview to be wearing a head covering, goggles, an N-95 mask, shoe coverings, and a cloth gown. Nurse #2 stated that she had a bottle of hand sanitizer on the medication cart that everyone could share because the hand sanitizer dispenser on the wall was clogged. Nurse #2 put the hand sanitizer bottle on the railing underneath the wall hand sanitizer dispenser. Nurse #2 revealed that she obtained her gown and N-95 mask at the beginning of the shift when she entered the facility. Nurse #2 stated that no gowns were kept at the Covid-19 Unit B and that to obtain a gown the Director of Nursing would have to be called. Nurse #2 stated that she always obtained her gown prior to the start of the shift when she entered the facility. Nurse #2 stated that if her gown got dirty, she would have to call out of the unit for someone to bring her one from the front of the building. Nurse #2 stated that all the resident room doors were kept open because everyone was Covid-19 positive on the unit. Nurse #2 stated that the supply staff member was very good at providing gloves to the Covid-19 Unit B but that the supply person had no control over the PPE (personal protective equipment). Nurse #2 unlocked the treatment cart and opened a drawer that contained two boxes of gloves. Nurse #2 stated that she saves some boxes of gloves and keeps them locked so they don't migrate. Nurse #2 locked the gloves back up in the treatment cart. Nurse #2 pointed out that the unit had a box of gloves on her medication cart that everyone could share. Nurse #2 further explained the process for obtaining a KN-95 mask at the facility. Nurse #2 revealed that in the front lobby there were file folders with staff member names on them. Inside the individual file folders were three KN-95 masks, each in a paper bag. Each KN-95 mask was to be rotated for use every three days until each mask was used twenty times. Nurse #2 stated that the staff member was to put the date on each paper bag to show when it was last used. After the mask was used twenty times then a new KN-95 mask could be obtained from the Director of Nursing. Nurse #2 was questioned what she would do if her KN-95 mask were to get soiled during her shift such as in tracheotomy care of Covid-19 positive Resident #19. Nurse #2 replied that she had a system to avoid getting the KN-95 mask soiled. Nurse #2 explained that she would go to the bathroom in the Covid-19 Unit room that was designated for staff to eat or take a break. She stated she would then remove her KN-95 mask, put it on a paper towel, and put on a duck bill mask (N95 mask). She stated she would then provide [MEDICAL CONDITION] care to Resident #19, go back into the bathroom, retrieve her KN-95 mask and dispose of the duck bill mask. An interview was conducted with Nurse #3 on 10/1/20 at 12:20 PM, who worked the 7:00 AM to 3:00 PM shift outside of the Covid-19 units. Nurse #3 confirmed that PPE was available and if she needed PPE, she could contact the staff member who distributed supplies. An interview was conducted with the staff member who distributes supplies on 10/1/20 at 12:26 PM. This staff member revealed that she distributed PPE to the Covid-19 units on Mondays to make sure they had enough. The staff member confirmed that she did not have access to the PPE, but the Director of Nursing and Administrator had access. This staff member stated she did not know if the Covid-19 units needed hand sanitizer in the area between the zippered enclosures, and that the staff inside the Covid-19 units would need to let her know if they needed anything. An interview was conducted on 10/1/20 at 12:49 PM with Nurse #4, who worked on the 11:00 PM to 7:00 AM shift. Nurse #4 confirmed that if more PPE was needed, the Director of Nursing needed to be called to retrieve the PPE from the locked storage and bring it to the staff. An interview was conducted on 10/1/20 at 4:40 PM with Nurse #6, who worked on the 3:00 PM to 11:00 PM shift. Nurse #6 also stated that if she needed PPE, she would contact the Director of Nursing to obtain it. An interview was conducted on 10/1/20 at 2:25 PM with Nurse # 5, the staff member responsible for infection control and staff development. Nurse #5 stated that the infection control policies and procedures for the facility were updated with the most current CDC guidelines. Nurse #5 stated that staff members should have full PPE on when they enter the Covid-19 units in the facility. Nurse #5 stated that the Administrator or the Director of Nursing needed to be called if at the change of shift PPE was not available. Nurse #5 stated that she did not have any control over the PPE and the Administrator, and the Director of Nursing were the only ones with access to the PPE storage. An interview with the Director of Nursing on 10/2/20 at 9:15 AM revealed that the corporate policy was for the PPE to be kept in a locked room with only the Director of Nursing or the Administrator would have access, due to theft of the PPE. If the staff needed PPE, they could request it from the Administrator or the Director of Nursing. In an interview on 10/5/20 at 9:15 AM, the Administrator revealed that if the facility staff really needed PPE immediately, they could call the Administrator or the Director of Nursing to obtain the code to get into the locked door with the PPE, because the code on the locked door could be changed later. Interview with the Director of Nursing on 10/5/20 at 9:15 AM revealed the nursing procedure of changing a KN95 mask to an N95 mask prior to care for a [MEDICAL CONDITION] patient was the facility policy to conserve PPE. 2. CDC guidelines, dated 7/15/20, stated under Recommended infection prevention and control practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-COV-2 (Covid-19) infection stated that management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. Observations were made of the meal service on Covid-19 Unit A on 10/1/20 beginning at 11:50 AM. A metal cart with open slats containing Styrofoam meal trays arrived was brought into the unit and NA #1 and NA #2 began to deliver the meal trays to each room. NA #1 opened the door to room [ROOM NUMBER] with a meal tray in her hand. Upon opening the door to room [ROOM NUMBER] NA #1 exclaimed as a flood of water began to pour out into the hallway. Nurse aide #1 set the meal tray down in the room. An occupational therapist (OT #1) exited the room and announced that the toilet was overflowing in Resident #13's room. The OT #1 went into the employee break room across the hall and obtained linens from the clean linen cart and handed them to the Nurse #1. Nurse #1 began to put towels on the floor in the flooded water while HK #1, whose cart was already in the hallway at the beginning of meal service, began to mop up the water with a mop. The flow of water continued out into the hallway as the HK #1 and Nurse #1 attempted to manage the water with towels and a mop. OT #1 exited out the back door, which led to outside the building. Nurse #1 obtained a large plastic bag and put the wet linen in the bag. NA #1 and NA #2 continued to pass out meal trays stepping in and around the water to deliver the rest of the meal trays to that end of the hall. After the meal trays were passed out NA #1 stayed on Covid-19 Unit A and NA #2 exited out the back door to go to Covid-19 Unit B. Nurse #1 and HK #1 continued to clean up the water in the hallway while NA #1 assisted residents with the meal. An interview was conducted with the Administrator and the Director of Nursing on 10/5/20 at 9:15 AM. The Administrator expressed that he thought his staff did the best they could in the situation. The Administrator stated he was aware of the toilet overflow that occurred on 10/1/20 during the meal service because OT #1 told him about it. The Administrator stated he asked OT #1 if the overflow was cleaned up and OT #1 assured him it had. The Director of Nursing indicated she was unaware of the toilet overflow on 10/1/20 on Covid-19 Unit A but the meal service should have been stopped until the toilet overflow was cleaned up. 3. CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019(Covid-19) Pandemic, dated 7/15/20, stated in part, HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. A facility policy titled, Infection Control Guidelines for all Nursing Procedures dated 1/24/19, read in part, employees must wash their hands before and after all patient contact. During a meal time observation on Covid-19 Unit A on 10/1/20 at 11:50 AM, Nurse Aide (NA #2) was observed NA #2 was observed to be wearing a gown, KN-95 face mask, and goggles. NA #2 was observed taking a meal tray into Resident #7 and setting up the meal tray for the resident. NA #2 was then observed to leave the room without performing any hand sanitation and put on gloves. NA #2 was observed to remove a meal tray from the cart and bring the meal tray into Resident #8 with the same gloves on and set up the meal tray for the resident. NA #1 was observed to remind NA #2 that she needed to perform hand hygiene when she came out of each room. NA #2 was observed to retrieve a meal tray from the cart with the same gloves and brought the meal tray to Resident #12. NA #2 was observed to set up the meal tray and retrieve a blanket giving it to Resident #12. NA #2 then left Resident #12 and retrieved another meal tray from the cart without removing her gloves or performing hand hygiene. NA #2 was observed to bring a meal tray into Resident #14 without removing her gloves and set up the meal tray. NA #2 was interviewed on 10/1/20 at 11:59 AM. NA #2 stated that she was supposed to use hand sanitizer or wash her hands every time she came out of a resident room. She revealed she forgot to use hand hygiene in between rooms during the meal service but that today was her first day on the Covid-19 unit and her first week in the facility. Documentation on an orientation hand hygiene competency validation dated 9/17/20 revealed NA #2 was competent in hand hygiene with soap and water as well as hand hygiene with alcohol-based hand rub. An interview was conducted with the Director of Nursing on 10/2/20 at 9:15 AM. The Director of Nursing stated that her facility was currently out of compliance with the infection control due in part to concerns with a lack of hand sanitation and that she had initiated in-services with her staff. 4. Centers for Disease Control (CDC) guidelines entitled Use Personal Protective Equipment (PPE) when caring for patients with confirmed or suspected Covid-19 dated 6/3/20 read in part, PPE must be donned correctly before entering the patient area (e.g. Isolation room, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. The same CDC guidelines indicated that both preferred and acceptable PPE included a face shield or goggles when caring for patients with confirmed or suspected Covid-19. CDC guidelines, updated 8/4/20, recommend all environmental services personnel who clean and disinfect rooms of Covid-19 residents should wear all the recommended PPE when in the room. The facility Covid-19 policy, dated 5/11/20, stated under Covid-19 Outbreak Precautions, Contact and droplet precautions are implemented during care of residents with suspected or confirmed cases, in addition to standard precautions used with all residents regardless of symptoms. The same facility policy under surveillance stated in part, Infection Preventionist shall ensure visible signage at entrances/exits that include instruction on hand hygiene, limiting surfaces touched, social distancing, use of hand sanitizer and PPE as well as signage to discourage, limit, or restrict visits as appropriate. Nurse Aide (NA #1) was observed to enter Covid-19 Unit B with glasses on and no face shield or goggles on 10/1/20 at 10:52 AM. NA #1 was interviewed at the time of this observation and she stated she was told she could wear her glasses as eye protection in the Covid-19 unit instead of a face shield or goggles. NA #1 was observed to then subsequently the room of Residents #22 and #23 vocalizing she was ready to give the resident a bath. NA #1 was observed on 10/1/20 at 11:10 AM to enter the room of Resident #17 without any goggles or face shield on. NA #1 was observed on 10/1/20 at 11:20 to enter Resident #3 without any goggles or face shield on. Housekeeper #1 (HK #1) was observed on 10/1/20 at 11:45 AM to be cleaning room for Resident #5 without any googles or face shield on. HK #1 was interviewed at the time of the observation and stated that her goggles were in her lunch container and she was not wearing them because they fog up. HK #1 was observed on 10/1/20 from 11:45 AM to 12:00 PM to perform her duties as a housekeeper without goggles or a face shield to include cleaning up an overflow of water from a toilet in the hallway. An interview was conducted on 10/1/20 at 2:25 PM with Nurse #5, the staff member responsible for infection control and staff development. Nurse #5 stated that the infection control policies and procedures for the facility were updated with the most current CDC guidelines. Nurse #5 stated that it was not appropriate to wear glasses as a substitute for goggles or a face shield on the Covid-19 units. Nurse #5 stated that when a staff member entered a facility Covid-19 unit, he or she should have on full PPE to include goggles or a face shield. Nurse #5 stated that if PPE was not available at the start of the shift, then the Administrator or the Director of Nursing should be called. Nurse #5 confirmed that housekeeping staff needed to wear the same PPE as the nursing staff. Nurse #5 stated that all the staff received infection control training and hand hygiene competency validation at the start of the pandemic. Nurse #5 also stated that the Director of Nursing completed audits to make sure the staff were following facility policies and procedures. An interview was conducted with the facility Director of Nursing on 10/2/20 at 9:15 AM and again on 10/2/20 at 11:43 AM. The Director of Nursing stated that glasses are not a substitute for goggles, or a face shield and she did not know who told NA #1 glasses were eye protection on the Covid-19 units. The Director of Nursing stated that the facility policies are based on the CDC guidelines. The Director of Nursing provided audits along with infection control training she had completed to make sure the facility staff were following the facility policies and procedures. 5. CDC guidelines dated, 4/2/20, stated under Limited re-use of N95 respirators, If no manufacturer guidance is available, data suggest limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin. The facility undated policy for Personal Protective Equipment - Reusing Face Masks (N95 or KN95) during a Pandemic stated in part, Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. Employee shall write name and date on the brown bag when receiving a new mask. Masks are to be worn in a 3 (three) day rotation, each mask may be worn up to 20 (twenty) uses unless soiled or damaged. The brown bags will be stored at (this part of the policy was left blank). Employees are required to leave their masks in their designated brown bags when leaving the facility at the end of their shift and retrieved from their designated bag in the storage container on their next incoming shift. An interview was conducted with Nurse #3 on 10/1/20 at 12:20 PM, who worked the 7:00 AM to 3:00 PM shift outside of the Covid-19 units. Nurse #3 also confirmed she was following the facility policy on wearing each of her three masks 20 times before she could obtain another one. An interview was conducted on 10/1/20 at 12:49 PM with Nurse #4, who worked on the 11:00 PM to 7:00 AM shift. Nurse #4 confirmed that she was given three masks that were each put in paper bags and kept in the front lobby. Nurse #4 said the staff were using too many masks, so the system was initiated of wearing the masks 20 times before a new one was obtained. Nurse #4 said that glue and a stapler were kept at the front desk to repair the masks for continued use of 20 times. An interview was conducted on 10/1/20 at 4:40 PM with Nurse #6, who worked on the 3:00 PM to 11:00 PM shift. Nurse #6 confirmed that she too followed the facility policy of wearing each of her 3 face masks 20 times, storing each mask at the front of the facility in paper bags. An interview was conducted on 10/1/20 at 2:25 PM with Nurse # 5, the staff member responsible for infection control and staff development. Nurse #5 stated that the infection control policies and procedures for the facility were updated with the most current CDC guidelines. Nurse #5 confirmed that it was facility policy to reuse face masks for up to 20 times but denied the staff would need to repair masks with glue and/or staples. Nurse #5 stated that the Administrator or the Director of Nursing would give a staff member a new mask if their mask was soiled or in disrepair. An interview was conducted with the Director of Nursing on 10/2/20 at 11:43 AM. The Director of Nursing confirmed that the staff were following the facility policy on reusing face masks (N95 or KN95 since the start of the facility Covid-19 outbreak in August 2020. The Director of Nursing stated that she thought the corporate policy came from a Centers for Medicare and Medicaid (CMS) transmittal. The Director of Nursing was not able to provide the CMS transmittal at the time of the investigation. 6. CDC guidelines, dated 7/15/20, stated under Recommended infection prevention and control practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-COV-2 (Covid-19) infection stated that management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. Observations were made in room [ROOM NUMBER] on Covid-19 Unit A on 10/1/20 at 3:57 PM. The room was observed to have a small table and chairs against one wall of the room. On the other side of the room was a covered linen cart against the wall with a housekeeping cart stored next to it. NA #1 was interviewed at the time of the observation in room [ROOM NUMBER] on Covid-19 Unit A. NA #1 stated that the room was used as an employee break room where the staff could eat because they were not allowed to leave the unit once they entered. NA #1 stated that the linen cart and the housekeeping cart were both also usually stored in the employee break room. An interview was conducted with the Administrator and the Director of Nursing on 10/5/20 at 9:15 AM. The Administrator and the Director of Nursing did not know the facility policy on storing the housekeeping cart and the clean linens in the employee Covid-19 break room. 7. CDC guidelines, dated 7/15/20, stated under Recommended infection prevention and control practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-COV-2 (Covid-19) infection that if admitted a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single person room with the door closed. Observations were made of Covid-19 Unit B on an initial tour on 10/1/20 from 10:17 AM to 10:30 AM. Covid-19 Unit B was located on the 300-hallway with a zippered plastic barrier with a sign titled Enhanced Barrier Precautions posted on the plastic barrier. On the other side of the zippered plastic barrier to Covid-19 Unit B was an area in between another zippered plastic barrier. On the other side of the second zippered plastic barrier were resident rooms with Covid-19 positive residents. Residents #3, #17, #18, #19, #20, #21, #22, #23 room doors were open. Loud coughing could be heard coming from the room of Resident #3, who resided across the hall from Resident #19. An interview was conducted with Nurse #2 inside Covid-19 Unit B on 10/1/20 at 10:30 AM. Nurse #2 stated that all the resident room doors were kept open because everyone was Covid-19 positive on the unit. An interview was conducted with the Director of Nursing on 10/5/20 at 9:15 AM. The Director of Nursing did not know the facility policy on if the resident doors on the Covid-19 Unit needed to be closed or could be open. On 10/5/20 at 2:38 PM, the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation of immediate jeopardy removal on 10/7/20 at 11:27 AM. The allegation of compliance indicated: Credible Allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The alleged deficient practice has the potential to affect all residents at the facility. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Director of Nursing and the Nursing supervisors completed education for all current licensed nurses on 10/06/2020, regarding the protocol for single use of N95(KN95) masks and the use of protective shield for the use of an aerosol generating treatment. The facility has a respiratory protection program and staff has completed the OSHA Respirator Medical Evaluation Questionnaire. The protocol indicates that single use will occur and be disposed of following the treatment and the shield will be cleaned with CDC approved disinfecting agents or wipes and allow to dry. Following completed of the aerosol generating procedure, the nurse will wipe down surfaces in the room with the approved disinfectant. The nurse will then remove the gown and gloves immediately prior to exiting the room (discard in trash can at door), perform hand hygiene and then go directly to the designated doffing area of the Covid unit. This area may be called the Anteroom. It is located on the Covid unit and is where the staff removes their PPE safely, without potential exposure. The staff member will remove the soiled mask and discard, wash their hands then return to the donning area which is also in a safe area at the entrance of the Covid unit. The staff member will then don a new N95(KN95) mask before re-entering the Covid unit. The Director of Nursing and administrator provides replacement PPE daily and as needed to include gowns, masks, eye shields and gloves at the PPE station at the entrance of the COVID unit. The Housekeeping supervisors verified the placement of gloves and sanitizer stations throughout the COVID unit on 10/6/20. All rooms were supplied with hand sanitizer and gloves. The director of nursing and nursing supervisors provided education and in-servicing to all staff members on 10/06/2020 to the location and availability of PPE throughout the COVID unit and upon entrance of the COVID unit. The director of nursing and nursing supervisors provided education and in-services to all supervisor to audit areas of PPE storage to ensure adequate supply of all items prior to the shift seven days per week. The director of nursing and supervisors provided in-servicing to all staff that they would alert supervisor when the PPE supplies were getting low prior to running out throughout their shifts so that items can be refilled throughout the shift as needed. This education was provided to all staff since all staff wear PPE on 10/06/2020. The director of nursing and nursing supervisors educated all staff to the use of eye shields/goggles while working in an COVID unit. The director of nursing and nursing supervisors verified availability and supplied staff members with eye shields on 10/06/2020 if they did not already have them. This in-servicing education was provided on 10/06/2020 by the director of nursing and nursing supervisors. The director of nursing and nursing supervisors received and provided education to all staff members on 10/06/2020 for hand washing through UTUBE Clean hands videos and supporting documentation as well as review of Ridgewood policy and procedure regarding handwashing prior to and following the care of residents. The director of nursing and/or administrator provided in-service education to all staff members in housekeeping and nursing on 10/06/2020 regarding the proper storage and use of linen supplies. The director of nursing moved storage to the hallway in the contained unit space of the COVID unit on 10/06/2020. Dirty linen storage and the housekeeping cart would be contained just on the other side of the curtain within the unit and used throughout the shift by designated housekeeping personnel, returning to this storage area when not in use. All housekeeping and nursing staff received training on 10/06/2020 regarding the safe handling of clean and dirty linens. The administrator and Director of nursing provided in-service education and training to all housekeeping, maintenance and nursing staff of the protocol to follow should a toilet overflow during meal service on 10/06/2020. Staff members that were involved in the toilet overflow were directed to disinfect their shoes on 10/6/20. Nursing and housekeeping staff were educated on the cleaning and disinfecting of soiled clothing/shoes. They were educated if their shoes or clothing becomes contaminated, they should obtain the disinfectant cleaner to sanitize their shoes but would need to return home to change clothing and or shoes. Staff were educated by the Administrator on 10/6/20 regarding how to turn off the water at the toilet using the toilet water valve located at the base of each toilet, turning valve to the right to turn water off and contact the maintenance director or assistant maintenance director. One staff member will be sure to contain the water from spilling into other resident areas. Should food trays, meal delivery carts or other clean items be in the area they will be removed to a safe location. Any items that are soiled, will be discarded and clean items will be prepared for the residents use/consumption. Should employee(s)' clothing become soiled or otherwise in contact with wastewater, they will be instructed to leave the facility, and return with clean clothing and disinfect their clothing and shoes using current CDC guidelines. The facility administrator and Director of nursing was provided with in-service education on 10/05/2020 by the regional director of clinical operations regarding the appropriate use of N95(KN95) during a national pandemic in accordance with CDC guidelines for appropriate reuse for a period of 5 uses. These masks may be reused up to 5 uses so long as they are not otherwise soiled, damaged etc. The director of nursing and nursing supervisors provided education to all facility staff on 10/06/2020 regarding the (TRUNCATED)

Based on observations, record review and resident, family, physician and staff, interviews the facility failed to secure 1 of 1 sampled residents in the transportation van according to manufacturer's recommendations while being transported back to the facility from a medical appointment by the facility's contracted transport company (Resident #68). Resident #68 slid from his wheelchair to the floor of the transportation van during transport and was not injured. Immediate Jeopardy began on 11/20/18 when Resident #68 was being transferred from an appointment by the facility contracted transport company. The resident was not secured according to manufacture's instructions in the wheelchair during transportation and slid to the van floor without injury when Van Driver #1 stopped at a stop light. Immediate jeopardy was removed on 12/5/18 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: During observation on 12/5/18 at 1:30 PM the manufacturer's instructional video for the locking mechanism used by the facility's contracted van company related to the correct securement of residents for transportation was watched. According to the video, the rear wheelchair locking straps were to be anchored behind the wheelchair to the inside of the wheels which avoided placing stress on the anchor straps. The rear anchors for the seat belt were to be placed behind the wheelchair inside the wheelchair strap anchors and wheels to avoid placing stress on the anchor straps. The video also stated the lap belt was never to be placed around the wheelchair's arm rests and instead was to run between the arm rest and seat back of the wheelchair. Resident #68 was admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Review of Resident #68's most recent minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He was documented to have no moods or behaviors. Resident #68 was independent with bed mobility and locomotion on and off unit. He required limited assistance with transfers. Resident #68 had impairment to both lower extremities and used a wheelchair as a mobility device. Review of Resident #68's care plan dated 10/29/18 revealed he was at risk for falls related to poor balance, poor communication and comprehension, psychoactive drug use, and an unsteady gait. The goal was for staff to maximize safety through interventions listed for Resident #68. The interventions included to assist the resident to bed to provide care, observe Resident #68 and record and report all unsafe conditions and situations, and monitor his neuro status and assess for a change in his level of consciousness. Review of a progress note dated 11/20/18 at 12:49 PM revealed the Unit Coordinator documented Resident #68 returned from his dental appointment with nothing written on the consult sheet. No further documentation was found for 11/20/18. Review of a written statement by Resident #68 dated 11/23/18, taken by the Director of Nursing revealed Resident #68 stated he was coming back from his appointment in the wheelchair van. He stated the driver did not strap him in and he slid right on the floor. Resident #68 stated he messed his arm up and they had just put a cortisone shot in his arm. He told the Director of Nursing he went down on his right elbow. During an interview on 12/3/18 at 11:47 AM Resident #68 stated he fell about a month ago in the transportation van because the seat belt was not placed across him. Resident #68 stated he did not notice he was not wearing a belt until he fell because he was used to being in a wheelchair. He further stated his Responsible Party was with them in the front passenger's seat and it was around noon. Resident #68 stated he was on his way back from the doctor's office and the van stopped at a stoplight and he slide forward out of the wheelchair and his bottom hit the wheelchair's foot rests and his arms hit the floor on both elbows and he came to rest on his back. He further stated then Van Driver #1 pulled over into a parking lot. Resident #68 continued stating Van Driver #1 came into the back of the van with him and began to help him back into his chair. He stated the van driver did not call anyone for assistance at that time and it took the driver a long time helping Resident #68 back into the wheelchair. He stated the van driver then brought him back to the facility. He stated he mentioned the incident to a staff member but did not remember who. He stated the facility did an x-ray on him but there were no breaks in his bones. Resident #68 stated he had shoulder pain after the fall. He stated he did not know who was notified in the facility of his fall in and no one assessed him when he returned. During an interview on 12/4/18 at 8:12 AM Resident #68 stated he told the Unit Coordinator at the desk that he fell in the van on 11/20/18 as soon as he was brought into the facility after the incident. He further stated he told the Unit Coordinator at that time he had right shoulder and arm pain because of the fall in the van. During an interview on 12/6/18 at 10:33 AM Van Driver #1 stated following the appointment on 11/20/18 he had placed Resident #68 in the van and secured the wheelchair. He further stated he then left the shoulder and lap belt slack on Resident #68 because he knew Resident #68 had a heart problem and Van Driver #1 did not want to have the belt tight across Resident #68's chest and waist. While transporting the resident he was approaching a stop light which turned to yellow and he stated he did not press the brakes any harder than a normal stop. At that point he looked at the rear-view mirror and saw that Resident #68 was about to come out of his chair and pulled into the closest parking lot. He stated Resident #68 slide forward and partially out of the wheelchair. Van Driver #1 stated Resident #68's buttocks was no longer in the seat of the wheelchair and the lower portion of Resident #68's back was resting on the front edge of the seat of the wheelchair with the seat belt and lap belt across his chest holding his upper body on the chair. He stated the outside of Resident #68's feet and his ankles did come in contact with the floor of the van, but no other body part of Resident #68 touched the floor. He stated the Responsible Party was sitting in the front seat at this time. During an interview on 12/3/18 at 12:40 PM Resident #68's Responsible Party stated she had traveled with Resident #68 in the van to his appointments twice. She further stated the two appointments were for Resident #68 to go to the dentist. She stated on 11/20/18 Van Driver #1 forgot to place the seatbelts on Resident #68 and she did not notice the concern. The Responsible Party stated the wheelchair was braced in tight, but the seatbelt strap was not on Resident #68 and a stop light changed to red, the car in front of them stopped quickly, and Van Driver #1 put on the brakes causing Resident #68 to fall out of the wheelchair. She stated he slid out of the chair across the foot rests and landed on his back with his legs out in front of him. She stated she was in the front passenger's seat and did not see the fall but turned around when she heard the noise of his fall and saw Resident #68 on the floor of the van. She stated she told Van Driver #1 to pull over into a parking lot near them and he did. She stated Van Driver #1 then got in the back with Resident #68 and tried to help him get back up in his chair since Resident #68 did not have much use of his legs. She stated the driver asked Resident #68 if he was okay and Resident #68 said yes. Once the driver got him in his wheelchair he placed the seatbelts on him. She stated Van Driver #1 knew he had made a mistake and was quiet for a while as he continued to drive back to the facility. After some time had passed, the driver told them he was going to call his boss. She stated he then called his boss while driving back to the facility and she heard him tell his boss Resident #68 was not strapped in to the wheelchair. After the phone call the driver hung up and told them he was fired and that it was his fault for not placing the seat belt on Resident #68. She stated the driver then took the resident in to the facility. She further stated she did not go in with them. She stated no one had contacted her about the incident in the facility. She further stated Resident #68 had started complaining more about his shoulder and arm on his right side. She further stated she came to the facility a few days later to sign some paperwork and mentioned Resident #68 had fallen on to the floor of the van during transportation to the Director of Nursing. She stated the Director of Nursing was not aware of the fall when she told her about it. She stated she did not remember what the Director of Nursing's response was to the fall, and the Responsible Party had not heard anything about the fall since then. Review of a written interview performed by the Director of Nursing dated 11/23/18 revealed the Director of Nursing performed a telephone interview with the facility's contracted Van Company Owner. The Van Company Owner stated he was aware of an incident with the resident and driver. He reported the driver told him the resident slipped to the front of the wheelchair because he (the driver) did not adjust the strap. The Van Company Owner told the Director of Nursing he terminated the driver for not adjusting the strap. The interview concluded that the facility was not notified because the Van Company Owner did not think the resident fell and stated the driver said he did not hit the floor or hit his head. During an interview on 12/3/18 at 3:06 PM the Van Company Owner he did remember on 11/20/18 a resident was being transported to or from an appointment and Van Driver #1 had called him and said that Resident #68 had an incident. He stated Van Driver #1 hit the brakes because a car in front of him had stopped and Resident #68 slid halfway out of the chair. The driver did not clarify if Resident #68 had hit the floor. He further stated the driver told the manager that he had not adjusted the shoulder and lap belts tightly enough which allowed the resident to slide halfway out of the chair. He further stated the van belts had two straps, one which went over the resident's shoulder and one that went across the resident's lap. He further stated had the driver adjusted the belts to the correct tightness, Resident #68 would not have slid out of the wheelchair and it was Driver #1's fault that the resident slid out of the chair. He further stated he asked the driver if the resident was hurt and the driver said the resident had not sustained any injuries and had already placed the resident back in his wheelchair. He stated staff were repeatedly trained on how to correctly apply the safety belts on residents when they are being transported and he had no idea why the driver did not correctly apply the safety belts and there was no excuse for not applying them appropriately. He further stated the van was inspected by the Transport Service Manager and there were no issues identified with the van. The Van Company Owner stated he did not inform the facility of the incident because the driver led him to believe there were no injuries because of the incident. He concluded he did not believe the van driver informed the facility either. Review of a written statement dated 11/23/18 by the Unit Coordinator responsible for resident appointments and transportation revealed Resident #68 did say something about the van driver getting fired when he returned from the appointment, but he did not say anything about a fall. She concluded the Responsible Party who was with Resident #68 did not report the fall to her. During an interview on 12/4/18 at 8:39 AM the Unit Coordinator stated she handled the appointments and transportation of residents. The Unit Coordinator stated Resident #68 left the faciity on [DATE] around 7:30 AM. She stated he did not mention anything about his appointment or anything unusual on 11/20/18 when he returned to the facility from his dental appointment around 12:15 PM. She stated Van Driver #1 did not inform her about anything as well. She stated she could not remember which day it was, but later that same week, Resident #68 came to the desk and said something about Driver #1 getting fired. She further stated the contracted van company did not contact the facility and inform them about the van incident and she had not discussed the incident with the van company. She further stated it was her expectation that the van company would notify her of any incidents during transportation of residents regardless if the incident resulted in an injury or not. The Unit Coordinator stated if a van incident occurred and a resident slid halfway out of his chair or sustained a fall, the van driver should immediately contact the facility. She stated she was the primary contact for the transport company at the facility. She stated she would then notify the Director of Nursing and the Administrator. She further stated Resident #68 did not inform her about any pain or concerns on 11/20/18 and the van driver gave her the paperwork from the doctor's office and did not inform her about any incidents in the van. She stated Resident #68's Responsible Party did ride in the van to the appointment on 11/20/18. Review of a written statement dated 11/23/18 by Nurse #1 who worked with Resident #68 on 11/20/18 on second shift revealed Resident #68 came to her at the medication cart and asked for a pain pill. Resident #68 then stated his Responsible Party had the transporter fired because he did not use a seat belt. Nurse #1 clarified that Resident #68's shoulder was hurting and gave him a pain pill. The nurse stated she understood Resident #68 had a history of [REDACTED]. The nurse stated he was propelling himself in his wheelchair without difficulty. During an interview on 12/4/18 at 10:53 AM Nurse #1 stated during her shift on 3 to 11, prior to thanksgiving, Resident #68 came to her while she was at her medication cart and said his shoulder was hurting. She stated she would get him his pain medication and while he was waiting he stated his Responsible Party had gotten the van driver fired. She stated she then made conversation with Resident #68 and stated, oh, really? Resident #68 then told her the van driver did not have him seat belted during transport. She further stated she was not aware of when the concern happened and took it as him giving a casual conversation because he spoke as if it happened in the past. She stated she did not report the conversation to anyone else in the facility or perform a fall assessment because he was casually chatting and did not say it had happened that day. She stated she gave him his as needed pain medication. She further stated because he did not verbalize it had happened that day or recently, and he had been self-propelling himself around the facility going about his daily routine, she did not notify anyone about the comment until the Director of Nursing requested a statement from her later that week. During an interview on 12/4/18 at 9:07 AM the Director of Nursing stated on 11/23/18 Resident #68's Responsible Party was in the facility to sign some consent forms and happened to mention there was an incident on 11/20/18. The Director of Nursing stated she had not been informed of the incident prior to the Responsible Party bringing it to her attention at that time. The Responsible Party stated Resident #68 was being transported back from his dentist appointment and the van driver had to stop short and Resident #68 slide from his wheelchair to the floor of the van. She stated the Responsible Party told her they struggled to get him back into his chair. The Responsible Party told the Director of Nursing that the driver was fired and did not share any further information about the incident. The Director of Nursing stated she then called the contracted transportation company and spoke with the Van Company Owner who told her that Resident #68 slipped to the front of the wheelchair because Driver #1 did not adjust the strap. She further stated she was told by the Van Company Owner he did not notify the facility because he did not think the resident had fallen, hit the floor, or hit his head. She further stated if there was any incident during transport of a resident where the resident had a risk for injury because a van driver did not appropriately secure the resident, especially if it warranted the van driver being fired, it was her expectation the van company notify her of the incident. She further stated after the incident on 11/20/18 it was her expectation that either the van driver or the owner of the company would have notified the facility of the incident. She stated on 11/21/18 a routine skin assessment was performed on Resident #68 by the facility and no concerns were identified at that time. She stated after learning of the incident on 11/23/18 Nurse #2 on the second shift contacted the on-call Nurse Practitioner #1 and informed her of the incident and the report of shoulder and arm pain for Resident #68. A mobile x-ray was ordered on [DATE] and performed on 11/24/18 which returned negative for any concerns besides the already identified [MEDICAL CONDITION] joint disease of the right shoulder. She further stated no injuries were identified as a result of the incident once the facility was made aware on 11/23/18. The Director of Nursing stated they suspended any further transportation of residents by the Medical Transport company on 11/23/18 while the transport company completed in services with all their staff. The suspension was lifted on 11/26/18. She stated audits of the transportation were initiated on 11/26/18. During an interview on 12/4/18 at 11:32 AM the Director of Nursing stated Nurse #1 worked with Resident #68 on 11/20/18 during the second shift. She further stated when Nurse #1 was informed of the incident by Resident #68 it was her expectation the nurse would have investigated more and report the concern to her Unit Coordinator and she did not believe the nurse did so because the nurse did not think it was an incident. During an interview on 12/3/18 at 3:41 PM the Transport Service Manager stated following the incident on 11/20/18 he serviced the van that was used to transport Resident #68 and identified no concerns with any of the safety features including the seat belts and wheelchair anchoring straps. He concluded the incident was a result of user error by Van Driver #1. Review of a progress note dated 11/23/18 at 9:34 PM revealed Nurse #2 documented she spoke to Nurse Practitioner #1 regarding Resident #68's right shoulder pain. An order was received to obtain an x-ray of Resident #68's right shoulder. Review of a radiology report dated 11/24/18 revealed Resident #68's right shoulder's joint was in alignment but there was narrowing of the joint space due to mild [MEDICAL CONDITION] changes. There were no shoulder fractures, separations, or dislocations observed. Review of a progress note dated 11/24/18 at 10:34 AM revealed Physician #1 was in the facility and reviewed Resident #68's right shoulder x-ray results. The results from the x-ray were mild [MEDICAL CONDITION] joint disease of the right shoulder, no fracture or dislocation were noted, and no new orders were given. During an interview on 12/6/18 at 7:46 AM Physician #1 stated he knew Resident #68 very well. He further stated Resident #68 had complained of right shoulder pain for at least a month prior to 11/13/18 and denied any injury to his arm and shoulder. The pain had been reported to him as gradually getting worse for Resident #68. The physician stated the pain had been on going prior to the incident on 11/20/18 and he had received a cortisone shot in his right shoulder on 11/13/18 from the orthopedic clinic after a referral for shoulder pain. He stated on 11/24/18 Resident #68 had a right shoulder x-ray which he reviewed and found only mild [MEDICAL CONDITION] joint disease as a significant finding. The physician stated mild [MEDICAL CONDITION] joint disease would not be caused from a fall but was a gradual disease process. The physician stated there were no other substantial findings from the x-ray and concluded Resident #68 did not sustain any injuries from any alleged fall on 11/20/18. During an interview on 12/5/18 at 8:10 AM the Administrator stated the Director of Nursing came to him on 11/23/18 after she spoke with the Responsible Party of Resident #68 and informed him of what the Responsible Party had shared with her. He stated he then went and interviewed the nine resident who had been transported that week and discovered no residents had any concerns about their transportation that week. The Administrator then stated he suspended transportation with the contracted company on 11/23/18 and then continued his contact with the transportation company to coordinate getting all the documentation of the in serviced staff members at the contracted transportation company. This was completed on 11/25/18 and transportation was resumed on 11/26/18. He stated he watched the training video about the appropriate way to secure a resident into a transportation van about a year ago. He stated the Director of Nursing and the Unit Coordinator had not been in serviced on how to appropriately secure a resident into a transportation van prior to monitoring the transportation starting 11/26/18. He further stated there were no in services provided to facility staff regarding the need to follow up on statements such as the ones Resident #68 made to staff members on 11/20/18 and 11/21/18. He further stated he would expect to be notified if any situation arose during transportation of a resident that could have compromised the safety of the resident. During an interview on 12/4/18 at 3:45 PM the Director of Nursing stated the Unit Manager and herself had not been in serviced about the appropriate way to secure a resident in the transportation van. She concluded none of her staff had received any in services related to following up on resident statements that they had not been secured appropriately in a van or about reporting such concerns to their supervisors and performing an assessment. During an interview on 12/5/18 at 8:52 AM the Unit Coordinator who monitored the transportation on 11/26/18 stated she had not been in serviced on how to appropriately secure a resident in a transportation van. She stated she was the only staff member present when performing the observation on 11/26/18 and she observed that all straps were placed properly, and the resident was observed to be secure in the van to the best of her knowledge. During an interview on 12/5/18 at 2:20 PM Van Driver #2 stated he had worked for the transportation company for 8 years. He further stated he had been in serviced on the correct way to transport residents in vans including how to secure residents for transport. He stated this training took place on 11/25/18. During observation on 12/5/18 at 2:36 PM Van Driver #2 was observed securing the Administrator in the transportation van. Van Driver #2 placed the rear wheelchair anchors on the outside of the wheelchair wheels. The anchor straps were then secured to the wheelchair frame causing the straps to wrap around the wheels of the wheelchair on both sides placing stress on the straps. Van Driver #2 then placed the seat belts on the administrator. The lap belt was observed to wrap around the left arm rest. The rear anchors for the lap belt was observed to be secured on the outside of the wheelchair wheels and wheelchair rear anchors. This caused the lap belt straps to wrap around the wheelchair wheels placing stress on the belt straps. During an interview on 12/5/18 at 2:40 PM Van Driver #2 stated he had finished securing the administrator in the van as he would secure a resident for transportation. Upon observing the lap belt secured around the left arm rest, Van Driver #2 stated the seat belt should not be around the arm rest and instead placed through the opening between the arm rests and the seat back. Upon being questioned about the placement of the wheelchair and seat belt anchors, Van Driver #2 stated the anchors could be moved to the correct positions and that they were not correct as the straps should not wrap across the wheelchair. When asked the reason he did not adjust the seat belts and anchors correctly he stated he did not have a reason as it was for demonstration. During an interview on 12/5/18 at 2:50 PM the Administrator stated it was his expectation that Van Driver #2 would have demonstrated the correct way to secure a resident in the transportation van according to manufacturer's instructions. The Administrator was notified of the immediate jeopardy on 12/5/18 at 12:30 PM. On 12/6/18 at 1:52 PM the facility provided the following credible allegation of compliance for immediate jeopardy removal: Free from Accident/Injury Corrective action that will be accomplished for Tag 689 Resident #68 currently resides at Ridgewood Rehabilitation Center and has no injury related to alleged incident 11/20/2018 of not being secured and allegedly falling from wheelchair while in a Contract Transportation company transport vehicle. Owner of the company, of the Contract Transportation company has in-serviced 100% of all transportation drivers who operate the wheelchair lift van to ensure appropriate connection of belt device completed by 11/25/2018. Provider has in-serviced 100% of all transportation drivers who operate the wheelchair lift van to ensure appropriate connection of belt device, this was completed through manufacturer video and slide show and verbal instruction and review of key points. No damage or malfunction of the device was noted. Upon revisit on 12/5/2018 it was observed that the driver did not apply the devices appropriately. Because of the above observation all transport persons were again trained by Owner on 12/5/2018. This training included a step by step demonstration by the owner of the company in the van, along with return demonstration. No personnel will be allowed to provide transportation until they have received re-in-service training. Additionally, each wheelchair vehicle has been provided a printed illustration of the directions. Nine other residents who were transferred during that week of alleged incident were interviewed on 11/25/18 and reported no other incidents or injuries related to transportation. All incidents and accidents are to be reported to the administrator, director of nursing (DON), or nursing supervisor immediately via cell phone. The administrator, Director of Nursing (DON), or nursing supervisor will be responsible for investigating any incidents/accidents. Identification of other residents: All residents that are transported are at risk for this alleged deficient practice. All transportation service aides who operate a wheelchair lift van were provided in-service education by?? the transportation company owner to prevent reoccurrence to this resident or any other resident. This was completed by or on (MONTH) 25, (YEAR). Upon revisit on 12/5/2018 it was observed that the driver did not apply the devices appropriately. Because of the above observation all transport persons were again trained by transportation company owner on 12/5/2018. This training included hands on application and return demonstration using the video and manufacturer's instructions. No personnel will be allowed to provide transportation until they have received re-in-service training. All licensed staff members were contacted by the Director of nursing and Assistant Director of Nursing and had not been made aware of any trends or patterns involving any other resident which had not been previously reported. No other residents were affected by this alleged deficient practice. This was completed on (MONTH) 5, (YEAR). Measures for system change: Director of Nursing (DON) and Administrator were provided in-services to the reporting and investigation of any incident reported by staff, resident, visitor by Regional Director of Operations on 12/5/2018. Administrator and Director of Nursing in-serviced all department manager staff currently working. The department managers provided training to their staff currently working. All staff who were not present will be unable to return to work until they have received in-service training. The training included 1) Appropriate and immediate notification of any incident or knowledge of any incident of any resident on or off premise to the director of nursing, administrator and/or unit coordinator. 2) Investigation of any incident or knowledge of any incident at the time of occurrence will be completed by the administrator, director of nursing and/or unit coordinator. No facility staff who were absent or PRN (pro re nata) staff will be allowed to return to work until this training/education has been completed. Systematic change to prevent reoccurrence will be that all contracted transportation services will include language within the contract to contact the facility immediately if an incident occurs. This language includes any incident involving injury must be immediately called to the administrator or Director of Nursing. Owner of the company requires a company provided cell phone be on the vehicle at all times. All staff members will report all incidents or accidents with or without injury to the nurse, administrator or Director of nursing. Upon receipt of this notification, alleged incident/accident will be fully investigated in accordance with the facility policy re: Incident/Accident Investigation. This new systematic change was implemented by the Regional Director Operations on 12/05/18. Director of Nursing (DON), and Administrator were in serviced by Regional Director of Operations on 12/05/18. Administrator and Director of Nursing in-serviced all department directors on 12/05/18. All Department directors in-serviced all staff currently working. No staff who was absent or PRN (pro re nata) staff will be allowed to return to the floor and resident care until this training/education has been completed. This education and information will be included with all new hires as part of the new hire training process. How corrective actions will be monitored: Administrator, Director of Nursing or other staff who have received training through manufacturer training video on how to properly secure a resident in the wheelchair van shall conduct random visual audit of 5 resident transports per week x 1 month, then 5 times per month times 3 months and report to QAPI. Modification of current plan and/or monitoring audits will continue at the discretion of the QAPI committee. Administrator and Director of Nursing will monitor all incident and accidents of residents weekly, ensuring that appropriate investigation and intervention of any incidents that occur is performed. This information will be reported to QAPI. Modification of current plan and/or monitoring audits will continue at the discretion of the QAPI committee. Director of Nursing or Assistant director of nursing will conduct random audits of nursing personnel, inquiring to the knowledge of accidents reported by residents, staff, and/or visitors which have not been communicated. This will be completed 5 times per week X 1 week and 5 times per month X 3 months and report to QAPI. Modification of current plan and/or monitoring audits will continue at the discretion of the QAPI committee. This will be monitored by the administrator. Credible allegation and all elements were in place on 12/5/2018. The credible allegation for Immediate Jeopardy removal was validated on 12/6/18 at 3:09 PM, which removed the Immediate Jeopardy on 12/5/18, as evidenced by staff interviews, in-service record reviews, a (TRUNCATED)

Based on observations, record review and staff interviews, the facility failed to evaluate and identify the cause of the falls so that effective interventions could be implemented for 1 of 3 residents (Resident #87) who had a history of [REDACTED]. The facility also failed to evaluate the blue hall exit door for resident safety and failed to implement interventions for prevention of residents exiting through the door for 1 of 1 residents (Resident #70) who was confused and wandered out the blue hall exit door down 2 flights of stairs. Findings included: 1. Resident #87 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) of 02/18/13 indicated Resident #87 had long and short term memory problems as well as impaired decision making skills. There were no behaviors noted. She needed limited assistance with bed mobility, transfer and walking in her room or corridor. She needed extensive assistance with locomotion. She was not steady when moving from a seated to a standing position and was only able to stabilize with human assistance. Resident #87 was not steady when walking or turning around and was only able to stabilize with human assistance. The Care Area Assessment (CAA) summary for this assessment indicated she triggered for falls and activities of daily living (ADL). The falls CAA detail identified her as being at risk for falls and had not had any falls recently. The ADL CAA noted she had declined recently due to pneumonia and was requiring more assistance than usual due to weakness. The March 2013 physician's order [REDACTED]. According to a progress note in Resident #87 ' s electronic record, she was observed on the floor at 1:00 AM on 03/07/13. The note indicated she was confused and disoriented. Resident #87 was transferring herself and sat on the floor. There were no injuries. The facility ' s occurrence report of 03/07/13 for Resident #87 ' s fall at 1:00 AM, indicated she was observed sitting on the floor in front of her bed and was confused and disoriented. She was bare foot and had attempted a non-capable walk and/or transfer. It was noted Resident #87 had poor safety judgment and had climbed out of bed without assistance slipping on the floor and fell . The intervention to prevent further falls was to place non-skid socks on Resident #87. According to the Quality Assurance worksheet for this fall investigation, Resident #87 was attempting to get out of bed and was in her normal state of confusion. She had been non-compliant with use of the call light. It was also noted on this worksheet that staff had been in 15 minutes prior to the fall to check on her. A bed alarm was in place and functioning at the time of the fall. The new intervention was non-skid socks and to offer to toilet her every 2 hours. According to the ECS computer care plan printout, Resident #87 was identified as having a history of falls on 03/11/13. Staff were to encourage her to ask for assistance and offer to toilet every 2 hours. A nurse progress note of 03/17/13 at 11:32 PM written by Nurse #3 indicated Resident #87 was observed on floor at 3:45 PM in her room. It was noted that the pad alarm was turned off. Resident #87 had a laceration with bleeding noted, a skin tear and complained of pain at a level of 5 out of 10 on the pain scale. Injuries were noted to the right ear, right eye, and right cheek. Resident #87 was sent to the emergency room . A telephone physician's order [REDACTED]. The facility ' s transfer form of 03/17/13 indicated Resident #87 was sent out to the emergency room for evaluation of a head injury following a fall. According to the emergency room records, she was discharged back to the facility with a face laceration and a C2 cervical spine fracture. The facility ' s occurrence report and investigation of 03/17/13 for Resident #87 ' s fall at 3:45 PM indicated she was observed on the floor. The possible cause was slipping on the floor. There was injury to the right ear, right eye and right cheek and nose as well as a skin tear. The physician and family were notified. It was noted that the fall had occurred during shift change from day shift to evening shift. It was noted Resident #87 was found on the floor alone after hearing " help " and a noise. The contributing factor indicated the bed or chair alarm was not on. Resident #87 had gotten up without assistance. Xray results from the emergency room indicated Resident #87 had a C2 cervical spine fracture. It was noted in the Quality Assurance worksheet attached to the report that the alarm was not sounding and the fall had been caused by no wheelchair and/or bed alarm being on. Interventions to prevent further falls included all alarms to be checked and implement one on one supervision for Resident #87. The last fall risk assessment score of 02/21/13 was 21 which indicated she was at high risk for falling. A nurse progress note of 03/18/13 at 3:19 AM indicated Resident #87 had returned to the facility at approximately 12:15 AM with a cervical collar in place with a dressing to the right eye. There were sutures to the right forehead in an almost circular pattern approximately the size of a quarter. Neurological checks were started. The nurse documented she was unable to obtain light reaction in the right eye due to the amount of swelling and bruising. It was noted that the bed alarm and the tabs alarm units were in place and functioning. There was a fall mat placed on the floor. Resident #87 ' s care plan for falls, last updated 03/20/13, indicated she was found on the floor. Staff were to ensure that the bed alarm was in place at all times with one on one care. Resident #87 was observed in bed wearing a cervical collar on 03/20/13 at10:00 AM. Her right eye was swollen and black purplish bruising with sutures just above the right eyebrow. There was no staff member present in her room at the time of the observation. There was a bed alarm noted in place. Nurse Aide #2 (NA #2) was observed sitting in a chair at the doorway of Resident #70 ' s room which was located next to Resident #87 ' s room. When NA #2 was interviewed at10:02 AM on 03/20/13, she stated she was monitoring Resident #87 ' s room as well as Resident #70 from Resident #70 ' s doorway. Resident #87 was observed in the wheelchair at 3:30 PM on 03/20/13. There was a clip alarm attached to the wheelchair and to her clothing. NA #3 was observed sitting in a chair just outside her doorway. When interviewed at 3:35 PM, NA #3 reported that Resident #70 had been moved to the room with Resident #87 so she could monitor both of them as well as the exit door. She added that Resident #87 was ambulatory prior to the fall of 03/17/13. NA#3 stated Resident #87 had poor vision and was not independent with ambulation since the fall. NA #3 commented that she was able to stand and pivot for transfers and had both a bed alarm and a clip alarm. The Director of Nurses (DON) was interviewed on 03/21/13 at 9:55 AM. She stated when a resident falls the nurse who assessed the resident completes a fall report as to the circumstances of the fall. She stated it then comes to her for review and she passes it on to Nurse #8 to complete the follow-up investigation. The DON reported that resident falls were discussed in the morning meetings to determine appropriate interventions. She commented that after Resident #87 fell on [DATE] a monitoring tool had been created for administrative nursing staff to start checking for placement of the alarms and their function. The DON stated the electronic charting system (ECS) was being checked to ensure that all residents with alarms were documented in the ECS. She stated the alarms would be added to the ECS medication administration record (MAR) for the nurses to make sure they were aware that the resident had an alarm. The DON stated in-services were in process to make sure all staff knew who had alarms and where to find the information in the ECS. The DON remarked she would be conducting audits. When questioned about the one on one supervision for Resident #87, she responded that they had placed the two residents who were currently on one on one supervision in the same room so as to utilize only one staff person. NA #4 was observed sitting just inside Resident #87 ' s doorway on 03/21/13 at 10:30 AM. Resident #87 was sitting in a wheelchair wearing yellow non-skid socks with the cervical collar in place. She was also noted to have a clip alarm in place. When interviewed about the function of the alarm at 10:35 AM, NA#4 stated she checked for placement of the alarm at the beginning of the shift and demonstrated its function by disconnecting it resulting in an audible sound. NA #4 also reported Resident #87 was non-ambulatory and she was assigned to supervise her to ensure that she did not attempt to get up unassisted. The nurse aide (NA #5) who had worked with Resident #87 on 03/17/13 day shift was interviewed on 03/21/13 at 10:57 AM. NA #5 stated Resident #87 needed total care and was alert but confused. NA #5 stated she was non-ambulatory and could stand and pivot to transfer. When questioned about the fall of 03/17/13, NA #5 stated she had been told that Resident #87 had fallen during shift change that day. She added that she had already left the premises when Resident #87 fell . NA #5 stated Resident #87 ' s family member had assisted her with placing Resident #87 back into bed toward the end of her shift on 03/17/13. She stated the sensor alarm was in place and working when she left the room. NA #5 stated if a resident had an alarm it was noted on the ADL sheet in the ECS. NA #5 added that she left at 3:00 PM on 03/17/13 and the second shift aide took over care at 3:00 PM. Nurse #6 was interviewed on 03/21/13 at 11:20 AM. She stated fall risk assessments were completed after each incident and if the resident had no falls, the falls risk assessment was completed quarterly with the MDS. Nurse #6 commented that Resident #87 was at risk for falls and her care plan had been updated to include the new intervention of one on one supervision. A telephone interview was conducted with Nurse #3 on 03/21/13 at 1:30 PM. She stated she was just coming on duty on 03/17/13 and received report about 3:30 PM. She stated at about 3:45 PM she walked down Resident #87 ' s hallway and heard someone calling for help. She stated she noticed upon entry into the room that there was no alarm sounding and when she checked the alarm was not turned on. Nurse #3 reported that Resident #87 ' s wheelchair was positioned next to the bed and her walker was placed behind the wheelchair. She stated she went into the room and found Resident #87 on the floor near the bathroom with bleeding noted over her right eyebrow. Nurse #3 stated she applied pressure and assessed her on the floor. She stated Resident #87 was left on the floor with supervision until the emergency service arrived to transport her to the emergency room . Nurse #3 commented she did not lose consciousness. She stated the resident reported she had gotten up to close the door. Nurse #3 stated she could not determine where Resident #87 had been positioned prior to the fall. She stated the on-coming nurse aides were getting their assignments and supplies in preparation for providing care during the time Resident #87 fell . When questioned how many nurse aides were on the hall, she replied that she knew one was there and another aide was late. Nurse #3 commented that one nurse aide did not show up for her shift. Nurse # stated when a resident fell the nurse assessed them, completed a fall report, an investigation form and a handwritten fall report. She stated the family as well as the physician were notified of the fall and the incident report was faxed to the physician. Nurse #3 added that Resident #87 had returned to the facility shortly after midnight with sutures to her upper right eyebrow. Nurse #8 was interviewed about Resident #87 ' s fall on 03/21/13 at 3:15 PM. She stated she completed the Quality Assurance worksheet incident prevention addendum for the fall of 03/17/13. When questioned as to her investigation, she stated she had not yet interviewed any of the staff who worked with Resident #87 the day she fell . Nurse #8 reported when Resident #87 fell , the staff working were PRN (as needed) staff and were often difficult to reach and had not been back into the building to work since 03/17/13. Nurse #8 commented that one of the nurse aides (NA #5) who worked on 03/17/13 had actually worked on day shift today but she did not interview her. She stated the fall prevention equipment was not in place when Resident #87 fell . Nurse #8 stated she was responsible for making sure there was a physician's order [REDACTED]. Attempts to contact the second shift nurse aide were unsuccessful so the DON was interviewed again on 03/21/13 at 4:30 PM. She provided a written statement from the second shift nurse aide (NA #8) which indicated NA #8 went into Resident #87 ' s room and she was on the floor near the bathroom. NA #8 assisted the nurse. There was no other information in this document. The DON stated she had not interviewed NA #8 since she had asked the nurse to obtain the statement. 2. Resident #70 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. According to the electronic computer system (ECS) for Resident #70, the last elopement/unsafe wandering risk assessment was completed on 12/18/12. She was not identified as being at risk for elopement or wandering. The most recent Quarterly Minimum Data Set (MDS) assessment of 01/12/13 indicated Resident #70 was not cognitively intact. She required limited assistance for bed mobility, transfer and to walk in her room. She was not steady when moving from a seated position to a standing position and could not stabilize without human assistance. She was not steady when walking but could stabilize without human assistance with the use of an assistive device. A physician ' s telephone order of 02/27/13 at 6:15 AM noted to obtain a UA (urine for analysis). A nurse ' s note of 02/27/13 at 6:26 AM indicated Resident #70 was noted to have confusion this morning. She attempted to exit the facility at 5:45 AM. The note indicated she had gone down hall 3 (her hall), went out the exit door and down 2 flights of steps before staff could get to her. She was put back in bed. It was also noted that the writer had attempted to find a wander guard for her but none were available so a tabs unit was placed on Resident #70 and a note was left for the Director of Nurses (DON). A physician ' s telephone order of 02/27/13 noted to check Resident #70 ' s wander guard bracelet every shift and to check the battery every night. On 02/27/13 at 9:22 AM, the family was notified about the incident of Resident #70 getting out of bed and going out of the door at the end of the hall and down 2 flights of stairs. The note indicated it was reported to the family that one on one supervision was instituted and staff would be attempting to obtain a urine specimen for urinalysis. A nurse ' s note of 02/27/13 at 3:35 PM indicated Resident #70 had delusional behaviors stating " I was chasing after those children last night " . The note indicated she was receiving one on one supervision at this time. Resident #70 ' s care plan, last updated 02/28/13 identified her as a wanderer. Staff were to check her wander guard bracelet to make sure intact. A physician ' s telephone order of 02/28/13 noted to give Septra DS (antibiotic for treatment of [REDACTED]. A late entry nurse ' s note of 02/28/13 at 10:00 AM indicated a wander guard bracelet was placed on Resident #70 ' s right wrist. A nurse ' s note of 02/28/13 at 3:37 AM indicated Resident #70 was resting quietly with one on one care. She had not attempted to wander this shift and her wander guard was on and functioning. A nurse ' s note of 03/01/13 noted her to be resting quietly in bed talking loudly in her sleep. Resident #70 had not attempted to exit her room. The tabs unit was on and functioning. Staff were sitting in front of her room when not having to attend to other residents. Resident #70 was monitoring closely and was receiving an antibiotic for a urinary tract infection (UTI). During a family interview with Resident #70 ' s family on 03/19/13 at 9:25 AM, she reported concern about the issue of Resident #70 getting out of the door and down 2 flights of stairs before staff came to get her. The family member stated Resident #70 could have been seriously injured. Nurse # 4 was interviewed on 03/19/13 at 3:30 PM. She stated she did not know if the wander guard alarm was on all of the exit doors. She stated she did not know what the circumstances were when Resident #70 attempted to leave the building but as a result she had a bed alarm, a clip alarm and a wander guard bracelet. Nurse #4 also stated she was receiving one on one supervision. On 03/19/13 at 4:00 PM the maintenance supervisor (MS) stated he checked all of the alarms twice weekly but they were not checked on weekends. He stated there were 7 exit doors in the building. The wander guard system was set up for the entrance door into the building, the service hall door which was in the center of the red hall (100/200 hall) and the vending room door. He stated the other doors alarmed when opened. The MS stated he had worked at the facility since October 2012 and one resident had attempted to leave the building. He walked to the blue hall or B3 as he referred to it. There was a door with the notation of " NO EXIT alarm will sound " . He walked to the end of the blue hall (Resident #70 ' s hall) and pushed open the exit door. Upon opening, a loud audible alarm sounded. He pressed in a code and the alarm stopped sounding. The MS commented that the door isn ' t locked from the inside but once the door closed you were not able to go back into the building. Once through the door to the immediate right were 2 flights of concrete steps which led down to a small hallway. Once to the hallway, there was a door noted on the left side which he reported as entry into the laundry room and a door to the right which was an exit door leading into the parking lot. The MS stated that the door to the right of the stairs had no alarms but was kept locked when the laundry room was closed. The exit door was not included with his twice weekly checks. Resident #70 was observed sitting in a gerichair on 03/19/13 at 4:40 PM. There was a clip alarm stretched across the bed but not attached to her clothing. There were no staff members present either in the room or just outside her room. At 4:45 PM on 03/19/13, Nurse Aide #6 was observed in the hallway across the hall from Resident #70. Upon interview, she stated Resident #70 was confused but ambulatory with her walker. NA #6 stated she had no alarms but did have a bracelet that alarmed if she attempted to exit the building. She explained that she thought Resident #70 had attempted to leave going out of the wrong door but staff got to her before she got out of the building. When questioned about monitoring, she stated she checked on Resident #70 about every 2 hours. NA #6 stated she had not been to any in-services on elopement. During an interview with Nurse #8 and Nurse #5 on 03/19/13 at 4:55 PM, both nurses reported that a recent in-service had been provided to staff regarding elopement. Nurse #8 commented that Resident #70 had attempted to leave the building. She stated Resident #70 went down 2 flights of stairs before staff got to her. Nurse #8 stated the alarm had sounded when Resident #70 went through it. When questioned as to whether that back door was kept locked, both nurses stated they did not know as they didn ' t use that exit. During the interview, the Director of Nurses (DON) came into the room. Nurse #8 asked the DON if the back door that led to the outside was kept locked and she replied she did not know. The DON was interviewed at 5:00 PM on 03/19/13. When questioned as to the investigation and the incident report for Resident #70 ' s attempt to leave the building, she replied that she didn ' t complete an incident report since the resident didn ' t actually get out of the building. The DON reported since the incident, Resident #70 had been on constant supervision on all three shifts for her safety. She stated she had a summary of her investigation that she could provide. She provided a document which documented she had spoken to one nurse and was given the particulars of the incident. It was also documented in the summary that she had in-serviced all staff on all shifts about elopement and staff were asked to sign in as evidence they attended. When questioned about the investigation, she stated she did not interview any other staff since the nurse who was working when the incident happened had provided her with the details During a telephone interview with Nurse #2 on 03/20/13 at 6:45 AM, she stated she worked the night that Resident #70 went out the exit door. She reported she was not assigned to the blue hall (hall where Resident #70 resided) but was at the nurses ' station and heard the exit door alarm sound and the door shut. She stated she proceeded down the blue hall (where Resident #70 resided) to see what was going on with the exit door. Nurse #2 stated the nurse aides were in rooms providing care and came out of the rooms when the alarm sounded. She reported that she as well as other staff went to check the exit door. Nurse #6 stated when she got to the door, NA #7 as well as 2 other aides were assisting Resident #70 back up the stairs. When questioned where the nurse was that was assigned to the blue hall, she responded she was in the front of the building and didn ' t get to the room until staff had brought Resident #70 back into her room. Nurse #2 stated she did not know whether the door at the end of the stairway that exits to the outside of the building was locked or not as staff didn ' t usually go out that door. Nurse #7 commented that a bed alarm was placed on her bed upon return to her room and staff monitored her one on one that night. Nurse #2 reported an in-service was held the next day. A telephone interview was conducted with NA #7 on 03/20/13 at 7:55 AM. She stated she was working the night Resident #70 attempted to exit the facility and was one of the aides who assisted her back up the stairway. NA #7 stated she was on the blue hall in a room providing care as were all of the aides. She stated she heard the exit door alarm sound and came out of the room she was in to see what was going on. NA #7 stated staff were headed toward the exit door at the end of the blue hall. She commented that Resident #70 was in the stairway wearing pajamas and socks when she got to her. When questioned about the last time she had seen Resident #70 she remarked that she couldn ' t remember the last time she had checked on her but she was sleeping every time she went into the room. NA #7 stated she had started her rounds about 4:45 AM that morning. NA #7 stated Resident #70 was not restless that night and usually toileted herself. She stated she seemed a bit more confused that night than usual. Resident #70 was observed in bed on 03/20/13 at 10:00 AM. There was a clip alarm attached to her clothing. NA #2 was sitting in a chair at her doorway. When NA#2 was questioned, she stated she was assigned to her today and was also watching Resident #87 ' s room. She reported that Resident #70 had attempted to go out of the back door so staff were assigned to sit with her one on one. NA #2 stated she had a clip alarm when she was in bed and in the chair. During an interview with laundry room staff #1 (LR #1) on 03/20/13 at 2:20 PM, she stated that she as well as other staff report to work at 8:30 AM and leave at 3:30 PM daily. She reported that another staff person (LR #2) reported to work early starting at 6:00 AM and leaves at 2:30 PM daily. LR #1 reported that the day Resident #70 had left the floor and came down the stairs LR #2 had told her when she got to work that day, Resident #70 was outside the laundry room. LR #1 stated LR #2 had stated she telephoned upstairs and alerted staff that she was down stairs. During an observation of Resident #70 on 03/20/13 at 2:45 PM, NA #1 was sitting outside the doorway of her room. On 03/20/13 at 6:05 PM when observed from the parking lot, the laundry area exit door was unlocked. LR #2 was interviewed on 03/21/13 at 8:15 AM. She stated she came in early the day Resident #70 went out the exit door on her hall. She stated she was not allowed to clock in early so she ate breakfast until 5:55 AM when she could clock in. LR #2 remarked that LR #1 must have misunderstood her communications to her. She stated when she came into the building the day Resident #70 went out the door staff commented to her that she had a visitor downstairs that morning. When questioned who used the exit door at the bottom of the stairs located in back of the building, she responded that the laundry room staff and the maintenance department were the only staff who went in or out that back door and it was always unlocked. LR #2 commented it was unlocked the morning Resident #70 made her way downstairs. The DON and the Administrator were interviewed on 03/21/13 at 9:00 AM. The DON stated Resident #70 did not exit the building but she did go out the door and down 2 flights of stairs. She commented that she did not talk with other staff regarding the incident as she felt Nurse #7 had given her the details. She stated the alarm on the door sounded and staff responded. The DON stated her first reaction was to make sure none of the other residents made their way out that door. She stated in-services were started and all staff had attended. According to the DON, that was the first time a resident had gone out the exit door and Resident #70 was not identified as a wanderer. The Administrator commented that it was a concern for them as no resident had attempted to leave the building from that door in the past. He stated he had always " hated " that exit door and the way it was set up. He commented that since the incident with Resident #70 he was looking into changing the alarm system and installing a better system. The Administrator reported 2 different companies had been out to look at the area but he had to clear any changes with life safety. The Administrator stated when the laundry room staff exit through the back door when their shift ended it was their responsibility to lock it. He commented that once it was locked no one could enter from the outside but it was possible to exit through that door from the inside when it was locked. During an interview with NA #4 on 03/21/13 at 10:30 AM, she stated she had not attended an in-service on elopement since Resident #70 attempted to exit the building. Nurse #6 was interviewed on 03/21/13 at 11:20 AM. She stated she had not completed in-services for all of the staff in regards to Resident #70 ' s attempt to exit the building. She stated she had a list of all staff and was marking them off as they attended. She also provided a wandering risk assessment, dated 02/28/13, for Resident #70 which indicated she was at risk for wandering as she had attempted to go out the fire exit door.