Every finding on record at Sanford Health & Rehabilitation Co

Based on record review, resident and staff interviews, the facility failed to honor a resident's choice and provide showers as scheduled (Resident #86) for 1 of 3 residents reviewed for choices. The findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, pain, osteoarthritis and muscle weakness. An admission Minimum Data Set assessment dated [DATE] indicated Resident #86 was cognitively intact and required maximum assistance from staff for bathing. A review of Resident #86's active care plan included a problem area that was initiated on 7/14/26 for requiring assistance from staff with Activity of Daily Living (ADL) care secondary to weakness and overall deconditioning. One of the interventions included assisting with ADLs. A review of the Nurse Aide (NA) Care Guide indicated Resident #86 was to receive a shower every Monday and Thursday on the 3:00 PM to 11:00 PM shift. A review of Resident #86's personal care flow records indicated she received one shower from 6/26/26 to 7/22/26. She received a shower on 7/9/26 on the 3:00 PM to 11:00 PM shift as scheduled. The nursing progress notes were reviewed from 6/26/26 to 7/22/26 and did not reveal any refusals of showers. An interview occurred with Resident #86 on 7/20/26 at 12:09 PM and stated that she had received one shower since her admission to the facility and would like them more regularly. She stated she was aware showers were provided twice a week, but she had only been offered a shower once by an NA that provided one for her. Resident #86 continued to say that she received a bed bath every morning before getting out of bed but would like to receive her showers as well. On 7/22/26 at 2:52 PM, an interview occurred with NA #5, who cared for Resident #86 during the 7:00 AM to 3:00 PM shift. She explained that Resident #86 was to receive her scheduled showers on the 3:00 PM to 11:00 PM shift on Monday and Thursdays. NA #5 stated that she provided Resident #86 with a bed bath in the morning and had not known Resident #86 to refuse a bed bath. An interview was completed with NA #3 on 7/22/26 at 3:21 PM. She had been assigned to Resident #86 on her scheduled shower days of 7/6/26, 7/13/26, 7/16/26 and 7/20/26 on the 3:00 PM to 11:00 PM shift. NA #3 was unable to state why she didn't provide Resident #86 with showers as scheduled. The Director of Nursing was interviewed on 7/23/26 at 1:17 PM and stated she expected all residents to receive showers as requested and scheduled. If a resident refused, the NA should alert the nurse so a progress note could be written, and an alternate means of a bath provided.

Based on observations, record review and interviews with the Nurse Practitioner and staff, the facility failed to assess the use of an abdominal binder (a wide compression belt worn around the abdomen) as a restraint and failed to obtain Responsible Party (RP) written consent for the use of a restraint. This deficient practice affected 1 of 1 resident reviewed for restraints (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, and metabolic encephalopathy.A review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had severe cognitive impairment, no documented behavior, and he was dependent on staff for feeding. The assessment further revealed Resident #12 had no impairment of range of motion (ROM) of the upper extremities and did not have a feeding tube.A review of a nursing progress note dated 6/26/26 by Unit Manager #2 indicated Resident #12 was discharged to the hospital on 6/26/26.A review of the hospital Discharge summary dated [DATE] revealed that during the hospitalization Resident #12 had a Percutaneous Endoscopic Gastrostomy (PEG) tube (a medical device used for long term nutritional support in patients who cannot safely swallow or consume adequate nutrition by mouth) placed in his abdomen on 7/2/26. Resident #12 was readmitted to the facility on [DATE]. There were no orders included in the hospital discharge summary for use of an abdominal binder.A nursing progress note dated 7/8/26 by Nurse #3 revealed Resident #12 readmitted to the facility from an acute care hospital. During Resident #12's assessment it was observed that he had a PEG tube present in the upper abdominal quadrant. The presence of an abdominal binder was not included in the progress note.During an interview with Nurse #3 on 7/22/26 at 12:58 PM she revealed she completed an admission assessment on Resident #12 when he returned from the hospital on 7/8/26 and the abdominal binder was in place over the PEG tube at that time. She stated the abdominal binder was used to help prevent Resident #12 from pulling out the PEG tube. Nurse #3 stated there was no physician order for the abdominal binder when Resident #12 returned from the hospital on 7/8/26 and she was not aware one was needed. She also stated that she had never observed Resident #12 pulling on the PEG tube or abdominal binder. Nurse #3 added that she was not aware the binder could be considered a restraint.A nursing progress note dated 7/9/26 at 11:29 AM indicated the Wound Nurse completed a skin check on Resident #12 following readmission. The Wound Nurse indicated there was a PEG tube in the upper abdomen with an abdominal binder present.During an interview with the Wound Nurse on 7/22/26 at 11:30 AM, he indicated Resident #12 returned to the facility from the hospital on 7/8/26. He stated the next morning on 7/9/26 he completed a skin check on Resident #12. The Wound Nurse stated that he observed the abdominal binder in place securing the PEG tube during his assessment. The Wound Nurse stated he had not observed Resident #12 pulling on the PEG tube or abdominal binder. The Wound Nurse added that he had never observed Resident #12 remove the binder and was unsure if he could.A nursing progress note dated 7/11/26 at 5:37 AM by Nurse #4 revealed that while making rounds she observed that Resident #12's feeding tube was out, while the abdominal binder remained in place. Resident #12 was sent to the hospital for replacement of the PEG tube on 7/11/26. Attempts to reach Nurse #4 during the survey were unsuccessful.A review of the hospital medical record dated 7/13/26 revealed that Resident #12's PEG tube was replaced on 7/13/26. The note further detailed the PEG tube had been replaced previously on 7/6/26 and 7/7/26. A review of the hospital Discharge summary dated [DATE] revealed that on 7/11/26, Resident #12 pulled out his PEG tube and was sent to the hospital for PEG tube replacement. Resident #12's PEG tube was replaced on 7/13/25. The discharge instructions included directions to keep an abdominal binder in place over the PEG tube to reduce the risk of Resident #12 dislodging it again.A nursing progress note by Nurse #3 dated 7/15/26 at 3:34 PM indicated Resident #12 was readmitted to the facility with a patent PEG tube in place. The presence of an abdominal binder was not documented.During an interview with Nurse #3 on 7/22/26 at 1:05 PM she stated that she completed Resident #12's readmission assessment on 7/15/26 and the abdominal binder was in place over the PEG tube at the time of admission. She stated the abdominal binder was in place to help prevent Resident #12 from pulling out the PEG tube. Nurse #3 stated that hospital records indicated Resident #12 had pulled his PEG tube out three or four times at the hospital since it was placed. Nurse #3 added that the PEG tube had been pulled out once at the facility. Nurse #3 stated she had never observed Resident #12 pulling on the PEG tube or abdominal binder and had never known him to remove the binder. Nurse #3 stated when Resident #12 returned from the hospital on 7/15/26 there was a physician's order for the abdominal binder to remain in place, but she was not aware that the abdominal binder was a restraint.A nursing progress note dated 7/16/26 at 6:49 AM by Nurse #4 revealed that Resident #12's abdominal binder was in place.A review of Resident #12's medical record revealed no written consent was obtained from the Responsible Party (RP) for the use of an abdominal binder. There was no documentation in the medical record that the RP was notified the abdominal binder was in place. Attempts to conduct a telephone interview with Resident #12's Responsible Party were unsuccessful.A review of Resident #12's medical record revealed there was no restraint assessment completed for use of the abdominal binder on Resident #12. A review of the physician orders included an order dated 7/16/26 for the use of an abdominal binder to secure the G tube (PEG tube) in place. The order included instructions to unfasten the binder every two hours to assess the skin for breakdown.A review of Resident #12's July 2026 Medication Administration Record (MAR) revealed documentation that the abdominal binder was unfastened every 2 hours to assess the skin for breakdown as ordered. A progress note dated 7/16/26 by Nurse Practitioner #1 indicated that Resident #12 was readmitted to the facility on [DATE] following PEG tube replacement at the hospital. The note further stated that Resident #12 returned from the hospital with an abdominal binder in place and instructions to monitor it with frequent skin checks.An observation on 7/20/26 at 10:32 AM revealed Resident #12 lying in bed with the abdominal binder in place and he was unable to remove or open it upon command.A progress note dated 7/22/26 at 10:05 AM by Unit Manager #2 indicated that Resident #12 was able to remove his abdominal binder on command without difficulty.During an observation of Resident #12 on 7/22/26 at 1:27 PM with Unit Manager #2 present, she asked Resident #12 to remove the abdominal binder. He did not respond or attempt to do so. Unit Manager #2 made three attempts to encourage him without success.During an interview with Unit Manager #2 on 7/22/26 at 1:37 PM, she stated that Resident #12 had removed the abdominal binder earlier in the day at her request but was unable to do so consistently due to his cognitive status. She acknowledged that she was unaware that inconsistent ability to remove the binder could classify the device as a restraint. Unit Manager #2 further stated that the facility had not considered the abdominal binder a restraint and consent had not been obtained. Unit Manager #2 stated that Resident #12 had been able to remove the binder on command earlier in the day but acknowledged he was unable to follow the command at this time. She added that she had not observed Resident #12 pulling on his PEG tube or abdominal binder.During an observation on 7/22/26 at 11:18 AM, with the Wound Nurse and Nursing Assistant (NA) #5, Resident #12 was unable to remove or open the abdominal binder on command.During an interview on 7/22/26 at 12:25 PM, NA #5 confirmed that Resident #12 was unable to remove the abdominal binder when requested. She stated she had never observed him pulling on his PEG tube or abdominal binder. NA #5 stated the binder was removed during his baths.During an observation of Resident #12 on 7/22/26 at 12:49 PM with Nurse #3 present, Nurse #3 asked Resident #12 to remove or open the abdominal binder, he did not respond or attempt to do so. An interview with Nurse Practitioner #1 on 7/23/26 at 10:01 AM revealed that the hospital had provided the abdominal binder to help secure Resident #12's PEG tube and prevent further dislodgement. She explained that according to hospital records, Resident #12's PEG tube had been dislodged while he was hospitalized and again at the facility. Nurse Practitioner #1 stated she was unaware that an abdominal binder could be considered a restraint if the resident was unable to remove it upon command. Nurse Practitioner #1 indicated she had never asked Resident #12 to remove the binder and was unsure whether he could. She added that Resident #12's cognitive status fluctuated and was inconsistent.During an interview with the Director of Nursing (DON) on 7/23/26 at 1:35 PM, she stated she was not aware that Resident #12 could not remove the abdominal binder upon request. The DON explained that hospital records indicated that Resident #12 had pulled out his PEG tube several times while hospitalized and that the abdominal binder was used to help secure the tube. She stated that if a resident was unable to remove an abdominal binder upon request, it should be documented as a restraint. The DON confirmed there was no restraint assessment or consent in the medical record, and she was unsure of the facilities policy regarding restraint use. She stated she would need to check on the policy. The DON did not return with a policy regarding restraint use. In an interview with the Administrator on 7/23/26 at 2:31 PM, he stated the abdominal binder was used to secure the PEG tube, but he was unaware it could be considered a restraint. The Administrator added that the facility did not have a policy related to restraint use because they were a restraint free facility.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of weights (Residents #32 and #124) and skin treatments (Resident #5) for 3 of 26 residents reviewed for MDS accuracy. The findings included: 1. Resident#32 was admitted to the facility on [DATE]. A review of Resident #32's weight history from January 2026 to July 2026 included one weight of 218 pounds on 1/1/26. A review of Resident #32's nursing progress notes revealed she had refused monthly weights from February 2026 to July 2026. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was cognitively intact and was coded with rejection of care one to three days during the seven-day look back period. Her weight was recorded as 218 pounds. On 7/23/26 at 12:38 PM, an interview was conducted with the MDS Nurse who stated the Registered Dietitian coded the nutritional section of the MDS assessment. She reviewed Resident #32's weight data and annual MDS assessment dated [DATE]. The MDS nurse confirmed the weight from 1/1/26 was used on the assessment in error. She further stated the section should have been marked with dashes since there was no weight within 30 days of 4/28/26 for Resident #32. The MDS Nurse acknowledged that Resident #32 refused weights from time to time. Attempts to contact the Registered Dietitian were unsuccessful during the survey. During an interview on 7/23/26 at 1:17 PM, the Director of Nursing indicated it was her expectation for the MDS to be coded correctly. 2. Resident #124 was admitted to the facility on [DATE] with diagnoses that included a stroke with dysphagia (difficulty swallowing), dementia, and adult failure to thrive. Resident #124's weight data revealed the following weights during the Minimum Data Set (MDS) assessment look back period of 11/13/25 to 12/12/25, which showed a weight loss of 5% in a month: 12/12/25 150.2 pounds (lbs.)11/13/25 158.3 lbs. (-8.1 lbs.) A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #124 had severely impaired cognition and required setup assistance for eating. Her weight was entered as 150 lbs. and was not marked for weight loss or weight gain in the past month. Resident #124's weight data revealed the following weights during the MDS assessment look back period of 9/12/25 to 3/16/26, which showed a weight loss of 25% in the past six months: 3/16/26 130 lbs. 3/10/26 131 lbs. 2/16/26 134 lbs. 1/19/26 137.5 lbs. 12/19/25 149 lbs. 11/19/25 152.3 lbs. 10/17/25 159.3 lbs. 9/17/25 174.3 lbs. 9/12/25 174 lbs. A quarterly MDS assessment dated [DATE] indicated Resident #124 had severely impaired cognition and required maximum assistance from staff for eating. Her weight was documented as 131 lbs. and weight gain was coded. An interview occurred with the MDS Nurse on 7/23/26 at 12:38 PM. She reviewed Resident #124's weight data and MDS assessments completed on 12/17/25 and 3/17/26. She explained that the Registered Dietitian coded the nutrition section of the MDS assessment and then she will review to ensure all areas were coded. After reviewing the weight data and MDS assessments, the MDS Nurse confirmed that both MDS assessments should have been coded with weight loss and stated it was an oversight. Attempts to contact the Registered Dietitian were unsuccessful during the survey. During an interview on 7/23/26 at 1:17 PM, the Director of Nursing indicated it was her expectation for the MDS assessments to be coded correctly. 3. Resident #5 was originally admitted to the facility on [DATE] with diagnosis that included diabetes mellitus, non-pressure chronic ulcer of lower leg, and peripheral vascular disease. Review of Resident #5's April 2026 physician orders included an order dated 04/17/26 to apply skin prep to left and right lateral lower legs daily. This order was discontinued on 06/05/26. A review of the May 2026 Medication Administration Records (MARs) indicated Resident #5 received the skin prep as ordered. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5's cognition was severely impaired. The area for skin conditions for Resident #5 was not coded for receiving ointments/medications. An interview was conducted on 07/23/26 at 12:37 PM with the MDS Nurse. The MDS Nurse verified the MDS annual assessment dated [DATE] was not coded for Resident #5 receiving ointments/medications under skin conditions. The MDS Nurse stated she was unsure if she was supposed to code the skin protectant in this area. She explained she did not look up the information in the Resident Assessment Instrument (RAI) manual for clarification. An interview was conducted on 07/23/26 at 12:42 PM with the Administrator. He indicated the MDS assessment should be accurately coded in all care areas.

Based on record reviews and interviews with the Medical Director, Pharmacy Consultant and staff, the Pharmacy Consultant failed to identify and address the use of antipsychotic medications without an adequate clinical indication for 2 of 6 residents whose medications were reviewed (Residents #4 and #88). The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and dementia without behavioral, psychotic, or mood disturbances. A review of Resident #4's active physician orders included an order dated 6/10/26 for Olanzapine (an antipsychotic medication) 2.5 mg (milligram) one tablet by mouth daily at 8:00 PM for dementia without behavioral disturbance. The Pharmacy Consultant's admission medication review, completed on 6/12/26, did not address the clinical indication for the use of Olanzapine to the physician or Director of Nursing (DON). An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had moderately impaired cognition and received an antipsychotic medication during the seven-day assessment period. A review of the June 2026 and July 2026 Medication Administration Record (MAR) indicated Resident #4 received the Olanzapine at 8:00 PM, as ordered by the physician. The Pharmacy Consultant was interviewed via telephone on 7/23/26 at 10:31 AM. He was able to review Resident #4's medical record and reviewed the admission medication review that was completed on 6/12/26. The Pharmacy Consultant acknowledged Olanzapine was ordered for Resident #4 and he did not request the physician to provide an appropriate clinical indication for the use of Olanzapine at bedtime. He was unable to comment as to why this was not addressed at the time of the admission medication review. A phone interview was held with the Medical Director on 7/23/26 at 10:17 AM and verified the diagnosis of dementia without behaviors attached to Resident #4's antipsychotic medication, Olanzapine, was not an appropriate clinical indication for its use. She indicated the Pharmacy Consultant should have made a recommendation to address the clinical indication. An interview occurred with the Director of Nursing (DON) on 7/23/26 at 1:17 PM and stated she expected the Pharmacy Consultant to address the inadequate clinical indication for the use of Olanzapine with either herself or the physician. 2. Resident #88 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, restlessness and agitation. A review of Resident #88's physician orders from May 2026 through June 2026 included the following antipsychotic medication orders: -An order dated 5/14/26 for quetiapine (an antipsychotic medication) 25 milligram (mg) at bedtime for restlessness and agitation. This order was discontinued on 05/21/26. -An order dated 5/21/26 for quetiapine 25 mg twice a day for dementia without behavioral disturbance. This order was discontinued on 06/04/26. -An order dated 6/04/26 for quetiapine 50 mg twice a day for restlessness and agitation. This order was discontinued on 06/25/26. - An order dated 6/25/26 for quetiapine 50 mg once a day for dementia without behavioral disturbance. Review of the consultant pharmacist's Medication Regimen Reviews (MRR) dated 05/18/26 and 06/09/2026, indicated that a monthly medication review was completed but did not address the clinical indication for the use of quetiapine to the physician or Director of Nursing (DON). An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #88's cognition was moderately impaired and received an antipsychotic medication during the seven-day assessment period. Verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others occurred 4 to 6 days, but less than daily during the look back period. A phone interview was conducted on 07/23/26 at 9:20 AM with the facility Pharmacy Consultant. He stated he was aware of the guidelines for needing a supporting diagnosis for prescribed antipsychotics. The Pharmacy Consultant indicated it was an oversight that he did not address and alert the physician or the DON that Resident #88's order for quetiapine did not include an appropriate clinical indication for its use. He did not realize he did not have a supporting diagnosis for the antipsychotic medication. The Pharmacy Consultant verified the last review he completed for Resident #88 was on 06/09/26 and he had a planned visit for 07/27/26. A phone interview was held with the Medical Director on 7/23/26 at 10:17 AM. The Medical Director verified that the diagnosis attached to Resident #88's antipsychotic medication, quetiapine, was not an appropriate clinical indication for its use. She indicated the pharmacy consultant should have made a recommendation as well An interview occurred with the DON on 7/23/26 at 3:27 PM, who explained that a resident should not be on antipsychotic medication without a supporting diagnosis. She indicated the Pharmacy Consultant should review the medications on admission and monthly to ensure there were no irregularities or concerns with the medications.

Based on record review and staff interviews, the facility failed to submit follow up documents for completion of a Preadmission Screening and Resident Review (PASRR) level I screen to determine appropriate placement for 1 of 3 residents sampled for PASRR (Resident #46). The findings included: A review of the diagnosis list for Resident #46 included diagnoses of psychotic disorder 05/24/2023 and bipolar disorder 06/12/2023. A review of the North Carolina Medicaid Long Term Care Facility Level (FL)2 Form dated 01/22/2024 revealed diagnoses including psychotic disorder 05/24/2023 and bipolar disorder 06/12/2023. Resident #46 was admitted to the facility on [DATE] with diagnoses including psychotic disorder and bipolar disorder. A review of the North Carolina PASRR level I screen submitted 02/28/2024 revealed diagnoses including bipolar disorder, and psychotic disorder. The screen requested additional information to include the most recent history and physical (H&P), FL2 signed by physician, psychiatric notes and comprehensive notes. The facility did not submit the information requested and never received a letter of determination for proper placement of Resident #46. The care plan dated 03/04/2025 had a focus of a history of mood distress as evidenced by finding little interest or pleasure in doing things. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact with moods that included little interest or pleasure in doing things, feeling down, depressed, and/or hopeless. An interview with the Administrator was conducted on 04/03/2025 at 1:22 PM. The Administrator stated the Social Worker (SW) was responsible for completing the PASRR screenings. The SW left her position in February of 2025, and they were interviewing potential SWs currently. On 02/28/2024, a PASRR level I was started but additional information was requested for submission to get a determination for placement of Resident #46. The SW did not submit the information requested for the completion of the screening. The Administrator also stated the additional information should have been submitted and he did not know why it was not completed. The Administrator further stated he was receiving assistance with PASRRs from their sister facility until a SW position was filled.

Based on record review, Medical Director, Nurse Practitioner, staff and resident interviews the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication administration when two blood pressure (BP) medications, Isosorbide mononitrate and hydralazine were not administered per orders for Resident #1. This resulted in Resident #1 ' s BP to drop to 82/50 causing a near syncope event that required a visit to the emergency room for further evaluation. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, hypertension (HTN) (high blood pressure), acute cerebral vascular accident (CVA) (an interruption in the flow of blood to cells in the brain), coronary artery disease (CAD) with history of two myocardial infarctions (MI) (heart attack), and coronary artery occlusion. The most recent Minimum Data Set (MDS) coded as an admission assessment on 06/02/24 revealed Resident #1 was cognitively intact. No behaviors coded and no rejection of care were coded. Record review of active medications revealed an order dated 05/27/24 that read in part, hydralazine 50 milligram (mg) tablet: give 1 tablet; by mouth, three times a day. (Hold for systolic blood pressure (SBP) less than 120 related to essential (primary) hypertension. It also revealed an order dated 05/27/24 that read in part, isosorbide mononitrate 30 mg tablet extended release over 24 hours; give 1 tablet; by mouth once a day for BP greater than 160/90. The Medication Administration Record (MAR) for June 2024 revealed Resident #1 ' s BP reading to be 112/61 on 06/04/24 at approximately 9:00 AM. The MAR also revealed hydralazine 50 milligram (mg) tablet, hold for systolic blood pressure (SBP) less than 120 and isosorbide mononitrate 30 mg tablet extended release tablet, give once a day for BP greater than 160/90 was administered by Nurse #1. A phone interview was conducted with Resident #1 ' s responsible party on 06/12/24 at 9:52 AM. He stated when he arrived at the facility Resident #1 was in her wheelchair sitting outside in the courtyard. She was in the sun, not responding to him and she had sweat on forehead. He then stated he thought she had another stroke because when she opened her eyes and started talking to him her speech sounded slurred. He indicated this had happened before and that her BP goes up and down a lot. He further stated he yelled into the building for help and the nurse came to assist. An interview was conducted with Nurse #1 on 06/12/24 at 1:23 PM. She verified she was Resident #1 ' s nurse on 06/04/24. She stated she checked Resident #1 ' s BP then administered hydralazine 50 mg 1 tablet and isosorbide mononitrate 30 mg tablet on 06/04/24. She indicated she did not thoroughly read the orders which included parameters for both medications. She further stated the hydralazine 50 mg tablet was to be held if her systolic blood pressure was below 120 and the isosorbide mononitrate 30 mg tablet was to be given for a BP greater than 160/90. She then indicated she was unaware of the parameters for the medications due to not thoroughly reading the orders. An interview was conducted with the Director of Nursing (DON) on 06/12/24 at 11:20 AM. The DON stated she was alerted by the voice of Resident #1 ' s responsible party that his mother appeared to be having another stroke. She then went to assist Nurse #1 with assessing Resident #1. She also stated Nurse #1 took her vital signs which were BP 82/50, temperature 97.1 axillary, and oxygen saturation was 98% on room air. She also had sweat on her forehead. Emergency Medical Services (EMS) were called for a possible stroke and while awaiting their arrival Resident #1 ' s BP went up to 104/66, she was alert and verbally responsive. Resident #1 ' s responsible party stated her BP fluctuates and sometimes bottoms out. She returned from the hospital with no issues noted. A review of Resident #1 ' s medication administration record (MAR) for 06/04/24 revealed a medication error related to BP medications being given outside of parameters to hold. She indicated that the medications should be given per order. Emergency Medical Services (EMS) records dated 06/04/24 revealed Resident #1 was assessed at the facility upon arrival at 10:52 AM. Call came in as possible stroke. Resident #1 ' s vital signs were as follows: blood pressure 128/69, pulse 77, respirations 14, temperature 98 degrees. Stroke screen with negative findings. Heart monitor applied and noted atrial fibrillation (A-Fib) present. Attempts to start intravenous saline lock times 2 were unsuccessful. Resident #1 was alert and oriented to event, person, place, and time. Skin diaphoretic, flushed, and hot. emergency room records revealed Resident #1 arrived on 06/04/24 at 11:30 AM with a damp gown on, awake, alert and oriented. She denied any pain and her responsible party stated she was close to her baseline. Her discharge diagnosis was near syncope (fainting or passing out), and no medications were given. Electrocardiogram (EKG) was performed which indicated A-Fib and a series of blood tests. No treatments, no intravenous fluids, or vital signs listed on emergency department records dated 06/04/24. An interview was conducted with the Administrator on 06/12/24 at 11:25 AM. She indicated that the medications should be given per order. She stated that an ad [NAME] (as needed) Quality Assurance Performance Improvement (QAPI) meeting was held on 06/04/24 to discuss the deficient practice, initiate the plan of correction and education for staff regarding following physician orders for medication administration. Review of the plans to monitor performance revealed the Staff Development Nurse or designee would review medication administration records to ensure physician parameters are followed for hypertension orders. This plan would not prevent another medication error from occurring.

Based on observations, staff, resident, Nurse Practitioner (NP) and Medical Director (MD) interviews and record review, the facility failed to obtain Physician orders for the care and maintenance of a peripherally inserted central catheter(PICC) intravenous line for 1 (Resident #33) of 1 residents reviewed for intravenous (IV) therapy. The findings included: Resident #33 was originally admitted on [DATE] with a diagnosis of Methicillin-resistant Staphylococcus Aureus (MRSA) infection following a right total knee replacement (TKA). Review of Resident #33's admission Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact and not coded for the use of an antibiotic (medication prescribed to treat bacterial infections). Review of Resident #33 electronic medical record (EMR) indicated she transferred to the hospital on 1/8/24 for scheduled knee procedure. She was readmitted on [DATE] with orders for an IV antibiotic. Resident #33 was care planned on 1/15/24 for the use of a PICC line. Interventions included to flush her PICC line per facility protocol. Review of Resident #33's January 2024 Physician orders did not include an order for the flushing of her PICC line. An observation and interview was completed with Resident #33 on 1/21/24 at 1:12 PM. Observed in her room was an IV pump with an empty medication bag and tubing from earlier IV medication on 1/21/24. The dressing to her PICC line was dated 1/18/24. Resident #33 stated she would be on IV antibiotic for a while due to a staph infection in her knee. An interview was completed on 1/23/24 at 11:30 AM with Nurse #1. She was asked to review Resident #33's January Physician orders to see if there were orders for flushing her PICC line. Nurse #1 verified there were no Physician orders for flushing the PICC line and stated she had been flushing Resident #33's PICC line using the SASH method (saline, administration of medication, saline then Heparin-(blood thinner)). Review of a new Physician order dated 1/23/24 read to flush Resident #33's PICC line with 10 cubic centimeters (cc's) of Normal Saline pre and post medication administration. A telephone interview was completed on 1/23/24 at 2:00 PM with the NP. He stated he was at the facility earlier and apparently the facility discovered earlier that there were no orders on how to flush Resident #33's. PICC line. He stated the use of Heparin would not have resulted in harm to Resident #33 but the facility should be flushing her PICC line at minimum using 10cc's of Normal Saline pre and post administration of the medication. An observation and interview was completed on 1/24/24 at 9:30 AM with Nurse #2. She was observed flushing Resident #33's PICC line with 10cc's of Normal Saline followed by the medication then flushed again with another 10cc's of Normal Saline. She stated she followed the Physician order that was entered yesterday on 1/23/24. An interview was completed with the MD on 1/24/24 at 9:45 AM. She stated there should always be specific Physician orders on the flushing of a PICC line. An interview was completed with the Director of Nursing (DON) on 1/24/24 1:25 PM. He stated there should have been a Physician order regarding the flushing of Resident #33's PICC line.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to obtain Physician orders for continuous oxygen (Resident #73). This was for 1 of 2 residents reviewed for respiratory care. The findings included: Resident #73 was admitted to the facility on [DATE] with diagnosis that included gastrointestinal hemorrhage, hypertension, and peripheral vascular disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact and was not coded for receiving oxygen therapy. Review of Resident #73's nursing progress notes dated 01/11/24 revealed Resident #73 was sent to the emergency room (ER) due to vomiting. She returned to the facility on 2L of oxygen (O2) via nasal cannula. The O2 was removed during transfer to the bed from the wheelchair causing her O2 saturation to drop to 86%. O2 was reapplied via nasal cannula raising her O2 sats to 95% on 2L. Review of Resident #73's nursing progress notes dated 01/12/24 revealed no new orders were received for treatment related to her emergency room visit on 01/11/24. Resident #73's active care plan, last reviewed 01/15/24, included a focus for oxygen (O2) therapy as needed to maintain 02 saturations of 90% or greater. The interventions included administering oxygen as ordered and encouraging the resident to wear oxygen as ordered. A review of Resident #73's December 2023 and January 2024 physician orders did not include an order for oxygen. During an observation and interview 01/21/24 at 11:51 AM, Resident #73 was lying in bed with oxygen running at 1 1/2 liters (L)/minute (min) flow via concentrator. She indicated she used oxygen all the time. In an observation on 01/21/24 at 2:51 PM, Resident #73 was lying in bed with oxygen running at 1 1/2 liters (L)/minute (min) flow via concentrator. In an observation on 01/22/24 at 8:38 AM, Resident #73 was lying in bed with oxygen running at 1 1/2 liters (L)/minute (min) flow via concentrator. An interview was conducted with Unit Manager #1 on 01/22/24 at 2:36 PM. She verified that Resident #73 did not have an active order for oxygen (O2). She stated the resident recently returned from the hospital and returned with no new orders. She indicated when residents returned from the hospital with O2 without an order they would initiate the order and notify the physician. A phone interview was conducted with Nurse #2 on 01/22/24 at 4:54 PM. She verified that Resident #73 returned to the facility on [DATE] on 2L of oxygen (O2) via nasal cannula. It was an oversight that an order for O2 was not added to her active orders. An interview was conducted with the Director of Nursing (DON) on 01/23/24 at 3:20 PM. He stated anyone that received oxygen (O2) should have an active order in place. An interview was conducted with the Medical Director (MD) on 01/24/24 at 9:55 AM. She stated anyone that received oxygen (O2) should have an order in place. She indicated she was not aware oxygen had been placed on Resident #73.

Based on observations, staff interviews, and record reviews, the facility failed to secure unused narcotic medications for disposition (the process of returning unused medications) resulting in possible diversion (the transfer of a controlled medication from a lawful to an unlawful channel of distribution or use). This was for 1 of 1 discharged resident (Resident #92) reviewed for pharmacy services. The finding included: Resident #92 was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #92 ' s physician orders revealed an order initiated on [DATE] and discontinued on [DATE] for oxycodone 5 milligrams (mg) tablet, take one tablet by mouth every 8 hours as needed for moderate pain. An attempt to interview the Weekend Supervisor was made on [DATE] at 1:02 PM without success. Weekend Supervisor ' s statement revealed he reported on [DATE] about 5:30 AM the door to the medication room on 100 hall was propped open. When he entered the room, the pharmacy tote's secure tags (tags applied to both ends of the tote to secure it shut) were cut and sitting on top of the tote. The Weekend Supervisor reported that on [DATE] he and another nurse had written up medications to be returned to the pharmacy to include non-narcotics and narcotics. They placed them into the pharmacy tote and applied the secure tags for return to the pharmacy. Upon further review of the tote, it was noted that the narcotic sheet that was previously in the tote was missing along with the bubble pack containing 16 Oxycodone 5mg tabs. A phone interview was conducted with the Staff Development Nurse on [DATE] at 1:24 PM. She stated she was made aware of missing narcotic medications at the facility on [DATE] between 5:30 and 6:00 AM by the weekend supervisor. She indicated he stated that at about 5:30 AM he seen that the door to the medication room on 100 hall was propped open. When he entered the room, the blue pharmacy tote's secure tags were cut and sitting on top of the tote and the narcotic sheet that was previously in the tote was missing along with the bubble pack containing 16 oxycodone 5mg tablets. She then stated she arrived at the facility on [DATE] between 8:00 and 9:00 AM to start her investigation for possible diversion of narcotic medications. She further stated she notified law enforcement, and they came to the facility to take the report. She also indicated she did not remember who she interviewed during her investigation. During an interview with the Director of Nursing (DON) on [DATE] at 3:20 PM he explained that he returned to work on [DATE] from a bereavement time off period. He indicated he completed the possible narcotic medication diversion investigation. He stated he located the missing narcotic sheet along with the empty narcotic bubble pack medication card in a shred box in the 100 hall locked nourishment room. All 16 oxycodone tablets had been removed from the bubble pack. He also indicated although the medication room door had been sticking at times the door should not have been propped open for any reason and all medications should be secured at all times.

Based on observations, record review and staff interviews, the facility failed to label multi-dose medications with the date they were opened on 1 of 3 medication carts reviewed (the 300 Hall Medication Cart). Findings included: An observation was conducted on 01/21/24 at 3:25 PM of the nurse ' s medication cart on the 300 Hall in the presence of Med Aide #1 and Unit Manager #1. The observation revealed no opened date on the following multi-dose medications: a. Two 10ml (milliliter) multi-dose vials of Humalog insulin with no open date. (Manufacturer ' s recommendation to discard 28 days after opening). first use b. two 10ml (milliliter) multi-dose vial of Novolog insulin with no open date. (Manufacturer ' s recommendation to discard 28 days after opening). c. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5 milligram (mg)/3mg per 3 milliliter (ml) inhalation vials. (Manufacturer ' s recommendation that once the foil pouch is opened, use vial within one week). d. One multi-dose 10ml bottle of Latanoprost 0.005% solution eye drops. (Manufacturer's recommendation to discard 6 weeks after opening). Unit Manager #1 verified the multi-dose medications were not dated and she removed them from the medication cart and discarded them. She indicated nurses and med aides were to write the date on all multi-dose medications upon opening and check dates prior to administration. She stated she did not realize they were not dated. She also stated that unit managers were to check med carts weekly, the pharmacy consultant checks medication carts for undated medications monthly and the administration staff audit carts monthly. An interview was conducted with the pharmacy consultant on 01/22/24 at 8:30 AM. He stated he comes to the facility on ce a month to perform medication audits and education when needed. He indicated he audits one medication cart, one medication room, and one medication pass monthly. He also stated he was here last week but did not audit 300 hall cart. When he audits the medication carts some things, he was looking for would include expired medications, lose pills, and if multiuse medications have an open date labeled on them. He further indicated that he had educated staff in the past on labeling multi-dose medications with an open date upon opening and this was an ongoing issue. An interview was conducted with the Director of Nursing (DON) on 01/23/24 at 3:20 PM. He stated it was the nurse ' s and med aides ' responsibility to date multi-dose medications upon opening and they should be checking for dates daily prior to administration. He also stated all multi-dose medications were to be dated when opened. He then stated there should not have been unlabeled multi-dose medications on the medication cart.

Based on observations, staff interviews, and record reviews, the facility failed to provide effective leadership and implement effective systems to thoroughly investigate possible diversion (the transfer of a controlled medication from a lawful to an unlawful channel of distribution or use) of missing narcotic medications from 100 hall medication room. The finding included: An attempt to interview the Weekend Supervisor was made on 01/23/24 at 1:02 PM without success. The Weekend Supervisor ' s statement revealed he reported possible narcotic diversion on 08/20/23 about 5:30 AM. He reported that the door to the medication room on 100 hall was propped open, upon entering the room, a pharmacy tote's secure tags (tags applied to both ends of the tote to secure it shut) were cut and sitting on top of the tote. Upon further review of the tote, it was noted that the narcotic sheet that was in the tote was missing along with a bubble pack containing 16 Oxycodone 5mg tabs. A phone interview was conducted with the Staff Development Nurse on 01/23/24 at 1:24 PM. She stated she was made aware of missing narcotic medications at the facility on 08/20/23 between 5:30 and 6:00 AM by the weekend supervisor. She indicated she arrived at the facility on 08/20/23 between 8:00 and 9:00 AM to start her investigation for possible diversion of narcotic medications. She also stated she notified law enforcement, and they came to the facility to take the report. She then indicated she received a statement from one nurse and one nursing assistant stating they did not notice anyone going in the medication room except one nurse when she was retrieving the Covid box. She further stated she did not remember who she interviewed during her investigation. Investigation records revealed approximately 8 nurses, 7 med aides, and 28 nursing assistants (NAs) worked in the building from 08/19/23 through the morning of 08/20/23. The investigation records revealed four written statements, two of the four statements referred to if they had observed anyone in the med room or observed anyone with medications. During an interview with the Director of Nursing (DON) on 01/23/24 at 3:20 PM he explained that he returned to work on 08/21/23 from a bereavement time off period. He indicated he completed the possible narcotic medication diversion investigation. He verified a police report had been completed and a report was sent to the Drug Enforcement Administration (DEA). He stated during the investigation he located the missing narcotic sheet along with the empty narcotic bubble pack medication card in a shred box in the 100 hall locked nourishment room. All 16 oxycodone tablets had been removed from the bubble pack. He also stated he had not interviewed all nursing staff that had worked on the weekend that the alleged diversion took place. The staff he interviewed were the nurses and med aides that worked the medication cart that would have handled the narcotic medication and/or the tote they were stored in. He verified that due to the medication room door being propped open all staff had access to the narcotic medications located in the tote. After completing the facility investigation, the facility was unable to determine who removed the narcotic medications from the medication room. During a phone interview with Administrator #2 on 01/24/24 at 3:39 PM he stated he did not participate in the possible diversion investigation. He then stated all he knew was that they were unable to determine who removed the narcotic medications from the medication room.

Based on record reviews, observations, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey on 5/6/21. This was for one deficiency that was cited in the area of Respiratory/Tracheostomy care and Suctioning. In addition, two additional deficiencies were cited during the annual recertification and complaint survey on 12/1/22 in the areas of Respiratory/Tracheostomy care and Suctioning and Label/Store Drugs and Biologics. The duplicate citations during three federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: The citations are cross referenced to: 1) F695- Based on observations, record review, and staff and Medical Director interviews, the facility failed to obtain Physician orders for continuous oxygen (Resident #73). This was for 1 of 2 residents reviewed for respiratory care. During the facility's annual recertification and complaint survey on 5/6/21, the facility failed to administer oxygen at the prescribed rate for 2 of 2 residents reviewed for respiratory care. During the facility's annual recertification and complaint survey on 12/1/22, the facility failed to obtain a Physician's order for a resident's use of continuous oxygen for 2 of 5 residents reviewed for respiratory care. Additionally, the facility failed to secure oxygen tanks that were not in use for 1 of 4 observations. 2) F761- Based on observations, record review and staff interviews, the facility failed to label multi-dose medications with the date they were opened on 1 of 3 medication carts reviewed (the 300 Hall Medication Cart). During the facility's annual recertification and complaint survey on 12/1/22, the facility failed to: 1) discard expired medications 2) keep a medication refrigerated per manufacturer guidelines 3) label medications with the date they were opened and 4) to keep a treatment cart locked and secured. In an interview with the Administrator on 1/24/24 at 10:00 AM, she indicated there had been recent turnover with staff and felt that education was needed for ensuring oxygen orders were in place, to check the medication carts for expired medications and to ensure that medications were dated when opened.

Based on record review, observation and staff interview, the facility failed to provide supervision to prevent a severely cognitively impaired resident from exiting the facility unsupervised, failed to ensure the resident was safe in the parking lot, and failed to report that a cognitively impaired resident was in the parking lot for 1 of 5 sampled residents reviewed for accidents (Resident #59). Resident #59, who was in his wheelchair, was found by Nurse Aide (NA) #1 in the parking lot unsupervised, didn't intervene and then, the resident was found to have gone out to the road. The resident was discovered by the Housekeeper on a 2-lane road where the speed limit was 55 miles per hour (MPH) west bound and was a quarter mile away from the facility's front door. In addition, the facility failed to ensure medications were not left unattended for 2 of 2 observations during the medication pass. Immediate jeopardy began on 11/22/22 when Resident #59 was observed out in the parking lot unsupervised in his wheelchair. Immediate jeopardy was removed on 12/2/22 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 of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. Example #2 was cited at scope and severity of D. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side and dementia. Resident #59 was assessed for elopement on 11/8/22 and he did not present an elopement risk. He was not care planned for elopement risk on admission. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #59 had severe cognitive impairment. The assessment further indicated that the resident needed extensive assistance with transfer and used a wheelchair for mobility. Resident #59 was not coded for wandering. A nurse's note dated 11/22/22 at 3:22 PM and was recorded as late entry on 11/25/22 at 6:27 PM by the former Treatment Nurse revealed that Resident #59 was noted attempting to go out of the front door of facility by the staff. The staff followed the resident out and redirected back in. The staff assisted the resident back inside the door safely at which time a wander guard was placed. The Director of Nursing (DON) and the Unit Manager were present and were aware. Several attempts to interview the former Treatment Nurse via phone were unsuccessful. A new elopement assessment was completed for Resident #59 by the Unit Manager (UM). The assessment had an event date of 11/22/22 and completion date of 11/30/22. The assessment indicated that Resident #59 was found outside the front door and was redirected back in. A wander guard was applied on resident. The evaluation indicated event still open. Review of Resident #59's care plan revealed that on 11/23/22, a care plan for elopement risk was initiated. The care plan problem was resident has a wander guard secondary to wandering/elopement risk. The goal was resident will not leave secured area unattended. The approaches included check functioning of alarm every shift, check placement of alarm and monitor skin under alarm for any indication of skin breakdown, contact physician and family if resident attempts to leave facility, if resident becomes confused and attempts to exit secure unit/facility, attempts diversional activities as able, observe resident's whereabouts when out of bed, personal secure alarm (wander guard) as ordered and redirect resident as indicated and as needed. The MDS Nurse was interviewed on 11/30/22 at 10:25 AM. She stated that she had interviewed the Housekeeper who found Resident #59 outside the facility on the road. When the resident was back to the facility, a wander guard was placed on his ankle. She indicated that the administration was aware and had investigated the elopement incident dated 11/22/22 with Resident #59. She added that she initiated the care plan for elopement on 11/23/22 after the elopement incident. She stated that a new elopement assessment was completed on 11/22/22 for Resident #59 and he was added to the wander guard book. On 11/30/22 at 12:30 PM, Nurse Aide (NA) #1 was interviewed. She stated that she was familiar with Resident #59. She was assigned to him in the past. He was confused and disoriented, and wheelchair bound. She reported that on 11/22/22, she was coming in to work on 3-11 shift. She observed Resident #59 in the parking lot around 2:45 PM. There were visitors on the porch, and she thought Resident #59 was with his family. The NA stated that she did not attempt to confirm if the resident was being supervised while he was outside, and she did not report that the resident was in the parking lot. She proceeded to enter the facility to work. The Regional Operation Manager, in the absence of the Administrator, was interviewed on 11/30/22 at 11:10 AM. She reported that Resident #59 was found outside the building on 11/22/22. She stated that the incident was investigated by the [NAME] President (VP) of clinical Operation. The Regional Operation Manager provided the investigation report including the timeline, the corrective actions, and the written statements from the staff for review. On 12/1/22 at 8:20 AM, the [NAME] President (VP) of Clinical Operation, in the absence of the Director of Nursing (DON) was interviewed. She reported that she had investigated the elopement incident that occurred on 11/22/22 with Resident #59. She reported that the front door was locked from 8 PM to 8 AM every day and there was a receptionist assigned at the front desk from 8 AM to 8 PM every day. The investigation report indicated that Resident #59's elopement incident happened on 11/22/22. The resident was seen during lunch in his room by the Wellness Coordinator/Nurse Aide (NA), was seen during medication pass at 1 PM by the former Treatment Nurse, was seen between 2:45 and 3:00 PM by NA #1, and was seen at 3:15 PM by a passerby who called the facility to inform them that a resident in a wheelchair was on the road with a staff member (Housekeeper). The written statement from the Housekeeper dated 11/22/22 revealed (Name of Housekeeper) reported that when she left work on 11/22/22, she left the facility and turned left and noted a resident in his wheelchair on the road. The Housekeeper stayed with resident until additional staff came to assist the resident. On 11/30/22 at 12:20 PM, the Housekeeper was interviewed. Due to language barrier, she was interpreted by Med Aide #5. She stated that it was around 3:04 PM she was leaving from work. She was driving and when she was turning from the parking lot to the main road, she saw Resident #59 on the main road. He was in his wheelchair. She parked her car and went to the resident. She pushed the resident to the side of the road on the grass. Staff members then came and assisted the resident back to the facility. The written statement from the Business Office Manager (BOM) revealed on 11/22/22 we received a call at the front desk that there was a man in a wheelchair with a woman in scrubs on the side of the road. The caller stated that he looked like he could be one of our residents. I walked out to the road to see, and I did see a man with a woman on the side of the road, so I proceeded to go help assist. The resident is fine and alert, so I assisted nursing with pushing him back into the facility. On 11/30/22 at 2:01 PM, the BOM was interviewed. He stated that the facility had received a call from a passerby that a resident in a wheelchair was on the side of the road with a woman. He went outside to the end of the parking lot and saw Resident #59 in his wheelchair and a Housekeeper on the side of the road. The distance from the front door to where the resident was located was about a quarter of a mile. He added that the weather was partly sunny and was not cold. The resident was fine. The written statement from the Wellness Coordinator revealed that On 11/22/22, I was alerted in the hall by a staff member that there was a resident that was on the road in a wheelchair. I immediately ran down to where the resident was sitting in his wheelchair. The BOM and another staff member were already standing with him in the road. This resident was not in any kind of distress. I pushed the resident back up to the facility in his wheelchair. Once inside, a wander guard was placed on him, and he was redirected. On 11/30/22 at 1:20 PM, the Wellness Coordinator was interviewed. She reported that she was helping as a Nurse Aide (NA) on the floor on 11/22/22. She reported that she had seen Resident #59 in his room eating lunch on 11/22/22. She indicated that she was notified that the resident was outside (unable to remember exact time). When she went outside in the parking lot, she saw the resident in wheelchair, the Housekeeper, and the Business Office Manager (BOM) on the side of the road. She reported that the resident was not in any distress. He was wearing a shirt and a pair of pants. She said the weather was not cold, it was partly sunny. She indicated that the distance from the front door to where the resident was located was about a quarter of a mile. The Social Worker (SW) was interviewed on 11/30/22 at 10:30 AM. She reported that Resident #59 had eloped on 11/22/22 and was found on the road by the Housekeeper. The SW reported that the resident did not have any history of elopement or attempts of leaving the facility. On 11/30/22 at 1:35 PM, the facility's Maintenance Director was requested to measure the distance from the front door to the location where Resident #59 was located. The Maintenance Director reported that the distance was a quarter of a mile. On 11/30/22 at 3:30 PM, the location where Resident #59 was found was observed. The same location was identified by the Housekeeper, the Wellness Coordinator and by the BOM as the exact location where the resident was located. The side of the road where the resident was found was grassy. The location was not visible from the front door. Review of the www.wunderground.com revealed that the weather on 11/22/22 was partly sunny and the highest temperature was 61 degrees Fahrenheit (F). On 11/30/22 at 12:24 PM, Medication Aide (Med Aide) #5 was interviewed. She stated that she was familiar with Resident #59. She was assigned to the resident, and he would always say door, door, door. She also stated the resident was wheelchair bound and was confused and disoriented. On 11/28/22 at 12:50 PM, Resident #59 was observed up in wheelchair in his room. His speech was mumbled and hard to understand and he was unable to answer to questions appropriately. On 11/29/22 at 9:30 AM, Resident #59 was observed up in wheelchair, wheeling self-up and down the hall saying, door, door, door. He was wearing a wander guard to his ankle. Review of the education records including the sign in sheets revealed that facility had in-serviced the staff from 11/22/22 through 11/30/22 on elopement, elopement risk changes, and ensuring resident's safety when outside and wander guard book. The facility's Quality Assurance and Performance Improvement (QAPI) plan for the elopement incident that occurred on 11/22/22 was reviewed. The interventions to correct the problem included: 1. Resident was identified outside in front of the facility with an employee from housekeeping. No injuries were noted. 11/22/22 2. A facility head count was completed, and all residents were accounted for. 11/22/22 3. A 100% audit of elopement risk observation will be completed for changes in risk by the Director of Nursing (DON) and Nurse Supervisor. 11/22/22 4. Facility staff in serviced by the DON on what an elopement is, the use of the wander guard books prior to letting someone out of a locked door, and placement of the wander guard. 11/22/22 5. The Regional Clinical Manager in-serviced the DON, the Assistant DON, Nurse Supervisor, and MDS Coordinator on making sure elopement assessments are accurate and done timely. The Regional Clinical Manager in-serviced the Social Worker on accuracy of the wander guard books and placement of books. 11/22/22 6. The DON will assign quarterly wandering assessments to a specific nurse and specific shift, when due. This will be done weekly x 12 weeks. The ADON or Nurse Supervisor will complete a weekly audit on all residents with wander guards to assure orders are accurate, functionality and placement are completed daily per shift, this will be completed weekly x 12 weeks. The Social Worker Director will complete a weekly audit of the wander guard books to ensure accuracy and updated information is available. This will be done weekly x 12 weeks. 1/14/23 7. The Administrator will bring the results of these audits to the Quality Assurance Committee monthly x 3 months. The Regional Operations Manager and the Division [NAME] President (VP) of Operation were notified of the immediate jeopardy on 11/30/22 at 5:45 PM. The facility's VP of Operation provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to provide supervision to prevent a cognitively impaired resident from exiting the facility unsupervised (Resident #59). Resident #59 was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and dementia. Cognition score was 5, no noted behavior and used wheelchair for mobility. An elopement assessment was completed on 11/8/22 and was not identified as an elopement risk at that time. Resident #59 was observed outside in the parking lot by NA #1 on 11/22/22 at approximately 2:45 PM. NA #1 reported she thought the resident was with his family, proceeded inside the facility to work. Resident was last seen in the facility at approximately 1 PM during the medication pass. The investigation of the incident revealed Resident #59 was able to push the door and maneuver the wheelchair over the threshold. The resident demonstrated a slow steady rock to roll over the threshold. This was observed by the [NAME] President of Clinical Services. The date of this observation was 12/1/22. NA #1 failed to notify the facility that resident #59 was unsupervised in the parking lot in his wheelchair. At approximately 3:15 PM, the facility received a call from a passerby that a resident in a wheelchair was on the road with a staff member. Several staff members exited the facility to find the resident with a housekeeping staff member on the side of the road. The housekeeper was leaving work at approximately 3:00 PM when she turned out of the facility and found the resident in his wheelchair on the road, approximately a quarter mile from the facility. The housekeeper stayed with the resident until additional staff came to assist the resident. The resident was returned to the facility in his wheelchair accompanied by staff at approximately 3:30 PM. The resident was assessed for any injury and no injury was identified. Once assessed, a wander guard, a door alarm bracelet, was applied to resident. Resident information was then placed in the facility elopement books. The elopement books are located at each nurse's station and the front reception desk. These books are accessed by all staff. The elopement books contain pictures and face sheets for all residents who have triggered as an elopement risk. An elopement assessment was completed at approximately 4:05 PM by the Unit Supervisor and all notifications to Responsible Party and Medical Director were initiated. The Responsible Party did not return the phone call. Another call was placed to Responsible Party on 11/23/22 with no response. Additional calls were placed to the Responsible Party by the Director of Nursing and floor Nurse with the last attempt being on 11/25/22 and all calls left unanswered. The facility completed a census to resident count at approximately 3:45 PM. All residents were accounted for. The Director of Nursing and Nurse Supervisor initiated a 100% of all in house resident's reevaluation of elopement risk assessments. These audits were completed on 11/22/22 by the Director of Nursing and the Unit Supervisor at approximately 7:15 PM. On 11/30/22, NA #1 was educated on residents outside the facility left unsupervised and ensuring their safety. The [NAME] President of Clinical Services educated NA #1. 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: On 11/22/22, the Director of Nursing and Unit Manager completed a reassessment of elopement risks of all in-house residents. No other residents who were not previously an elopement risk were identified. Residents who previously triggered elopement risk were validated to have pictures and face sheets in each elopement books, care plan s were verified for wandering behaviors and interventions. On 11/22/22, the Director of Nursing initiated in-servicing on elopement and wander guard books to include locations of each book to all staff. The wander guard books are located at each nurse's stations and the front receptions desk. The Director of Nursing or designee will be responsible for keeping the elopement books up to date with all residents who trigger as an elopement risk. Any staff who did not complete the in-service prior to 11/30/22 are not allowed to work until this in-service has been completed. The Regional Operation Manager will track the in-services to ensure all staff have received. On 11/22/22, the Regional Clinical Manager in-serviced the Director of Nursing, Assistant Director of Nursing and Nurse Unit Supervisors on what an elopement is. The Director of Nursing began an in-service on 11/22/22 for all staff on elopement and completed on 11/30/22. Any staff that did not receive the in-service will not be allowed to work after 11/30/22 until the in-service has been completed. The regional Operation Manager is responsible for tracking the completion of the in-service. On 11/30/22, the Regional Operation Director in-serviced all department heads on ensuring residents safety when unsupervised outside. This in-service includes staying with a resident until staff can ensure the resident is not at risk of endangerment. 100% of staff were in-serviced on 11/30/22 by the Department heads on ensuring resident's safety when unsupervised outside and staying with resident until a staff member can ensure resident is not at risk of endangerment. Any staff member who did not receive the in-service on 11/30/22 will not be allowed to work until the in-service has been completed. The Regional Operations Manager is responsible for tracking any staff that needs to be in-serviced. This education has been added to the new hire orientation process effective 11/30/22, by the Director of Nursing. As of 12/1/22, all residents who have been identified by the nurse to be unsafe and unsupervised while outside will have a profile maintained at the receptionist desk. This profile will include picture identification. The receptionist will monitor residents, between the hours of 8AM and 8 PM, wishing to exit the facility by verifying the resident profile. Any resident who has been identified as being unsafe and needs supervision while outside will be provided with facility staff to accompany them. The receptionist will notify the nurse that the unsafe resident wishes to go outside, and a staff member will be assigned to the resident. The staff member will remain with the resident while outside. The facility will also provide education on elopement, elopement risk changes, and ensuring resident safety when outside during the monthly staff meeting x 3 months starting with the next all staff meeting. IJ removal date 12/2/22 On 12/1/22, the facility's credible allegation for immediate jeopardy removal was validated by observation of the wander guard books at each nurse's stations and at the front reception desk. The residents who were identified as elopement risk had their pictures and face sheets in the wander guard books. Multiple staff interviews including administrative staff and the receptionist were conducted and revealed that they had received in-services on elopement, wander guard books and ensuring resident's safety when unsupervised outside. Care plan of residents identified as elopement risk were initiated and reviewed and sign in sheets for the in-services were reviewed. Immediate jeopardy was removed on 12/2/22. 41437 2. a. On 11/29/2022 at 8:45 AM Medication Aide (MA) #4 was observed during medication administration. When approaching the MA's medication cart there were three pills in a clear medication cup and a nicotine patch sitting on the cart. MA#4 pulled medications for another resident and left the cart to administer those medications. The three pills in the medication cup and the nicotine patch were left unattended on her medication cart. At the time the medications were unattended, Resident #59, a severely cognitively impaired resident, was observed sitting in his wheelchair next to the medication cart. Immediately after completing the medication administration, MA #4 was interviewed. She stated the three pills and nicotine patch were for another resident who refused their medications. She further stated she should not leave medications on the cart unattended. Instead, she should have disposed of the medications or secured them in the locked cart until she had time to dispose of them. On 11/30/2022 at 4:08PM and interview was conducted with the Regional Operations Manager. She stated medications should never be left unsecured on the medication cart. 2. b. On 11/30/2022 at 10:45AM an observation of medication administration with Charge Nurse #2 was completed. Charge Nurse #2 was observed pulling Medications for Resident #325. The Charge nurse stated the resident had an order for Ferrous Sulfate solution 300milligrams (mg) per 5 milliliters (ml) but the solution on the cart was not 300mg/5ml, it was 220mg/5ml. Charge Nurse #2 asked another staff member to look in the medication storage room for Ferrous Sulfate. The staff member returned with another bottle of 300mg/5ml solution. The Charge Nurse stated she would need to call the provider prior to administering the medication for clarification. She placed both bottles on top of the medication cart and left them unattended while she went down the hall to administer medications to Resident #325. On 11/30/2022 at 11:15AM and interview was conducted with Charge Nurse #2. She stated she did not realize she left the medications on the cart unattended. She should have secured the medications prior to leaving the cart. On 11/30/2022 at 4:08PM and interview was conducted with the Regional Operations Manager. She stated medications should never be left unsecured on the medication cart.

Based on record review, observation and resident and staff interview, the facility failed to promote dignity by failing to address resident's repeated request for incontinence care (Resident #60) and by ignoring resident's request and allowing a resident to lay in a wet pad (Resident #51) for 2 of 3 sampled residents reviewed for dignity (Residents #60 & #51). The facility's failure to promote dignity made Resident #60 angry and made Resident #51 feel deserted. The findings included: 1. Resident #60 was admitted to the facility 9/5/2022 with diagnoses that included cerebral infarct (stroke). Resident #60's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, had clear speech, understood others and could be understood by others. She was coded as requiring extensive assistance for all activities of daily living and dependent upon staff for toileting during the assessment period. The resident's comprehensive care plan, last revised 11/18/2022, had a focus for assistance with activities of daily living related to weakness and overall deconditioning. Interventions included provide incontinence care on routine rounds and in a timely manner. On 11/30/2022 at 9:09 AM Resident #60 was heard yelling out for someone help me. The resident also made the statement, I am wet. Someone come help me. Resident #60 was sitting on the side of her bed in a pajama top and nothing but an incontinent brief on her lower body. The incontinent brief was visibly wet and the resident's bed linens were visibly wet with urine (yellow in color). When standing at the threshold of the room, a strong smell of urine was present and there was a pile of wet clothing on the floor next to the resident's feet. The resident was easily visible from the hall where other residents, staff, and family could see her sitting in a wet brief. At 9:09 AM when resident was yelling out for assistance, there was a housekeeper and a medication aide (MA) observed in the hall outside her door. At 9:15 AM Resident #60 called out again for assistance. The activity director entered the room and offered the resident a newspaper. The resident stated she wanted to talk to the lady from the state. The activity director told the resident she would let the lady from the state know. The activity director did not acknowledge the resident was sitting in urine or that her call bell was on the floor next to her bed. She did not offer the resident assistance or offer to find assistance for the resident. At 9:25 AM Medication Aide (MA) #4 entered Resident #60's room and administered medications to her roommate. Resident #60 was observed making derogatory comments regarding the facility and the staff for letting her sit in a wet bed with a wet brief. These comments were made while MA#4 was in the room. The MA exited the room without acknowledging the resident's condition or offering to get assistance for the resident. An interview was conducted with the MA on 11/30/2022 at 9:30AM. She stated she did not hear Resident #60 calling out for assistance and when she went into the room to administer medications to the roommate, she did not see that Resident #60 was sitting in a wet incontinent brief, nor did she smell urine while she was in the room. At 9:45 AM NA #9 was observed entering Resident #60's room. The NA closed the door and provided incontinence care. An interview was conducted with NA #9 on 11/30/2022 at 10:45. She stated she was in another room and did not hear Resident #60 calling out. The activity director let her know the resident needed assistance. She stated when she entered Resident #60's room there was a strong smell of urine and she found the resident sitting in a wet and soiled incontinent brief with wet bed linens and there was wet clothing on the floor. She stated the resident does typically use the call bell for assistance, but her call bell had fallen on the floor next to her bed and she did not believe the resident was able to reach the call bell. On 11/30/2022 at 11:00AM an interview was conducted with Resident #60. She stated it makes her angry and sad when staff leave her in a wet bed with wet brief smelling of urine after she asked repeatedly for help. She stated she would have cleaned herself up if she could have, but she could not. An interview was conducted with the Regional Nurse Consultant on 12/1/2022 at 4:08PM. She stated all residents should be treated with dignity and provided incontinent care when requested. 14652 2. Resident # 51 was admitted to the facility on [DATE] with multiple diagnoses including cerebrovascular accident (CVA) with left hemiplegia. The quarterly Minimum m Data Set (MDS) assessment dated [DATE] indicated that Resident #51's cognition was intact, and she did not have any behaviors. The assessment further indicated that Resident #51 was always incontinent of bowel and bladder, and she needed extensive assistance from the staff with personal hygiene. Review of Resident #51's active care plan, last reviewed on 11/18/22 was conducted. The care plan problem was resident has potential for skin breakdown related to functional and mobility deficits with incontinence. The approaches included provide assistance with toileting as needed, monitor for incontinence on routine rounds and provide incontinent care in a timely manner. On 11/28/22 at 11:20 AM, Resident #51 was interviewed. She reported that on 11/27/22 between 3 and 4 PM, she was soaking wet, from her gown to the bed. She used her call light to call for assistance and had waited for 2 hours (pointed the clock on the wall) and nobody came. Finally, a Nurse Aide (NA) (didn't know her name) came, provided her with incontinent care and changed her wet gown. She requested the NA to change her pad as it was also wet but the NA ignored her and left the room. She again pushed her call light for assistance to change her wet pad. Resident #51 stated that she had to lay in a wet pad until the corporate staff member came and changed the wet pad. The resident had shared the name of the corporate staff member who had changed her wet pad. On 11/29/22 at 12:05 PM, the Division [NAME] President (VP) of Operation was interviewed. He reported that he remembered changing Resident #51's wet pad, but he could not remember the date and time. He indicated that the resident did not inform him of what had happened, she just requested her pad changed since it was wet. On 11/29/22 at 12:50 PM, Resident #51 was again interviewed. The resident was consistent with her story. She reported same information she shared on 11/28/22 interview. She stated that the delay in answering the call light and incontinent care and laying in a wet pad made her feel deserted and she felt like staff don't care about me. On 12/1/22 at 8:21 AM, the VP of Clinical Operation was interviewed. She stated that Nurse Aide (NA) #10 was assigned to Resident #51 on 11/27/22. She indicated that NA #10 was a traveler from other sister facility and the facility did not have her telephone number. On 12/1/22 at 3:20 PM, the Regional Clinical Manager was interviewed. She stated that she expected staff to provide dignity to all residents.

Based on record review, observation and resident and staff interview, the facility failed to provide nail care to residents who needed extensive assistance and/or were dependent for activities of daily living (ADL) for 4 of 6 sampled residents reviewed for ADL care (Residents #3, #51, #18 & #67). Findings included: 1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3's cognition was intact, and he had no behavior of rejection of care. The assessment further indicated that Resident #3 needed extensive assistance from the staff with personal hygiene. Review of Resident #3's active care plan, last reviewed on 9/27/22 was conducted. The care plan problem was resident requires assistance from the staff with activities of daily living (ADL) related to weakness and overall deconditioning and dementia. The goal was resident will have his needs met daily. The approaches included prefers to keep a clean shave and short nails and provide ADLs. Review of the nursing notes from the October through November 2022, revealed no refusal of nail care documented. Resident #3 was observed on 11/28/22 at 11:26 AM with long fingernails on both hands with a brown substance noted underneath his nails. He did not know when the last time his nails were trimmed. On 11/29/22 at 9:10 AM and 12:50 PM, Resident #3's fingernails were again observed. His nails remained unchanged from previous observation. On 11/29/22 at 12:50 PM, Nurse Aide (NA) #9, assigned to Resident #3, was interviewed. She stated that nail care was provided during showers. NA #9 observed the resident's nails and confirmed that they were long and dirty and needed to be cleaned and trimmed. She added that the resident had not been refusing care. NA #9 was unable to explain why the resident's nail care had not been completed. On 12/1/22 at 3:20 PM, the Regional Clinical Manager was interviewed. She stated that she expected nursing to provide nail care to residents when needed. 2. Resident #51 was admitted to the facility on [DATE] with multiple diagnoses including cerebrovascular accident (CVA) with left hemiplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #51's cognition was intact, and she had no behavior of rejection of care. The assessment further indicated that Resident #51 needed extensive assistance from the staff with personal hygiene. Review of Resident #51's active care plan, last reviewed on 11/28/22 was conducted. The care plan problem was resident requires assistance from the staff with activities of daily living (ADL) related to functional and mobility deficit and history of CVA with left side hemiplegia. The goal was resident will have her needs met daily. The approaches included prefers to keep her nails long and assist resident with cleanliness of nails as needed. Review of the nursing notes from the October through November 2022, revealed no refusal of nail care documented. Resident #51 was observed on 11/28/22 at 11:20 AM with long fingernails on both hands with a brown substance noted underneath her nails. She did not remember when the last time her nails were cleaned. She stated that she preferred to have long nails, but she needed help to clean them. She reported the staff cleaned her nails during showers but since she did not have a shower for months, they had not been cleaned. On 11/29/22 at 10:15 AM, Resident #51's fingernails were again observed. Her nails remained unchanged from previous observation. On 12/29/22 at 12:5 PM, Nurse Aide (NA) #9, assigned to Resident #51, was interviewed. She stated that nail care was provided during showers. NA #9 observed the resident's nails and confirmed that they were dirty and needed to be cleaned. She added that the resident had not been refusing care. NA #9 was unable to explain why the resident's nail care had not been completed. On 12/1/22 at 3:20 PM, the Regional Clinical Manager was interviewed. She stated that she expected nursing to provide nail care to residents when needed. 40197 3. Resident #18 was originally admitted to the facility on [DATE] with diagnoses that included a stroke affecting the left side and contracture to the left hand. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact and displayed no behaviors or refusal of care. He required extensive assistance from staff for personal hygiene. A review of Resident #18's active care plan, last reviewed on 9/14/22, included a focus area for requiring assistance from staff for Activities of Daily Living (ADL) care secondary to history of a stroke with left sided paralysis and left upper extremity contracture, right above the knee amputation, obesity, and overall functional and mobility deficits. One of the interventions included he preferred short nails. A review of Resident #18's nursing progress notes from 5/1/22 to 11/30/22 revealed no refusals of nail care documented. On 11/28/22 at 10:31 AM, Resident #18 was observed while lying in bed. He was noted to have long fingernails to the right and left hand as well as a dark substance under the nails to the right hand. The left hand was contracted with fingernails observed touching the palm of his hand. Resident #18 was observed on 11/29/22 at 10:41 AM, while lying in bed. His nails remained unchanged from previous observations. On 11/29/22 at 10:55 AM, an interview occurred with Nurse Aide (NA) #2 who was familiar with Resident #18. She stated she was not assigned to care for him, but nail care should be rendered on shower days and during personal care if the need was present. She was unable to state why his nail care had not been completed. An interview occurred with NA #3 on 11/29/22 at 12:10 PM, who was assigned to care for Resident #18. During an observation of Resident #18's fingernails, the NA confirmed they were long, and the right hand had a dark substance underneath them. She added she had not noticed the need during Resident #18's morning care. NA #3 stated nail care should be completed during showers and personal care if the need was present. NA #4 was interviewed on 11/29/22 at 3:30 PM and was assigned to care for Resident #18 on the evening shift (3:00 PM to 11:00 PM). She explained Resident #18 readily accepted care from her and had no refusals. Nail care was to be done during showers/complete bed baths and as needed but she couldn't recall the last time she had performed nail care for Resident #18. The Regional Nurse Consultant was interviewed on 12/1/22 at 1:45 PM and stated nail care should be rendered during shower days and during personal care when needed. 4. Resident #67 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, and weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 had severe cognitive impairment and displayed no behaviors or refusal of care. He required extensive assistance from staff for personal hygiene. A review of Resident #67's active care plan, last reviewed on 10/12/22, included a focus area for requiring assistance from staff for Activities of Daily Living (ADL) care related to Parkinson's with weakness and deconditioning. One of the interventions included to provide assistance with ADL's, mobility and transfers as needed being careful not to overwhelm resident. A review of Resident #67's nursing progress notes from 5/1/22 to 11/30/22 revealed no refusals of nail care documented. On 11/29/22 at 8:55 AM, Resident #67 was observed sitting upright in bed. He was noted to have long fingernails to the right and left hand with a dark substance under them. On 11/29/22 at 10:55 AM, an interview occurred with Nurse Aide (NA) #2 who was familiar with Resident #67. She stated she was not assigned to care for him, but nail care should be rendered on shower days and during personal care if the need was present. She was unable to state why his nail care had not been completed. An interview occurred with NA #3 on 11/29/22 at 12:15 PM, who was assigned to care for Resident #67. During an observation of Resident #67's fingernails, the NA confirmed they were long and had a dark substance underneath them. She added she had not noticed the need during Resident #67's morning care. NA #3 stated nail care should be completed during showers and personal care if the need was present. NA #4 was interviewed on 11/29/22 at 3:30 PM and was assigned to care for Resident #67 on the evening shift (3:00 PM to 11:00 PM). She explained Resident #67 readily accepted care from her and had no refusals. Nail care was to be done during showers/complete bed baths and as needed but she couldn't recall the last time she had performed nail care for Resident #67. The Regional Nurse Consultant was interviewed on 12/1/22 at 1:45 PM and stated nail care should be rendered during shower days and during personal care when needed.

Based on record review, observations, Wound Nurse Practitioner and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 1 of 4 residents reviewed for pressure ulcers (Resident #56). The findings included: Resident #56 was admitted to the facility 2/22/21 with diagnoses that included adult failure to thrive and dementia. Resident #56's active physician orders included an order dated 9/29/22 for an alternating pressure air mattress to the bed. Nursing to check every shift to ensure properly functioning and/or settings are in place. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #56 had severely impaired decision-making skills, one stage 3 pressure ulcer and a pressure reducing device to the bed. A review of Resident #56's active care plan, last reviewed 10/28/22, included a focus area for potential for further skin breakdown secondary to mobility deficits with incontinence. One of the interventions included pressure relieving device to bed and wheelchair, if indicated. A review of Resident #56's medical record revealed from 7/29/22 to 11/3/22 wound care was provided to a sacral pressure ulcer. Resident #56's weight on 11/3/22 was 94.1 pounds (lbs.). The November 2022 Treatment Administration Record (TAR) revealed nursing staff had been documenting the alternating pressure air mattress was functioning properly. On 11/28/22 at 10:15 AM, an observation was made of Resident #56. She was lying in bed with her eyes closed. The alternating pressure reducing mattress machine was set at 600 to 1000 plus lbs. weight setting. The machine indicated to set according to the resident's weigh per pounds. Resident #56 was observed sitting up in her wheelchair on 11/28/22 at 11:41 AM. The alternating pressure reducing mattress machine was set at 600 to 1000 plus lbs. An observation occurred of Resident #56 on 11/29/22 at 8:50 AM, while she was lying in bed. The alternating pressure reducing mattress machine was set at 600 to 1000 plus lbs. On 11/30/22 at 12:10 PM, an observation was made with Medication Aide (MA) #2 of Resident #56's alternating pressure reducing mattress machine, confirming it was set at 600 to 1000 plus lbs. The MA stated she checked the functionality of the air mattress daily during her rounds to make sure the connections were secured, and the mattress was inflated. The MA stated the former Treatment Nurse was the one that set up the pressure reducing mattresses and set the weights. The Wound Nurse Practitioner (NP) was interviewed on 11/30/22 at 12:13 PM and stated she would expect the alternating pressure reducing mattress machines to be checked daily and set according to the resident's weight as stated on the machine. She added large gaps between the resident's weight and the weight on the machine would not be a useful intervention. On 12/1/22 at 1:45 PM, an interview was held with the Regional Nurse Consultant, who stated she expected the alternating pressure reducing mattress machine to be set according to the resident's weight as stated on the machine. She further added that due to recent staff turnover, education regarding pressure reducing mattresses was needed. Multiple phone calls were placed to the former Treatment Nurse from 11/30/22 to 12/1/22 with no return call received.

Based on staff interviews, Program of All-Inclusive Care for the Elderly (PACE-a Medicare/Medicaid program for older adults and people over age 55 living with disabilities) Site Director interview and record review, the facility failed to obtain ordered psychological consultation due to a new diagnosis onset of dementia with behaviors to include hallucinations and delusions. This was for 1 (Resident #64) of 1 residents reviewed for behavioral, emotional and mood concerns. The findings included: Resident #64 was admitted on [DATE] with cumulative diagnoses of dementia without behaviors, anxiety and major depression. A nursing note dated 8/2/22 at 6:30 PM indicated that Resident #64 had an episode of delusion/hallucination by dialing 911 telling the dispatcher that she was told to dial 911 by someone calling her name on the loud speaker. PACE was notified of her new behaviors with no new orders. A nursing note dated 8/3/22 at 5:34 PM indicated that Resident #64 demonstrated hallucinations by referencing someone in the room with her but nobody was there. She remained calm and was easily redirected. A new order dated 8/3/22 was received from PACE for Seroquel (antipsychotic) 25 milligrams (mg) at bedtime. Review of Resident #64 ' s comprehensive care plan included a new problem with behavioral symptoms of visual and audible hallucinations and delusions as of 8/3/22. The intervention dated 8/3/22 read to obtain a psychological consult if eligible, notify psychological services of her behaviors and the facility SW to visit her as needed to identify appropriate coping mechanisms. A nursing note dated 8/5/22 at 6:45 AM indicated Resident #64 she packed her belongings and could not stay because someone had put a spell on her and she remained awake the majority of the night. Another note dated 8/5/22 at 2:10 PM read she again packed her personal items and stated a family member was coming to get her. There were signs of anxiety to include restlessness and staff were concerned of her increased fall risk. PACE gave orders for Ativan (an antianxiety medication) 0.5 mg daily and another dose in 4 hours for persistent agitation. A nursing note dated 8/10/22 at 6:44 PM indicated Resident #64 called 911 several times during the shift stating the staff was putting a spell on her. A nursing note dated 8/11/22 at 12:21 PM indicated Resident #64 called 911 stating she wanted to get her hair done. PACE notified and ordered a dose of Ativan 0.5mg and continue to monitor. A Social Worker (SW) note dated 8/15/22 at 12:30 PM read the PACE staff encouraged gospel music, personal items added to her room and walks to reduce the medication use and a psychologist evaluation consult was also placed with the PACE psychological service provider. Review of a PACE SW note dated 8/16/22 at 1:15 PM read a psychiatry consult has been ordered by the PACE Physician for further evaluation. Review of a PACE nursing note dated 8/25/22 at 1:32 PM read Resident #64 reported a poor appetite and staff reported she was refusing meals and made statements about wanting to leave. A nursing note dated 8/28/22 at 12:00 AM indicated Resident #64 was observed sitting in the staff breakroom stating she wanted to go home. She was redirected back to her room and a wanderguard (a discreet bracelet that triggers an alarm while locking a monitored door to prevent elopement) was placed on her left lower extremity with the consent of her family member. PACE staff were notified. A nursing note dated 8/30/22 at 3:23 AM indicated Resident #64 was observed sticking her finger down her throat and vomited after receiving her medications. She denied the event but stated she was being poisoned. PACE and family were notified. Resident #64 was care planned 8/30/22 for the use of a wanderguard. Review of a PACE Physician note dated 8/31/22 at 10:37 AM read the evaluation today was consistent with depression with psychotic behavior. Resident #64 has been unhappy and trying to leave the facility. The intervention was to reach out to recreational therapy for her activities of interest. Review of an email correspondence dated 8/31/22 at 12:44 PM sent by the facility ' s SW to the PACE Site Director read that she was asked to consult the facility ' s psychological services provider who stated they were unable to assist because Resident #64 was on the PACE program and they provided her psychological services through the PACE program. Review of the reply email dated 8/31/22 at 2:31 PM from the PACE Site Director to the facility SW read the PACE contract person had not been able to get a response from the facility ' s psychological services provider. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #64 had moderate cognitive impairment, no mood symptoms, exhibited hallucinations, delusions, rejection of care and wandering. Resident #64 was coded as receiving an antipsychotic and antidepressant. The care plan was revised in 9/1/22 to include the following behaviors: exit-seeking, belief she was being poisoned, attempts to vomit up her medications, repeatedly packing to go home and calling 911. Review of a SW note dated 9/1/22 at 11:42 AM read as follows: Resident #64 remains at facility for long term care (LTC) followed by PACE and has had some changes with her dementia and behaviors. She believed she was being poisoned when given her medications, she attempted to throw up medications, she called 911 to have her hair done, she was exit-seeking, wandering to break room and trying to get out of unit. Resident #64 also packed up her belongings and stated she was going home and PACE providers were aware. The SW note read the PACE Site Director asked her to have the facility psychological service provider see Resident #64. The note read the facility SW notified their psychological services provider who stated they were unable to see a PACE participant and the PACE Site Director was made aware on 8/31/22 and informed that if PACE provided a contract with the facility ' s psychological provider, the facility could move forward. The note read Resident #64 had lost interest in their 1:1 meetings and she was also noted still rummaging and packing her belongings. A PACE Physician note dated 9/8/22 at 8:50 AM read Resident #64 had significant unhappiness staying at the facility. A nursing note dated 9/8/22 at 3:46 AM indicated Resident #64 was hallucinating that children were running around in her room as well as a male peeping in her window. She was sitting at the nurses station at the time. Review of a PACE SW note dated 10/5/22 read Resident #64 presented with a flat affect congruent to her mood and conversation. She was also observed during lunch and she barely touched her meal. The PACE SW would continue to monitor her mood and offer support as needed. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #64 had moderate cognitive impairment, reported feeling down and lacked energy. She was not coded for hallucinations, delusions, rejection of care or wandering. Resident #64 was coded as receiving an antipsychotic and antidepressant. Review of a SW note dated 10/31/22 at 11:22 AM read Resident #64 continued on PACE services and was wearing a wanderguard due to wandering and an elopement risk. Resident #63 stated that she wished she had someone to talk to and reported mild depression. The PACE provider was still trying to obtain a psychological services provider to meet Resident #64 ' s needs. Review of an email correspondence dated 10/26/22 at 2:50 PM to the PACE Physician and the PACE Site Director from the PACE operational provider read there was a continued effort to find a psychological provider for Resident #64. An interview was completed on 11/29/22 at 12:15 PM with Resident #64. She stated she no longer felt that her food was poisoned and staff were assisting her with her activities of daily living (ADLs). Resident #64 stated she had not attended PACE since sometime in September that she could recall. She verified the facility and PACE SW had been coming a few times a week to talk with her but she still wanted to go home and was unhappy in the LTC setting. An interview was completed on 11/29/22 at 5:02 PM with the facility SW. She stated she had worked at the facility for [AGE] years and was familiar with the PACE program and how it related to the facility ' s residents. She stated when a resident was admitted on the PACE program, the PACE Physician and staff were responsible for all of her care. The SW stated the facility often reminded PACE of the need for them to provide the PACE Physician ordered consults to include psychological services. She stated PACE staff stated they could not find a provider and the facility ' s contracted psychological services provider would not contract with the PACE program. The SW stated if the PACE provider would agree to allow the facility to bill for the psychological services, they would reach out and confirm that this option was agreed upon by the facility ' s psychological service provider but to date, that had not occurred. The SW stated to her knowledge, they have not procured a psychological service provider so she had taken it upon herself to visit Resident #64 at least three times a week to allow her to talk and voice her feelings and concerns. She stated she began this as soon as her behavioral symptoms started in early August 2022. The SW stated there had been improvement in her hallucinations, delusions and noncompliance with care but she still reporting feeling down and wanted to go home. An interview was conducted on 11/30/22 at 12:20 PM with Nursing Assistant (NA) #11. She stated she had worked at the facility for 3 years. She stated she was very familiar with Resident #64 and there had been improvement in her hallucinations but she still on occasion would refuse to eat her food for fear of being poisoned and voiced her sadness about not being able to go home. An interview was completed on 11/30/22 at 12:30 PM with Nurse #5. She stated she had worked at the facility for 4 years. She stated Resident #64 ' s behaviors and mood over the last several months had worsened but she noted improvement with getting her to take her medications or calling 911. She stated she still experienced the occasional hallucination and delusion. Nurse #5 stated Resident #64 ' s care was overseen by the PACE provider and PACE physician. In a telephone interview on 11/30/22 at 5:03 PM, the PACE Site Director stated she was aware that Resident #64 had not been provided the psychological services ordered by the PACE Physician and were continuously working to obtain a contract with a psychological service provider. She stated the PACE provider would work out payment outside of their lack of a contract and that she would have the PACE physician to call surveyor. At the time of the survey exit on 12/1/22, there were no return calls from the PACE physician. An interview was conducted on 12/1/22 at 3:05 PM with the Regional Nurse Consultant. She stated the expectation was for Resident #64 to receive all consults and services ordered for her well-being to include psychological services but it was difficult when Resident #64 ' s care was provided by the PACE program.

Based on record review and interview with the Consultant Pharmacist and staff, the Consultant Pharmacist failed to identify and to report drug irregularity to the Director of Nursing or the Attending Physician regarding the transcription error for the Famotidine (used to treat Gastroesophageal reflux disease (GERD)) for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #51). Findings included: Resident # 51 was admitted to the facility on [DATE] with multiple diagnoses including GERD. Resident #51 had a doctor's order dated 9/22/20 for Pantoprazole (Protonix) 40 milligrams (mgs.) once a day for GERD. On 6/14/22, the Pharmacist had recommended to discontinue Pantoprazole due to long term use had been associated with increased risk of Clostridium difficile (C diff) colitis and to replace it with Famotidine (Pepcid) 20 mgs twice a day as needed (PRN) for indigestion/heartburn. The attending physician had responded agree, please write order to the recommendation on 6/17/22. On 6/26/22, the former Director of Nursing (DON) entered the order in the computer for Famotidine 20 mgs BID (scheduled) instead of BID PRN as ordered. Review of the Medication Administration Records (MARs) from June through November 2022, revealed that the Famotidine was administered to Resident #51 twice a day (scheduled). Resident #51's drug regimen was reviewed by the Consultant Pharmacist on 7/27/22, 8/15/22, 9/22/22, 10/10/22 and 11/14/22 and missed to identify that the Famotidine was administered BID (scheduled) instead of BID PRN as ordered. On 12/1/22 at 4:00 PM, the Consultant Pharmacist was interviewed. He reviewed his recommendation for the Famotidine in June 2022 and verified that the attending physician had agreed to discontinue the Pantoprazole and to replace it with Famotidine 20 mgs twice a day as needed. He also reviewed that the Famotidine was entered in the computed on 6/26/22 to be given twice a day (scheduled) instead of BID PRN. He indicated that he did not catch this irregularity, he missed it. On 12/1/22 at 3:20 PM, the Regional Clinical Manager was interviewed. She stated that she expected the Consultant Pharmacist to identify and to report any drug irregularity to the Director of Nursing or the Physician.

Based on record review and Nurse Practitioner (NP) and staff interview, the facility failed to transcribe the Famotidine (used to treat gastroesophageal reflux disease (GERD)) as ordered resulting in the administration of Famotidine twice a day instead of twice a day as needed (PRN) for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #51). Findings included: Resident # 51 was admitted to the facility on [DATE] with multiple diagnoses including GERD. Resident #51 had a doctor's order dated 9/22/20 for Pantoprazole (Protonix) (used to treat GERD) 40 milligrams (mgs.) once a day for GERD. On 6/14/22, the Pharmacist had recommended to discontinue Pantoprazole due to long term use had been associated with increased risk of Clostridium difficile (C diff) colitis and to replace it with Famotidine (Pepcid) 20 mgs twice a day as needed (PRN) for indigestion/heartburn. The attending physician had responded agree, please write order to the recommendation on 6/17/22. On 6/26/22, the former Director of Nursing (DON) entered the order in the computer for Famotidine 20 mgs BID (scheduled) instead of BID PRN as ordered. Review of the Medication Administration Records (MARs) from June through November 2022, revealed that the Famotidine was administered to Resident #51 twice a day (scheduled) instead of twice a day PRN. On 12/1/22 at 9:40 AM, Charge Nurse #2 was interviewed. She stated that the once the doctor agreed and signed the recommendation of the Consultant Pharmacist, it was considered a doctor's order. The Nurse was expected to enter the order in the computer for the pharmacy to dispense the medication. The Charge Nurse reviewed the Consultant Pharmacist Communication to Physician form and the doctor's order for the Famotidine and stated that it was a transcription error. The former Director of Nursing (DON) transcribed the Famotidine as twice a day (scheduled) instead of twice a day PRN as ordered. She added that she would inform the NP of the transcription error on Resident #51. On 12/1/22 at 12:44 PM, the NP was interviewed. The NP stated that she was informed by the Charge Nurse regarding the transcription error for the Famotidine on Resident #51. She stated that she expected nursing to enter orders in the computer correctly to prevent unnecessary medications. She stated that she would write an order to administer the Famotidine BID PRN. On 12/1/22 at 3:20 PM, the Regional Clinical Manager was interviewed. She stated that she expected nursing to enter orders in the computer correctly.

Based on observations, record reviews, and staff interviews the facility failed to have a medication error rate of less than 5% as evidenced by 4 medication errors out of 37 opportunities, resulting in a medication error rate of 10.81% for 3 of 5 residents (Resident #26, Resident #46, and Resident #18) observed during medication administration. The findings included: 1.Resident #26 had a physician's order for ipratropium-albuterol solution for nebulization, 0.5 milligram (mg) per 3 milliliters (ml), three times daily for seven days. On 11/30/2022 at 8:30 AM Medication Aide (MA) #5 was observed administering medications to Resident #26. The MA was observed picking the nebulizer mask up out of the bedside chair and loading the medication chamber with 3ml of ipratropium-albuterol solution. MA#5 placed the mask on Resident #26 and pressed the start button on the nebulizer machine. MA#5 then left the resident's room and began to move her medication cart to the next room. When asked to go back into Resident #26's room and examine the nebulizer mask, the MA stated the medication would take 15 minutes to administer. The surveyor pointed out to the MA, the tubing was not connected to the nebulizer machine and therefore the resident was not getting the medication. MA#5 stated she should have checked the nebulizer mask and tubing to ensure they were connected before she left the room. 2. Resident #46 had a physician's order for lactulose, 10 Gram (G) per 15ml solution daily. On 11/30/2022 at 8:45 AM MA #4 was observed administering medications to Resident #46. Upon approaching the MA and the medication cart, she was observed crushing medications and placing them in a clear 30 milliliter (ml) medication cup. She then poured the crushed medication into a larger cup with water for administration. There were small remnants of medication still in the cup and on the cart around the medication cup. The MA began to pull medications for Resident #46 and poured 15ml of lactulose into the clear 30ml medication cup, she previously used, with remnants of crushed medication. MA#4 took the lactulose and other medications into the resident's room where she was instructed by the surveyor not to administer the lactulose. MA#4 was interviewed and stated she did not realize she used the same medication cup for the lactulose and the crushed medications. She stated separate cups should have been used to prevent cross contamination of medications. 3. Resident #18 had a physician's order to flush the percutaneous gastrostomy tube (G-tube) with 30 ml of water pre and post medication. Additionally, the resident had an order for isosorbide 30mg to be crushed and administered four times daily and valproic acid, 10ml of 250ng per 5ml solution to be given three times daily. On 11/30/2022 at 1:35 PM the ADON was observed administering medication to Resident #18. Resident #18 had a percutaneous gastrotomy tube for medication administration. The ADON was observed crushing the isosorbide and the valproic acid and placing them in clear 30ml cups. The ADON placed the clear medication cups with the isosorbide and the valproic acid on the bedside table and retrieved two larger cups from the medication cart. She took the two cups containing isosorbide and valproic acid into the bathroom and set them on the back of the toilet while she filled two cups with water. She brought the cups of isosorbide and valproic acid back to the bedside table and diluted each medication cup with a small amount of water. She then stated she needed more water to flush the tube. She took both medication cups with isosorbide and valproic acid back into the bathroom and again set them on the back of the commode while she got more water in the larger cups. She then took both cups of medication with her and exited the room. After several minutes, the ADON returned with the medication cups of isosorbide and valproic acid. The ADON opened the stopcock, attached a syringe, and flushed the tube with 30ml of water. The ADON poured the first cup of diluted isosorbide into the syringe followed by the second cup with diluted valproic acid. She flushed the tube with 30ml of water and turned the stopcock to the off position. The ADON was interviewed immediately after the medication administration was completed. She further stated she should have flushed between each medication.

Based on record review, observation and staff interview, the facility failed to determine root causes of each fall and to revise the care plan intervention after each fall (Residents #34 & #70) and also failed to put effective interventions in place following each fall to prevent repeated falls (Resident #70). This was evident for 2 of 5 sampled residents reviewed for accidents (Residents # 34 & # 70). Resident #34 ' s falls resulted in abrasions, lump, bruises, pain and emergency room (ER) evaluation. Findings included: 1. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses including dementia with behavioral disturbances and [CONDITION(S)]/[CONDITION(S)] following cerebro vascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #34 has severe cognitive impairment and needed extensive assistance with transfers and bed mobility. The assessment further indicated that Resident #34 had falls with injury since admission/entry/reentry or prior assessment. Resident #34's care plan for falls was initiated on 9/17/19 and was last revised on 4/20/21. The problem was resident was at risk for falls and fall related injuries and the goal was to minimize potential for significant injury related to falls through to next review. The approaches included to place resident in a low bed (4/15/21), fall mats to be placed to both sides of bed when the resident is in bed (4/14/21), encourage the resident to get out of bed daily as resident agrees ( 4/12/21) and to get the resident out of bed at appropriate time for designated smoking schedule as resident agrees ( 2/15/21). Resident #34's progress notes for the last 6 months were reviewed. The notes revealed that the resident had a fall with injuries on 2/24/21, 4/9/21 and 4/12/21. The progress note dated 2/24/21 at 8:00 PM (written by Nurse # 5) revealed that Resident #34 was found on the floor around 6:30 PM. The resident was found with abrasions above both eyes, a raised bump above the right eye and a bruise on the right side of lower back. The resident was reminded to ask for assistance and not to try to get out of bed alone. On 5/5/21 at 2:56 PM, Nurse #5 was interviewed. She indicated that she was assigned to Resident #34 on 2/24/21 when he fell out of bed and he sustained a laceration on his eyebrow. Nurse #5 reported that Resident #34 was cognitively impaired and was high risk for falls. His bed was in the lowest position and there were no mats on the floor during his fall. She added that the Unit Manager was responsible for the investigation and for the interventions. Review of the investigation/incident report dated 2/24/21, there was no possible root cause of the fall documented nor intervention put into place. There was no new intervention added to the care plan after 2/24/21 fall. The progress note dated 4/9/21 at 4:18 PM (written by the Physician Assistant) indicated that Resident #34 was seen due to a fall out of bed. He has a lump above his eyebrow on left side of his forehead. A family member was informed of the fall and was upset that the resident was in bed in afternoon and he continued to have a fall. The family member would like him to be checked for any acute infection. On examination, the resident did not show any signs of infection and he was afebrile. Laboratory works were ordered. On 5/5/21 at 12:10 PM, the Physician Assistant was interviewed. She stated that she was made aware of Resident #34 ' s falls. She reported that she had notified the family about his fall and the family wanted the resident out of bed and this was shared with the staff. She attended the falls meeting weekly and the administrative staff discussed the falls and put interventions in place, and she expected the staff to implement the interventions to prevent further falls and fall related injuries. The progress note dated 4/9/21 at 5:01 PM (written by Nurse #1) revealed that Resident #34 was observed on the floor partially prone position with his right body on the floor mat and his forehead touching the floor. He had a bump to his left forehead and little amount of bleeding to his left wrist (old wound). On 5/4/21 at 2:45 PM, Nurse #1 was interviewed. She reported that she was assigned to Resident #34 on 4/9/21 when he had a fall. It was around 2-3 PM, she was off the floor for lunch when she was informed by NA #1 that the resident was on the floor. She went immediately to his room and found him on the floor. There were floor mats on each side of bed, but they were small. His body was on the mat and his forehead hit the floor causing a big bump. He had an old wound to his left wrist and that was bleeding. The bed was on the lowest position. Nurse #1 further indicated that Resident #34 has cognitive impairment and was a high risk for falls. He was known to play with his bed remote control making the bed up and down. Nurse #1 reported that she came back to work on 4/13/21 and she was informed that Resident #34 had another fall on 4/12/21. He had bruises on his face and bump on his forehead. She had administered Tylenol due to signs of pain since he was unable to make his needs known. Nurse #1 added that on 4/13/21, Resident #34 had a new bed with a lock feature to prevent him from raising or lowering his bed. The Nurse reported that the Unit Manager investigated the fall and put intervention in place. On 5/5/21 at 1:50 PM, NA # 1 was interviewed. She stated that she was assigned to Resident #34 when he had a fall on 4/9/21. She indicated that she found the resident on the floor face down and he was not on the floor mat, he might have pushed the mat away from the side of the bed. He was known to play with his bed remote control, raising the bed up and down, and he was not supposed to have the remote control with him, but somebody had handed it to him. He was found with his bed not on the lowest position. He had a large bump on his left forehead. Review of the investigation/incident report dated 4/9/21, there was no possible root cause documented. Floor mat to the right side of bed was documented on the report as intervention. There was no new intervention added to the care plan after the 4/9/21 fall. The progress note dated 4/12/21 at 3:15 PM (written by Unit Manager #1) revealed that she was notified that Resident #34 was on the floor. The resident was observed on the left side of bed on the floor mat. A nurse aide (NA #5) was in the bathroom preparing to give resident a bath. Prior to the fall, the resident's bed was observed on the lowest position. On 5/4/21 at 3:05 PM, Unit Manager #1 was interviewed. She stated that she was the Unit Manager assigned to Resident #34 and she had investigated the 4/12/21 fall. She remembered that Resident #34 was found on the floor mat. She verified that the resident was found to have bruises on his face, but she had no idea what causes the bruises. She also indicated that the resident was known to play with his bed remote control, up and down, so the maintenance staff member had changed his bed after the fall on 4/12/21. This new bed had a lock feature that would allow the resident to elevate the head and foot part of the bed but would not allow him to raise the bed up and down. On 5/5/21 at 10:15 AM, NA #5 was interviewed. She stated that she was assigned to Resident #34 when he had a fall on 4/12/21. She indicated that another staff member found the resident on the floor (unable to remember the name of the staff member). She also could not remember the events of the fall (what, when, where and how). The progress note dated 4/12/21 at 4:30 PM (written by the Physician Assistant) revealed that Resident #34 had another fall with no injury. The laboratory works were ordered, and the results came back with nothing out of range. The urinalysis was still pending. A family member was called and was adamant that she did not want the resident in bed during the day and she had discussed this with the staff. Review of the Medication Administration Records (MARs) revealed that Tylenol (pain reliever) was administered to Resident #34 on 4/13/21 at 8:41 AM and on 4/14/21 at 8:27 AM due to pain. The progress note dated 4/14/21 at 2:45 PM (written as late entry by Unit Manager #1) indicated that resident continued to have bruising around both eyes from the previous fall and hematoma to the left forehead. The progress note dated 4/14/21 at 4:59 PM, (written by the Physician) revealed that Resident #34 had a fall on 4/9/21. He fell out of bed and noted to have a swelling/lump on his left forehead with some bruising. Resident had another fall out of bed on 4/12/21. Resident was seen today, sitting in wheelchair not able to hold his head up 90 degrees and his shoulder bent down. This was new today. The resident has a left forehead swelling/lump, bruising of forehead, ecchymosis around both eyes down left side of face and behind left ear to neck. Bruising in different stages, some darker areas/purplish around eyes and neck with edges more yellowish in color. The resident denied pain, but it was hard to understand him. Due to inability to lift his head up/more ecchymosis noted today, the resident was sent to the emergency room (ER) for further evaluation. The ER records dated 4/14/21 were reviewed. The records revealed that Resident #34 presented to ER due to fall on 4/9/21 and again on 4/12/21. The resident was nonverbal but pointed to back of neck when asked about pain. The physical examination revealed resident had significant left forehead hematoma with diffuse ecchymosis throughout the forehead, intraorbitally bilaterally, inferior to the angle of the mandible on the left side. The assessment/plan were fall, closed head injury, facial trauma, and traumatic hematoma of forehead. The result of the Computerized Tomography (CT) of head dated 4/14/21 revealed moderate left frontal soft tissue swelling/contusion, and CT of cervical spine and maxillofacial revealed no fractures. The progress note dated 4/15/21 at 6:38 AM revealed that Resident #34 was transferred back to the facility on [DATE] at 11:45 PM. Unit Manager #1 was interviewed on 5/5/21 at 9:45 AM. She stated that she was assigned to Resident #34 when he had a fall on 2/24/21, 4/9/21 and 4/12/21. She investigated the falls and all the falls were from the bed, the resident tried to get out of bed unassisted and he was known to play with his bed remote control, raising the bed up and down. She indicated that on 4/9/21 fall, she added a floor mat to one side of bed (unable to remember if on the right or left side). When asked what interventions put in place after the 2/24/21 and 4/9/21 falls, she stated that she just started as Unit Manager. Unit Manager (UM) #2 was interviewed on 5/5/21 at 9:50 AM. She indicated that the facility had a fall meeting once a week consisted of the Director of Nursing, Unit Managers, Staff Development Coordinator, MDS Nurse, and Therapist. They discussed the falls that week and tried to put interventions in place. She added that the facility had identified issues around March or April 2021 regarding falls investigation, not consistently documenting the root cause of the fall and the appropriate fall interventions. A plan of correction was initiated at that time and they were still working on it. When asked about Resident #34, she stated that the root cause of the falls and the interventions should have been documented on the investigation reports, but they were not consistently documented. She also stated that the MDS Nurse should have revised the care plan to reflect new interventions after each fall. UM #2 verified that new interventions (bed change and encourage resident to be out of bed) were added after the 4/12/21 fall. Resident #34 was observed in bed on 5/5/21 at 3:25 PM. There was a bedside table and a mat on the left side of the bed and the mat was folded in half. At 3:35 PM, NA #7 was interviewed. She stated that she was assigned to Resident #34. She explained that she folded the mat because of the bedside table on the left side of the bed. She added that this was her first assignment on the 100 hall, since she normally works in the office. On 5/6/21 at 4:15 PM, interview with the Director of Nursing (DON) and the Director of Clinical Resources was conducted. The DON indicated that she just started as DON on 4/3/21 and not familiar with Resident #34 yet. The Director of Clinical Resources indicated that the facility had identified a problem with their fall management and provided a copy of their Quality Assurance (QA) tool. The QA tool revealed that on 4/6/21, the facility identified problems with fall interventions, documentation, follow up and neuro checks. The interventions to correct the problem included in part, all in house residents who had a fall in the last 6 months were reviewed for appropriate fall interventions and care plans and care guides were updated to show most up to date interventions and plans of care on 4/6/21. The DON, Unit Coordinators (UC), MDS Nurse and Director of Rehabilitation (Rehab) were in-serviced on managing fall interventions and root cause analysis of residents with falls on 4/6/21. All licensed nurses, medication aides, certified nursing assistants and patient care assistants were in-serviced on 4/6/21 on what constitutes a fall, what to do in the event of a fall and notification of falls. The DON or designee will be notified of each fall and will determine intervention necessary for resident after each fall (goal date 4/12/21 and on-going). Following business day after the fall, the DON, UC, Staff Development Coordinator (SDC), Rehab department and or MDS Nurse will ensure intervention is documented on the care plan and care guide (on-going). Weekly in the falls meeting, the DON, UC, SDC and or MDS Nurse will review all falls for the week prior, review all interventions are appropriate and reeducate staff as necessary. Any concerns identified will be addressed immediately during this meeting (initiated on 4/6/21 and on-going). Identified fall concerns will be addressed in the QA meeting no less than quarterly (goal date 7/31/21). 2. Resident #70 was admitted on [DATE] with cumulative diagnoses of Cerebral Vascular Accident (CVA) with left side [CONDITION(S)] and a history of falls. Resident #70's annual Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairment and he exhibited no behaviors. He was coded for limited assistance with bed mobility and transfers, walking did not occur, extensive assistance with hygiene and total assistance with toileting. Resident #70 was coded as being incontinent of bladder and bowel, impairment in mobility to side of his upper and lower extremity. He was also coded for 2 or more falls without injuries. Resident #70's Fall Care Area assessment dated [DATE] read Resident #70 had a history of falls and remained at risk for additional falls. Resident #70 had a history of a CVA with resulting left side [CONDITION(S)], balance deficits, requiring staff assistance with all transfers. Resident #70 would however often transfer independently despite re-education and the daily use of psychotropics. His psychotropics have the potential for adverse side effects that may increase Resident #70's risk for falls, side effects of drowsiness and dizziness with visual deficits also present. Will proceed to care plan with interventions of therapy if ordered, keep call light within easy reach, answer in a timely manner, anticipate his needs as able, keep his environment well-lit and free from clutter. Additional interventions included keeping his personal items within easy reach, assisting Resident #70 with toileting, provide verbal cues for resident to not attempt to transfer without assistance, ensure Resident #70 was wearing nonskid soles for transfers, instruct and reinforce use the of assistive equipment if indicated, monitor prescribed drug use for any adverse side effects that would increase Resident #70's risk for falls. Resident #70's falls care plan initiated 4/17/19 and last revised on 4/21/21 read he was at risk for falls and fall related injuries. The goal initiated on 4/9/21 read to minimize potential for significant injury related to falls through to next review. Interventions included the following: *Room rearranged to allow more space for safe transfers dated 4/20/21 * Stop sign placed on his bathroom door to remind him to call for assistance prior to attempting self-toilet or transfer dated 2/12/21 *Resident #70 was reminded and re-educated to ensure his brakes are engaged on wheelchair prior to standing and of the importance of calling for assistance with toileting and transfers dated 1/18/21 *Encourage Resident #70 to ask for assistance when retrieving items from the floor dated 12/4/20 *Remind him to ask for assistance before transferring dated 5/27/20 *Administer his medications as ordered and observe him for adverse side effects of medications in current drug regimen. Contact the Physician with abnormal findings dated 4/17/19 * Anti-tippers, anti-roll backs to his wheelchair and a brake extender to left wheelchair brake dated 11/25/19 *Anticipate his needs as able dated 4/17/19 *Assist Resident #70 with transfers as needed dated 4/17/19 * Continue to keep his environment well lit, free from clutter and potential safety hazards dated 4/17/19 * Do not move Resident #70's wheelchair from his bedside when he's is in bed as he will often transfer himself despite recommendations for assistance dated 4/17/19 * Ensure that Resident #70 has and wears properly fitting nonskid footwear for transfers dated 4/17/19 * Ensure the wheelchair wheels are locked prior to standing or transferring Resident #70. Educate/remind him as needed dated 4/17/19 * Keep his call light within easy reach and answer his call light in a timely manner dated 4/17/19 * Observe Resident #70 for any signs and symptoms that would predispose him to falls such as change in level of consciousness, dizziness, sign or symptoms of an infection dated 4/17/19 * Orient him to new surroundings as needed dated 4/17/19 * Place frequently used items within easy reach of Resident #70 to reduce his risk of reaching for items dated 4/17/19 * Therapy to eval and treat if indicated dated 4/17/19 Review of Resident #70's fall incidents from 1/1/21 to 5/3/21 revealed a total of 10 falls: a. 1/18/21 at 4:00 PM-Unwitnessed fall while attempting to the use toilet. The nursing note read he was calling for help and found on the bathroom floor. His wheelchair was noted outside the bathroom door with the wheels unlocked. He was wearing sneakers and the bathroom floor was not wet. He was assessed and absent of injuries. Review of the fall incident report read there were orders to initiate the fall prevention program twice daily and he monitor Resident #70 for 72 hours for bruising, change in mental status/condition, pain or other injuries related to his fall. b. 2/15/21 at 6:45 PM-Unwitnessed fall in his room from the bed. The nursing note read he was trying to get into the wheelchair and fell . No apparent injuries, neurological (neuro) checks started and read he was on physical therapy (PT) and occupational therapy (OT) caseload for safe transfers. The incident report read the immediate intervention was rest and orders to initiate fall prevention program. Review of Resident #70's February 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. c. 2/21/21 at 2:00 PM-Unwitnessed fall in his room. The nursing note read Resident #70 he was lying on the floor and stated he was trying to get back into the bed. His wheelchair was at his side, wearing nonskid shoes and he was reminded to call for assistance. Neuro checks were initiated for 72 hours and a urine sample was obtained due to increased confusion. (His urinalysis returned negative for a urinary tract infection). The incident report read a [NAME] pad was added to his wheelchair and the fall prevention program was initiated. Review of Resident #70's February 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. d. 2/28/21 at 3:52 PM-Unwitnessed fall in the hallway. The nursing note read Resident #70 was observed in the hallway sitting on his bottom in front of his wheelchair with his head against the seat of the chair. Neuro checks were initiated, and OT was to assess for a cushion device for his wheelchair. The incident report read the interventions were effective and the fall prevention program was initiated. Review of Resident #70's February 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. e. 3/21/21 at 1:30 PM-Unwitnessed fall in his room attempting to take his cloths out of his closet. The nursing note read staff heard a loud noise and went to Resident #70's room. He was taking his cloths from his closet so he could leave the facility. He had turned the wheelchair over and was lying on his left side. No injuries were noted, returned to the wheelchair and staff would continue to monitor. Review of Resident #70's MAR indicated he was administered 1 milligram of [MEDICATION(S)] (antianxiety medication) in an injection at 2:00 PM per orders from the psychiatric Nurse Practitioner (NP). The incident report read there was no intermediate interventions, initiate fall prevention program and read this fall was reviewed in a fall committee meeting on 4/6/21. Review of Resident #70's March 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. His March 2021 MAR also read he received one mg of [MEDICATION(S)] in an injection at 2:00 PM. f. 3/21/21 at 3:45 PM-Unwitnessed fall at the nursing station. The nursing note read at 3:45 PM, Resident #70 was laying on floor at nursing station on his left side with his wheelchair about 20 feet behind him. He was assisted back to into his wheelchair, taken to his room and placed in bed. His range of motion was within normal limits and he was assessed as he would allow. The incident report read the interventions were ineffective, his medication was adjusted, and he was referred to therapy for trying to walk without assistance. The fall prevention program was initiated, and the incident was reviewed in the fall committee meeting on 4/6/21. Review of Resident #70's March 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. g. 3/21/21 at 4:00 PM-Unwitnessed fall in his room. The nursing note read Resident #70 tried to walk in his room and was found lying on his left side with his wheelchair beside him. He was placed back into bed. The psychiatric NP was again notified, and a second dose of one mg [MEDICATION(S)] was giving in another injection. The incident report read the interventions were ineffective, the fall prevention program was initiated, and the incident was reviewed in the fall committee meeting on 4/6/21. Review of Resident #70's March 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. His March 2021 read he received a second dose of one mg of [MEDICATION(S)] in an injection at 4:30 PM. h. 3/21/21 at 4:30 PM-Unwitnessed fall in his room. The nursing note written at 5:45 PM read Resident #70 was status post 3 falls (3:45 PM, 4:00 PM and 4:30 PM-there was no reference to the fall at 1:30 PM). Resident #70 was noted with increased agitation and anxiety. He was up swinging arms and legs purposely trying to slid self out of his wheelchair. The dose of [MEDICATION(S)] he was previously given with no effect. The psychiatric NP was called again and notified of increased behaviors with orders to give an additional dose of [MEDICATION(S)]. Resident #70 continues to yell out I am getting the hell out of here. Staff tried calling his Responsible Party (RP) and his second emergency contact to speak to Resident #70 but there was no answer at either number. Resident #70 was resting comfortably at this time, his bed was in a low position, a therapy referral was placed, medication adjusted, and staff would continue to monitor. The incident report read this fall was an isolated event and resident had increased behaviors. The evaluation note read the fall prevention program was initiated and the fall was reviewed in a fall committee meeting on 4/6/21. Review of Resident #70's March 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. i. 3/22/21 at 12:26 AM-The incident report does not indicate if this fall was witnessed or where it occurred. The nursing note read Resident #70 was trying to transfer from the bed to his wheelchair without assistance and fell . He had no injuries and denied hitting his head. The note read staff would continue to monitor. The incident report read the fall prevention program was initiated and he was educated on requesting for help with transfers. His call light was in reach and his bed was in the low position. Review of Resident #70's March 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. j. 4/20/21 at 8:25 PM-Unwitnessed fall in his room. The nursing note read Resident #70 was laying on his right side on the floor. He stated he was trying to get into the bed from his wheelchair. His wheelchair brakes were locked but the chair was very close to the bedside table leaving no room to self-transfer. Resident #70 was assessed and denied pain or injury. He sustained a skin tear and a scrap to his head where he struck his head on the bedside table. Neuro checks were initiated, the Director of Nursing was notified, and staff would continue to monitor. The incident report read his nightstand and bedside table were pulled down to give him more room to move around. The report read the intervention was effective. Resident #70 continued to self-transfer from his wheelchair to the bed and staff were to continue to encourage him to call for assistance. The fall prevention program was initiated. Review of Resident #70's April 2021 MAR included the fall prevention program twice daily and was initiated off by the nursing staff. Resident #70 was seen by PT from 1/18/21 to 2/18/21 for abnormal gait and weakness. His discharge summary did not include any documented evidence that his 2 falls were addressed while he was on PT caseload. Resident #70 was seen by OT from 2/12/21 to 3/10/21 for [CONDITION(S)], arm pain and abnormal posture. His discharge summary did not include any documented evidence that a wheelchair cushion was addressed and that his 3 falls were addressed while he was on OT caseload. A therapy referral was made on 3/21/21 by Nurse #2 due to 4 falls while attempting to walk. Resident #70 was seen by PT from 3/22/21 to 4/8/21 for repeated falls. His discharge summary read he was discharged to a restorative nursing program. In an observation and interview on 5/3/21 at 2:23 PM. He was lying in bed and appeared disheveled and wearing white socks without a nonskid surface. His bed was in the normal position and his wheelchair was pushed close to his bed with the brakes locked. Resident #70 stated he was doing fine and did not need assistance from the staff to go to the bathroom. An interview was conducted on 5/5/21 at 8:16 AM with the Director of Clinical Resources. She stated falls were discussed in the morning clinical meetings. She stated the fall incident reports were not closed out until the team had time to ensure any interventions were effective. She stated the facility started a quality improvement for falls on 4/6/21. She stated the reason the fall committee was started was because the fall incidents were not thoroughly documented with a root cause analysis with effective interventions. The Director of Clinical Resources stated the fall committee met weekly and include the unit managers, the Director of Nursing (DON), MDS and therapist. An interview was conducted on 5/5/21 at 9:15 AM with the Rehabilitation Director. He stated Resident #70's falls were reviewed daily in the morning clinical meeting and therapy would provide input as needed. He stated each incident was reviewed for documentation and that the Unit Managers (UM) had implemented the recommended interventions. The Rehabilitation Director stated the facility recently started to meet weekly to review the falls from the previous week before closing out each incident report. He stated Resident #70 was impulsive and did not understand is own limitation. He stated safeguards were put in place that on occasion do not work. He stated when Resident #70 was discharged to a restorative nursing program, it meant to nursing. An interview was conducted on 5/5/21 at 9:43 AM with UM #1 and UM #2. UM #2 stated there should be an intervention for every fall. They stated management noted a problem in early April with the facility's response to resident falls. There was no root cause analysis of each fall and no evaluation to see if the interventions were effective. UM #2 stated that was when the weekly fall meeting started. UM #1 stated she recently became an UM when the previous UM moved to the position of Staff Development Coordinator (SDC). Another interview was conducted on 5/5/21 at 10:05 AM with UM #2. She stated where each fall incident report read the fall prevention program was initiated, she did not exactly know what that meant because she was not aware of a fall prevention program. UM #2 was unable to explain why there was no investigation, root cause analysis and no follow up to ensure the effectiveness of the interventions. She was also to explain why the was no documented evidence that nonpharmacologic interventions were attempted. An interview was conducted on 5/5/21 at 3:27 PM with Nursing Assistant (NA) #3. She stated she was familiar with Resident #70 and that he would not listen to the staff when they reminded him to call for assistance before transferring. She stated toileting him was not one of the interventions that she was aware of because he was always incontinent. NA #3 stated she had been able to distract Resident #70 in the past with watching television. An interview was conducted on 5/6/21 at 8:29 AM with the SDC. She stated she an UM up until the first of April 2021 and stated she was involved in the fall meetings. She stated she was not sure what was meant by the fall prevention program and the facility did not have a restorative program. When questioned about the multiple falls Resident #70 experienced in March 2021 she stated he was very agitated for some reason at that time. She stated he was not easily redirected so the psychiatric Nurse Practitioner (NP) was notified and orders were given for the 2 [MEDICATION(S)] injections. The SDC stated she did not recall if the facility considered placing Resident #70 on 1:1 or implementing nonpharmacological interventions other than attempting to contact his RP. She stated she did not think any nonpharmacological interventions would have worked at that time but agreed that none were attempted. A second observation was conducted on 5/6/21 at 10:10 AM. Resident #70 was again lying in bed. His bed was in the normal position with his wheelchair moved away from his bedside. He was wearing white socks with no nonskid surface. An interview was conducted on 5/6/21 at 11:32 AM with the facility Physician Assistant (PA). She stated she recalled when Resident #70 had several falls, and this was not his baseline and he was not acting normally. She stated with falls, she looked for an acute infectious process as the cause first. She stated she ordered lab work and a urinalysis, but everything came back negative on Resident #70. The PA stated most of Resident #70's falls were when he tried to transfer from his wheelchair to his bed. She stated the staff and tried to educate him to no avail. She stated he had a CT scan done on 3/25/21. She stated his CT scan came back positive for pneumonia and some inflamed nodules in his lungs that would require close observation. The PA stated her practice was to discuss the use of the [MEDICATION(S)] with the Physician to see if it was appropriate. She stated the staff would call the psychiatric NP and she often

Based on record review, Physician, Physician Assistant (PA), Nurse Practitioner (NP), Pharmacist and staff interviews, the facility failed to prevent significant medication errors by not administering a medication as ordered, not entering verbal order, not verifying medication orders and not transcribing physician's prescribed medications to the Medication Administration Record (MAR) which resulted in prescribed medications not administered as ordered for 3 of 3 sampled residents reviewed for medication administration (Residents #5, #11 & #12). Resident #5 was prescribed intravenous (IV) [MEDICATION NAME] (an antibiotic drug) for bacteremia (presence of bacteria in the bloodstream) on 1/8/21. [MEDICATION NAME] was not verified and transcribed to the MAR until 1/11/21 and he missed 5 doses. In addition, Resident #5 was prescribed [MEDICATION NAME] capsule (an antibiotic drug) for pneumonia on 1/8/21. The verbal order for the [MEDICATION NAME] was not entered in the computer until 1/10/21 and Resident #5 missed 5 doses. Resident #5 was sent to the emergency room (ER) on 1/11/21 due to shortness of breath and he tested positive for COVID-19. On 1/12/21, Resident #5 was transferred to another hospital for the need of intensive care unit (ICU) bed. Immediate jeopardy began on 1/8/21 when the facility failed to verify and to transcribe the order for the IV [MEDICATION NAME] and failed to enter the verbal order for the [MEDICATION NAME] for Resident #5. Resident #5 was sent to ER due to shortness of breath on 1/11/21. Immediate jeopardy was removed on 1/23/21 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 of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) due to examples #2 and #3 to ensure monitoring systems put into place are effective. Findings included: 1. Resident # 5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. a. Review of the hospital discharge summary dated 1/7/21 revealed under discharge plan to continue IV [MEDICATION NAME] for staphylococcus aureus bacteremia until 1/13/21. The progress note written by the PA on 1/8/21 revealed under assessment and plan: MSSA bacteremia - to continue IV [MEDICATION NAME] 1 gram (gm) every 12 hours with end date of 1/14/21. The electronic doctor's orders for Resident #5 were reviewed. On 1/8/21 at 12:39 PM, there was a prescription order for [MEDICATION NAME] 1 gm IV every 12 hours (8 AM & 8 PM) with the end date of 1/14/21. The order was entered in the computer by the PA. Review of Resident #5's January 2021 MAR revealed that the [MEDICATION NAME] was not administered on 1/8/21 (8 PM dose), on 1/9/21 (8 AM & 8 PM doses), and on 1/10/21 (8AM & 8 PM doses), a total of 5 missed doses. Review of the progress note dated 1/11/21 at 10:12 PM written by the Physician revealed that she was contacted by the facility staff and was informed that Resident #5's lungs sounded a little bit wet and the family was adamant about sending the resident to ER. Review of Resident #5's nurse's note dated 1/12/21 at 7:03 PM revealed that on 1/11/21 at 9:15 PM, Nurse #2 had received a call from Resident #5's family wanting the resident sent to the hospital. The Nurse assessed the resident and had notified the Physician. The Physician had given an order to send the resident to the hospital for evaluation and treatment. Resident #5's blood pressure (B/P) was 110/60, respiration rate (RR) of 16, temperature of 98.6 degrees Fahrenheit (F) and oxygen saturation of 96% on 2 liters (L) per minute oxygen. The hospital ER note dated 1/11/21 at 10:58 PM revealed that Resident #5 presented in ER with worsening shortness of breath (RR 30), hypotensive (B/P 87/54), and bradycardic (HR 59). He was stuporous and minimally responsive to painful stimuli with opening of his eyes. The assessment and plan included acute kidney injury due to COVID -19 and pneumonia due to COVID - 19 virus, renal transplant failure and rejection, septic shock, metabolic acidosis and [MEDICAL CONDITION]. The note further indicated that the decision was made to transfer the resident to another hospital due to need for intensive care unit (ICU) bed. On 1/12/21, the resident was transferred to another hospital. On 1/20/21 at 11:05 AM, the Unit Manager (UM) was interviewed. She stated that the medication error for Resident #5 was identified and investigated by the facility and a plan of correction was put into place. The UM revealed that the order for the IV [MEDICATION NAME] was entered in the computer by the PA on 1/8/21 and Nurse #1 who was assigned to Resident #5 failed to verify the order for the IV [MEDICATION NAME] and therefore the medication was not transcribed to the MAR until 1/11/21. She added that on 1/11/21, she was informed by a nurse (didn't remember the name) that she needed to verify the order for the IV [MEDICATION NAME] and that was when she identified the medication error. The UM indicated that Nurse #1 should have checked the computer during her shift for new orders and verify the orders if any. On 1/20/21 at 12:45 PM, the PA was interviewed. She stated that she was new to the facility and she started end of November 2020. She revealed that she had seen Resident #5 on 1/8/21 and reviewed his hospital records. Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. She was not aware until 1/11/21 that the IV antibiotic was not administered due to transcription error. On 1/11/21, Resident #5 was sent to the ER and the ER notes revealed that the resident was having worsening shortness of breath, and he tested positive for COVID in ER. The PA indicated that missing doses of the antibiotics could have contributed to the resident's decline in condition but also had to consider that he had multiple medical history/comorbidities being immunocompromised (s/p kidney transplant) and tested positive for COVID. On 1/20/21 at 3:40 PM, Nurse #1 was interviewed. She verified that she worked day shift and was assigned to Resident #5 on 1/8/21. On 1/12/21, she was informed by the UM that the PA had entered an order in the computer for IV [MEDICATION NAME] for Resident #5 on 1/8/21. She was told that the order was not verified in the computer and was not transcribed to the MAR. Nurse #1 stated that she was not in-serviced on this new system of verifying orders in the computer. She was not aware that a new order was written for Resident #5 on 1/8/21. Nurse #1 revealed that on 1/12/21, she was educated by the Corporate Nurse on how to verify orders. She must check the computer so often during her shift to see if any new orders. If there were new orders, she must verify those orders, and once the orders were verified, the medications would appear on the MAR. On 1/20/21 at 3:59 PM, the Physician was interviewed. She stated that she had seen Resident #5 on 1/11/21 (not sure morning or evening). The resident had decreased breath sounds but had no complaints. At around 10 PM, she received a call from the facility that the resident was having trouble breathing and the family wanted to send him to the hospital. The Physician further stated that she was made aware on 1/11/21 that Resident #5 did not receive the IV antibiotic ordered on [DATE]. She indicated that the use of the antibiotic could have helped with the infections especially with the pneumonia but could not tell if that was the cause of his decline or hospitalization given his medical history and he tested positive for COVID in ER. On 1/21/21 at 9:05 AM, Nurse #3 was interviewed. She stated that she worked at the facility for less than a year on night shift. Nurse #3 indicated that she was not in-serviced on how to verify orders in the computer until this week (unable to remember exact date). She was in-serviced by the UM that she must check the computer several times a day during her shift to check for new orders and to verify if any. Once the order was verified, the medication would appear on the MAR. On 1/21/21 at 9:18 AM, Nurse #8 was interviewed. She stated that she didn't receive any training on how to carry out orders in the computer nor how to verify orders in the computer. On 1/21/21 at 9:28 AM, Nurse #2 was interviewed. She was assigned to Resident #5 on 1/11/21 on night shift when the resident was transferred to ER. Nurse #2 stated that the resident's oxygen saturation was around 95% on room air and he was a little bit short of breath, so she started him on 2 L/min oxygen. At around 9 PM, Resident #5's family member had called wanting the resident transferred to the ER. She called the doctor and the doctor ordered to send him out. Nurse #2 further indicated that the resident's vital signs were within normal limits before the discharge. Nurse #2 also revealed that she was not in-serviced on how to verify orders in the computer until 1/21/21 when the Director of Nursing (DON) had called and educated her on how to verify new orders. On 1/21/21 at 3:50 PM, the Pharmacist was interviewed. He stated that there were no records in their system dated 1/8/21 for IV [MEDICATION NAME] for Resident #5. On 1/11/21, there was a prescription order for [MEDICATION NAME] 1 gm IV twice a day but that was discontinued on 1/11/21. The Pharmacist indicated that he was not familiar with the facility's system in transcribing orders. On 1/22/21 at 1:41 PM, the DON was interviewed. He stated that he was made aware of the medication error on Resident #5. an order for [REDACTED].#1 failed to verify the order. The system was Physician/PA enters the order in the computer, the nurse must verify the order. After the order was verified, the medication would appear on the MAR and the pharmacy dispense the medication to the facility. The order for the [MEDICATION NAME] was later verified by the UM on 1/11/21 and the medication was administered to the resident. The DON further indicated that he expected the nurses to check the computer several times a day during their shift to check for new orders and to verify the orders timely. The DON confirmed Resident #5's [MEDICATION NAME] was not administered on 1/8/21 (8 PM dose), on 1/9/21 (8AM & 8 PM doses), and on 1/10/21 (8AM & 8 PM doses), for a total of 5 missed doses. b. A nurse's note (written by Nurse #1) dated 1/8/21 at 8:26 AM (recorded as late entry on 1/10/21 at 8:32 AM) was reviewed. The note revealed that the PA was informed of the resident's fall and his lung fields sounded a little diminished bilaterally. The PA had ordered for chest x-ray and the report came back pneumonia. The DON and responsible party (RP) were made aware of the fall and the need for antibiotic. Interview with Nurse #1 on 1/20/21 at 3:40 PM was conducted. Nurse #1 verified that she was assigned to Resident #5 on 1/8/21 on day shift. The resident had a fall that day (1/8/21) and his lungs sounds were diminished. She called and informed the PA of the fall and the diminished lung sounds and the PA ordered chest x-ray. The x-ray result came back with pneumonia and the PA had given a verbal order to start [MEDICATION NAME] 500 milligrams (mgs) by mouth for 7 days for the pneumonia. Nurse #1 revealed that she was overwhelmed that day and she forgot to enter the order for the [MEDICATION NAME] in the computer. She remembered and entered the order for [MEDICATION NAME] on 1/10/21 and the medication was started on 1/11/21. The chest x-ray result dated 1/8/21 bilateral lower lobe infiltrates and effusions. The January 2021 MAR revealed that Resident #5 had received [MEDICATION NAME] 500 mgs tablet on 1/11/21 at 8 AM dose. Resident #5 did not receive the [MEDICATION NAME] on 1/8/21 (8 PM dose), 1/9/21 (8AM & 8 PM doses) and 1/10/21 (8AM & 8 PM doses), a total of 5 missed doses. On 1/20/21 at 2:58 PM, the Unit Manager (UM) was interviewed. She stated that the medication error for Resident #5 was identified and investigated by the facility and a plan of correction was put into place. The UM revealed that the PA had given Nurse #1 a verbal order on 1/8/21 for [MEDICATION NAME] 500 milligrams (mgs) by mouth twice a day (8 AM & 8 PM) for 7 day for pneumonia. Nurse #1 who was assigned to Resident #5 on 1/8/21 failed to enter the order for [MEDICATION NAME] in the computer until 1/10/21 and the medication was not started until 1/11/21. On 1/20/21 at 3:55 PM, the PA was interviewed. She stated that Nurse #1 had called on 1/8/21 and informed her that Resident #5 had a fall and with diminished lungs sounds. Chest x-ray was ordered, and the result came back positive for pneumonia. A verbal order was given to Nurse #1 on 1/8/21 to start [MEDICATION NAME] 500 mgs by mouth twice a day for 7 days for pneumonia. On 1/11/21, she was notified that the order for [MEDICATION NAME] was not transcribed and was not administered until 1/11/21. The PA indicated that missing doses of the antibiotics could have contributed to the resident's decline in condition but also had to consider that he had multiple medical history/comorbidities being immunocompromised (s/p kidney transplant) and tested positive for COVID. On 1/21/21 at 3:50 PM, the Pharmacist was interviewed. He stated that there were no records in their system dated 1/8/21 for [MEDICATION NAME] for Resident #5. The Pharmacist indicated that he was not familiar with the facility's system in transcribing orders. On 1/22/21 at 1:41 PM, the DON was interviewed. He stated that he was made aware of the medication error on Resident #5. A verbal order for [MEDICATION NAME] was given to Nurse #1 on 1/8/21. The Nurse forgot to enter the order in the computer timely and the medication was not transcribed and administered timely. Nurse #1 entered the order on 1/10/21 and the medication was administered on 1/11/21. The DON indicated that he expected the nurses to enter orders in the computer and to administer ordered medications timely and as ordered. The DON confirmed that Resident #5 did not receive the [MEDICATION NAME] on 1/8/21 (8 PM dose), 1/9/21 (8AM & 8 PM doses) and 1/10/21 (8AM & 8 PM doses), a total of 5 missed doses. The Administrator and the Director of Clinical Resources were notified of the immediate jeopardy on 2/3/21 at 8:27 AM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 2/4/21 that read: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident # 5 was admitted to the facility on [DATE] with [MEDICAL CONDITION] Susceptible Staphylococcus aureus bacteremia. Upon admission, orders were transcribed, not to include the IV [MEDICATION NAME] due to the discharge summary did not give a dose or frequency. On 1/8/21, the Physician Assistant (PA) entered an order for [REDACTED]. The medication order was not verified by the Nurse #1 in the computer system until 1/11/21, resulting in the medication not being delivered, added to the Medication Administration Record or the administration of the medication. The IV [MEDICATION NAME] was administered to Resident #5 on 1/11/21 at 8:00am. Due to failure to verify the order, Resident #5 missed 5 doses of the IV Medication. On 1/8/21, chest x-ray results reporting pneumonia was called to the PA. The PA gave a verbal order to Nurse #1 [MEDICATION NAME] 500 mg by mouth for 7 days for the pneumonia. The order was not entered until 1/10/21 to start 1/11/21 at 0800. The failure of the Nurse #1 to transcribe the PA order resulted in Resident #5 not receiving the administration of the medication. Resident #5 did receive the oral [MEDICATION NAME] 1/11/21 at 8:00AM. Due to failure to transcribe the order, Resident #5 missed 5 doses of the oral medication. Resident #5 was sent out the ER per the family request on 1/11/21 at approximately 2115. The assessment of Resident #5 vital signs was blood pressure 110/60, respiration rate 16, temperature of 98.6, and oxygen saturation 96% on 2 liters of oxygen. Resident #5 was a little short of breath, hence the oxygen. Resident #5 was seen by the PA earlier in the day on 1/11/21, with decreased breath sounds, but had no other complaints. Resident tested positive for COVID-19 in the emergency room (ER). The ER assessment and plan included acute kidney injury due to COVID -19 and pneumonia due to COVID - 19 virus, renal transplant failure and rejection, septic shock, metabolic acidosis and [MEDICAL CONDITION]. On 1/12/21, the resident was transferred to another hospital for the need of ICU bed Immediately upon acknowledgement of the unverified orders for Resident # 5 on 1/11/21, a report was pulled from the Matrix Care system, to assess for any open and unverified orders by the Unit Manager (UM) on 1/11/21. At the time of the report, there were no orders left unverified. The acknowledgement of the failure to transcribe a PA order, all nurses notes were reviewed by the Director of Nursing (DON) on 1/11/21 for the previous week (7 days) to assess for a change in condition, notification to the PA, or potential order needs. Progress notes reviewed, did not show any other resident to be affected by the failure to transcribe a verbal PA or physician order. 2. 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. An In-service was provided to the Nurse #1 who did not verify the PA order and did not transcribe the PA order given on 1/8/21 by the Regional Clinical Manager on 1/12/21. This in service included verification and transcription of orders and entering orders given verbally by a Physician, Physician Assistant or Nurse Practitioner. An in Service was initiated by the Director of Nursing (DON) on 1/12/21 via an electronic system to all Nurses for the process of verifying orders in Matrix and transcribing verbal orders. Nurses who received the electronic in service responded with a thumbs up, or response to the notification system. Agency nurses were educated prior to the start of the following working shifts. The DON was responsible for verifying the education had been completed on all licensed nurses. On this in service, two licensed nurses did not receive the required education, resulting in additional education on the new plan 1-19-21. On 1/19/21, the Director of Clinical Resources provided additional In- Servicing to the Director of Nursing, on the use of the Admission Documentation Checklist, of which was updated from a previous version to add orders, to check admission orders [REDACTED]. Verification report follow up reeducated to the DON during this in service. Additional in-servicing was initiated by the Director of Nursing to the Nurse Supervisors and Staff Development Coordinator (SDC) on 1/19/21 to encompass all areas of verification of orders, Admission Documentation Checklist, Verification Report, transcription of orders to include verbal orders, reading progress notes to evaluate for changes of condition related to medication or order changes. During this in service they were also educated that the Admission Checklist and Verification Report would be reviewed daily during the clinical meeting and would be monitored on the weekend remotely or in the facility, by the DON, SDC , and/or the Nurse Supervisors per rotating schedule. The Director of Nurses, Nurse Supervisors and Staff Development Coordinator, on 1/20/21 in-serviced all nurses on the proper protocol (comparing orders from admission paperwork to what has been entered into the Matrix system) for checking orders, to include the verification of orders (To be checked at the beginning and end of shift) and entering orders to include verbal orders (upon receipt) into Matrix. In addition to the in-service education, the DON spoke to each licensed staff member individually by phone and/or in person to go over the expectations of transcribing and verifying all orders to include verbal orders. Agency staff attended the in-service meeting and individual meetings with the DON. Any agency staff that work will be in serviced prior to the start of his/her shift by the DON, Nurse Supervisor or SDC. All nurses including agency staff received training by 1/23/21, any nurse that had not received the training, was not allowed to work until the training was completed (due to work schedules, prn staff or agency staff that had not worked. The DON will keep a training tracker of the nurses to ensure that no nurse has been missed in the in servicing. Any staff hired after 1/23/21, received and will receive this training during orientation. IJ Removal Date: 1/23/2021 On 2/8/21 at 10:30 AM, the facility's credible allegation for immediate jeopardy removal was validated by the following: - review of the one on one education with Nurse #1 on verifying, processing of orders timely and verification of orders - review of the in-service records on medication verification/transcription, admission documentation checklist and entering of orders and the signed in sheets for the licensed nurses and administrative staff -review of their daily monitoring and the admission documentation checklist to verify orders were entered, verified and transcribed - interview with the nursing staff to verify they had received the in-service on verifying, transcribing and entering of orders. - review of the records of 3 new admit/readmit residents to verify the admission orders [REDACTED] The facility's date of immediate jeopardy removal of 1/23/21 was validated. 2. Resident # 12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #12 had impaired cognition and had received 2 days of antibiotic medication during the last 7 days. The hospital discharge summary dated 1/8/21 listed the discharge medications which included [MEDICATION NAME] (an antibiotic drug) 875-125 milligrams (mgs) by mouth every 12 hours for urinary tract infection [MEDICAL CONDITION]. The admission orders [REDACTED]. The January 2021 Medication Administration Record (MAR) revealed that Resident #12 did not receive [MEDICATION NAME] on 1/8/21 (8 PM dose), 1/9/21 (8 AM & 8 PM doses), 1/10/21 (8 AM & 8 PM doses) and 1/11/21 (8 AM dose), a total of 6 missed doses. On 1/20/21 at 2:58 PM, the Unit Manager (UM) was interviewed. She verified that she received the order for the [MEDICATION NAME] for Resident #12 on 1/8/21 from the Physician. She verified the order in the computer on the same day 1/8/21 and didn't know why the medication did not appear on the MAR to be administered until 1/11/21. On 1/21/21 at 9:28 AM, Nurse #2 was interviewed. She stated that she was assigned to Resident #12 on 1/10/21. She indicated that she didn't see an order for [REDACTED]. On 1/21/21 at 3:50 PM, the Pharmacist was interviewed. He stated that the pharmacy had received the order for Resident #12's [MEDICATION NAME] and the medication was dispensed on 1/8/21 at 6:15 PM. On 1/22/21 at 1:35 PM, Nurse #4 was interviewed. She was assigned to Resident #12 on 1/9/21 and 1/11/21. She stated that she didn't see an order for [REDACTED]. On 1/22/21 at 1:41 PM, the DON was interviewed. He stated that it looked like the order for the [MEDICATION NAME] was entered in the computer on 1/8/21 but was not verified until 1/11/21 and so it was not showing on the MAR from 1/8/21 through 1/10/21. The DON stated that he expected the nurses to verify orders timely. The DON confirmed Resident #12 did not receive [MEDICATION NAME] as ordered on [DATE] (8 PM dose), 1/9/21 (8 AM & 8 PM doses), 1/10/21 (8 AM & 8 PM doses) and 1/11/21 (8 AM dose), for a total of 6 missed doses. On 2/2/21 at 12:50 PM, the PA was interviewed. The PA stated that she was notified by the staff that the prescribed [MEDICATION NAME] for Resident #12 on 1/8/21 was not administered until 1/11/21. She added that she could not remember if there was a negative outcome to the resident for missing 6 doses of [MEDICATION NAME], and she added that it was not good for the resident to miss doses of prescribed antibiotic. On 2/2/21 at 1:05 PM, the Physician was interviewed. She stated that she was informed by the PA that Resident #12's prescribed antibiotic was not administered on 1/8/21 as ordered. The Physician revealed that the resident had missed 6 doses however there were no negative effects on the resident. She added that it was not good for the resident to miss doses of the prescribed antibiotic. 3. Resident # 11 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#11 had moderate cognitive impairment and had not received an antianxiety medication during the last 7 days. Review of the electronic records revealed that Resident #11 was receiving psychiatric (psych) services. On 12/29/20 at 4:41 PM, the psych Nurse Practitioner (NP) had entered an order in the computer for [MEDICATION NAME] (an antianxiety drug) 0.5 milligrams (mgs) by mouth every 6 hours (12 MN, 6 AM, 12 Noon and 6 PM) for mood disorder with the end date of 1/11/21. Review of the December 2020 and January 2021 Medication Administration Records (MARs) revealed that Resident #11 did not receive [MEDICATION NAME] on 12/29/20 (6 PM dose), 12/30/20 (12 MN, 6 AM, 12 Noon and 6 PM doses), 12/31/20 ( 12 MN, 12 Noon and 6 PM doses), and on 1/1/21 (12 MN, 6 AM, 12 Noon doses), a total of 11 missed doses. On 1/22/21 at 11:11 AM, interview with the Medication Aide (MA) #1 assigned to Resident #11 on 1/1/21 revealed that she didn't administer the [MEDICATION NAME] on 1/1/21 since it was not available. The MA indicated that she should have informed the nurse, but she did not. On 1/22/21 at 1:25 PM, Nurse #5 who was assigned to Resident # 11 on 12/29/20 was interviewed. Nurse #5 stated that she was not aware that there was an order entered on 12/29/20 for Resident #11. The order for the [MEDICATION NAME] was entered by the psych NP on 12/29/20 and was not verified until 12/30/20. Nurse #5 indicated that she didn't administer the [MEDICATION NAME] on 12/30/20 since the medication was not available. Attempts made to interview the nurses assigned to Resident #11 on 12/31/20 but were unsuccessful. On 1/22/21 at 1:35 PM, Nurse #4 who was assigned to Resident #11 on 1/2/21 and 1/3/21 was interviewed. She stated that the [MEDICATION NAME] for Resident #11 was not available on 1/2/21. She went to get the medication from the pyxis (a medication dispensing cabinet) and administered it to the resident. On 1/3/21, the [MEDICATION NAME] was still not available, and she thought that the pharmacy might need a hard script before dispensing the medication since it is a controlled drug. Nurse #4 called the psych NP for the hard script and the NP gave an order to discontinue the [MEDICATION NAME] since the resident was already stable and was not anxious anymore. On 1/22/21 at 1:41 PM, the Director of Nursing (DON) was interviewed. The DON stated that the order for the [MEDICATION NAME] on 12/29/20 for Resident #11 was not verified until 12/30/20. The pharmacy did not dispense the medication since it was a controlled drug and it needs a hard script from the doctor. The DON stated that [MEDICATION NAME] was available in the pyxis and he expected the nurses to use the pyxis if the medication was not available. He added that when a medication was taken from the pyxis that would alert him to check as to why the pharmacy did not send the medication. The DON confirmed Resident #11 did not receive [MEDICATION NAME] on 12/29/20 (6 PM dose), 12/30/20 (12 MN, 6 AM, 12 Noon and 6 PM doses), 12/31/20 ( 12 MN, 12 Noon and 6 PM doses), and on 1/1/21 ( 12 MN, 6 AM, 12 Noon doses), a total of 11 missed doses.

Based upon resident interview, staff interview and medical record review it was determined that the facility failed to provide 2 persons for assistance during transfer from the lift to the bed causing injury to the leg of 1 of 2 residents (Resident #1) reviewed for accidents when she leaned on the resident while removing the lift pad. Resident #1 experienced a fractured leg and developed wound. Findings included: Resident #1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. She received a [DIAGNOSES REDACTED]. Review of the Resident's Quarterly MDS (minimum data set assessment) dated 10/4/19, revealed that the resident scored 15 on the brief interview of mental status indicating that the resident had no cognitive deficits. Resident #1 was coded as requiring extensive 2 + person physical assistance for bed mobility and personal hygiene. She was coded as being totally dependent for transfer with 2+ person physical assistance and as being totally dependent on staff for dressing and toileting with1 person physical assist. She required staff assistance to complete activities of daily living including dressing. Review of Resident #1's care plan dated 10/11/19 stated problem as, Resident requires assistance from staff with activities of daily living care secondary to [MEDICAL CONDITION] with noted functional deficits and impaired mobility. The goal for this problem stated, Resident will have her needs met daily. Medical record review on 11/17/19 revealed a Nurses note (NN) dated 10/29/19 7:11 AM which stated, Resident complained of pain in right lower leg, resident stated CNA (Certified Nursing Assistant) bumped her elbow on resident leg. Tylenol was administered for pain, effective pain decreased. A few hours later resident awoke with complaints of severe pain and discomfort to right lower extremity. Small warm round swollen area noted to right lower extremity. Resident requested EMS. EMS called, resident currently at hospital. Staff will continue to monitor when resident returns. RP (responsible party) notified, MD was notified. Review of hospital emergency department (ED) notes dated 10/29/19 stated Chief Complaint, right leg swelling stated that it was from a staff member at the facility hitting the patients' with her elbow. ED notes (History of Present Illness) stated, EMS (emergency services) reports patient from nursing home-staff there report an aide at their facility accidentally fell and struck the patient with her elbow on her right shin. Since then has had acute swelling of the right shin, with severe pain. No blood thinners on MAR (medication administration record). Pain is 8/10 intensity, without +/- factors, it started easing up then started getting worse again. Denies any other problems with bleeding/bruising. Patient reports she was sitting on the side of the bed and she leaned over and put her weight on me with her elbow. Review of X-Ray documentation dated 10/29/19 from the ED revealed that there were 2 views of the right tibia/fibula. On one view there is concern for a non-displaced proximal fibular fracture. Review of ED note dated 10/29/19 9:38 stated, plain films read as possible non-displaced proximal fib fracture. ED dated 10/29/19 11:24 stated, pain improved status [REDACTED]. admission. Hospital records review of ED note dated 10/29/19 12:28 stated, Patient feels better-recommend non-adherent dressing and will follow up in the clinic tomorrow. Patient agrees with discharge bac to rehab facility and follow up as outpatient. Has narcotic pain meds on her MAR. Assessment/Plan 1. Fracture of right proximal fibula 2. Hematoma 3. [MEDICAL CONDITION] Medical record review of NN dated 10/29/19 7:01 PM revealed that Resident #1 returned from the emergency department with a new [DIAGNOSES REDACTED]. Medical record review revealed a Physician Assistant (PA) note dated 11/4/18 which stated, the resident's right lower extremity had significant swelling and bruising and the residents skin had extensive ecchymosis with superficial blisters and mixed bloody/purulent drainage. The note further stated, suspect that the traumatic pressure that caused the fracture, and associated inflammation, have disrupted the integrity of the skin, causing superficial skin infection and an extensive trauma induced hematoma/blood filled bullae. Review of PA note dated 11/12/19 revealed that the resident continued wound care and the hematoma had improved. Review of a written interview statement dated 10/29/19 signed by the admissions director stated, The CNA's (NA #1) and (NA #2) transferred me to the shower bed for my evening shower. NA #1 said, have to give you a shower because, if I get one more complaint, I'm gonna get fired. After my shower NA #1 put me back in bed with the Hoyer lift by herself. She sat on the bed and leaned into my leg with her elbow, it felt like all her weight. I don't think she did it on purpose, but she is lazy and always tries to take care of me sitting on the side of my bed. After she leaned into my leg, I felt pain. I let the nurse know and she gave me something for the pain. The pain got a little better but when I woke up it was worse than before. (Nurse) sent me out to the hospital. I don't want NA #1 taking care of me anymore. Resident describes the CNA, tall, black lady, short hair, glasses and heavy set. During interview with Resident #1 on 11/17/19 at 3:52 PM she stated, nursing assistant #1 (NA#1) gave her a shower which was fine. The NA put her in bed and leaned over her (Resident #1) to unclip the lift pad and put her elbow on her leg with all her(NA#1) body weight. The resident stated that she didn't really say anything. When NA moved her elbow the NA asked, I didn't hurt you did I? Resident #1 reported that she told her, I said I guess not. Per Resident #1, a nurse came in the room later and asked her if she had always had a bruise on her leg. The resident stated, The next day, I'd never been in so much pain my life and I've had 2 children. Interview with Resident #1's family member on 11/17/19 at 3:55 PM revealed that the resident's skin was not previously open on that area of her leg. The family reported that NA #1 had not been back in the room to work with the resident. During interview with the Director of Nurses (DON) at 5:02 PM on 11/17/19 she reported that the nursing assistant (NA #1) was sitting on the bed talking to resident #1. NA #1 put pressure on the resident's leg when she got up. Resident #1 said ouch. The NA is no longer at the facility due to her sitting on the bed and for not telling nursing staff that the resident was in pain. The DON stated that NA #1 was automatically suspended. The facility did education with the nursing assistants regarding staff reporting pain, not being on cell phones, and reporting pain. The DON stated that NA # 1 was not a small lady. Interview with Resident #1 at 5:39 PM 0n 11/17/19 revealed that her leg had not healed completely. She stated the leg was a little better. The resident reported that her leg still has some pain and that she gets medication prior to the dressing change because the area is still sore. Review of a statement dated 10/29/19 signed by NA #1 stated, the first time was getting ready to change her, I was sitting on the end of her bed; was looking for a black hand fan and I was looking under the covers etc. I couldn't find her fan, so I handed her her pocketbook. When I leaned across her, I was reaching for the blankets to look for her handheld fan. Residents states oh my leg. I did not lay or put pressure on her leg. Resident never mentioned anything else about her leg to me. I did not have my cellphone with he in the room. I always sit on the end/edge of her bed and we talk about her grandkids, etc. I was looking for her hand held fan. I didn't realize I bumped her leg as she did not mention anything to me about any pain/issues with her leg during my shift. During interview with NA#1 on 11/17/19 at 6:39 PM she stated, Before I gave her a shower, I was looking under her cover and I guess my elbow hit her. She (Resident #1) did not get a shower until 3rd shift. I put her back in bed by myself as usual. Whole time while in the shower no complaints. I heard nothing about her leg until the next day when they called me. NA #1 said that the resident's bed was high and because the bed was high she leaned against the bed at the foot and talked to her (Resident #1). Interview with the Facility Admissions Director at 6:58 PM revealed that she was asked to see how Resident #1 was doing and to get her statement. The Admissions Director stated that she believed that NA #1 put Resident #1 back in bed. The NA was leaning over her or sitting on the bed. The Admissions Director said that her written statement is how the resident laid out the incident for her. Interview with the Physician's Assistant (PA) was conducted at 7:45 on 11/17/19. The PA stated that Resident#1's current wound is a direct result of the injury she sustained by the NA leaning on her leg. The fracture caused a lot of inflammation and the resident already had some chronic [MEDICAL CONDITION] due to size. Per the PA, the resident's skin opened as a result of the injury, resident size and immobility. The large hematoma opened up and atypical of a simple fracture has been very slow to heal. Facility Plan of Correction Date 10/28/19. Facility alleged date of compliance 11/1/19. Corrective Action for the resident involved, (Resident #1): Resident sent to hospital for evaluation on 10/28/19. Identification of potentially affected resident and corrective actions taken: Facility performed 100% audit on all residents for pain and skin assessments. All residents identified with pain or skin issues were addressed and all concerns resolved by 10/30/19 Measures put in place or systemic changes that were made to ensure that the deficient practice will not reoccur: Facility completed 100% in-service to all nursing assistants and nurses regarding reporting pain and completing pain assessments, no phone use in resident care areas, and no sitting on resident beds. In-service to be completed by 10/30/19. Employees will not be allowed to work until in-serviced. Unit Managers or Designee to perform random skin and pain assessments on 5 residents a week X 4 weeks, then 3 residents a week X 4 weeks, then monthly thereafter X2. Results will be reviewed weekly X4 weeks by DON and will be brought to QA monthly X1 then will determine continued need for monitoring. Review of the facility's Plan of Correction on 11/17/19 revealed an In-Service dated 10/30/19 for checking/reviewing care guides. Program content stated Care guides are located at each nursing station and completed for each resident on the hall. Care guides should be checked daily at the start of your shift and throughout your shift. You should always check the care guide prior to transferring a resident or providing any direct care to the resident. Care guides are updated daily and frequently so it should be checked prior to any care provided to determine if any changes have been made. An In-service was conducted 10/28/19 regarding Reporting Pain. In-Service content included reporting a resident complaints of pain, reporting signs of pain such as facial grimaces to the nurse right away, and pain as the 5th vital sign. Nurses must perform pain assessments under observations. An In-service was conducted 10/28/19 regarding Customer Service. In-Service content included not sitting on resident beds and no use of cell phones while providing care. Review of facility monitoring on 11/17/19 revealed Resident skin assessments were conducted 10/29/19. Follow up assessments were conducted on the following dates 11/4, 11/5, 11/7, 11/11, 11/12, 11/13, 11/14 and 11/15. Review of the facility tracking sheets revealed that monitoring/audits were conducted per the plan of correction. Interview with facility staff on 11/17/19 at 7:50 PM and 8:08 PM revealed that they participated in In-Service training regarding cell phone, sitting on residents bed, checking care guides and reporting resident pain. Date of 11/1/19 was verified as the facility's date of correction.

Based on observation, record reviews, staff interviews, resident Power of attorney (POA) interview, and dentist office staff interview, the facility failed to provide supervision to a non-verbal cognitively impaired resident, who was assessed to be a risk for elopement, during a visit to a dental office for 1 of 3 residents reviewed for accidents (Resident #1). The resident was left unattended at the dental office. He self-propelled his wheelchair out of the building, traveled approximately 25-30 feet where he rolled off the sidewalk. The wheelchair overturned and the resident fell forward out of the chair and onto the concrete parking lot. The resident was transported to the hospital by Emergency Medical Services (EMS), where he was treated for [REDACTED]. After being treated at the hospital, the resident returned to the facility. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognition and is coded as needing supervision/oversight with locomotion. Resident #1's active care plan dated 9/17/2019 indicated the resident exhibited signs of cognitive loss/dementia with impaired memory and had a wanderguard (a departure alert system to prevent residents from exiting the facility unsupervised) secondary to wandering/elopement risk. The goal indicated, resident will not leave secured area unattended. Interventions/approach for wandering/elopement risk included to observe resident's whereabouts when out of bed. The resident's nursing notes revealed a note written on 9/17/2019 at 11:05 PM that specified the nurse aide (NA) working on resident's hall found the resident face down on the fall mat next to his bed which was noted to be in the lowest position. The NA made the nurse aware and the resident was assessed for injuries. The nurse's documentation indicates the resident had redness to right cheek and ear as well as a dime size abrasion to his left knee. The doctor, Director of Nursing (DON), and POA were notified of the fall. The POA requested the resident be sent to the emergency department for evaluation of injuries. The EMS report dated 9/18/2019 indicated they received the call from the facility at 1:03 AM, reached the resident at 1:20 AM, where he was found to be in his bed asleep, easily aroused and responding appropriately to staff. The report indicated he arrived at the hospital at 1:55 AM on 9/18/2019. Resident #1's hospital records indicated he was evaluated for injuries, diagnosed with [REDACTED]. In a nurse's progress note dated 9/18/2019, Nurse #1 documented that Resident #1 was transported from the facility to a dental appointment by a contracted transport company around 10:15 AM. She also indicated she sent paperwork with the resident and that the Power of Attorney (POA) was scheduled to meet the resident at the dental office. Nurse #1, later documented the dental office receptionist had called the facility at approximately 11:30 AM to let them know the resident had wheeled himself out into the parking lot, fallen, and was injured. The dental office receptionist reported EMS had transported the resident to the hospital emergency department (ED). The EMS report dated 9/18/2019 indicated they reached the resident at 11:13 AM and found him lying on the concrete next to a concrete car [MEDICATION NAME]. Resident #1 was on his right side with obvious laceration to his right forehead that was not actively bleeding. The report indicated the dental office staff advised EMS the resident was left unattended by facility transport and that he wheeled himself out to the parking lot where the resident fell forward out of the wheelchair onto the concrete. EMS noted the resident was non-verbal but answered yes/no with his head. Resident #1 was transported to the hospital where he was evaluated for injuries. Review of ED provider note dated 9/18/2019 revealed Resident #1 arrived at the ED at 11:27 AM and was evaluated for injuries after an unwitnessed fall from his wheelchair. Computed [NAME]ography (CT) of the cervical spine revealed no evidence of fracture. CT of the pelvis revealed no acute fracture. ED physician reported resident had laceration to head. Bleeding was controlled with no need for laceration repair, however, surgical glue was applied at the request of the POA for wound protection. On 9/23/2019 at 10:30 AM the resident was observed in his room within the secured unit, lying in his bed, eyes closed with NA #1 at bedside in one on one capacity. The resident appeared to understand communication from others but did not attempt to respond verbally. The resident had bandages on right temporal region with redness and bruising just below the bandage. He also had bandages covering the right elbow, right thumb, left elbow, and left thumb. Observed wander guard on left ankle. An interview was conducted with NA#1 9/26/2019 at 10:30 AM. NA #1 stated the resident had been one on one since his fall on 9/18/2019. NA#1 reported the resident communicates mainly through gestures. She gave examples of how he gestured for smoke, go to bed, and get wheelchair. She stated he did very well self-propelling himself down hall when going to smoking area. NA#1 described the resident's exit seeking behaviors occur mostly when he is wanting to smoke. On 9/23/2019 an interview was conducted at 1:10 PM with the receptionist at the dental office where this incident occurred. The receptionist working the day of the incident stated Resident #1 was brought into the office in a wheelchair being pushed by the driver for the contracted transport company. She reported the driver came to the desk and gave her the resident's name and paperwork prepared by the facility. At that time, the receptionist stated she told the driver the resident would not be seen by the dentist without a POA present. The driver then told her the POA was on her way to meet the resident at the dental office per the facility. The dental receptionist further stated the driver told her she could not stay with the resident because she (the driver) had other residents on the van that needed to be transported to appointments as well. The dental receptionist stated she turned her back to the resident to look up the facility's number and call the facility. She stated she spoke with a nurse, she could not recall her name, regarding the POA not being in the office and that the dentist would not be able to see the resident without a POA being present. She was told by the nurse, they would try to contact the POA and if they could not get up with her, they would call transport to go back to the office and get the resident. The dental receptionist stated when she hung up the phone and turned around, Resident #1 had made his way out of the building. She immediately called the facility and let them know the resident was no longer in the waiting area. The dental receptionist further stated shortly after she hung up the phone, a client ran into the office and asked her to call 911 because a man in a wheelchair had fallen and was bleeding. She called the facility back and let them know what had happened and that EMS was enroute. The dental receptionist reported she was not told the resident was at risk for elopement or wandering by the facility or by the transport driver. A phone interview was conducted on 9/24/2019 at 8:34 AM with the driver who transported Resident #1 to his dental appointment on 9/18/2019. She stated she picked the resident up at the facility on the morning of 9/18/2019. She stated when she got there, the resident was in his wheelchair and parked inside the building at the side entrance sliding door with several other residents scheduled for transport that morning. The nurse handed her his paperwork and gave her his name and where he was to be transported. The transport driver stated she was never told the resident lived in the secured unit, wore a wander guard, or had behaviors such as wandering. She further stated she pushed the resident into the dentist office, checked him in and told the receptionist the POA was meeting the resident at the office. The receptionist at the dental office told her the resident would not be seen without a POA, and stated she would call the facility. The transport driver stated she had other residents on the van that needed to get to medical appointments. The transport driver reported returning to the dental office after receiving a call from the facility. She did not remember what time that call was received. She was instructed to go back and get the resident from the dental office and bring him back to the facility. The driver stated when she returned to the dental office, she passed the ambulance as she was pulling into the parking lot of the dental office. A phone interview with the POA was conducted on 9/23/2019 at 12:17 PM. She stated the resident had a scheduled dental appointment on 9/18/2019 at 11:00 AM to be seen for mouth ulcers on the resident's lower lip. On the night before the appointment she received a call from the facility stating the resident had fallen. She requested the resident be transported to the ED for evaluation. The POA further stated she was present in the ED when the ED physician evaluated the oral ulcers, diagnosed the resident with thrush, and prescribed medications to treat the thrush. The resident was transferred back to the facility in the early morning hours of 9/18/2019, she was not certain of the exact time. The POA stated on the morning of 9/18/2019 she called the facility and spoke with Nurse #2 regarding the medication for thrush. The POA stated she did not tell the nurse to cancel the dentist appointment but assumed she would since the ulcers were the reason the resident was going to the dentist. The POA further stated that later that same morning she got a call from the facility regarding the dental appointment and fall. Observation of the dental office parking lot and interview with dental office receptionist on 9/23/19 at 1:10 PM revealed the parking lot was located at the top of a hill that lead to a heavily traveled, four lane highway with a 45 miles per hour speed limit. The receptionist pointed out the sidewalk where Resident #1 self-propelled his wheelchair approximately 20-25 feet before falling forward out of his wheelchair onto the concrete, next to a concrete car [MEDICATION NAME]. The receptionist specified the resident was found lying on his right side with a laceration to his right forehead. The receptionist stated the Dental office staff stayed with the resident until EMS arrived. Interview with the administrator was conducted on 9/23/2019 at 11:45 AM, she was aware of the incident with Resident #1 being left at dentist office unaccompanied and the subsequent fall. She further stated the POA was to meet the resident at the dental appointment but did not show. The facility administrator reported she learned of the incident when the dental office called the facility and let them know the POA had not shown for the appointment. The administrator stated the facility attempted to call the POA, and then called the transport driver to go back and get the resident. By the time the transport van returned to the office, the resident had been transported to the hospital ED by ambulance. The facility administrator acknowledged the resident was left at the office unattended and did self-propel his wheelchair out of the dental office which lead to a fall and injury. The administrator confirmed the resident did live in the secured unit and did wear a wanderguard due to risk for elopement. At 2:26 PM on 9/24/2019 another interview was conducted with the facility administrator in which she reported the facility typically transported residents but they did occasionally use two other transport companies. She stated they put a performance improvement plan into place immediately on 9/18/2019. This included a staff member accompanying residents who needed supervision during transport and to outside appointments. She reported Resident #1 was evaluated by a physician in the ED, returned to the facility the same day, and was immediately placed on one to one observation with a staff member. She further stated he has remained on one to one since the incident on 9/18/2019. The following is the facility's corrective action plan: Facility compliance date of corrective action 9/19/2019. Corrective Action for the resident involved: Resident involved in the elopement was transported from the dental office to the hospital ED by EMS for evaluation. The resident returned to the facility via EMS from the ED post evaluation. No follow up treatment was required for the resident. To prevent the event from recurring, the resident will be accompanied by a staff member to all outside appointments. Identification of potentially affected residents and corrective actions taken: An audit of all resident with need for supervision who had appointments on 9/18/2019 was conducted to ensure a staff member would be present with the resident at the appointment and during transport. Completed 9/18/2019. One resident requiring supervision had an appointment on 9/18/2019 at 2:15pm, this resident was accompanied by a N[NAME] Systemic Changes: Education On 9/18/2019 the Staff Development Coordinator and RN Supervisor began education of all licensed nurses and transportation aides/transport drivers that included the following information: All appointment schedules must be reviewed daily by Nurse Administration to ensure any identified resident in need of supervision has an appointed staff member assigned to them to accompany the resident to scheduled appointment. A staff member from the facility must attend appointment with resident and stay with them until the arrive back to the facility. If family decided to transport the identified resident, then a staff member does not have to accompany resident to the appointment. Quality Assurance The Director of Nursing, Administrator, Unit Manager, RN Supervisor, or Staff Development Coordinator will review the transportation log daily, Monday thru Friday to assess which residents are in need of supervision at the outside appointment. Any resident that has triggered as an elopement risk, resides in the secured unit, or needs additional supervision for tasks required at the outside appointment shall have a staff member accompany them. The employee that will accompany the resident on an outside appointment will be written next to the resident's name on the transportation appointment calendar. The Director of Nursing, Administrator, Unit Manager, RN Supervisor, or Staff Development Coordinator will review the transportation log Monday thru Friday for four weeks, then monthly for one month to ensure that residents who have need for supervision had a staff member present during an appointment unless a family member took the resident to the appointment. The Director of Nursing will review these audits monthly and present the findings to the facility Quality Assurance Committee for further recommendations monthly for two months. The facility's date of compliance was validated as 9/19/2019. Review of the facility Plan of Correction on 9/23/2019 revealed an Inservice record for ensuring any identified resident in need of supervision had an appointed staff member assigned to them to accompany them to outside appointments dated 9/18/2019, which included a sign in sheet with signatures of nurse, nurse aides, and transportation aides/drivers. Review of the transportation calendar from 9/19/2019 thru 9/24/2019 revealed the facility utilized accompanying staff member on one occasion, 9/24/2019, and that the daily transportation calendar was reviewed by one of the designated staff members as signified by their initials and date signed. Additionally, staff interviews and observations were conducted during the survey which showed staff were knowledgeable on plan of correction and received the education on 9/18/2019. Review of the facility plan of correction revealed evidence of 100% auditing of residents requiring transportation.

Based on record review, observation, resident and staff interview, the facility neglected to report and to assess a resident after a fall and after the resident complained of ankle pain for 1 of 5 sampled residents reviewed for accidents (Resident #102). Resident #102 had a fall and had complained of ankle pain on 5/15/19 was not assessed until the next day and the x-ray showed an acute avulsion [MEDICAL CONDITION] tip of the medial malleolus (a bone chip caused by a ligament or tendon that tears away a part of the bone). Findings included: Resident #102 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #102's cognition was intact, and she needed extensive assistance with transfers. Resident #102 had a doctor's order dated 3/20/19 for Tylenol (pain reliever) 325 milligrams (mgs) 2 tablets by mouth every 6 hours as needed (PRN) for mild pain. Resident #102's care plan with the revised date of 4/14/19 and the Kardex revealed that the resident needed 1 person assist with transfer. Resident #102's nurse's notes were reviewed. There were no notes on 5/15/19 and 5/16/19 regarding a fall. A note dated 5/17/19 at 6:08 AM (written by Nurse #2) revealed that the nurse was called to the resident's room around 9 PM of 5/16/19 to look at the resident's right ankle. The right ankle appeared to be swollen with bruising and the resident stated that it was hurting. The resident also stated that she stumbled with a walker the previous day. The nurse reported that she notified the doctor and an order for [REDACTED].>The right ankle x-ray report dated 5/17/18 revealed acute avulsion [MEDICAL CONDITION] tip of the medial malleolus. The (MONTH) 2019 Medication Administration Record [REDACTED]. The Physician Assistant (PA) progress notes were reviewed. The note dated 5/15/19 indicated that Resident #102 was seen for a routine visit and the resident had no concerns per nursing. The note dated 5/17/19 revealed that Resident #102 was seen for a follow up visit. X-ray of the right ankle was done, and the resident has acute avulsion [MEDICAL CONDITION] tip of the medial malleolus. The resident reported she stumbled a couple of days ago, felt a pop when she fell . She had increasing pain last night, swelling and bruising noted. Pain improved with Tylenol. The note further indicated that the right ankle was [MEDICAL CONDITION] with several ecchymosis and tenderness noted to medial malleolus. The range of motion was restricted due to pain. The plans were to apply immobilizer per therapy, to refer to orthopedic for definitive management, weight bearing as tolerated, Tylenol and [MEDICATION NAME] for pain and ice packs for 15 minutes (min) on and 45 min off every hour as needed (PRN). Resident #102's nurse's note dated 5/17/19 at 8:57 PM indicated that the doctor was informed of the right ankle x-ray result. Orthopedic consult was ordered, and the resident was placed on right foot air boot to float and to stabilize the foot at all times and non- weight bearing to the right foot. The doctor also ordered [MEDICATION NAME] (narcotic pain reliever) 50 milligrams (mgs) every 6 hours as needed (PRN) for pain. Tylenol was administered for complaint of right ankle pain with positive results. The orthopedic consult dated 5/23/19 revealed that Resident #102's ankle would be immobilized with a short leg cast and she would need to be on non-weight bearing on the right leg. The follow up appointment would be in 3 weeks or sooner if needed and to continue with the [MEDICATION NAME] for pain. On 8/4/19 at 1:30 PM, Resident #102 was observed up in wheelchair in her room with a boot on the right leg. When interviewed, the resident stated that she had a fall few months ago when a Nurse Aide (NA) assisted her with transfer from bed to wheelchair using a walker. The resident added that she had complained of pain on her ankle after the fall and the nurse assigned to her did not assess her after the fall and did not report the fall. On 8/5/19 at 4:10 PM, a follow up interview was conducted with Resident #102. She reported that it was in (MONTH) 2019 when she requested to use the bathroom. A NA assisted her with the transfer from bed to the wheelchair using a walker, when she fell on to the floor. She heard a pop and told the NA that her ankle was hurting. The NA took her anyway to the bathroom. The resident stated that she could not stand up from the wheelchair to the commode due to pain on her ankle. The NA went to get another NA to help her. Resident #102 stated that the next day after the fall, the same NA was assigned to her. When she requested to use the bathroom, two (2) NAs assisted her with the transfer and she was telling the NA that her ankle was hurting. On 8/6/19 at 9:45 AM, NA #1, assigned to Resident #102 on 5/15/19, was interviewed. The NA stated that she had worked on 5/15/19 and 5/16/19 (7-3 shift) and was assigned to Resident #102. She stated that it was before lunch on 5/15/19 when she assisted the resident from the bed to the wheelchair using a walker, when the resident fell . The resident was on the floor sitting on her leg. She went to get help and Nurse #1 assisted her to get the resident up from the floor to the wheelchair. The resident stated that she was fine. The NA denied that resident had told her she heard a pop. NA #1 further reported that around 1:30 PM, the resident requested to use the bathroom. The NA noticed that the resident was unable to stand on her feet and was complaining of pain on her ankle, so she went to get another NA (didn't remember the name of the NA) to help her. She then informed Nurse #1 that the resident was complaining of pain on her ankle. The NA indicated that she didn't know if Nurse #1 had assessed the resident and she didn't remember if she had informed the 3-11 shift NA about the resident's fall and complained of ankle pain. On 8/6/19 at 12:30 PM, NA #4 was interviewed. The NA indicated that she was with NA #1 in the room of Resident #102 when the resident complained of pain on her ankle on 5/15/19. She informed NA #1 to let the nurse know about the resident's complaint. NA #4 reported that she heard NA #1 informing Nurse #1 about Resident #102's complaint of pain. The NA further indicated that she didn't know if the nurse had assessed the resident afterwards. On 8/6/19 at 1:08 PM, the Treatment Nurse was interviewed. The Treatment Nurse stated that she went to Resident #102's room on 5/15/19 with the wound doctor. When she asked the resident how her day was, the resident responded not good since she had a fall that morning. The nurse reported that when she asked the resident if the nurse was aware about the fall and the resident responded yes. On 8/6/19 at 4:44 PM, a phone interview was conducted with Nurse #1. She stated that she was assigned to Resident #102 on 5/15/19 and she worked from 7 AM to 5 PM that day. The Nurse indicated that she was questioned by the administration and the corporate on several occasions and her story did not change. She reported that she did not assist NA #1 in getting Resident #102 up from the floor to the wheelchair and she was not informed about the fall. She went to the resident's room to administer the resident's medications and the resident was already up in her wheelchair and she did not complain of any pain. Attempted to interview the PA and the doctor but were not available. On 8/7/19 at 9:50 AM, the Med Aide was interviewed. She stated that she was assigned to Resident #102 on 5/15/19 from 5 PM to 1 AM. She verified that she administered Tylenol to Resident #102 on 5/15/19 at 8:35 PM due to complain of ankle pain. The Med Aide indicated that she didn't look/assess the ankle since she was not a nurse. She also stated that she was not aware that Resident #102 had a fall that morning. On 8/7/19 at 10:10 AM, Unit Manager (UM) #2 was interviewed. She stated that she worked 5/15/19 and 5/16/19 and she was not made aware that Resident #102 had a fall. She stated that she heard about the fall on 5/17/19 and she was asked to interview the resident. The resident stated that she fell on a Wednesday (5/15/19) when the NA was assisting her transfer from bed to the wheelchair using a walker and she fell to the floor landing on her knees and she heard something pop. On 8/7/19 at 1:30 PM, the Director of Nursing (DON) was interviewed. The DON stated that when she heard that Resident #102 had acute fracture on her ankle, she reported it as injury of unknown origin. She started the investigation by interviewing the staff and the resident and after the interview, it was not an injury of unknown origin, she found out that the resident had a fall. The corporate took over the investigation. On 8/7/19 at 1:47 PM, the Regional Consultant was interviewed. She stated that she was made aware of the incident with Resident #102 on 5/17/19. She was informed that the DON had started the investigation and had suspended NA #1 for not reporting the fall. She came to the facility on [DATE] and again interviewed the staff and Resident #102. She suspended Nurse #1 and after the investigation, she substantiated neglect for not reporting, not assessing the resident and not documenting the fall in the resident's medical records. Nurse #1 was terminated, and NA #1 was educated on reporting incident to the nurse and to the next shift NA and if the nurse would not intervene, to report the incident to the managers. The Regional Consultant also indicated that the DON had completed a Quality Assurance and Performance Improvement (QAPI) of the incident. On 8/7/19 at 4:30 PM, the DON had provided a copy of the time line and the QAPI and were reviewed. The time line revealed that on 5/16/19, Resident #102 had complained of right ankle pain and x-ray was ordered, and the report showed acute [MEDICAL CONDITION] ankle. There was no incident report or nurse's notes suggested evidence of a fall. Fall was reported on 5/17/19 by Resident #102 and the incident of fall occurred on 5/15/19. Interview with Resident #102 revealed that upon getting out of chair, resident grabbed her walker, the walker went forward, she lost her balance and fell on to the floor on her knees and then to her side. The resident stated that she felt something pop. NA #1 asked Nurse #1 for assistance in helping resident off the floor. Nurse #1 assisted resident from the floor to the chair. The conclusion of the investigation was: Resident #102 had a brief interview for mental status score (BIMs) of 15. Nurse #1 failed to report the fall and assess Resident #102 following the incident. Assessment of skin and pain was conducted on all residents. Physical Therapy conducted an in-service on transfer to all staff. All staff were in-serviced on fall assessment, reporting and neglect. Law enforcement was notified. The investigation was completed on 5/21/19. Nurse #1 was terminated due to failure to report and to assess Resident #102. Allegation of neglect was substantiated based on interviews with the staff and resident. Nurse #1 failed to report the fall and failed to assess the resident after the fall. The QAPI has the completion date of 5/17/19. A. Resident #102 reported to NA #1 that she hurt her foot when she fell on [DATE]. No record of fall was made in the resident's medical record. Resident's pain and skin was immediately assessed, and findings were reported to the responsible party (RP) and the doctor. X-ray was ordered and the resident was found to have a right ankle fracture. Orders for a boot, pain medication, orthopedic consult and ice to ankle. B. A 100% audit was completed by assessing all residents' skin and pain. The results of the assessment were communicated to the RP and to the doctor. All care plans were updated by the MDS Nurse. The audit was completed by the Unit Managers, Treatment Nurse and the Assistant Director of Nursing (ADON) on 5/17/19. C. All staff were educated on fall reporting (if nurse would not intervene to report to the managers), neglect and gait belt usage. All licensed nurses were educated on facility's fall protocol which included reporting, assessment and documentation. Education was conducted by the DON and the ADON and was completed on 5/17/19. D. A Quality Assurance meeting was held on 5/24/19 to review pertinent incident information, investigation, all audits and education associated with the event. The DON or her designee with continue to monitor skin assessment and review pain assessment to ensure appropriate follow up. The DON or her designee will do random audit on 5 skin and pain assessment 5 days a week weekly x 4 weeks, 2 days a week x 4 weeks and then monthly. A copy of the 24 hour (5/17/19) and the 5-day (5/21/19) reports were provided by the DON. The allegation on the 5-day report was resident neglect. The allegation was substantiated, and Nurse #1 was terminated. Education was validated on 8/8/19 by staff interview. The staff stated that they had received in-service on facility's Falls Protocol (reporting, assessment and documentation), Neglect, and Safe transfer.

Based on record review, observation and staff, Physician Assistant (PA) and Geriatric Nurse Practitioner (GNP) interview, the facility failed to protect cognitively impaired residents from physical abuse for 2 of 3 sampled residents reviewed for abuse (Residents #3 & #4). Resident #3 who was cognitively impaired and had repeated aggressive behaviors towards other residents, had beaten Resident #9 (who was cognitively impaired) with a call bell on 9/26/18 and had thrown a chair on Resident #2 (who was cognitively impaired) and had punched her on the shoulder on 10/9/18 causing a red spot on Resident #2's leg. Resident #4 who was cognitively intact and was verbally abusive to other residents pushed Resident # 1 (who was cognitively impaired) with a walker causing Resident #1 to fall and sustained a left [MEDICAL CONDITION] on 10/28/18. Immediate jeopardy began on 9/26/18 when the facility failed to protect Resident #9 from abuse by Resident #3 and failed to manage Resident #3's behavior causing her to abuse another resident, (Resident #2) on 10/9/18. The facility also failed to protect Resident #1 from abuse by Resident #4 causing Resident #1 to fall and fractured her hip on 10/28/18. Immediate jeopardy was removed on 11/28/18 when the facility provided an acceptable credible allegations. The facility remains out of compliance at a lower scope and severity of D (no harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3 had severe cognitive impairment and she had physical and verbal behavioral symptoms and wandering. Resident #3 resided in the memory care unit. Resident #3's care plan dated 8/6/18 indicated that Resident #3 had behaviors of yelling, cursing and she had threatened and attempted to hit staff. On 8/10/18, Resident #3 was aggressive and violent with staff and other residents. A one on one sitter was provided from 8/10/18 through 8/14/18. The approaches included to approach the resident calmly and positively, Social Worker (SW) to evaluate and visit the resident as needed, monitor and document resident's behavior as needed and report increase in negative behavior to the physician. Resident # 2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#2 had severe cognitive impairment and had no behaviors. Resident #2 resided in the memory care unit. Resident #2's care plan dated 9/24/18 indicated that she was a wanderer. The approaches included to observe the resident's whereabouts when out of bed and to redirect resident as indicated and as needed. The psychiatric notes for Resident #3 were reviewed. The notes dated 8/8/18 revealed that Resident #3 continued to have aggressive and combative behaviors. She was hitting staff and other residents. The plan was to discontinue the [MEDICATION NAME] (antipsychotic drug) and to increase [MEDICATION NAME] (antipsychotic drug) and to add [MEDICATION NAME] (antianxiety drug) as needed for agitation. The notes dated 9/18/18 revealed that Resident #3 had episode of [MEDICAL CONDITION] along with agitation, complaining about her roommate, telling her to get out of her room. There was an addendum note dated 9/26/18 which indicated that the nurse had called and reported that Resident #3 was up during the night and was agitated with the roommate. Later on she was found beating her roommate with her call bell. The roommate was not injured as she was under her blankets. They were separated and her medications were changed. The dose of her [MEDICATION NAME] was increased. The notes dated 10/9/18 revealed that the GNP had observed Resident #3 sitting at the dining table and was threatening other resident saying that she would kill her if she touched her food. The notes revealed that Resident #3 had several altercations with other residents and one resulting in a minor leg injury. The plan was to increase her [MEDICATION NAME]. There was an addendum note indicating that the of Director of Nursing (DON) had called informing her that Resident #3 required one on one sitter and that the DON wanted to send Resident #3 out to a psychiatric hospital. The GNP had changed Resident #3's [MEDICATION NAME] to [MEDICATION NAME] (antipsychotic drug)) and had increased the [MEDICATION NAME] as needed. Resident #3's nurses' notes were reviewed. The notes dated 9/26/18 at 8:50 PM revealed that Resident #3 had an episode of agitation and aggressive behavior throughout the shift. She was determined that she didn't want her roommate in her room. She had it in her head the whole room was hers and belonged to her. She was cursing and being disrespectful to her roommate. She became combative with staff. She attempted to hit the nurse aide with her bedside commode. Resident #3 was left alone to calm down. Afterwards, she was reoriented to her room and her roommate (Resident #9). The curtain was pulled to allow Resident #9 to enter the room and go to bed. Nurse 2 instructed Resident #9 to ring the call light if needed. A 15 minute check was conducted to monitor Resident #3. Resident #9 rang the call light at 12:15 AM and Resident #3 was observed standing over Resident #9. Resident #3 had pulled her call bell out of the wall and was striking Resident #9 with it. Resident #3 was removed from the room and was brought to the nurse's station. She stayed up until 3 AM when she became sleepy and was brought back to her bed. A 15 minute check was continued and the psychiatric services was notified. The nurse's notes dated 10/7/18 at 6:25 PM revealed that Resident #3 was yelling at other resident saying that she stole her water pitcher. The other resident was explaining that it was not hers and Resident #3 became agitated yelling at her saying give me my damn cup back. Resident #3 snatched the cup from other resident's hand and the staff intervened. The notes dated 10/10/18 (addendum from 10/9/18) revealed around 2 PM Resident #3 was in the television/dining room and started accusing another resident (Resident #2) of stealing her purse. Resident #3 picked up a chair and threw it at another resident (Resident #2). As Resident #2 tried to walk away, Resident #3 balled her fist and hit Resident #2 in her right shoulder. The incident was witnessed and Resident #3 was immediately redirected to her room where one on one sitter was provided. An incident report dated 10/9/18 was reviewed. The report indicated that Resident #3 was noted to be agitated while in the television/dining room. Resident #3 stated someone took my pocketbook. Resident #3 was observed to take a chair and threw it at another resident (Resident #2). When the other resident (Resident #2) walked away, Resident #3 balled her and hit her in the right arm. Residents #2 and #3 were separated and Resident #3 was taken to her room where one on one sitter was initiated as well as psychiatric services was made aware. The facility's investigation of the incident dated 10/15/18 was reviewed. The investigation revealed that on 10/9/18 at 2:30 PM, Resident #3 threw a chair at another resident (Resident #2). When Resident #2 got up to walk away, Resident #3 punched her in her right arm. Residents #2 and #3 were separated immediately. Both residents resided in the memory care unit. An assessment was completed on Resident #2 with no apparent injury noted. The responsible parties (RP) were made aware of the incident. Skin checks were obtained on all residents residing in the memory care unit with no injuries noted. RPs were called and interviewed and no reports of abuse reported. The psychiatric services was made aware and Resident #3's medications were reviewed and changes were made accordingly. Resident #3 had history of behaviors and had been followed by the psychiatric services with no improvement. Resident #3 was sent for evaluation at the psychiatric hospital per doctor's order due to ongoing violence towards staff and other residents. Investigation was completed on 10/15/18 and allegation of abuse was substantiated. The 24 hour report that was sent on 10/9/18 and the 5 day report that was sent on 10/16/18 were reviewed. The allegation of resident abuse on Resident #3 was substantiated. A written statement from the witness (undated) was reviewed. The statement was written by Nurse Aide (NA) #4 (employed by home health agency) who was a sitter of another resident in the memory care unit. The statement indicated that Resident #3 took a chair on 10/9/18 and threw it at Resident #2 and the chair hit her in the right leg. Then as Resident #2 walked away, Resident #3 punched Resident #2 in the right shoulder. An interview was conducted with Nurse #1 on 11/14/18 at 11:46 AM. Nurse #1 stated that she worked 7A-7P shift in the memory care unit. She indicated that Resident #3 was very combative, physically and verbally abusive to staff and residents when first admitted . The psychiatric services began working with her and slight improvement on her behavior was noted. On 10/9/18 after lunch, Resident #3 was very agitated. She was in the television/dining room with Resident #2. Nurse #1 stated that she was at the nurse's station when she heard the commotion. She went to the television/dining room and NA #4 informed her that Resident #3 was agitated, picked up a chair and threw it at Resident #2 hitting her right leg. When Resident #2 walked away, Resident #3 punched her on her right shoulder. Nurse #1 stated that she assessed Resident #2 after the incident and she noticed a red spot on her right leg. An interview with Nurse Aide (NA) # 2 was conducted on 11/14/18 at 12:05 PM. NA #2 stated that she was assigned to work in the memory care unit. She stated that Resident #3 was mean, and she threatened staff and residents saying I will knock you out. She was verbally abusive to staff and residents. NA #2 stated that she had informed the nurses and had tried to redirect Resident #3 when she was displaying behaviors. An interview with NA #1 was conducted on 11/14/18 at 1:16 PM. NA #1 was assigned in the memory care unit. She stated that Resident #3 was mean and hateful. She was very combative. NA #1 stated that on 10/9/18, there were 2 NAs in the unit and they were busy passing lunch trays. She heard a commotion in the television/dining room. NA #4 who was in the television/dining room had witnessed Resident #3 picked up a chair and threw it at Resident #2 and then punched her when she tried to walk away. NA #1 stated that the nurses were aware of Resident #3's behavior and when she observed Resident #3 having behaviors, she had tried to calm her down and had to redirect her away from other residents. An interview with NA #4 was conducted on 11/14/18 at 2:21 PM. NA #4 stated that she was sent by the home health agency to sit with a resident in a memory care unit. She stated that she was sitting in the television/dining room with the resident. She observed Resident #3 agitated looking for her pocket book. Suddenly, she picked up a chair and threw it at Resident #2 hitting her right leg and when Resident #2 tried to get up to walk away, Resident #3 punched Resident #2 on her right shoulder. NA #4 stated that there were no staff member present in the television/dining room. The nurse's aides were busy passing the trays on the other hall dining room. She immediately separated Residents #2 and #3 before the staff members came to the room. NA #4 stated that Resident #2 did not provoke Resident #3. Resident #2 was quiet sitting in the dining table. An interview was conducted with the PA on 11/15/18 at 10:05 AM. The PA indicated that she expected the residents in the memory care unit to be safe. An interview with the Unit Manager (UM) was conducted on 11/15/18 at 11:56 AM. The UM stated that she was informed by Nurse #1 that there was no contact when the chair was thrown to Resident #2 by Resident #3. She indicated that she didn't know that there was a witness to the incident who observed Resident #3 threw a chair at Resident #2 hitting her right leg. On 11/15/18 at 2:50 PM, the GNP was interviewed. She stated that she had been following Resident #3 due to her aggressive and combative behaviors. She had made changes to her medications by increasing the dose of the [MEDICATION NAME] and adding [MEDICATION NAME]. The GNP further indicated that the staff in the memory care unit were good on non- pharmacological approaches like redirection, keeping them busy, playing music and offering snacks when they were agitated. On 11/16/18 at 10:24 AM, the DON was interviewed. The DON stated that her expectation in the memory care unit was to keep the residents safe. On 11/27/18 at 12:53 PM, Nurse #2 was interviewed. Nurse #2 stated that she worked 7P - 7A in the memory care unit. She was assigned to Resident #3 on 9/26/18. Resident #3 was agitated that evening when she came to work at 7 PM. Resident #3 was confused and she didn't recognize her roommate (Resident #9). Nurse indicated that she had placed Resident #9 to bed, placed her call bell within reach and instructed her to call when needed. Nurse #2 further stated that when the call light came on, she came to the room of Resident #3 and #9, and found Resident #3 standing over Resident 9 who was in bed covered up with a blanket. Resident #3 had a call bell in her hand and was beating Resident #9. Nurse #2 reported that she took Resident #3 out of the room into the nurse's station until she became sleepy and then she was placed back in bed. Nurse #2 stated that the Unit Manager was aware of Resident #3's behavior 2. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed that Resident #4's cognition was intact and had no behavior. Resident #4 resided in the memory care unit. Resident # 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1 resided in the memory care unit. The interim care plan dated 10/25/18 revealed that Resident #1 was a wanderer. The approaches included to monitor resident's whereabouts frequently and to intervene and redirect for safety as needed. Resident #1's nurse's notes were reviewed. The notes dated 10/25/18 at 6:23 PM revealed that Resident #1 was alert to self only. The notes dated 10/27/18 at 4:00 PM revealed that Resident #1 was able to ambulate independently within the locked unit. The notes dated 10/28/18 at 7:42 PM revealed that Resident #1 entered the room of another resident (Resident #4). Resident #4 pushed Resident #1 causing her to fall. Resident #1 hit her left shoulder on the door jam and then fell on to her left side. Resident #1 was unable to extend her leg and she screamed in pain with range of motion. The staff attempted to assist Resident #1 to stand but the resident was unable to bear weight on her left leg. Resident #1 had complained of pain on her left leg/hip. The doctor was notified and he ordered x-ray of the femur/hip. The result of the x-ray showed fracture of left femur. Resident #1 was discharged to the hospital on [DATE]. Resident #4's nurse's notes dated 10/28/18 at 7:58 PM revealed that Resident #4 was in her room when Resident #1 entered her doorway. Resident #4 pushed Resident #2 with her walker causing Resident #2 to fall. Resident #4 denied pushing Resident #2 stating that she saw resident #2 on the floor and she shut the door because she didn't want to be involved with her. The incident report dated 10/28/18 was reviewed. The report revealed that Resident #1 entered the doorway of another resident's room (Resident #4). Resident #4 pushed Resident #1 causing her to fall. Resident #1 complained of pain on her left leg/hip. The hospital discharge summary dated 10/29/18 was reviewed. The discharge summary revealed that Resident #1 had severe dementia and was brought to the emergency room from a nursing home following a fall. Resident #1 complained of pain in her left hip and had difficulty ambulating. Left hip x-ray was done at the facility showing a left femoral fracture. Resident #1 was admitted and she underwent left hip surgery. The psychiatric notes of Resident #4 dated 10/30/18 were reviewed. The notes revealed that Resident #4 had dementia and delusions and she continued to have delusions of her doll being a live person. The notes indicated that the staff had requested a psychiatric visit as Resident #4 had pushed her walker purposely into another resident causing the resident to fall and to break her hip. Resident #4 reported no recall of the incident. The Staff reported that Resident #4 could be bossy and pushy at times with other residents but has never been physical before. Resident #4 was also noted not to like b people and had been verbally abusive to other residents and staff. The facility's investigation report dated 11/2/18 was reviewed. The report revealed that the Director of Nursing (DON) was called on 10/28/18 at approximately 4:30 PM to report that Resident #4 had pushed Resident #1 to the floor. Nurse #1 had witnessed Resident #1 attempting to enter Resident #4's room. Resident #1 was standing in the front of Resident #4's doorway, when Resident #4 took her walker and pushed it into Resident #1, causing Resident #1 to fall. The report revealed that Resident #1 hit her left shoulder on the door jam and falling on her left side. Resident #1 and #4 were separated immediately. Resident #1 was assessed and found to be in pain and unable to bear weight. The attending physician and the responsible party (RP) were contacted. The physician had ordered for an x-ray to left femur/hip on Resident #1. The x-ray result revealed a fracture to the left femur. Resident #1 was sent to the hospital at 8:10 PM. The psychiatric services was contacted and updated on the incident with Resident #4. All RPs were contacted and interviewed and there were no abuse allegations reported. Hundred percent (100%) skin assessment was conducted to all residents residing in the memory care unit. When interviewed, Resident #4 denied pushing Resident #1 stating that she was not involved at all but the incident was witnessed by Nurse #1. Resident #4 had history of becoming aggravated with other residents and she had history of wandering. A 24 hour sitter was assigned to Resident #4 and she was moved out of the memory care unit with wander guard on 10/28/18. The investigation was completed on 11/2/18 and the incident was substantiated. The 24 hour report that was sent on 10/28/18 and the 5 day report that was sent on 11/2/18 were reviewed and the allegation for abuse on Resident #4 was substantiated. An interview with NA #2 was conducted on 11/14/18 at 12:05 PM. Nurse Aide (NA) #2 stated that Resident #4 was verbally abusive to staff and residents. She had witnessed Resident #4 threatening other residents when they tried to enter her room. NA #2 stated that the nurses were informed and were aware of Resident #4's behavior. An interview was conducted on 11/14/18 at 1:16 PM with NA #1. NA #1 was assigned in the memory care unit (MCU). She stated that she normally was scheduled to work 7-3 shift but on 10/28/18 she was asked to stay over to help. NA #1 indicated that Resident #1 was confused and she wandered. Resident #4 was alert and oriented with some confusion and verbally abusive to staff and residents. Resident #4 didn't want anybody on her space and occasionally, she wound have arguments with her roommate. NA #1 stated that she tried to redirect other residents away from Resident #4's room. An interview was conducted on 11/14/18 at 3:15 PM with Nurse #1, assigned to Resident #1. She stated that Resident #1 had memory problems and was a wanderer. Resident #4 was alert and oriented, she didn't want anybody in her room or near her room. She was verbally abusive to staff and other residents. She stated that she had witnessed Resident #4 had threatened and had pushed other residents in the past but did not cause them injuries or to fall. Nurse #1 indicated that on 10/28/18 at 4:30 PM, she had witnessed Resident #1 standing at the doorway of Resident #4, when Resident #4 with her walker pushed Resident #1. Resident #1 hit her left shoulder on the door frame and then she landed on the floor. When Resident #1 was on the floor, Resident #4 was observed pushing the door against Resident #1 trying to close the door. The nurse indicated that when she interviewed Resident #4, Resident #4 denied pushing Resident #1 but she admitted that she was trying to close the door because she didn't want to be involved with Resident #1. Nurse #1 stated that she was standing at the nurse's station when the incident happened and could see the doorway of Resident #4. Nurse #1 further indicated that Resident #4 was being followed by the psychiatric services for management of her behaviors and medications. The Nurse stated that the staff members were trying to redirect other residents away from her room. On 11/14/18 at 4:23 PM, Resident #4 was observed in bed and was interviewed. She stated that Resident #1 was coming into her room and she told her no. Resident #4 then said I shut the door on her face because she didn't want anybody in her room. On 11/15/18 at 10:05 AM, the PA was interviewed. She stated that she was informed of the incident that occurred with Residents #1 and #4. The PA indicated that she expected the residents in the memory care unit to be safe. On 11/15/18 at 11:15 AM, the Social Worker (SW) was interviewed. She stated that she was responsible for assessing the resident's cognition on the MDS assessments. The SW indicated that Resident #4's cognition was intact and she had a Brief Interview for Mental Status (BIMS) score of 14. The SW indicated that Resident #4 was alert and oriented to person, place and time but was delusional. She added that Resident #4 had exhibited some behaviors lately and these behaviors might be due to the passing of her sister about 2 weeks ago. On 11/15/18 at 11:40 AM, NA #3 was interviewed. NA #3 stated that Resident #4 could be verbally abusive to staff and other residents. She had witnessed her telling other residents get out of my room or else . NA #3 indicated that she tried to redirect other residents away from Resident #4's room. On 11/15 at 10:05 AM and 1:30 PM, Resident #4 was observed in bed (outside the memory care unit) with a sitter at bedside. On 11/15/18 at 2:50 PM, the GNP was interviewed. She stated that she had been following Resident #4 due to her delusional disorder with wandering. The GNP indicated that Resident #4 was a pleasant, calm and sweet lady and she did not have any behaviors until one day she had pushed another resident. She stated that she made changes to her medications and for the staff to continue the monitoring. The GNP further indicated that the staff in the memory care unit were good on non- pharmacological approaches like redirection, keeping them busy, playing music and offering snacks when they were agitated. On 11/16/18 at 10:24 AM, the DON was interviewed. The DON stated that her expectation in the memory care unit was to keep the residents safe. The Administrator and the Director of Nursing were notified of the immediate jeopardy on 11/27/18 at 8:55 AM. On 11/28/18 at 5:07 PM, the facility provided the following credible allegation of immediate jeopardy removal: Address how corrective action will be accomplished for those resident found to have been affected by the deficient practice; On 9-26-18, Resident #3 was put on Q 15 minute checks. She was monitored by the charge nurse until 9/28/18 for 24 hours/7 days a week due to cursing at her roommate, attempting to hit staff, and hitting roommate with call bell. At that time, roommate was moved out of Resident #3 room, [MEDICATION NAME] 50 mg by mouth at 1pm and [MEDICATION NAME] 150mg by mouth at 7PM were initiated by Psychiatric PA. an order for [REDACTED].#3 was moved into a private room. On 9/28/18 resident was argumentative with another resident, spit out medications and refused remainder of medications. No noted behaviors until 10-7-18, when resident yelled at another resident and snatched a cup out of resident hand. The residents were separated by staff and redirected. On 10-8-18, new orders for [MEDICATION NAME] 0.5mg by mouth at bedtime was ordered due to increasing behaviors due to resident yelling at a resident on 10-7-18. On 10-9-18, at 2:00PM Resident # 3, picked up a chair and threw it at Resident # 2, then proceeded to punch Resident #2 in her arm when she got up out of her chair to walk away. Home Health Certified Nursing Assistant witnessed the incident and Resident #3 was immediately separated by the aides and removed by the charge nurse from Resident # 2 and placed Resident # 3 on 1:1 until she was transported to the hospital via facility transport and sitter on 10/10/18. An assessment was done by the Nurse on Resident # 2, and noted a red mark on her leg. Police were called by the DON at 2:20 PM and both residents were interviewed by the officer. Neither resident was able to explain what happened as both Brief Interview for Mental Status scores are 0. Both Responsible Person and Physician were made aware of the incident by the Unit Manager. Skin checks were obtained by the Unit Manager on all residents residing in the memory care unit. No abuse was reported or assessed. Psychiatric Physician Assistant was in house during the time of the incident on 10-9-18. Psychiatric PA reviewed Resident #3's medications and made changes to include discontinuation of [MEDICATION NAME], order for [MEDICATION NAME] 0.5 mg every 6 hours as needed, discontinuation of [MEDICATION NAME] 150mg daily at 1pm, start [MEDICATION NAME] 100mg at bedtime. Psychiatric PA noted in note that no incidents since 9-26-18 and the increase of [MEDICATION NAME]. The event occurred due to interventions put in place failed to prevent Resident #3 from having behaviors. 100% skin assessment of all residents in the secured memory care unit was completed by the Unit Managers on 10-9-18 No concerns were identified. 100% Resident Representative Interviews were completed for the locked unit residents by the Social Worker, Unit Managers, Director of Nursing, Medical Records, Maintenance Director, Dietary Manager, Admissions, Business Office, Minimum Data Set Nurse, Activities. No concerns from voiced from interviews. Example of Interview Questions: Do you feel the resident been harmed by another resident in the facility? If yes, was facility made aware? Do you feel resident is safe in the facility? A 100% all staff In-service was initiated on 10-9-18 on abuse Prevention/Intervention by the Director of Nursing. The in service included prevention of resident abuse, and recognizing signs and symptoms of abuse, dementia protocol, behavioral assessment, intervention and monitoring and behavioral management to include updating of plan of care. The In service was completed by 10/11/18. On 10-28-18, Residents #1 and #4 were immediately separated by staff. Resident #4 was immediately placed on a 1:1 sitter secondary to knocking Resident # 1 down. Resident #4 was reassessed for Brief Interview for Mental Status and proper placement in the memory care unit. Resident # 4 was moved to a room out of the memory care unit with a 1:1 sitter in an effort to decrease her agitation and her care plan was updated to reflect changes. Resident # 1 was immediately assessed and found to be in pain and unable to bear weight. XRAY was ordered for Resident # 1. Resident # 1 was found to have a [MEDICAL CONDITION], and transported to the hospital on 10-28-18. 100% skin audit was completed by the unit manager and charge nurse on all residents in the secured memory care unit on 10-28-18, no concerns identified. 100% Resident Representative Interviews were completed for the locked unit residents by the Social Worker, Unit Managers, Director of Nursing, Medical Records, Maintenance Director, Dietary Manager, Admissions, Business Office, Minimum Data Set Nurse, Activities. No concerns from voiced from interviews. Example of Interview Questions: Do you feel the resident has been harmed by another resident in the facility? If yes, was facility made aware? Do you feel resident is safe in the facility? The event occurred as staff did not document and report increasing behaviors as reported during the investigation. The staff interviewed during complaint survey on 11/14-11/16 reported Resident #4 with increasing verbal aggression towards others, though the documentation in the resident chart does not reflect any concerns. A 100% all staff In Service was conducted by the Director of Nursing on 10-28-18 to include abuse and neglect, signs and symptoms of abuse and prevention of abuse, proper documentation of problematic behavior to include onset, frequency and precipitating factors. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 11/21/18 100% audit by the unit managers and DON of all current resident notes were reviewed back to 8/01/18 for effectiveness of interventions that were put in place regarding behaviors. Changes in plan of care were made as they were identified during the audit. Address what measure will be put into place or systemic changes made to ensure that the deficient practice will not recur; An in service on behavior management was initiated on 11/24/18 by the ADON to 100% all nursing staff to include all licensed nurses and certified nursing assistants to include interventions and monitoring residents, and documentation of interventions and behaviors and reporting to the on call nurse and behaviors that show signs of harm to other residents, staff, or self- harm. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: and include dates when corrective action will be completed; Beginning 11/21/18, Utilizing behavior documentation flowsheet audit tool, the Unit Managers, RN Supervisors, ADON, and/or DON reviewed progress notes and 24 hour report sheets during M-F clinical meeting 5 x weekly x 12 weeks to identify reported behaviors of residents that require intervention of services or changes in staffing ratio based on resident needs and behaviors. This will be reviewed daily by the DON, ADON, RN Supervisors, Unit Managers or Administrator. The results will be presented to the Quality Assurance Committee monthly x 3. The credible allegation was verified on 11/28/18 as evidenced by interview of licensed and unlicensed staff on in-service training on abuse policy and procedure and signs and symptoms of abuse and abuse prevention. Nursing staff were interviewed and they verified that they received an in-service on behavior management, documentation of behavior and reporting of behavior to the on-call nurse supervisor. The Unit Managers and the Assistant Director of Nursing were interviewed and they verified that the audit was started on 11/21/18. The behavior documentation flowsheet audit tool was reviewed and the audit of the progress notes and the 24 hour report was started on 11/21/18.

Based on record review, observation and staff interview, the facility failed to provide sufficient nursing staff to protect residents from physical abuse for 2 of 3 sampled residents reviewed for abuse (Residents #3 & #4). Resident #3 had beaten Resident #9 with a call bell on 9/26/18 and had thrown a chair on Resident #2 and had punched her on the shoulder on 10/9/18 causing a red spot on Resident #2's leg. Resident #4 had pushed Resident # 1 with a walker causing Resident #1 to fall and sustained a left [MEDICAL CONDITION] on 10/28/18. Immediate jeopardy began on 9/26/18 when the facility failed to have sufficient nursing staff to monitor and to protect Residents # 9 and #2 from abuse by Resident #3. Resident #3 had beaten Resident #9 with a call bell on 9/26/18 and had thrown a chair and punched Resident #2 causing a red spot on her leg on 10/9/18. The facility also failed to have sufficient nursing staff to monitor and to protect Resident #1 from abuse by Resident #4 by pushing Resident #1 with a walker causing Resident #1 to fall and to fracture her hip on 10/28/18. Immediate jeopardy was removed on 11/28/18 when the facility provided an acceptable credible allegations. The facility remains out of compliance at a lower scope and severity of D (no harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: This tag is crossed referred to: F 600 - Based on record review, observation and staff, Physician Assistant (PA) and Geriatric Nurse Practitioner (GNP) interview, the facility failed to protect cognitively impaired residents from physical abuse for 2 of 3 sampled residents reviewed for abuse (Residents #3 & #4). Resident #3 who was cognitively impaired and had repeated aggressive behaviors towards other residents, had beaten Resident #9 (who was cognitively impaired) with a call bell on 9/26/18 and had thrown a chair on Resident #2 (who was cognitively impaired) and had punched her on the shoulder on 10/9/18 causing a red spot on Resident #2's leg. Resident #4 who was cognitively intact and was verbally abusive to other residents pushed Resident # 1 (who was cognitively impaired) with a walker causing Resident #1 to fall and sustained a left [MEDICAL CONDITION] on 10/28/18. An interview with Nurse #1 was conducted on 11/14/18 at 11:46 AM and at 3:15 PM. Nurse #1 stated that she had worked 7A-7P in the memory care unit. She indicated that the residents needed constant monitoring especially Resident #3. Resident #3 was very combative, physically and verbally abusive to staff and residents and she needed constant redirection. Resident #4 was verbally abusive and she didn't want anybody in her room or near her room so other residents needed to be redirected away from her room. Nurse #2 stated that two Nurse Aides (NAs) were not enough to take care of resident's needs and to monitor the residents in the unit. She indicated that when the 2 NAs were in the resident's rooms providing care and she was passing medications, there were no staff members on the hall to keep an eye on these residents. An interview with NA #2 was conducted on 11/14/18 at 12:05 PM. NA #2 stated that she worked in the memory care unit. She stated that the residents in the unit had behaviors and they needed to be redirected. She indicated that their behaviors were unpredictable and they could hurt other residents. NA #2 stated that two NAs on the hall were not enough to monitor the residents and at the same time to provide care. An interview with NA #1 was conducted on 11/14/18 at 1:16 PM. NA #1 stated that she had worked in the memory care unit. She stated that Resident #3 was very combative, mean and hateful. She needed to be redirected all the time away from other residents. NA #1 indicated that Resident #4 didn't want anybody on her space so other residents had to be redirected away from her room. NA #1 reported that the facility was short of staff especially nurse aides. At times, there were three NAs assigned but when another NA had called out in the other hall, the NA in the unit was the first one they had to pull out leaving the unit with just two NAs. With two NAs in the unit was very hard. She tried her best to provide the care but she didn't have the time to monitor the residents. An interview with the Director of Nursing (DON) was conducted on 11/16/18 at 10:24 AM. The DON stated that she assigned nursing staff in the unit depending on the resident's needs and the behaviors. She would like three NAs assigned at all times but that varies depending on the resident's needs. The DON also reported that the facility was short of NAs especially on the second shift and they had tried hiring more NAs. The DON stated that her expectation in the memory care unit was to keep the residents safe. An interview with Nurse #3 was conducted on 11/27/18 at 4:30 PM. Nurse #3 stated that she had worked in the memory care unit. She indicated that residents in the unit had behaviors that needed to be monitored. She indicated that with two NAs assigned in the hall was not enough to take care of the residents and to keep an eye on them. She added that the unit was short staff and was really bad couple of months now. On 11/27/18 at 4:35 PM, the memory care unit was observed. There were no NAs observed on the hall. When interviewed, Nurse #3 stated that one NA was giving a shower and the other NA was taking a resident to smoke. She also stated that the third NA was pulled to work on the other hall but she was told that another NA was coming to replace. The Unit Manager and the Social Worker were observed in the unit but they were in their offices. An interview with NA #5 was conducted on 11/28/18 at 8:50 AM. She stated that she had worked in the memory care unit. She stated that at times she was asked to stay over due to short staff. NA #5 indicated that two NAs in the unit was rough, a lot of residents with behaviors and they needed to be monitored. If the two NAs were in the resident ' s room, there were no NA on the hall to monitor the residents. An interview with Scheduler #1 and #2 was conducted on 11/28/18 at 10:05 AM. Scheduler #1 stated that she tried to schedule 2-3 NAs in the unit depending on the census. She stated that the facility was short of NAs and they were trying to hire more NAs but most of them would not stay. When there were call outs, she tried to call other NAs to come in or she would request other NAs to stay over. Scheduler #2 stated that the facility had staffing issues but they had tried to hire more staff especially NAs. The Administrator and the Director of Nursing were notified of the immediate jeopardy on 11/27/18 at 8:55 AM. On 11/28/18 at 5:07 PM, the facility provided the following credible allegation of immediate jeopardy removal: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 10-9-18 and 10-28-18, Resident #3 and Resident #4, showed behaviors towards other residents. Both residents were placed on 1:1 for continuation of monitoring of behaviors and aggression to others. Based on interviews of RP ' s for non-alert and oriented, staff and skin assessments, no other residents had an increased monitoring need to adjust for increased staffing. On 10-9-18 the incident was not witnessed by facility staff. The 10-28-18 incident was witness by a staff member, but the staff member was unable to intervene timely. The nurse was standing at her cart and saw resident #1 walking down the hall approximately 75 to 100 feet from her. She then saw resident #4 push her walker into resident #1 causing resident #1 to fall. On 10-7-18, Resident #3 showed aggressive behaviors toward another resident and residents were separated. On 10-8-18, [MEDICATION NAME] every 6 hours as needed was ordered. On 10/9/18, Resident #3 and Resident #2 were separated after resident # 3 threw a chair at resident #2 and then hit her arm as she stood from her chair to walk away. Resident #3 was placed on a 1:1. Resident #3 was seen by the Psychiatric PA on 10-9-18, with medication changes. On 10-10-18, Resident #3 showed increased aggressive behaviors to staff and residents, and was discharged to the hospital for evaluation and treatment. Resident #2 was assessed and denied pain and was taken to activities. On 10-28-18, Resident #4 was placed on a 1:1 sitter secondary to knocking Resident # 1 down. Residents were immediately separated, to include placing Resident #4 on 1:1 sitter. Resident #1 was transported to the hospital secondary to a [MEDICAL CONDITION]. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 11-21-18 an audit was conducted by the Unit Managers to evaluate residents for behaviors that require additional services or change of staffing need to accommodate the residents. The audit was conducted on progress notes and 24 hour reports dating back to (MONTH) 1, (YEAR) to present. Based on the evaluations, one resident was identified as having an increased need, and resident was put on Q15 mins behavior checks, Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 10-28-18, a 100% staff in service was provided by the Director of Nursing to include Abuse and prevention of abuse, signs and symptoms of abuse, proper documentation and reporting of problematic behavior to include onset, frequency and precipitating factors. This was completed on 10/31/18. An in service was initiated on 11-24-18 by the Director of Nursing and the Assistant Director of Nursing, and completed on 11/26/18 to include monitoring of behavior and behavioral interventions to all licensed nurses by the Director of Nursing and the Assistant Director of Nursing. The in service also covered notification of the on call nurse immediately for resident behaviors that show signs of aggression, harm to others or harm to self to accommodate for resident needs and staffing changes. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. Based on the resident needs and behaviors, resident monitoring by staff will be adjusted accordingly in order to provide adequate supervision to the changing needs of the resident behaviors. The QA process began on 11-21-18 by utilizing the review of progress notes and verbal report in the M-F clinical meeting and from the on call nurse to assist in the determining residents that may need increased monitoring by staff. The DON, ADON, RN Supervisors, Wound Nurse or Unit Managers will use the behavior staffing monitoring tool to document residents with behaviors. The QA team will review the results of the behaviors documentation weekly to ensure interventions are appropriate and effective weekly x 12 weeks beginning 11/21/18. The Director of Nursing will bring the results of the audits to the Quality Assurance Committee Meeting Monthly x 3. This in service will be added to the new nurse hire orientation. The credible allegation was verified on 11/28/18 as evidenced by interview of licensed and unlicensed staff on in-service training on abuse policy and procedure and signs and symptoms of abuse and abuse prevention. Nursing staff were interviewed and they verified that they received an in-service on behavior management, documentation of behavior and reporting of behavior to the on-call nurse supervisor. The Unit Managers and the Assistant Director of Nursing were interviewed and they verified that the audit was started on 11/21/18. The behavior documentation flowsheet audit tool and the behavior staffing monitoring tool were reviewed and the audit of the progress notes and the 24 hour report was started on 11/21/18.

Based on record review, observation and staff interview, the facility failed to provide supervision to prevent a resident who required extensive assistance of 1 person for toileting from having an unsupervised fall in the bathroom for one of seven sampled residents reviewed for accidents. Resident #57 experienced an unsupervised fall in the bathroom and sustained a right femur fracture requiring open reduction internal fixation (ORIF) surgery (a surgical procedure to fix a severe broken bone). Findings included: Resident #57 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #57 had moderate cognitive impairment and needed extensive assistance with one person physical assist for toileting. The assessment further indicated that Resident #57 was not steady (only able to stabilize with staff assistance) in moving on and off toilet. The incident report dated 1/30/18 revealed that Resident #57 went to the bathroom unassisted and fell sustaining a right proximal femur fracture. She went to the hospital for surgery and was readmitted on [DATE]. The surgical consult dated 3/7/18 ordered for the resident to have 30% weight bearing as tolerated to right lower extremity. The consult dated 4/4/18 ordered for the resident to have 60% weight bearing with immobilizer to the right lower extremity Resident #57's care plan with the last review date of 4/4/18 was reviewed. The care plan problems included resident had activities of daily living (ADL) self-care deficit related to dementia with impaired mobility and at risk for falls and fall related injuries. The goal was to minimize potential for significant injury related to falls. The approaches included 60% weight bearing as tolerated to right lower extremity and knee immobilizer in place for all weight bearing. The care plan did not address supervision. The nurse's notes (written by Nurse #1) dated 4/11/18 at 3:33 PM revealed that Nurse #3 was cleaning Resident #57 in the bathroom after having a bowel movement. Then, the Nurse sat the resident on the toilet and left the bathroom to get a disposable brief leaving the resident unattended. While Nurse #3 stepped out of the bathroom to the resident's room, the resident stood up and fell . The resident complained of pain on the right knee and x-ray was ordered. The x-ray report showed [MEDICAL CONDITION] femur and the resident was sent to the hospital. The hospital discharge summary dated 4/16/18 revealed that the resident was admitted after having a fall at the nursing facility and sustained a right distal femur fracture and underwent ORIF. On 8/8/18 at 9:05 AM, Resident #57 was observed up in wheelchair in her room. She was able to remember what she ate for breakfast but she could not tell the time, day or month. On 8/8/18 at 10:58 AM, Nurse #1 was interviewed. She was assigned to Resident #57 on 4/11/18. She stated that Resident #57 was confused. The resident was on partial weight bearing at that time due to right femur fracture and was wearing an immobilizer to her right lower extremity. Nurse #3 had answered the call light and found the resident in the bathroom. She cleaned the resident, sat her on the toilet and left the room to get a disposable brief. When the nurse stepped out of the bathroom to the resident's room, the resident stood up and fell . On 8/9/18 at 9:05 AM, Nurse #3, the previous Director of Nursing (DON) was interviewed. She stated that she answered the bathroom call light on 4/11/18 and found Resident #57 in the bathroom on the toilet. She stepped out of the bathroom to the resident's room to get a disposable brief, when the resident stood up and fell . Nurse #3 revealed that she didn't know the resident's mental status nor her weight bearing status at that time. On 8/9/18 at 9:10 AM, Clinical Manager #1 was interviewed. She stated that she had investigated the fall incident on 4/11/18. Resident #57 was left in the bathroom unattended by Nurse #3 after providing care. The resident was on partial weight bearing status and should have not left in the bathroom by herself. The Clinical Manager further indicated that the resident went to the bathroom by herself. On 8/9/18 at 9:52 AM, Nurse #1 was again interviewed. She stated that she didn't know who brought the resident to the bathroom but she had a tendency of going to the bathroom by herself. The nurse indicated that Resident #57 could not get herself up nor clean herself. She was not steady and was wearing an immobilizer. She should have not left alone in the bathroom. On 8/9/18 at 4:07 PM, the Administrator and the Director of Nursing were interviewed. The Administrator stated that she expected the staff to know the resident's status and if he/she didn't know the resident, the resident should have not left unattended.

Based on record review and interviews with facility staff, the facility neglected to use 2 staff members to provide incontinence to Resident #1, failed to report a fall sustained by Resident #1 to the nurse or any other staff. The staff member moved the resident, alone, before being assessed for serious injury, from the floor to the bed using a mechanical lift (resident required the assistance of two persons) putting the resident at risk for more injuries. This resulted in delay in treatment of [REDACTED]. This was evident for 1 of 3 residents reviewed for neglect. Immediate jeopardy began on 3/07/18 when nurse aide (NA) #1 failed to report a fall sustained by Resident #1 to the nurse or any other staff member, moved the resident by herself from the floor to the bed using a mechanical lift, putting the resident at risk for more injuries. This resulted in delay of treatment of [REDACTED]. Immediate jeopardy was removed on 3/12/18. The facility remains out of compliance at a lower scope and severity of D' (no harm with the potential for more than minimal hard that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. Resident's #1 Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident's #1 cognition was moderately impaired. The resident had no behaviors or moods. Resident #1 was totally dependent on staff for bed mobility and transfers and required the assistance of 2 people. The resident also was totally dependent on staff with locomotion, dressing, toilet use and personal hygiene and supervisor with eating. Resident #1 was not steady with surface to surface transfers and had impairment on 1 side of her upper extremity and on one side of her lower extremity. The resident was always incontinent of bowel and bladder. Review of Resident #1's current care guide (which are located in the resident's closet) dated 2/22/18 revealed that the resident required 2 people for assistance with turning, repositioning, and incontinence care. Review of the Medication Administration Record [REDACTED]. The pain assessment on the MAR indicated [REDACTED]. A nursing note dated 3/7/18 written by Nurse #1 stated that Resident #1 complained of increased pain to legs this shift and the physician was contacted and received a new order to increase the [MEDICATION NAME] (a medication given for neuropathic pain) dosage and to administer three times a day. A nursing note dated 3/10/18 written by nurse #6 revealed Resident #1 complained of pain to the left femur and hollered out in pain when palpated. The physician was notified and a left femur X-RAY was ordered. The X-RAY result showed a displaced spiral [MEDICAL CONDITION] femur. The physician was notified and the resident was sent to the hospital. Resident #1 left the facility via Emergency Medical Services at 6:00 PM. An incident report (no incident time or date) but had a date of 3/10/18 under notification. The incident report stated that Resident #1 had a fall/injury and the resident had a fracture. After complaint of increased left leg pain and a nursing assessment, an X-RAY was ordered and revealed a left femur fracture. The Resident denied accident/injuries. The resident's roommate (Resident #2) reported that NA #1 rolled the resident off of the bed and onto the floor while performing care on the morning of 3/7/18. The left femur X-RAY revealed a displaced spiral [MEDICAL CONDITION] femur. The physician was informed and the resident was sent to the hospital on [DATE]. The incident report also revealed that the incident was reported to the state on 3/11/18 at 8:35 PM. Review of Resident #1's Hospital records dated 3/10/18 revealed that the resident was admitted with reports of left, thigh pain and was noted to have an acute left, proximal, spiral, displaced [MEDICAL CONDITION]. There were no reports from the nursing facility of trauma. The resident's hemoglobin was 4.3 and she was admitted to the intensive care unit for profound [MEDICAL CONDITION] and required multiple blood [MEDICAL CONDITION]. Orthopedics were consulted, and on assessment, showed that the resident was unable to move her left lower extremity. NA #1 (who worked with Resident #1 during the night shift of 3/6/18 and the early morning on 3/7/18) was interviewed on 3/13/18 at 12:59 PM. NA #1 stated Resident #1 was in the bed most of the time. Resident #1 was alert and oriented. NA #1 stated on 03/07/18, Resident #1 was incontinent and she went to change her. During the provision of care, Resident #1 rolled off the left side of the bed onto the floor. NA #1 stated she was changing Resident #1 by herself and she tried to stop her from rolling off the bed by grabbing her arm. She stated that after the resident fell off the bed, she left the resident's room to get the mechanical lift. NA #1 stated that she moved the furniture in the resident's room and placed Resident #1 back in the bed with the lift on her own. She stated that the resident reported pain and she let the nurse know the resident was in pain. NA #1 stated she did not report to the nurse that Resident #1 fell from her bed onto the floor and she knew it was wrong, but she didn't want to lose her job. NA #1 stated that she did not report the incident to anyone. NA #1 stated they were supposed to have 2 people to help with the lift and providing care to Resident #1 but sometimes you could not get 2 people to help and the nurses would not help sometimes so they had to use only 1 person. Nursing Assistant #2 (who worked with Resident #1 during the 7:00 AM to 3:00 PM shift on 3/7/18, 3/8/18, 3/9/18, and 3/10/18) was interviewed on 3/13/18 at 12:16 PM. NA #2 stated Resident #1 was alert and oriented. The resident would be changed in the bed but would get up occasionally. The resident transferred via the mechanical lift and the assistance of 2 people. She stated Resident #1 required 2 people to be turned in bed but sometimes she just did it herself. She stated she was recently giving Resident #1 a bed bath and the Resident complained of pain in her leg (stated this was on Tuesday, 3/6/18 or Wednesday 3/7/18). NA #2 stated that the Resident's roommate (Resident #2) stated that something happened to Resident #1 and Resident #1 told Resident #2 to mind her business. Resident #1 stated that nothing happened but that her leg hurt. She stated that she told nurse #1 and she didn't get the resident up. Resident #2 never said exactly what happened and could be confused at times. Resident #1 then became very drowsy and did not want to get up. Resident #1 also stated that she had pain whenever she asked her. NA #2 stated she got Resident #1 up one time that week (either on Wednesday, 3/7/18 or Thursday 3/8/18) because the resident stated she wanted to see if it would help with the pain. She gave the resident her lunch tray and it was usual that Resident #1 fell asleep when she gave her meal. However, on Saturday 3/10/18, she gave Resident #1 her lunch and Resident #1 was confused and started saying where am I. NA #2 stated that she and Nursing Assistant #3 were changing Resident #1 and when they turned the Resident, she started hollering, crying and grabbed NA #2 like she was in horrible pain. Nurse #1 came in to see the resident and barely touched her leg and the resident yelled out. NA #2 stated that the Resident's roommate (Resident #2) then stated that earlier in the week, NA #1 was changing the resident by herself and rolled her off the bed. Nurse #1 (who worked with Resident #1 on 3/7/18 and 3/8/18 during the 7:00 AM to 7:00 PM shift was interviewed on 3/13/18 at 2:15 PM. She stated Resident #1 was alert and oriented and could make her needs known. Nurse #1 specified that Resident #1 required maximum assistance and the assistance of 2 people to get up. Resident #1 needed 2 people for transfers and for bed mobility. Nurse #1 stated during the morning of 03/07/18, the NA informed her that Resident #1 was having some pain. Nurse #1 stated that Resident #1 was complaining of pain in her leg but could not pinpoint the location of the pain. The Resident stated that the pain was burning and she gave the resident some medication for pain. She stated the Resident was also rubbing her leg but it was not red or swollen. She stated that she looked at the Resident's leg and that she was able to move the Resident's leg, adjust it and it was ok but it just hurt per the Resident. Nurse #1 stated she contacted the doctor and was given orders for [MEDICATION NAME] to be increased to three times a day and she gave the resident the medication. She thought the Resident was having possible nerve pain, which was why she got the [MEDICATION NAME] medication increased. Nurse #1 stated that she did not get any reports from the staff that night about Resident #1 falling. Attempts were made to contact Nurse #5, who worked with Resident #1 on 3/7/18 from 7:00 PM to 7:00 AM, but Nurse #5 could not be contacted for an interview. NA #4 (who worked with Resident #1 on 3/7/18 from 3:00 PM to 11:00 PM) was interviewed on 3/13/18 at 3:57 PM. NA #4 stated she got in report that the Resident's leg had been sore. NA #4 stated that Resident #1 informed her that her leg was hurting and that Resident #1 did not usually complain of pain. NA #4 stated that she told the nurse that Resident #1 was in pain. Resident #1 would not tell her why her leg was hurting. NA #4 stated that the Resident would let them change her, but was having pain in her leg when they rolled her over so she adjusted how she rolled her and the resident seemed fine. NA #5 (who worked with Resident #1 during the 3rd shift on 3/7/18 and 3/9/18) was interviewed on 3/13/18 at 2:43 PM. She stated the resident was incontinent and she usually changed the resident by herself but technically they were supposed to have 2 people. NA #5 stated that she changed Resident #1 by herself because she was used to the resident. NA #5 stated that Resident #1 was usually alert and oriented and would tell staff if something was wrong. She stated that recently she turned Resident #1 on the right side, crossed her legs over with a little push and the resident said it hurt so she turned the Resident on the other side. She thought the Resident was uncomfortable and she turned her the other way and the resident seemed ok the other side. NA #8 was (who assisted NA #2 with the care of Resident #1 on 3/10/18 during 3:00 PM to 11:00 PM shift) was interviewed on 3/13/18 at 3:54 PM. She stated that Resident #1 needed 2 people to get her up and needed the lift. The Resident was usually alert and oriented. NA #8 stated that NA #2 asked her to come in the room to help with the care of Resident #1 on 3/10/18 and she asked the resident if she was having pain. The resident was rubbing her leg. She stated she also asked the Resident if she had a fall and the resident did not respond. NA #8 went to turn Resident #1 and the resident started hollering. The Resident's Roommate (Resident #2) then told them that the resident had fallen. The nurse came in and assessed Resident #1 and the resident was having pain when the nurse touched the area on her leg. NA #8 stated she stayed with the resident until she was transferred to the hospital. The resident's roommate (Resident #2) was interviewed on 3/13/18 at 12:50 PM. Resident #2 stated that on 03/07/18 she was in her room when she heard Resident #1 fall out of bed. Resident #2 specified that NA #1 was providing care to Resident #1 by herself when the resident fell out of bed. She stated the fall occurred between the evening and early morning. Resident #2 stated the staff member did not get the nurse after the fall occurred. Resident #2 stated she observed the NA push the lift pad under the resident after she fell and use the lift to lift by herself and put the resident back in the bed. She stated Resident #1 would holler every time she was moved. Resident #2 stated that it was about 3 or 4 days later when Resident #1 went to the hospital. Resident #2 further stated that the nurse was right across the hall when Resident #1 fell , but the NA never got the nurse after the resident fell . Attempts were made to contact Nurse #6 (who worked on 3/10/18 from 7:00 AM to 7:00 PM with Resident #1) for an interview but she could not be contacted. The Administrator was interviewed on 3/13/18 at 4:25 PM. She stated that on 12/15/17, when the Resident #1's first fall from bed occurred with the same NA (NA #1) independently assisting her with care they determined all residents who needed 2 person assistance with care. Education included for the staff to follow the care guides in the resident's closet and use 2 person assistance. An incident report was put in on 3/10/18 about Resident #1's fall on 3/7/18, so she did not find out about the fall which occurred on 03/07/18 until 3/10/18. The administrator stated that Resident #1 denied that the incident had occurred. Resident #1's roommate spoke up and stated aren't you going to tell them about you rolling them out of bed. When they found out about the resident's fracture and since they had a report from the roommate, they started contacting staff when the resident started complaining of pain, which was on 3/7/18. They started interviewing all staff about the resident being dropped out of the bed. On 3/11/18, NA #1 was questioned and this was the first time they were able to get in contact with her. NA #1 admitted that she rolled Resident #1 out of the bed and that she did not report the fall to anyone. NA #1 admitted to her that on 3/07/18 the resident was laying on her left and she was the only staff member providing care to Resident #1 and the resident rolled off the bed. NA #1 stated she used the mechanical lift to get Resident #1 back into the bed with no assistance. The administrator stated she contacted the sheriff's office and contacted the state with all the paper work and turned over the investigation to the sheriff's office. Resident #1's Physician was interviewed on 3/14/18 at 11:18 AM. The Physician stated a nurse called the office and said Resident #1 was having increased pain in her left leg and the nurse thought it was neuropathic pain and wanted an increase in her [MEDICATION NAME] pain medication (he could not recall the exact date). He stated that 99% of the time when he saw the resident, the resident was just lying in bed with the covers over her and that she usually never had complaints of pain. He stated that Saturday morning (3/10/18), the nurse called and said the Resident was having pain in the left thigh and he thought the nurse assessed the patient at that time. They got an X-RAY and it showed a display spiral fracture to the leg. The resident was admitted to the hospital. When Resident #1 got to the hospital, the resident was hypothermic and her Hemoglobin was 4.3. The Resident was close to hemorrhagic shock and the Resident still has not had surgery yet at the hospital. The Physician further stated that Resident #1 was on anticoagulation therapy and was probably bleeding into her leg. He thought the resident probably had a history of [REDACTED]. He stated that he asked the resident that happened and she told him that she fell out of bed the other night and stated that she didn't tell the nurse. NA #1 was interviewed again on 3/14/18 at 2:51 PM. NA #1 stated that the fall Resident #1 experienced on 03/07/18 occurred at around 5:30 AM to 6:00 AM. NA #1 stated the resident on her left side and she told the resident to roll. The Resident was rolled away from her and off of the bed. Nurse #1 was interviewed again on 3/14/18 at 3:03 PM. She stated that if a resident fell she would assess the resident, call the doctor, report the fall to the family and supervisors and fill out an incident report. NA # 4 stated on 3/14/18 at 3:11 PM that she would report it to the nurse if a resident was abused or had a fall. The Administrator was interviewed on 3/15/18 at 3:40 PM and stated that she would expect for any witness or involved party to report any incident of abuse or neglect. The Administrator was notified of Immediate Jeopardy on 3/14/18 at 2:22 PM. On 03/15/18 at 1:41 PM, the facility provided the following credible allegation of Immediate Jeopardy removal. 1. Resident #1 reported leg pain to Nurse #1 on 3/7/18 at approximately 3:35 pm. Nurse #1 contacted physician with new orders for increased [MEDICATION NAME] on 3/7/18 at 6pm. The RP was notified on 3/7/18 of complaint of pain and new order. The Resident reported relief with new orders on 3/7/18. The Resident reported on 3/8/18 that [MEDICATION NAME] continued to be effective for leg pain. Resident reported increased leg pain to Nurse #2 on 3/10/18 at approximately 3:00 pm. Assessment by Nurse #2 indicated increased pain upon palpation. The Physician was notified by Nurse #2 with orders for an x-ray. The X-ray was obtained on 3/10/18 at 4:30 pm and indicated a left femur fracture. The Physician was notified of results by Nurse #2 on 3/10/18 at approximately 5:00pm with new orders to send resident to the hospital for direct admission. The RP was notified by Nurse #2 on 3/10/18 at approximately 5:00pm. The Resident denied any accidents/injuries when assessed by Nurse #2 on 3/10/18; however, resident's roommate reported that during care, a CNA (nurse aide) rolled Resident #1 off bed and onto floor. Resident #1 was coded as moderately cognitively impaired, was usually understood, and always understood others per the MDS assessment of 1/3/18. The roommate was assessed as cognitively intact, was always understood, and always understood others per the MDS assessment of 12/28/17. The roommate was interviewed on 3/11/18 by the Director of Nursing, and reported she had not confided in any staff that Resident #1 was rolled onto the floor on 3/7/18. The event occurred as a staff member did not follow facility procedures for following the care guide for turning and repositioning, did not follow facility procedures for use of a mechanical lift, and did not follow facility procedures for reporting accidents/incidents. CNA #1 reported during an interview on 3/11/18 that she was aware of her requirements to report accidents and injuries, follow the care guide, and did not ask for assistance although assistance was available. Resident #1's care guide indicated that the resident required 2-person assistance with turning, repositioning, and incontinent care. CNA #1 reported during the interview that she was in a hurry to complete her last rounds and did not ask for help as she felt she could care for the resident alone. CNA #1 stated in the interview that she was aware of her responsibility to report but neglected to do so without reason. CNA #1 was aware that failure to report an incident is considered neglect as per education and in-servicing providing throughout her employment. CNA #1 informed the DON on 3/11/18 at approximately 11:30am that while providing care on the morning of 3/7/18 that she accidentally rolled Resident #1 out of the bed and onto floor. CNA reported that she was aware that care path indicated resident requires 2-person assistance, but she was in a hurry and failed to illicit assistance. CNA #1 reported that after Resident #1 was on the floor, working alone, she utilized a mechanical lift to transfer resident from floor to bed. CNA #1 stated that she was aware of reporting requirements, but failed to report the incident to anyone. CNA#1 was removed from the schedule on 3/11/18. The Police were contacted by the Director of Nursing, on 3/11/18 at 7:29pm. A 24-hour report for neglect was submitted by the Director of Nursing on 3/11/18 at 8:35pm. The resident left the facility with EMS on 3/10/18 at approximately 5pm in transfer to the hospital. 2. A 100% skin assessment of all residents was completed by the Director of Nursing, and staff nurses on 3/11/18 including assessment of ROM, bruising, swelling, and signs/symptoms of pain. During the assessments, the Director of Nursing questioned the alert and oriented residents if they have had any pain, accidents, falls or issues with feeling they have been neglected. No concerns were identified. An in-service was initiated on 3/11/18 by the Staff Development Coordinator to include all staff regarding reporting of incidents/accidents and abuse/neglect immediately to the Charge Nurse. The in-service included that lack of providing care to a resident per the care plan is considered neglect and included the definition of neglect. This in-service included instruction on not moving a resident after a fall due to danger of causing further injury until assessed by a nurse. All employees receive education on hire and annually that indicates that it is safe to report accidents/injuries without fear of disciplinary action. No staff will work beyond 3/11/18 until they have received the in-service. Newly hired staff will receive the in-service during orientation. 3. Utilizing a Progress Note Review QI Audit Tool, the Unit Managers x 2 will review progress notes daily to identify any resident complaints of pain to assure a full assessment had been documented. The Weekend Supervisor will review progress notes each weekend daily to identify any resident complaints of pain to assure a full assessment had been documented. Utilizing a Resident Interview for Neglect QI Audit Tool, the Social Worker will interview 5 alert and oriented residents weekly to ensure no neglect of care had occurred. Utilizing a Pain Audit tool, the Unit Managers x 2 will review progress notes daily to identify any nonverbal resident's with complaints of pain to assure a full assessment has been documented. Audits will occur Monday through Friday x 2 weeks, Weekends x 2, then twice weekly x2 weeks, then weekly x 4 weeks, then monthly x 1 month. The Director of Nursing will review the QI Audit Tools weekly x 8, then monthly x 1 for trends and concerns. 4. The Administrator will report the results of the monitoring to the Quality Assurance Committee monthly x 3 months for trends, concerns, and recommendations for any modification of the process. The Administrator will be responsible for implementing this credible allegation of removal. The credible allegation was verified on 3/15/18 at 3:30 PM as evidence by interviews of licensed and non-licensed staff on in- service training on when and how to report incidents, accidents, neglect and abuse. Nursing staff were interviewed on how to document pain assessments and when to assess a resident after an incidents/accident. The abuse protocol was initiated and other residents were interviewed on neglect/abuse. The facility's abuse policy and procedure for abuse/neglect was also reviewed along with other abuse cases that had been reported. Record review revealed the QA neglect audit tool was completed on 100 % of residents in the facility on 3/11/18. In-service on abuse was started on 3/11/18. All residents' interviews about abuse were conducted on 3/11/18. QA tool for pain was started on 3/11/18.

Based on record review and interviews with the staff, family, and the physician the facility failed to provide the assistance of two staff members during the provision of incontinence care to prevent a resident from falling from bed and sustaining an injury for 1 of 3 residents sampled reviewed for accidents (Resident #1). Resident #1 fell from her bed when only one nurse aide was providing her with incontinence care and she sustained a fractured left femur. The staff member moved the resident, alone, before being assessed for serious injury, from the floor to the bed using a mechanical lift (resident required the assistance of two persons) putting the resident at risk for more injuries. This resulted in delay in treatment of [REDACTED]. Immediate jeopardy began on 3/07/18 when nurse aide (NA) #1 failed to report a fall sustained by Resident #1 to the nurse or any other staff member, moved the resident by herself from the floor to the bed using a mechanical lift, before being assessed for injury putting the resident at risk for more injuries. This resulted in delay of treatment of [REDACTED]. Immediate jeopardy was removed on 3/12/18. The facility remains out of compliance at a lower scope and severity of D' (no harm with the potential for more than minimal hard that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. An incident report dated 12/15/17 stated Resident #1 was receiving incontinent care by nursing assistant (NA) #1. The Resident was on her left side while the NA was cleaning the resident. The Resident reached out as to grab onto the non-existing bedrail and rolled off the bed onto the floor. Resident #1 was assessed and put back to bed. Vital signs were taken. The immediate action taken stated that Resident #1 needed the assistance of 2 people to change her and for perineal care. No injury was noted. Review of Resident's #1 Quarterly Minimum Data Set ((MDS) dated [DATE] revealed her cognition was moderately impaired. The Resident had no behaviors or moods. Resident #1 required total dependence for bed mobility and transfers and required the assistance of 2 people. The Resident also required total dependence with locomotion, dressing, toilet use and personal hygiene and supervisor with eating. Resident #1 was not steady with surface to surface transfers and had impairment on 1 side of her upper extremity and on one side of her lower extremity. The resident was always incontinent of bowel and bladder. Resident #1's current care plan, which was most recently updated/reviewed by staff on 3/14/18, addressed issues including her need for assistance with activities of daily living and for being at risk falls which were initiated on 8/5/17. Interventions for falls included that the resident would be transferred with the assistance of 2 people via a mechanical lift and repositioned in the bed as she often leans to the right side. Review of Resident #1's current care guide (which are located in the resident's closet) dated 2/22/18 revealed that the resident required 2 people for assistance with turning, repositioning, and incontinence care. A nursing note dated 3/7/18, written by Nurse #1, stated that Resident #1 complained of increased pain to legs this shift and the physician was contacted and received a new order to increase the [MEDICATION NAME] (a medication given for neuropathic pain) dosage and to administer three times a day. A nursing note dated 3/10/18, written by Nurse #6, revealed Resident #1 complained of pain to the left femur and hollered out in pain when palpated. The physician was notified and a left femur X-RAY was ordered. The X-RAY result showed a displaced spiral [MEDICAL CONDITION] femur. The physician was notified and the resident was sent to the hospital. Resident #1 left via Emergency Medical Services at 6:00 PM. An incident report (no incident time or date) but had a date of 3/10/18 under notification. The incident report stated that Resident #1 had a fall/injury and the resident had a fracture. After complaint of increased left leg pain and a nursing assessment, an X-RAY was ordered and revealed a left femur fracture. The Resident denied accident/injuries. The resident's roommate (Resident #2) reported that NA #1 rolled the resident off of the bed and onto the floor while performing care on the morning of 3/7/18. The left femur X-RAY revealed a displaced spiral [MEDICAL CONDITION] femur. The physician was informed and the resident was sent to the hospital on [DATE]. Review of Resident #1's Hospital records dated 3/10/18 revealed that the resident was admitted with reports of left, thigh pain and was noted to have an acute left, proximal, spiral, displaced [MEDICAL CONDITION]. The resident reported that she fell out of the bed on 3/7/18 and that she crawled back in the bed. There were no reports from the nursing facility of trauma. The resident's hemoglobin was 4.3 and she was admitted to the intensive care unit for profound [MEDICAL CONDITION] and required multiple blood [MEDICAL CONDITION]. Orthopedics were consulted and on assessment showed that the resident was unable to move her left lower extremity. NA #1 (who worked with Resident #1 during the night shift of 3/6/18 and the early morning on 3/7/18) was interviewed on 3/13/18 at 12:59 PM. NA #1 stated Resident #1 was in the bed most of the time. Resident #1 was alert and oriented. NA #1 stated on 03/07/18, Resident #1 was incontinent and she went to change her. During the provision of care, Resident #1 rolled off the left side of the bed onto the floor. NA #1 stated she was changing Resident #1 by herself and she tried to stop her from rolling off the bed by grabbing her arm. She stated that after the resident fell off the bed, she left the resident's room to get the mechanical lift. NA #1 stated that she moved the furniture in the resident's room and placed Resident #1 back in the bed with the lift on her own. She stated that the resident reported pain and she let the nurse know the resident was in pain. NA #1 stated she did not report to the nurse that Resident #1 fell from her bed onto the floor and she knew it was wrong, but she didn't want to lose her job. NA #1 stated that she did not report the incident to anyone. NA #1 stated they were supposed to have 2 people to help with the lift and providing care to Resident #1 but sometimes you could not get 2 people to help and the nurses would not help sometimes so they had to use only 1 person. Nursing Assistant (NA) #2 (who worked with Resident #1 during the 7:00 AM to 3:00 PM shift on 3/7/18, 3/8/18, 3/9/18, and 3/10/18) was interviewed on 3/13/18 at 12:16 PM. NA #2 stated Resident #1 was alert and oriented. The resident would be changed in the bed but would get up occasionally. The resident transferred via the mechanical lift and the assistance of 2 people. She stated Resident #1 required 2 people to be turned in bed but sometimes she just did it herself. She stated she was recently giving Resident #1 a bed bath and the Resident complained of pain in her leg. NA #2 stated that the Resident's roommate (Resident #2) stated that something happened to Resident #1 and Resident #1 told Resident #2 to mind her business. Resident #1 stated that nothing happened but that her leg hurt. NA #2 stated that on 3/10/18, she and Nursing Assistant #3 were changing Resident #1 and when they turned the Resident, she started hollering, crying and grabbed NA #2 like she was in horrible pain. Nurse #1 came in to see the resident and barely touched her leg and the resident yelled out. NA #2 stated that the Resident's roommate (Resident #2) then stated that earlier in the week, NA #1 was changing the resident by herself and rolled her off the bed. Nurse #1 (who worked with Resident #1 on 3/7/18 and 3/8/18 during the 7:00 AM to 7:00 PM shift was interviewed on 3/13/18 at 2:15 PM. She stated Resident #1 was alert and oriented and could make her needs known. Nurse #1 specified that Resident #1 required maximum assistance and the assistance of 2 people to get up. Resident #1 needed 2 people for transfers and for bed mobility. Nurse #1 stated during the morning of 03/07/18, the NA informed her that Resident #1 was having some pain. Nurse #1 stated that Resident #1 was complaining of pain in her leg but could not pinpoint the location of the pain. The Resident stated that the pain was burning and she gave the resident some medication for pain. She stated the Resident was also rubbing her leg but it was not red or swollen. She stated that she looked at the Resident's leg and that she was able to move the Resident's leg, adjust it and it was ok but it just hurt per the Resident. Nurse #1 stated she contacted the doctor and was given orders for [MEDICATION NAME] to be increased to three times a day and she gave the resident the medication. She thought the Resident was having possible nerve pain, which was why she got the [MEDICATION NAME] medication increased. Nurse #1 stated that she did not get any reports from the staff that night about Resident #1 falling. Attempts were made to contact Nurse #5, who worked with Resident #1 on 3/7/18 from 7:00 PM to 7:00 AM, but Nurse #5 could not be contacted for an interview. NA #4 (who worked with Resident #1 on 3/7/18 from 3:00 PM to 11:00 PM) was interviewed on 3/13/18 at 3:57 PM. NA #4 stated she got in report that the Resident's leg had been sore. NA #4 stated that Resident #1 informed her that her leg was hurting and that Resident #1 did not usually complain of pain. NA #4 stated that she told the nurse that Resident #1 was in pain. Resident #1 would not tell her why her leg was hurting. NA #4 stated that the Resident would let them change her, but was having pain in her leg when they rolled her over so she adjusted how she rolled her and the resident seemed fine. NA #5 (who worked with Resident #1 during the 3rd shift on 3/7/18 and 3/9/18) was interviewed on 3/13/18 at 2:43 PM. She stated the resident was incontinent and she usually changed the resident by herself but technically they were supposed to have 2 people. NA #5 stated that she changed Resident #1 by herself because she was used to the resident. NA #5 stated that Resident #1 was usually alert and oriented and would tell staff if something was wrong. She stated that recently she turned Resident #1 on the right side, crossed her legs over with a little push and the resident said it hurt so she turned the Resident on the other side. She thought the Resident was uncomfortable and she turned her the other way and the resident seemed ok the other side. NA #8 was (who assisted NA #2 with the care of Resident #1 on 3/10/18 during 3:00 PM to 11:00 PM shift) was interviewed on 3/13/18 at 3:54 PM. She stated that Resident #1 needed 2 people to get her up and needed the lift. The resident was usually alert and oriented. NA #8 stated that NA #2 asked her to come in the room to help with the care of Resident #1 on 3/18/18 and she asked the resident if she was having pain. The resident was rubbing her leg. She stated she also asked the Resident if she had a fall and the resident did not respond. NA #8 went to turn Resident #1 and the resident started hollering. The Resident's Roommate (Resident #2) then told them that the resident had fallen. The nurse came in and assessed Resident #1 and the resident was having pain when the nurse touched the area on her leg. NA #8 stated she stayed with the resident until she was transferred to the hospital. The resident's roommate (Resident #2) was interviewed on 3/13/18 at 12:50 PM. Resident #2 stated that on 03/07/18 she was in her room when she heard Resident #1 fall out of bed. Resident #2 specified that NA #1 was providing care to Resident #1 by herself when the resident fell out of bed. She stated the fall occurred between the evening and early morning. Resident #2 stated the staff member did not get the nurse after the fall occurred. Resident #2 stated she observed the NA push the lift pad under the resident after she fell and use the lift to lift by herself and put the resident back in the bed. She stated Resident #1 would holler every time she was moved. Resident #2 stated that it was about 3 or 4 days later when Resident #1 went to the hospital. Resident #2 further stated that the nurse was right across the hall when Resident #1 fell , but the NA never got the nurse after the resident fell . Attempts were made to contact Nurse #6 (who worked on 3/10/18 from 7:00 AM to 7:00 PM with Resident #1) for an interview but she could not be contacted. The Administrator was interviewed on 3/13/18 at 4:25 PM. She stated that on 12/15/17, when the Resident #1's first fall from bed occurred with the same NA (NA #1) independently assisting her with care they determined all residents who needed 2 person assistance with care. Education included for the staff to follow the care guides in the resident's closet and use 2 person assistance. An incident report was put in on 3/10/18 about Resident #1's fall on 3/7/18, so she did not find out about the fall which occurred on 03/07/18 until 3/10/18. The administrator stated that Resident #1 denied that the incident had occurred. Resident #1's roommate spoke up and stated aren't you going to tell them about you rolling them out of bed. When they found out about the resident's fracture and since they had a report from the roommate, they started contacting staff when the resident started complaining of pain, which was on 3/7/18. They started interviewing all staff about the resident being dropped out of the bed. On 3/11/18, NA #1 was questioned and this was the first time they were able to get in contact with her. NA #1 admitted that she rolled Resident #1 out of the bed and that she did not report the fall to anyone. NA #1 admitted to her that on 3/07/18 the resident was laying on her left and she was the only staff member providing care to Resident #1 and the resident rolled off the bed. NA #1 stated she used the mechanical lift to get Resident #1 back into the bed with no assistance. The administrator stated she contacted the sheriff's office and contacted the state with all the paper work and turned over the investigation to the sheriff's office. Resident #1's Physician was interviewed on 3/14/18 at 11:18 AM. The Physician stated a nurse called the office and said Resident #1 was having increased pain in her left leg and the nurse thought it was neuropathic pain and wanted an increase in her [MEDICATION NAME] pain medication (he could not recall the exact date). He stated that 99% of the time when he saw the resident, the resident was just lying in bed with the covers over her and that she usually never had complaints of pain. He stated that Saturday morning (3/10/18), the nurse called and said the Resident was having pain in the left thigh and he thought the nurse assessed the patient at that time. They got an X-RAY and it showed a display spiral fracture to the leg. The resident was admitted to the hospital. When Resident #1 got to the hospital, the resident was hypothermic and her Hemoglobin was 4.3. The Resident was close to hemorrhagic shock and the Resident still has not had surgery yet at the hospital. The Physician further stated that Resident #1 was on anticoagulation therapy and was probably bleeding into her leg. He thought the resident probably had a history of [REDACTED]. He stated that he asked the resident that happened and she told him that she fell out of bed the other night and stated that she didn't tell the nurse. NA #1 was interviewed again on 3/14/18 at 2:51 PM. NA #1 stated that the fall Resident #1 experienced on 03/07/18 occurred at around 5:30 AM to 6:00 AM. NA #1 stated the resident on her left side and she told the resident to roll. The Resident was rolled away from her and off of the bed. The Administrator was interviewed on 3/15/18 at 3:40 PM and stated that she would expect for any incident to be reported to her immediately. The Administrator was notified of Immediate Jeopardy on 3/14/18 at 2:22 PM. On 03/15/18 at 1:41 PM, the facility provided the following credible allegation of Immediate Jeopardy removal. 1. Resident #1 reported leg pain to Nurse #1 on 3/7/18 at approximately 3:35 pm. Nurse #1 contacted physician with new orders for increased [MEDICATION NAME] on 3/7/18 at 6pm. The RP was notified on 3/7/18 of c/o of pain and new order. The Resident reported relief with new orders on 3/7/18. The Resident reported on 3/8/18 that [MEDICATION NAME] continued to be effective for leg pain. Resident reported increased leg pain to Nurse #2 on 3/10/18 at approximately 3:00 pm. Assessment by Nurse #2 indicated increased pain upon palpation. The Physician was notified by Nurse #2 with orders for an x-ray. The X-ray was obtained on 3/10/18 at 4:30 pm and indicated a left femur fracture. The Physician was notified of results by Nurse #2 on 3/10/18 at approximately 5:00pm with new orders to send resident to the hospital for direct admission. The RP was notified by Nurse #2 on 3/10/18 at approximately 5:00pm. The Resident denied any accidents/injuries when assessed by Nurse #2 on 3/10/18; however, resident's roommate reported that during care, a CNA (nurse aide) rolled Resident #1 off bed and onto floor. Resident #1 was coded as moderately cognitively impaired, was usually understood, and always understood others per the MDS assessment of 1/3/18. The roommate was assessed as cognitively intact, was always understood, and always understood others per the MDS assessment of 12/28/17. The roommate was interviewed on 3/11/18 by the Director of Nursing and reported she had not confided in any staff that Resident #1 was rolled onto the floor on 3/7/18. The event occurred as a staff member did not follow facility procedures for following the care guide for turning and repositioning, did not follow facility procedures for use of a mechanical lift, and did not follow facility procedures for reporting accidents/incidents. CNA #1 reported during an interview on 3/11/18 that she was aware of her requirements to report accidents and injuries, follow the care guide, and did not ask for assistance, although assistance was available. Resident #1's care guide indicated that the resident required two-person assistance with turning, repositioning, and incontinent care. CNA #1 reported during the interview that she was in a hurry to complete her last rounds and did not ask for help as she felt she could care for the resident alone. CNA #1 informed the DON on 3/11/18 at approximately 11:30am that while providing care on the morning of 3/7/18 that she accidently rolled Resident #1 out of the bed and onto floor. CNA reported that she was aware that care path indicated resident requires 2-person assistance, but she was in a hurry and failed to illicit assistance. CNA #1 reported that after Resident #1 was on the floor, working alone, she utilized a mechanical lift to transfer resident from floor to bed. CNA #1 stated that she was aware of reporting requirements, but failed to report the incident to anyone. CNA#1 was removed from the schedule on 3/11/18. The Police were contacted by the Director of Nursing on 3/11/18 at 7:29pm. A 24-hour report for abuse was submitted by the Director of Nursing on 3/11/18 at 8:35pm. The resident left the facility with EMS on 3/10/18 at approximately 5pm in transfer to the hospital. 2. A 100% skin assessment of all residents was completed by the Director of Nursing, and staff nurses on 3/11/18 including assessment of ROM, bruising, swelling, and signs/symptoms of pain. During the assessments, the Director of Nursing questioned the alert and oriented residents if they have had any pain, accidents, or falls. No concerns were identified An in-service was initiated on 3/11/18 by the Staff Development Coordinator to include all licensed nurses regarding assessment upon notification of pain including AROM and PROM and documentation of findings in the resident's progress notes. No licensed staff will work beyond 3/11/18 until they have received the in-service. Newly hired licensed nursing staff will receive the in-service during orientation. An in-service was initiated on 3/11/18 by the Staff Development Coordinator to include all clinical staff including nurses and certified nursing assistants regarding use of care guide, 2-person assist requirements, and use of mechanical lift requiring 2-persons. Although staffing was not an issues; staff were made aware that they can illicit help from any clinical staff member. No staff will work beyond 3/11/18 until they have received the in-service. Newly hired nursing staff will receive the in-service during orientation. An in-service was initiated on 3/11/18 by the Staff Development Coordinator to include all staff regarding reporting of incidents/accidents and abuse/neglect immediately to the Charge Nurse. This in-service included that is safe to report accidents/injuries and included the definition of neglect. This in-service included instruction on not moving a resident after a fall due to danger of causing further injury until assessed by a nurse. No staff will work beyond 3/11/18 until they have received the in-service. Newly hired nursing staff will receive the in-service during orientation. 3. Utilizing a QI audit tool, the unit managers x2 will observe 3 incidents of staff operating mechanical lifts Monday through Friday x 2 weeks, then twice weekly x 2 weeks, then weekly x 4 weeks, then monthly x 1 month to ensure that the resident is being transferred via mechanical lift according to the care guide and the resident's care plan. The Weekend Supervisor will observe 3 incidents of staff operating mechanical lifts on weekends x 2 weekends, then every other weekend x 2, then monthly x 1 month to ensure that the resident is being transferred via mechanical lift according to the care guide and the resident's care plan . Utilizing a QI audit tool, the unit managers x 2 will observe 3 incidents of staff turn and reposition residents Monday through Friday x 2 weeks, then twice weekly x 2 weeks, then weekly x 4 weeks, then monthly x 1 month to determine if the resident is being turned and repositioned in bed according to the resident care guide and care plan. The Weekend Supervisor will observe turning/repositioning on weekends x 2 weekends, then every other weekend x 2, the monthly x 1 month to determine if the resident is being turned and repositioned in bed according to the resident care guide and care plan. Utilizing a Progress Note Review QI Audit Tool, the Unit Managers x 2 will review progress notes daily to identify any resident complaints of pain to assure a full assessment had been documented. The Weekend Supervisor will review progress notes each weekend daily to identify any resident complaints of pain to assure a full assessment had been documented. Pain assessments are completed by the charge nurse each shift for all residents, including those residents who are nonverbal. Utilizing a Pain Audit tool, the Unit Managers x 2 will review progress notes daily to identify any nonverbal residents with complaints of pain to assure a full assessment has been documented. The Weekend Supervisor will review progress notes each weekend daily to identify any nonverbal residents with complaints of pain to assure a full assessment has been documented. Audits will occur Monday through Friday x 2 weeks, Weekends x 2, then twice weekly x 2 weeks, then weekly x 4 weeks, then monthly x 1 month. The Director of Nursing will review the QI Audit Tools weekly x 8, then monthly x 1 for trends and concerns 4. The Director of Nursing will report the results of the monitoring to the Quality Assurance Committee monthly x 3 months for trends, concerns, and recommendations for any modification of the process. The Administrator will be responsible for implementing the credible allegation of removal. The credible allegation was verified on 3/15/18 at 3:30 PM as evidence by nurse's interviews regarding in-servicing on pain assessment, documentation and notification. Licensed and non-licensed staff were interviewed on in- servicing about when to use 2 person assistance when providing resident care, proper use of the mechanical lift, and reporting of accidents and incidents. Review of on- going in service records revealed that staff present would receive training who did not receive in servicing prior to working the floor. An observation was made on 3/15/18 at 1:56 PM of the mechanical lift being used properly by staff.

Based on staff, Physician, Physician Assistant (PA), Wound Nurse Consultant interviews and record review, the facility failed to notify the physician of the resident's pressure ulcers on the resident's admission and failed to obtain treatment orders, resulting in the resident's delay in treatment from 1/9/18 till 1/12/18. The facility failed to get the physician approval before the initiation of pressure ulcer treatment. The facility failed to notify the physician of the Wound Nurse Consultant treatment orders for Resident #1's pressure ulcers. The facility failed to notify the physician of the worsening of the pressure ulcers and seek an order for [REDACTED]. Resident #1 was hospitalized with an infected stage 4 pressure ulcer requiring sharp debridement and antibiotic therapy. Immediate jeopardy began on 01/09/18 for Resident #1 when the facility failed to notify Physician #1 of the resident's pressure ulcers and failed to obtain treatment orders, resulting in the resident's delay in treatment from 1/9/18 till 1/12/18. On 01/12/18, the Treatment Nurse began implementing treatment orders without approval of the physician. The facility failed to notify the physician of the Wound Nurse Consultant treatment orders on 1/15/18 for Resident #1's pressure ulcers. The facility failed to receive approval of the physician before starting new pressure ulcer treatment on 1/16/18. The facility failed to notify the physician of the worsening of the pressure ulcers on 1/22/18 and seek an order for [REDACTED]. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and that all staff have been in-serviced. The findings included: Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #1's admission orders [REDACTED]. Review of Resident #1's admission nursing note dated 01/09/18 at 4:36 PM read there was a quarter sized open area on his right buttock which was described as brownish/dark in color with a slight odor and minimal serosanguinous drainage. There was no documented evidence that Physician #1 was notified. Review of Resident #1's Wound Assessment Report dated 01/09/18 read Resident #1 was admitted with an unstageable pressure ulcer to his right buttock measuring 3.5 centimeters (cm) length, 7.5 cm width and 0.5 cm depth. It was described as 40% eschar (dry, dark scab of dead skin) and 60% granulation (pink tissue containing capillaries formed around the wound edges). The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/09/18 with treatment orders pending. Review of Resident #1's Wound Assessment Report dated 01/09/18 read Resident #1 was admitted with an unstageable, due to suspected deep tissue injury, pressure ulcer to his sacrum measuring 3.5 cm length and 7.5 cm width. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/09/18 with treatment orders pending. Review of Resident #1's Wound Assessment Report dated 01/09/18 read Resident #1 was admitted with an unstageable pressure ulcer to his left buttock measuring 3.5 centimeters (cm) length, 7.5 cm width and 0.5 cm depth. It was described as 60% Eschar and 40% granulation. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/09/18 with treatment orders pending. Review of Resident #1's January 2018 Treatment Administration Record (TAR) included no treatment orders to his bilateral buttocks and sacrum from 01/09/18 through 01/12/18. Review of the electronic physician orders [REDACTED]. It was to be covered with a protective foam dressing daily and as needed. There were no written physician orders [REDACTED]. A telephone interview was conducted with Nurse #2 on 02/14/18 at 3:25 PM. Nurse #2 stated she admitted Resident #1 on 01/09/18 and completed his initial skin assessment and noted a small area on his sacrum. She stated she completed a wound communication form and gave it to the Treatment Nurse on 01/09/18 as she was leaving. Nurse #2 stated the physician had to be contacted for orders for every new or worsening pressure ulcer. She stated it was the responsibility of the Treatment Nurse to contact Physician #1 for treatment orders. During an interview on 2/14/18 at 12:05 PM, the Treatment Nurse stated she was not made aware of any pressure ulcers found on Resident #1 until 01/12/18. When questioned regarding the Wound Assessment Report she completed on 01/09/18 on Resident #1, the Treatment Nurse stated she must have dated the assessment incorrectly and it should have been dated 01/12/18. She stated she did not recall asking for treatment orders for Resident #1 on 01/09/18 as documented on the Wound Assessment Report dated 01/09/18. The Treatment Nurse stated she did not receive a wound communication form until 01/12/18. The facility provided no evidence of a wound communication form at the time of exit on 02/15/18. The Treatment Nurse stated when she found out about Resident #1's pressure ulcers on 01/12/18, she notified the Physician Assistant (PA) who gave her the original treatment orders entered in the electronic record dated 01/12/18 but she must have forgotten to write an original physician order. The Treatment Nurse stated she thought the PA could give her orders on Resident #1. An Interview was conducted with the PA on 02/14/18 at 1:30 PM. The PA stated she did not give any treatment orders for Resident #1 because he was under the care of Physician #1 and it was an unacceptable medical practice to give orders or direction on Resident #1. She stated she did not recall the Treatment Nurse asking her for advice or orders regarding the worsening of Resident #1's pressure ulcers. The PA stated Resident #1 was being followed by the facility Wound Nurse Consultant. Physician #1 was interviewed via Telephone on 02/13/18 at 3:50 PM. Physician #1 stated he was in office 01/09/18 through 01/12/18 and noted that the facility let him know that Resident #1 was admitted but he was unsure if there was a request for treatment orders. Physician #1 stated the request for treatment orders could have gotten lost but he would have expected the facility to contact him again if they had not received a reply for treatment to Resident #1's pressure ulcer. Based on record review and interviews with the physician, physician assistant, Nurse #2 and Treatment Nurse, there was no evidence that the admitting nurse (Nurse #2) or the Treatment Nurse notified the physician of the condition of pressure ulcer and the need for treatment on 1/9/18. The resident did not receive assessment and treatment of [REDACTED]. Also there was no evidence that the treatment nurse got approval from the physician regarding the treatment orders that the treatment nurse initiated on the Treatment Administration Record (TAR) on 1/12/18. Review of Resident #1's January 2018 TAR indicated documented initials that his treatment was completed with [MEDICATION NAME] and Silver Alginate to his sacrum on 01/13/18 and 01/14/18. There was no documented description of the appearance of his sacral pressure ulcer on 01/13/18 or 01/14/18. There was no documentation that the pressure ulcer wound was ever assessed again after 01/09/18 until the Wound Nurse Consultant saw the area on 01/15/18. Review of the Wound Nurse Consultant report dated 01/15/18 read Resident #1 had an unstageable pressure ulcer to his sacrum measuring 3.5 cm length, 7.5 cm width and 0.5 cm depth. It was described as having excessive necrotic tissue appearing yellow/black in color. There was noted mild serous drainage with no odor. The note indicated there was no debridement completed and new orders for Medi-honey (medical-grade honey products for the management of wounds), Calcium Alginate (wound dressing made with the ingredient alginate, a highly-absorbent substance that is extracted from brown seaweed) and a foam dressing daily and as needed. During a telephone interview on 02/14/18 at 4:10 PM, the Wound Nurse Consultant stated she recently took over the wound care and treatments at the facility. She stated she first assessed Resident #1 on 01/15/18 and gave new orders for Medi-honey and Calcium Alginate to all areas on his sacrum. She stated it had been her experience in working with the Treatment Nurse that she wrote the new orders and contacted Physician #1. During an interview on 2/14/18 at 12:05 PM, the Treatment Nurse stated that she never saw the new order written in the Wound Nurse Consultant report on 01/15/18. There was no evidence that the Treatment Nurse notified the physician of the Wound Nurse Consultant new orders or that the orders were implemented. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment with no behaviors. He was coded requiring extensive assistance with bed mobility and total assistance with toileting and hygiene. Resident #1 was coded for an indwelling urinary catheter, always incontinent of bowel, and as admitted with two unstageable pressure ulcers. Review of the electronic physician orders [REDACTED].#1's unstageable wound to his sacrum with [MEDICATION NAME] spray (gentle antimicrobial wound cleanser with broad-spectrum bactericidal properties) for odor control. Pat the area dry and apply [MEDICATION NAME] to the peri-wound then apply Calcium Alginate to the wound bed only. Cover with a foam dressing daily and as needed. There were no written physician orders [REDACTED]. During an interview on 2/14/18 at 12:05 PM, the Treatment Nurse stated that, regarding the missing written order for treatment change on 1/16/18, the Wound Nurse Consultant gave her those orders on 01/15/18 but the Wound Nurse Consultant was responsible for writing her own treatment orders. The Treatment Nurse stated she only entered the new treatment order into the electronic medical record on 01/16/18 and never saw an original written order. During a telephone interview on 02/13/18 at 3:10 PM, the Wound Nurse Consultant confirmed she had not spoken with Physician #1 regarding Resident #1's pressure ulcers. Review of Resident #1's Wound Assessment Report dated 01/22/18 read Resident #1's unstageable pressure ulcer to his right buttock status deteriorated measuring 6.0 cm length, 6.0 cm width with no documented depth. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/22/18 with no new orders. Review of Resident #1's Wound Assessment Report dated 01/22/18 read Resident #1's unstageable pressure ulcer to his sacrum was unchanged measuring 3.5 cm length, 7.5 cm width with no documented depth. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/22/18 with no new orders. Review of Resident #1's Wound Assessment Report dated 01/22/18 read Resident #1's unstageable pressure ulcer to his left buttock status deteriorated measuring 7.5 cm length, 3.5 cm width and 0.3 cm depth. It was described as 60% Eschar, 30% slough and 10% granulation. There was noted moderate serous drainage with no evidence of infection. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/22/18 with no new orders. Review of the Wound Nurse Consultant report dated 01/22/18 read Resident #1 had an unstageable pressure ulcer to his sacrum measuring 13.5 cm length, 12.5 cm width and 1.5 cm depth. It was described as having excessive necrotic tissue appearing yellow/black in color and as deteriorated. There was noted moderate serous purulent drainage with no odor. The note indicated there was no debridement completed and no new orders. The treatment was to continue with Medi-honey, Calcium Alginate and a foam dressing daily and as needed. There was no evidence that the physician was notified of the deterioration of the pressure sores. Review of Physician #1's progress notes dated 01/26/18 read Resident #1 had a 4.0 length with 4.0 cm width sacral pressure ulcer. The note read the pressure ulcer needed [MEDICATION NAME] and intense wound care. The plan read to consult the wound consultant for wound care. Additional orders included a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and pre-[MEDICATION NAME] (marker of nutritional status and was used to help detect and diagnose protein-calorie malnutrition). Review of Resident #1's January 2018 TAR indicated documented initials that his treatments were completed to his sacrum with [MEDICATION NAME] spray and Calcium Alginate on 01/25/18, 01/26/18, 01/27/18 and 01/28/18. Review of the final wound culture dated 01/28/18 read Staphylococcus Aureus was present in Resident #1's sacrum. It was noted the results of the wound culture were faxed to Physician #1 on 01/28/18. Review of nursing note dated 01/28/18 read Physician #1 was aware of the wound culture result and there were no new orders except Physician #1 stated would treat with [MEDICATION NAME] already ordered on [DATE] for pneumonia. Review of a nursing note dated 01/29/18 read that on 01/28/18 at 9:30 PM, Resident #1's responsible party (RP) requested Resident #1 be sent to the hospital for intravenous (IV) antibiotics. Physician #1 was contacted and Resident #1 was transferred to the hospital as requested. Review of the hospital admission summary dated 01/29/18 read Resident #1 was admitted with [MEDICAL CONDITION] secondary to a urinary tract infection and an infected pressure ulcer. Bed-side debridement was completed on 01/29/18 of a stage 4 sacral pressure ulcer. It measured 10 cm length, 12 cm width and depth was down to the muscle. He was started on wound management and IV antibiotics. Resident #1 was discharged from the hospital on [DATE] to another facility. During an interview on 02/15/18 at 12:05 PM the Director of Nursing (DON) stated there were no facility standing orders for the treatment of [REDACTED]. She stated it was her expectation that whoever found a pressure ulcer would communicate it to the floor nurse who would then communicate it to the Treatment Nurse. The Treatment Nurse was then to notify the resident's physician to obtain orders for treatment. The DON stated she did not know where the Treatment Nurse was getting the orders she implemented for Resident #1. Physician #1 was interviewed via Telephone on 02/13/18 at 3:50 PM. Physician #1 stated he was responsible for his residents in the facility. He stated he was under the impression that Wound Nurse Consultant was also involved in the treatment of [REDACTED]. Physician #1 stated the facility did not notify him of the need of Resident #1 for treatment orders on admission and did not notify him of worsening of the pressure ulcers. Physician #1 stated it was his expectation that the facility would have re-attempted to contact him for treatment orders, notified him of worsening of the pressure ulcers and provided any treatments as ordered. Physician #1 stated the worsening of Resident #1's pressure ulcers was likely avoidable. The Medical Director was interviewed via Telephone on 2/13/18 at 5:15 PM. The Medical Director stated he was unaware until recently of the new Wound Care Management providers that apparently replaced the previous providers two weeks ago. He stated he was under impression the Wound Nurse Consultant was following all residents with pressure ulcers. He stated there was a Physician Assistant (PA) at the facility Monday through Friday but Resident #1 was admitted under the services of Physician #1 and would not have been involved in giving treatment orders for Resident #1. He stated it was his expectation Physician #1 would have been contacted for treatment orders. During an interview on 2/14/18 at 9:50 AM, the Administrator stated the facility had no standing orders for new or worsening pressure ulcers but rather the nurse was to notify the responsible physician each time for specific orders. She stated when an order is received from the attending physician, the Wound Nurse Consultant or the Physician Assistant, it was her expectation that the original order be written with the prescriber's signature then entered into the electronic medical record. The Administrator stated nothing should be entered into the electronic medical record unless there was a written order. The Administrator stated it was her expectation that residents be assessed timely for new or worsening pressure ulcer and the attending physician be notified timely. The Administrator was notified of immediate jeopardy on 02/15/18 at 9:10 AM. The Administrator provided the following Credible Allegation: Resident#1 no longer resides in the facility The nurses were unsure to call the Medical Director for treatment orders when the attending physician was unable to be reached. There was a lack of follow through by nursing to assure orders were received for treatment and a lack of oversight to identify and treat any worsening wound condition. The Treatment Nurse was removed from completing treatments 2/14/18 and retraining initiated. Floor staff will complete treatments beginning 2/14/18 until the Treatment Nurse' retraining is completed. A 100% audit all current residents with a wound was completed by the Regional Clinical Consultant on 2/15/18 to verify physician and Responsible Representative notification of the wound was completed when discovered. 3 instances lacked Responsible Party notification at the time of discovery. In those 3 instances, the wound was a surgical incision and the resident was deemed alert and oriented. One instance of delayed notification was noted. The Responsible Representative was contacted on 2/15/18 by the Unit Manager and given the history and status of the wound. The Staff Development Coordinator initiated an in-service on 2/15/18 to 100% of all nursing assistants on reporting skin changes noted during care by completing a full body shower sheet and submitting the sheet to the Charge Nurse. The Staff Development Coordinator initiated an in-service on 2/14/18 to 100% of all licensed staff to complete admission/re-admission head to toe skin assessments and weekly head to toe skin assessments with documentation of the assessment in the electronic medical record. The in-service will include calling the physician for treatment orders for all wounds identified with the admission skin assessment. The in-service included what to do when a new skin issue is identified and notification to the MD for treatment orders, Responsible Representative, Treatment Nurse, and Unit Managers. All newly hired nursing staff will receive the appropriate education during orientation. No staff will work until the in-service is completed. Utilizing a Wound Notification QI Audit Tool, the Unit Managers will review the Wound Communication Book to assure the physician and Responsible Representative have been notified of any new wound. Monitoring will occur Monday through Friday x 2 weeks then twice weekly x 2 weeks, then weekly x 4 weeks, then monthly x 1 month. The Weekend Supervisor will complete the audit on the weekend x 2. Using an Admissions Wound QI Tool, the Unit Managers will review all new admission/re-admission records to assure a skin assessment was completed on admission and any identified skin issues were addressed with a treatment order, progress note, notification to the MD and RP was made, and notification was completed in the Wound Communication book. The Director of Nursing will review the QI Audit Tools weekly x 8, then monthly x 1 for trends and concerns. The Director of Nursing will report the results of the monitoring to the Quality Assurance Committee monthly x 3 months for trends, concerns, and recommendations for any modification of the process. This Administrator will be responsible for implementing the credible allegation of removal on 2/15/18. The credible allegation was verified on 02/15/18 at 5:00 PM as evidence by staff interviews on regarding notification of new pressure ulcers or worsening of pressures and actions to take immediately when a newly in-house acquired pressure ulcer identified or worsened. Review of on-going in-service records revealed licensed and unlicensed staff present at the facility received training and staff who did not have the in-servicing would be in-serviced prior to working on the floor.

Based on staff, physician, physician assistant, Wound Nurse Consultant interviews and record review, the facility failed to obtain physician orders [REDACTED].#1 resulting in delay in treatment, failed to obtain physician orders [REDACTED].#1), and failed to consistently provide treatment to the pressure ulcer. Resident #1 was hospitalized with an infected stage 4 pressure ulcer requiring debridement and Intravenous antibiotics. The facility also failed to assess for the development of a facility acquired pressure ulcer (Resident #2), failed to immediately initiate treatment of [REDACTED].#2). Resident #2 had a stage 4 pressure ulcer requiring debridement and intravenous antibiotics. This was for 2 (Resident #1 and Resident #2) of 4 residents reviewed for pressure ulcers. Immediate jeopardy began on 01/09/18 for Resident #1 when he came in with a pressure ulcer on 1/09/18 and received no pressure ulcer treatment until 1/12/18. The facility provided no evidence of standing orders for pressure ulcer treatments. On 01/12/18, the Treatment Nurse began implementing treatment orders without approval of the physician. Resident #1 was seen by the Wound Nurse Consultant on 01/15/18 and her orders were not followed. There was no documented evidence of Resident #1's receiving pressure ulcer treatments from 01/09/18 through 01/12/18, 01/16/18, 01/18/18, 01/19/18, 01/23/18 and 01/24/18. The outcome for Resident #1 was the worsening of a pressure ulcer resulting in hospitalization with an infected stage 4 pressure ulcer requiring sharp debridement and antibiotic therapy. Resident #2 was admitted without any pressure ulcers on 01/01/18. Resident #2 developed a pink area on his sacrum on 01/09/18 with no evidence of interventions until 01/13/18. The Treatment Nurse began implementing treatment orders without approval of the physician. The outcome for Resident #2 was hospitalization on [DATE] with a stage 4 pressure requiring sharp debridement and antibiotic therapy. Immediate jeopardy was removed on 02/15/18 when an acceptable credible allegation was provided. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and that all staff have been in-serviced. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #1's admission orders [REDACTED]. There were no admitting lab-work and no treatment orders for pressure ulcers. Review of Resident #1's admission nursing note dated 01/09/18 at 4:36 PM read there was a quarter sized open area on his right buttock which was described as brownish/dark in color with a slight odor and minimal serosanguinous drainage. There was an eraser size area to his coccyx. There was no documented evidence that the physician or treatment nurse was notified. Review of Resident #1's Wound Assessment Report dated 01/09/18 read Resident #1 was admitted with an unstageable pressure ulcer to his right buttock measuring 3.5 centimeters (cm) length, 7.5 cm width and 0.5 cm depth. It was described as 40% eschar (dry, dark scab of dead skin) and 60% granulation (pink tissue containing capillaries formed around the wound edges). The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/09/18 with treatment orders pending. Review of Resident #1's Wound Assessment Report dated 01/09/18 read Resident #1 was admitted with an unstageable due to suspected deep tissue injury pressure ulcer to his sacrum measuring 3.5 cm length and 7.5 cm width. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/09/18 with treatment orders pending. Review of Resident #1's Wound Assessment Report dated 01/09/18 read Resident #1 was admitted with an unstageable pressure ulcer to his left buttock measuring 3.5 centimeters (cm) length, 7.5 cm width and 0.5 cm depth. It was described as 60% Eschar and 40% granulation. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/09/18 with treatment orders pending. A telephone interview was conducted with Nurse #2 on 02/14/18 at 3:25 PM. Nurse #2 stated she admitted Resident #1 on 01/09/18 and completed his initial skin assessment and noted a small area on his sacrum. She stated she completed a wound communication form and gave it to the Treatment Nurse on 01/09/18 as she was leaving. She stated she did not recall if the Treatment Nurse assessed Resident #1 on 01/09/18 because he was admitted at the end of first shift and the Treatment Nurse usually left around 3:00 PM. Nurse #2 stated she was not aware of any standing orders for the treatment of [REDACTED]. She stated it was the responsibility of the Treatment Nurse to contact the physician. Regarding the missing treatment on 01/24/18, Nurse #2 stated she provided Resident #1 his treatment on 01/24/18 but forgot to initial the TAR. During an interview on 2/14/18 at 11:10 AM, Nursing Assistant (NA) #1 stated on 01/09/18 she assisted Nurse #2 with Resident #1's skin assessment and Nurse #2 noted a small area on his bottom. She stated Nurse #2 completed a wound communication form and gave it to the Treatment Nurse before she left for the day. NA #1 stated Resident #1 was always cooperative with his care, gotten up daily and laid back down after lunch. During an interview on 2/14/18 at 12:05 PM, the Treatment Nurse stated she was not made aware of any pressure ulcers found on Resident #1 until 01/12/18. When questioned regarding the Wound Assessment Report she completed on 01/09/18 on Resident #1, the Treatment Nurse stated she must have dated the assessment incorrectly and it should have been dated 01/12/18. She stated she did not recall asking for treatment orders for Resident #1 on 01/09/18 as documented on the Wound Assessment Report dated 01/09/18. The Treatment Nurse stated she did not receive a wound communication form until 01/12/18. The facility provided no evidence of a wound communication form at the time of exit on 02/15/18. The Treatment Nurse stated when she found out about Resident #1's pressure ulcers on 01/12/18, she notified the PA who gave her the original treatment orders entered in the electronic record dated 01/12/18 but she must have forgotten to write an original physician order. The Treatment Nurse stated she thought the PA could give her orders on Resident #1. In an Interview was conducted with the PA on 02/14/18 at 1:30 PM. The PA stated she did not give any treatment orders for Resident #1 because he was under the care of Physician #1 and it was an unacceptable medical practice to give orders or direction on Resident #1. She stated she did not recall the Treatment Nurse asking her for advice or orders regarding the worsening of Resident #1's pressure ulcers. The PA stated Resident #1 was being followed by the facility Wound Nurse Consultant. Review of the 48-Hour Baseline Care Plan dated 01/10/18 read Resident #1 was admitted with pressure ulcers. Interventions included pressure ulcer care, pressure reducing mattress to the bed and wheel-chair. Review of Resident #1's January 2018 Treatment Administration Record (TAR) included no treatment orders to his bilateral buttocks and sacrum from 01/09/18 through 01/12/18. Review of the electronic physician orders [REDACTED]. The Treatment Nurse entered the following new treatment orders which auto-populated the TAR: bilateral buttocks and sacrum were to be cleansed with wound cleanser, patted dry and [MEDICATION NAME] ointment ([MEDICATION NAME], antiseptic, [MEDICATION NAME], and skin protectant combination) was to be applied to the peri-wound with Silver Alginate (an antimicrobial, highly absorbent wound dressing with ionic silver) to the wound bed. It was to be covered with a protective foam dressing daily and as needed. There were no written physician orders [REDACTED]. Review of Resident #1's January 2018 TAR indicated documented initials that his treatment was completed with [MEDICATION NAME] and Silver Alginate to his sacrum on 01/13/18 and 01/14/18. Review of the Wound Nurse Consultant report dated 01/15/18 read Resident #1 had an unstageable pressure ulcer to his sacrum measuring 3.5 cm length, 7.5 cm width and 0.5 cm depth. It was described as having excessive necrotic tissue appearing yellow/black in color. There was noted mild serous drainage with no odor. The note indicated there was no debridement completed and new orders for Medi-honey (medical-grade honey products for the management of wounds), Calcium Alginate (wound dressing made with the ingredient alginate, a highly-absorbent substance that is extracted from brown seaweed) and a foam dressing daily and as needed. There was no Wound Assessment Report completed for Resident #1 the week of 01/15/18 through 01/19/18. This was the responsibility of the Treatment Nurse. Review of the written physician orders [REDACTED]. Review of the electronic physician orders [REDACTED].#1's unstageable wound to his sacrum with [MEDICATION NAME] spray (gentle antimicrobial wound cleanser with broad-spectrum bactericidal properties) for odor control. Pat the area dry and apply [MEDICATION NAME] to the peri-wound then apply Calcium Alginate to the wound bed only. Cover with a foam dressing daily and as needed. There were no written physician orders [REDACTED]. Review of Resident #1's January 2018 TAR indicated no documented initials that his treatment was completed to his sacrum with [MEDICATION NAME] and Silver Alginate on 01/16/18. Review of the archived Time Card Report indicated the Treatment Nurse worked 01/16/18. Review of the daily schedule assignment sheet indicated the Treatment Nurse was assigned all treatments 01/16/18. During an interview on 2/14/18 at 12:05 PM, the Treatment Nurse stated that, regarding the missing written order for treatment change on 1/16/18, the Wound Nurse Consultant gave her those orders on 01/15/18 but the Wound Nurse Consultant was responsible for writing her own treatment orders. The Treatment Nurse stated she only entered the new treatment order into the electronic medical record on 01/16/18 and never saw an original written order. During a telephone interview on 02/14/18 at 4:10 PM, the Wound Consultant Nurse stated she recently took over the wound care and treatments at the facility. She stated she first assessed Resident #1 on 01/15/18 and gave new orders for Medi-honey and Calcium Alginate to all areas on his sacrum. She stated it had been her experience in working with the Treatment Nurse that she wrote the new orders. She stated it was her expectation that the order she gave to the Treatment Nurse on 01/15/18 would have been written and implemented. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment with no behaviors. He was coded requiring extensive assistance with bed mobility and total assistance with toileting and hygiene. Resident #1 was coded for an indwelling urinary catheter, always incontinent of bowel, and as admitted with two unstageable pressure ulcers. The Care Area Assessment (CAA) dated 01/16/18 read Resident #1 was admitted with multiple wounds and remained at risk for the development of additional skin impairments. The CAA indicated a care plan would be developed. Review of Resident #1's care plan dated 01/16/18 read he had an unstageable pressure ulcer to his sacrum. Interventions included the following: provide timely incontinence care, measure the wound at least weekly, report any decline in wound status to physician, administer treatments as ordered and document. Review of Resident #1's January 2018 TAR indicated documented initials that his treatment was completed to his sacrum with [MEDICATION NAME] and Silver Alginate on 01/17/18. Review of Resident #1's January 2018 TAR indicated no documented initials that his treatment was completed to his sacrum with [MEDICATION NAME] and Silver Alginate on 01/18/18. Review of the daily schedule assignment sheet indicated the floor nurses were responsible for their own treatments on 01/18/18. Nurse #1 was assigned to complete Resident #1's treatment on 01/18/18. During a telephone interview on 02/12/18 at 11:30 AM, Nurse #1 stated she completed the treatment on 01/18/18 but must have forgotten to initial the TAR. Review of Resident #1's January 2018 TAR indicated no documented initials that his treatment was completed to his sacrum with [MEDICATION NAME] and Silver Alginate on 01/19/18. Review of the archived Time Card Report indicated the Treatment Nurse worked 01/19/18. Review of the daily schedule assignment sheet indicated the Treatment Nurse was assigned all treatments on 01/19/18. Review of Resident #1's January 2018 TAR indicated documented initials that his treatment was completed to his sacrum with [MEDICATION NAME] spray and Calcium Alginate on 01/20/18 and 01/21/18. Review of Resident #1's Wound Assessment Report dated 01/22/18 read Resident #1's unstageable pressure ulcer to his right buttock status deteriorated measuring 6.0 cm length, 6.0 cm width with no documented depth. There was no additional documented description of the pressure ulcer on his right buttock. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/22/18 with no new orders. Review of Resident #1's Wound Assessment Report dated 01/22/18 read Resident #1's unstageable pressure ulcer to his sacrum was unchanged measuring 3.5 cm length, 7.5 cm width with no documented depth. There was no additional documented description of the pressure ulcer to his sacrum. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/22/18 with no new orders. Review of Resident #1's Wound Assessment Report dated 01/22/18 read Resident #1's unstageable pressure ulcer to his left buttock status deteriorated measuring 7.5 cm length, 3.5 cm width and 0.3 cm depth. It was described as 60% Eschar, 30% slough and 10% granulation. There was noted moderate serous drainage with no evidence of infection. The report was completed by the Treatment Nurse and indicated Physician #1 was notified on 01/22/18 with no new orders. Review of the Wound Nurse Consultant report dated 01/22/18 read Resident #1 had an unstageable pressure ulcer to his sacrum measuring 13.5 cm length, 12.5 cm width and 1.5 cm depth. It was described as having excessive necrotic tissue appearing yellow/black in color and as deteriorated. There was noted moderate serous purulent drainage with no odor. The note indicated there was no debridement completed and no new orders. The treatment was to continue with Medi-honey, Calcium Alginate and a foam dressing daily and as needed. Review of Resident #1's January 2018 TAR indicated no documented initials that his treatment was completed to his sacrum with Anaspet spray and Calcium Alginate 01/23/18. Review of the archived Time Card Report indicated the Treatment Nurse worked 01/23/18. Review of the daily schedule assignment sheet indicated the Treatment Nurse was assigned all treatments 01/23/18. Review of a physician order [REDACTED].#1 was ordered a wound culture of his sacrum. During an interview on 2/14/18 at 12:05 PM, the Treatment Nurse stated that, regarding all the missing documentation for treatments on the TAR, she must have forgotten to initial the TAR but Resident #1 received his treatments on 01/16/18, 01/19/18 and 01/23/18. Review of Resident #1's January 2018 TAR indicated no documented initials that his treatment was completed on his sacrum with Anaspet spray and Calcium Alginate on 01/24/18. Review of the daily schedule assignment sheet indicated the floor nurses were responsible for their own treatments on 01/24/18. Nurse #2 was assigned to complete Resident #1's treatment on 01/24/18. During a telephone interview on 02/15/18 at 2:40 PM,Nurse #2 stated she provided Resident #1's pressure ulcer treatment on 01/24/18 but forgot to inital off on the TAR. Review of a physician order [REDACTED].#1 was prescribed an antibiotic ([MEDICATION NAME]) daily for ten days for pneumonia. Review of Physician #1's progress notes dated 01/26/18 read Resident #1 had a 4.0 length with 4.0 cm width sacral pressure ulcer. The note read the pressure ulcer needed [MEDICATION NAME] and intense wound care. The plan read to consult the wound consultant for wound care. Additional orders included a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and pre-[MEDICATION NAME] (marker of nutritional status and was used to help detect and diagnose protein-calorie malnutrition). Review of Resident #1's January 2018 TAR indicated documented initials that his treatments were completed to his sacrum with [MEDICATION NAME] spray and Calcium Alginate on 01/25/18, 01/26/18, 01/27/18 and 01/28/18. Review of the final wound culture dated 01/28/18 read Staphylococcus Aureus was present in Resident #1's sacrum. It was noted the results of the wound culture were faxed to Physician #1 on 01/28/18. Review of nursing note dated 01/28/18 read Physician #1 was aware of the wound culture result and there were no new orders except Physician #1 stated would treat with [MEDICATION NAME] already ordered on [DATE] for pneumonia. Review of a nursing note dated 01/29/18 read that on 01/28/18 at 9:30 PM, Resident #1's responsible party (RP) requested Resident #1 be sent to the hospital for intravenous (IV) antibiotics. Physician #1 was contacted and Resident #1 was transferred to the hospital as requested. Review of the hospital admission summary dated 01/29/18 read Resident #1 was admitted with [MEDICAL CONDITION] secondary to a urinary tract infection and an infected pressure ulcer. Bed-side debridement was completed on 01/29/18 of a stage 4 sacral pressure ulcer. It measured 10 cm length, 12 cm width and depth was down to the muscle. He was started on wound management and IV antibiotics. Resident #1 was discharged from the hospital on [DATE] to another facility. An interview was conducted on 02/13/18 at 11:10 AM, with the Treatment Nurse. She stated she began working at the facility sometime in October 2017 but started as a floor nurse on night shift. She stated she began doing treatments a few month ago. The Treatment Nurse stated during that time, she received no training except for two days with the previous treatment nurse. She stated there was a lack of communications from the floor staff to her so she instituted a wound communication notebook and placed one at each nursing station. When a new area was identified, she would know about it if the nurses documented it in her wound communication notebook. She stated she checked the wound communication notebooks daily. The Treatment Nurse stated the facility did not have any standing orders for pressure ulcer treatments and the physician should be contacted for new orders when a new area or worsening area was noted. The Treatment Nurse stated she normally arrived to work at 7:00 AM and worked eight hours. She stated she did not always attend morning stand-up meeting with the management team and floor staff supervisors. She stated some morning she was busy with the wound nurse consultant or working on a cart. During a telephone interview on 02/13/18 at 3:10 PM, the Wound Nurse Consultant stated she only recently started coming to the facility and it was her practice not to be overly aggressive. She stated she chose to act conservatively when treating pressure ulcers. She stated Resident #1's missing treatments could have caused his pressure ulcers to have worsened rather than the lack of debridement. She confirmed she had not spoken with Physician #1 regarding Resident #1's pressure ulcers. The Wound Nurse Consultant stated the Treatment Nurse should have written the orders she gave on 01/15/18. She confirmed the Treatment Nurse made wound rounds with her weekly. An interview was conducted with the Unit Manager (UM) #1 on 02/15/18 at 11:35 AM. UM #1 stated Resident #1 was on her unit. She stated concerns regarding the Treatment Nurse performing her duties became evident sometime in January 2018. UM #1 stated the interim Administrator was notified and aware of the concerns and worsening of Resident #1's pressure ulcers. She stated the new Administrator started on 02/12/18 but she was also aware of concerns related to the Treatment Nurse. UM #1 stated the Treatment Nurse was never pulled from treatments but rather she was left in her position until the new Administrator suspended her on 02/14/18. UM #1 stated the Treatment Nurse did not attend the morning stand up meeting where residents were discussed daily. She stated the floor nurses were instructed by the Treatment Nurse to complete a wound communication form which was a shower sheet and put it in her notebook for her to address. During an Interview on 02/15/18 at 12:05 PM the Director of Nursing (DON) stated there were no facility standing orders for the treatment of [REDACTED]. She stated it was her expectation that whoever found a pressure ulcer would communicate it to the floor nurse who would then communicate it to the Treatment Nurse. The Treatment Nurse was then to notify the resident's physician to obtain orders for treatment. The DON stated she did not know where the Treatment Nurse was getting the orders she implemented for Resident #1. She stated she did not complete wound rounds with the Treatment Nurse but rather thought wound rounds were completed by the Wound Nurse Consultant. She stated Patient at Risk (PAR) were discussed daily in morning stand up meetings but the Treatment Nurse did not attend. The DON stated the interim Administrator was notified of the concerns about the Treatment Nurse not completing her treatments but the interim Administrator did not offer any directive. Physician #1 was interviewed via Telephone on 02/13/18 at 3:50 PM. Physician #1 stated he was in office 01/09/18 through 01/12/18 and noted that the facility let him know that Resident #1 was admitted but he was unsure if there was a request for treatment orders. Physician #1 stated the request for treatment orders could have gotten lost but he would have expected the facility to contact him again if they had not received a reply for treatment to Resident #1's pressure ulcer. Physician #1 stated he was responsible for his residents in the facility. He stated he was under the impression that Wound Nurse Consultant was also involved in the treatment of [REDACTED]. Physician #1 stated it appeared the facility was not adequately treating Resident #1's pressure ulcers and did not notify him of worsening of the pressure ulcers. He stated it was his expectation that the facility would have re-attempted to contact him for treatment orders, notified him of worsening of the pressure ulcers and provided any treatments as ordered. Physician #1 stated the worsening of Resident #1's pressure ulcers was likely avoidable. The Medical Director was interviewed via Telephone on 2/13/18 at 5:15 PM. The Medical Director stated he was unaware until recently of the new Wound Care Management providers that apparently replaced the previous providers two weeks ago. He stated he was under impression the Wound Nurse Consultant was following all residents with pressure ulcers. He stated there was a Physician Assistant (PA) at the facility Monday through Friday but Resident #1 was admitted under the services of Physician #1 and would not have been involved in giving treatment orders for Resident #1. He stated it was his expectation that all newly developed or worsening pressure ulcers be assessed, treatment orders obtained timely, and treatments be completed as ordered. The Medical Director stated there seemed to be a lack of reaction and communication on the part of the facility. During an interview on 2/14/18 at 9:50 AM, the Administrator stated the facility had no standing orders for new or worsening pressure ulcers but rather the nurse was to notify the responsible physician each time for specific orders. She stated when an order is received from the attending physician, the Wound Nurse Consultant or the Physician Assistant, it was her expectation that the original order be written with the prescriber's signature then entered into the electronic medical record. The Administrator stated nothing should be entered into the electronic medical record unless there was a written order. She stated she took over as the facility Administrator on 02/12/18 and prior to 02/12/18, there was an interim Administrator. She stated she was still involved and had knowledge of concerns related to the treatment nurse not performing her duties. The Administrator stated it became evident around mid-January 2018 during inclement weather. She stated the Unit Managers (UM) brought it to the attention interim Administrator. The Administrator stated she only recently became aware of how the facility staff were completing skin assessment by only documenting whether the skin was intact or not-intact. She stated it was her expectation a full body inspection be completed weekly with a narrative description of each resident's skin status. She stated she also recently became aware that the Treatment Nurse was not attending morning stand-up meetings where patients at risk (PAR) were discussed daily. She stated it was her expectation that the Treatment Nurse would have attended those meetings. The Administrator stated it was her expectation that residents be assessed timely for new or worsening pressure ulcers and treatments be initiated and followed as ordered. 2. Resident #2 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #2's admission Minimum Data Set ((MDS) dated [DATE] indicated severe cognitive impairment with rejection of care on one to three days. He was coded as requiring extensive assistance with bed mobility, toileting and hygiene. Resident #2 was coded as incontinent of bladder and bowel and as admitted with one arterial ulcer. The Care Area Assessment (CAA) dated 01/08/18 read Resident #2 was admitted to the facility with no existing pressure ulcers but one arterial ulcer was noted and he was non-ambulatory. He was at risk for the development of additional skin impairments. The CAA indicated a care plan would be developed. Review of Resident's #2's admission orders [REDACTED]. Review of Resident #2's admission nursing note dated 01/01/18 at 2:40 PM did not include any documentation regarding his skin condition. Review of Resident #2's Interim Care Plan dated 01/01/18 read repositioning every two hours for pressure ulcer relief. Review of Resident #2's Admission Skin assessment dated [DATE] read pink area to his sacrum. There was no evidence of new orders. Review of Resident #2's new admission skin assessment documented on a shower sheet dated 01/03/18 read a pink area to his sacrum. This assessment was completed by the Treatment Nurse. There was no evidence of any new orders. Review of Resident #2's care plan dated 01/05/18 read he had the potential for skin breakdown related to his recent history of refusing to lie down in bed from his wheelchair to assess for incontinence. Interventions included the following: encourage resident to turn and reposition on routine rounds, provide assistance with repositioning as needed, observe skin daily and report any redness or impairment to nurse, full weekly skin assessment by the nurse, keep skin clean, dry and apply barrier cream if ordered and encourage resident to shift weight frequently while up in chair. Review of Resident #2's skin assessment documented on a shower sheet and dated 01/09/18 read pink area to sacrum. This assessment was completed by the Treatment Nurse. There was no evidence of any new orders. Review of an occupational therapy assistant (OTA) note dated 01/10/18 at 2:12 PM read nursing aware of skin breakdown to Resident #2's buttocks. During an interview on 02/15/18 at 12:20 PM, NA #2 stated she recalled the day when she and the OTA were in Resident #2's room together. She stated she recalled applying barrier cream because his buttocks were only red at the time. She stated Resident #2 was on a pressure reducing mattress and had a cushion in his wheelchair. During a telephone interview on 02/15/18 at 12:10 PM, the OTA stated she was in the room with Resident #2 and the NA #2 on 01/10/18 working on his upper body range of motion when she noticed NA #2 putting an ointment on Resident #2's buttocks. She stated she charted that nursing was aware of his skin impairment in her note dated 01/10/18. Review of Resident #2's January 2018 physician's orders [REDACTED]. Review of a nursing note dated 01/13/18 at 3:24 PM read the Nursing Assistant reported open area to Resident #2's right and left buttocks. New orders to cleanse the right and left buttock with wound cleanser, apply [MEDICATION NAME] ointment and foam dressing every other day and as needed. The note read the wound communication notebook was updated. This note was completed by Nurse #1. During a telephone interview on 02/12/18 at 4:50 PM, Nurse #1 stated the aide reported to her an area on Resident #2's sacrum on 01/13/18 so she completed the wound communication form and put a copy in the wound communication notebook and left a copy for the Director of Nursing (DON). She stated she contacted the PA and received orders for treatment. Review of a shower sheet dated 01/13/18 completed by Nurse #1 read Resident #2 had open areas to his left and right buttock and sacrum. The shower sheet indicated the Medical Director, the Responsible Party (RP), the Treatment Nurse and the Director of Nursing (DON) were all notified on 01/13/18 at 2:30 PM. Review of Resident #2's January 2018 Treatment Administration Record (TAR) indicated he received his treatment as written by Nurse #1's nursing note on 01/13/18 with the next treatment due until 01/15/18. Review of Resident #2's January 2018 TAR indicated he received his treatment on 01/15/18 as written by Nurse #1's nursing note on 01/13/18. Review of the Wound Nurse Consultant note dated 01/15/18 read Resident #2's arterial ulcer was assessed. There was no mention of an assessment to Resident #2's right or left buttocks open areas. Review of a nursing note dated 01/16/18 at 9:30 AM as an addendum for 01/14/18 was conducted. The note read on assessment, Resident #2 was noted with a stage 3 pressure ulcer to his right buttock measuring 7.0 cm length, 3.5 cm width and 0.2 cm depth. It was described as having 80% slough (soft, moist avascular dead tissue) and 20% granulation tissue (pink tissue containing capillaries formed around the wound edges). There was a st (TRUNCATED)

Based on observation, resident interview, staff interview, and record review, the facility failed to provide effective supervision to prevent injury for a resident (Resident #78) who was identified as an unsafe smoker for 1 of 1 residents reviewed for smoking. Resident #78 dropped a cigarette on herself while smoking causing second degree burns to her upper and lower left thigh. The findings included: Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The plan of care dated 3/20/17 indicated Resident #78 required supervision for safe smoking. The interventions in place included staff supervision of Resident #78 in the designated smoking area. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78's cognition was moderately impaired. She was assessed with [REDACTED]. Resident #78 required the extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, dressing, and personal hygiene. She was assessed as not steady on her feet and was only able to stabilize with staff assistance. Resident #78 had impairment on one side of the lower extremity and utilized a wheelchair. A safe smoking assessment dated [DATE] required an observation of Resident #78 smoking to determine if she was able to smoke safely. The requirements for safe smoking included, in part, Does not allow ashes or lit material to fall while smoking, inhaling, or holding smoking item .does not endanger self or others while smoking .does not burn furniture, clothing, skin, self, or others. Resident #78 was assessed as unsafe for independent smoking. An incident report completed by Nurse #1 dated 5/8/17 indicated Resident #78 obtained a burn caused by direct heat exposure at 11:00 AM. The narrative of the incident and description of injuries read, Resident (#78) in smoking area for scheduled smoke time supervised. Apron on resident at the time of smoking per Assistant Director of Nursing (ADON) and the Director of Nursing (DON). When Resident (#78) return to unit, (Nurse #1) noted burn hole to towel resting in resident lap. Removed towel and skin assessment revealed blistered area to upper left thigh. Burn to left upper thigh/blister 2.5 centimeters (cm) by 3.0 cm. Immediate actions included vital signs, a full skin assessment, pain medication, and notification of the physician with treatment orders provided to Resident #78. A nursing note dated 5/8/17 at 5:25 PM written by Nurse #1 indicated she observed Resident #78 with a burned hole on a towel that was in her lap when she returned from a smoking break. Nurse #1 completed a skin assessment and noted a blistered area to Resident #78's left upper thigh. The area surrounding the blister was noted to be reddened. Resident #78 reported her pain level as a 4 out of 10. Scheduled pain medication was provided. The Unit Manager, the Director of Nursing, and Administrator were notified. The physician was notified and treatment orders were provided to Resident #78. The Responsible Party of Resident #78 was notified. A physician's orders [REDACTED].#78. The burn area was to be covered with non-adherent dressing twice daily until healed. A review of the Treatment Administration Record indicated Resident #78 received treatment as ordered by the physician. An incident report follow up dated 5/11/17 indicated Resident #78 denied pain or discomfort post incident. A Plan of Correction (P(NAME)) was implemented and continued. The treatment for [REDACTED]. A physician's orders [REDACTED].#78. The facility wound assessment dated [DATE] indicated Resident #78 had a burn to the left front lateral thigh first identified on 5/8/17 caused by an accident/other trauma. The assessment indicated the Wound Care Physician (WCP) was consulted due to poor healing of the burn. The WCP's initial evaluation dated 5/30/17 indicated Resident #78 was referred for evaluation of a burn wound of the left upper thigh of at least 21 stays in duration. There was no indication of pain associated with the condition. Resident #78 was noted to have dropped a cigarette on herself that ignited her clothing. Two wound sites were identified: - Site 1: Burn wound of the left upper thigh (wound size 0.9 cm length, 1.1 cm width, and 0.10 cm depth) - Site 2: Burn wound of the left lower thigh (wound size 4.5 cm length, 5.0 cm width, and 0.10 cm depth) The medical record indicated Resident #78 was seen by the WCP for continued evaluation of her burn wounds on 6/5/17, 6/13/17, 6/20/17, 6/27/17, 7/3/17, 7/11/17, 7/18/17 and 7/25/17. Resident #78 was assessed with [REDACTED]. Both wound sites were noted as improved on each subsequent evaluation. Resident #78's burn wound to the left upper thigh was assessed as resolved on 6/27/17 (duration of greater than 46 days) and the burn wound to the left lower thigh (duration of greater than 72 days) was assessed as resolved on 7/25/17. An interview was conducted with Resident #78 on 8/15/17 at 1:50 PM. Resident #78 confirmed she was a smoker, she required supervision while smoking, and was to wear a smoking apron for safety during the act of smoking. She verified she had been burned on the thigh by a cigarette, but she was unable to provide any additional information on the incident due to cognitive impairments. An interview was conducted with Nurse #1 on 8/15/17 at 1:55 PM. She verified she had completed the incident report dated 5/8/17 for Resident #78. She reported Resident #78 had returned to the unit following the completion of her supervised smoking on 5/8/17. She explained that Resident #78 often kept a towel on her lap to protect her clothing from food and other items as she tended to have spastic and uncontrolled movements. Nurse #1 stated she noticed a burn hole on the towel that was in Resident #78 ' s lap which led to the identification of the burn to Resident #78's left thigh. She stated the Administrator and DON were on the unit at that time and were notified of the injury. Nurse #1 indicated the Physician Assistant (PA) was also on site at the facility and she came to the unit to assess Resident #78 and she provided orders for treatment. An interview was conducted with the Administrator on 8/15/17 at 2:10 PM. She indicated she was familiar with Resident #78 and was aware of the incident on 5/8/17. She stated the DON was supervising the smoking area at the time of 5/8/17 incident with Resident #78. She reported the investigation into the incident revealed Resident #78 had her smoking apron on, but it was tied around her waist. She indicated Resident #78 was in a wheelchair and the cigarette had fallen in the gap between the arm of the wheelchair and Resident #78's leg. Her leg was not fully protected by the smoking apron. The Administrator reported a P(NAME) was immediately implemented. She stated this P(NAME) included changing the placement of the smoking aprons for residents in wheelchairs and/or seated in chairs. She indicated instead of tying the aprons around the waist of the resident, the apron was to be tied around the arms of the wheelchair/chair to protect their entire lap and leg area. She reported the P(NAME) additionally included re-education of all facility staff on safe smoking practices as well as smoking assessments and ongoing audits. An interview was conducted with the DON on 8/15/17 at 2:29 PM. She confirmed she was supervising the smoking area during the incident on 5/8/17 with Resident #78. She explained that on the date of the incident, smoking time was initially supervised by Nursing Assistant (NA) #1. NA #1 reportedly had an emergency and she (the DON) was called to the smoking area to replace NA #1 and to supervise the remainder of the smoking time. She reported the smoking area was supervised by at least one staff member throughout this smoking time. The DON verified Resident #78 had her smoking apron on, but it was tied around her waist which allowed for a gap between the arm of the wheelchair and Resident #78's legs. She explained that Resident #78's hands tended to tremble which caused her difficulty extinguishing her cigarette. She reported Resident #78 was instructed by staff to drop her cigarette on the ground and the staff then extinguished and disposed of the cigarette. She explained when she replaced NA #1 as the smoking supervisor, Resident #78 had no cigarette in her hand. She stated she lit a cigarette and gave it to Resident #78. She reported when the smoking time had been completed she removed Resident #78 ' s smoking apron and accompanied her back to her unit. She stated she assisted Resident #78 with repositioning in her wheelchair when she noticed a brown mark on the towel in the resident's lap. She revealed when the towel was removed from Resident #78, it was apparent the cigarette the burned through the towel, through her pants, and burned the top of her leg. She stated Resident #78 had not said anything about the burn or about any pain. The DON stated Resident #78 was immediately assessed by herself, Nurse #1 and the PA. She revealed the injury was assessed as a second degree burn. She reported pain medication was administered and new treatment orders were received from the PA. This interview with the DON continued. She stated an investigation into the incident began that day (5/8/17) as well as the initiation of a P(NAME). The DON explained that Resident #78 had a towel that was partially rolled up between the arm of the wheelchair and her leg. The smoking apron was tied around Resident #78 ' s waist. She stated Resident #78 had dropped her cigarette in the gap between the arm of the wheelchair and her leg, which was not fully covered by the smoking apron. The DON stated she believed Resident #78 had meant to drop her cigarette on the ground, but had mistakenly dropped it on herself. She indicated Resident #78 was unable to explain what had happened. The DON reported Resident #78's burn to the left thigh was treated as ordered by the physician until the burn was fully healed. She confirmed the WCP was consulted on 5/30/17 for evaluation of the burn wound due to poor healing. The DON verified the WCP had evaluated Resident #78's burn wound as two separate wound sites to the left thigh. She stated both of these wound sites were identified on 5/8/17, they were assessed as one wound site, and had had been treated as ordered with wound care since the time of the incident. NA #1 was unavailable for interview. An observation was conducted on 8/16/17 at 10:08 AM of Resident #78 in the designated smoking area at the designated smoking time with staff supervision. Resident #78's smoking apron was tied around the chair and there were no concerns observed with the safety of her smoking. The corrective action for past non-compliance dated 5/8/17 was as follows: 1. Resident #78 was given a full skin assessment from head to toe by the DON and PA on 5/8/17. Any areas of skin concern were addressed and treatment orders were obtained. Resident #78 was assessed for pain at the time of skin inspection. Resident #78 received scheduled pain medication prior to the skin inspection and had no complaint of pain at the time of the inspection. Resident #78 received another smoking assessment by the SW on 5/8/17. Resident #78 was again assessed as unsafe to smoke independently and required staff supervision when smoking. Date of completion: 5/8/17. 2. All residents who smoke (safe and unsafe) were given a smoking assessment by the SW and the Activities Director on 5/8/17. Any resident determined to be unsafe with smoking was placed on the list for supervised smoking immediately. All smoking aprons were assessed for integrity by the DON and the Administrator on 5/8/17. An inspection of the clothing of all residents who smoke (safe and unsafe) was performed by laundry personnel on 5/8/17 and 5/9/17 to determine if residents deemed safe could possibly be unsafe at times other than when the smoking assessment was completed. No concerns were identified by this review. All residents who smoke (safe and unsafe) were given a head to toe skin assessment by the Registered Nurse Supervisor between 5/8/17 and 5/9/17. No concerns were identified by this review. Date of completion: 5/9/17. 3. All staff (licensed and unlicensed in all departments), including the DON, were in-serviced regarding the procedure for safe smoking practices. This inservice included, but was not limited to, times for supervised smoking, duties of supervising staff, signs to recognize safe smokers, and the proper technique for placing a smoking apron on residents. These in-services were provided by the Assistant Director of Nursing on 5/8/17 through 5/10/17. The Environmental Services Director (ESD) will wash and inspect all smoking aprons weekly for integrity. If an apron is determined to be unsafe/worn/damaged the ESD is to dispose of the apron and order a new one if needed. All residents that smoke will be evaluated by a smoking assessment at least quarterly or at the time of their MDS assessment. These assessments will be completed by the SW. All newly admitted or readmitted residents will receive a smoking assessment upon admission by the admitting nurse. All residents determined to be unsafe to smoke independently will have their smoking materials (lighters, cigarettes, etc.) in the facility container which is only accessible by staff. The smoking materials will be made available to residents under supervision only. Date of completion: 5/10/17. 4. To maintain quality assurance, a member of the management team will provide impromptu inspection of the smoking area at least once daily for one week, weekly for one month, and monthly for three months. Findings of these inspections will be presented in the monthly Quality Assurance and Improvement Meeting for a minimum of three consecutive months. As part of the validation process on 8/16/17 and 8/17/17, the plan of correction was verified. The re-education of staff (in-service sign in sheets dated 5/8/17 through 5/10/17) was reviewed. Interviews with staff (licensed and unlicensed) revealed they were retrained on safe smoking practices following the 5/8/17 incident with Resident #78. Observations were conducted of the smoking area to ensure residents were smoking safely with effective supervision. Resident #78 was observed smoking safely with no identified concerns. A review of the monitoring tools revealed the facility completed all audits as noted in their P(NAME). A review of the audits revealed the apron inspection audits had been completed weekly beginning on 5/8/17 and were ongoing. A review of the smoking area audits revealed it had been completed once a day from 5/8/17 through 5/16/17, once a week from 5/17/17 through 6/19/17, and once a month from 7/4/17 through present (most recent review on 8/14/17). No concerns were identified during the audits. The final correction date was 5/10/17.

Based on observation, record review and staff, physician, and Nurse Practitioner interviews, the facility failed to prevent 1 of 1 sampled cognitively impaired residents (Resident #1), reviewed for wandering behaviors from exiting the facility while unsupervised. The immediate jeopardy began on 11/07/15 when Resident #1 exited the facility unattended by the facility staff, and was found beside the facility building about 10 feet from a fire exit door. The immediate Jeopardy was removed on 11/14/15 at 3:30 PM when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy (s/s of D). At the time the Immediate Jeopardy (IJ) was removed, the facility was in the process of full implementation and monitoring of the acceptable Credible Allegation (CA). Resident #1 was monitored and evaluated to be safe from exiting the facility while residing in the facility ' s Secured Unit. The findings included: Resident #1 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the resident's quarterly care plan dated 8/09/15 addressed the problem of resident wanders throughout the building/attempts to exit the building and/or is an elopement risk. The goals stated for this problem were: 1. Resident will remain safe (inside the building except for designated areas outside with staff) & remain free of injuries and 2. Will not present with any episodes of elopement daily over the next review. The interventions listed for this problem included: 1. Redirect resident as needed. 2. Approach resident in calm manner and explain risk if trying to exit. 3. MD (medical doctor) & psychological evaluation as needed. 4. Monitor for changes in resident mood, behaviors, confusion, etc. (etcetera) and consult with MD (medical doctor) as needed. 5. Social Services to evaluate resident. 6. Monitor resident for behaviors (attempts at elopement, wandering, etc.) every shift. Record any incidents of elopement in nurse notes. Notify physician of any increased moods or behaviors. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired and exhibited behavioral symptoms occurring 1 to 3 days of physical and verbal behaviors directed toward others and other behavioral symptoms not directed toward others. The assessment also indicated the resident needed extensive assistance of two person for dressing, hygiene, and transfer and extensive assistance of one person for locomotion. The resident was assessed as ambulatory but balance not steady and only able to stabilize with human assistance. The resident was assessed to require a wheelchair for safe mobility. The resident was not coded for wandering behavior on the MDS. Nursing Note dated 10/26/15 at 2:27 AM read: Resident (#1) is up out of bed and room heading toward the exit door on 200 hall, states he is going out to find his brother so they can work on the car. When attempts were made by staff to redirect him back toward his room and away from the exit, he became hostile, threatening, swinging at the staff. He was able to get the door open but was not able to leave the building. Refusing all attempts to return to room or to sit down in w/c (wheelchair) in hall. Med. (medicated) with prn (as needed) Haldol 2.5mg (milligram) and after about 30 minutes he allowed staff to assist him into w/c and stayed within view of staff. This note was signed by Nurse #1. Resident Incident Report for Resident #1 dated 11/07/15 at 2:30 PM stated resident found outside - back of building, stated he was going to his truck which he had parked out back. Vital signs were documented: temp (temperature) 97.6, pulse 76, resp. (respirations) 20, B/P (blood pressure) 132/76, pain denied. Vital signs documented were stable. The report indicated the resident ' s Responsible Party (RP) was present and notified at 2:32 PM and the resident's primary physician was notified at 4:00 PM of the incident. The Incident report documented none apparent beside the section labeled Type of Injury. The report included an Immediate Post-Incident Action of keep personal alarm in place/functioning/audible/every 15 minute checks. The Incident Report documented immediate action as assessed for injury and assisted back to room. Nursing Note dated 11/07/15 at 4:56 PM read: At 2:30 PM - When coming from 300 hall, (Resident #1 ' s family member) asked where her (family member) was as he is not in his room- checked bathroom, therapy room and the dining room where activities were going on - without success - at this time (family member) mentioned hearing an alarm when she came in- while heading outside, housekeeping staff notified us the resident was at the back of the building, where we went immediately - resident stated he went out the end door (201) to go check on his truck - which he stated he had parked at the back of the building - only had on a t-shirt and adult briefs - no injuries noted - assisted back into the building and to his room without incident. Note was signed by Nurse #1 Review of Resident #1's facility timeline dated 11/13/15 revealed on Saturday, 11/07/15 around 2:00 PM the resident was seen by Nurse #1 sitting in his room on the side of his bed in no acute distress. The next observation of the resident was made by Housekeeper #1 at around 2:30. She stated she observed the resident standing outside the facility about 10 feet from the 200 Hall exit door at that time. Housekeeper #1 stated she left the resident alone outside for about 3 to 4 minutes (her estimate) to go back into the building and get help. Restorative Aide #1 reported that Housekeeper #1 stopped her in the 200 hall at about 2:30 and asked her to come with her to help get Resident #1 back inside. Housekeeper #1 left Restorative aid #1 with the resident while she went back into the facility to find a nurse. Housekeeper #1 estimated it took her about 3 minutes to find Nurse #1 at the nursing station on the 200 hall. Nurse #1 stated she and the resident ' s family member (who stated to Nurse #1 that she had been looking for the resident for about 15 minutes) immediately went out the 200 hall exit door and assisted the resident back into the building in a wheelchair. Nurse #1 stated the resident was back inside the facility in his room with his family member at his side by 2:50 PM. The Resident Incident Report for this incident is dated 11/07/15 at 2:30 PM. An interview was conducted on 11/13/15 at 12:00 PM with Housekeeper #1 who found Resident #1 outside the facility on 11/07/15. Housekeeper #1 stated in her estimation at around 2:30 PM she was walking toward the 200 hall when she heard the exit door alarm going off. She stated that she saw no other staff on the hall. She further stated she opened the door blinds to see if anyone was outside and did not see anyone so she cut the alarm off. She stated she went outside through the laundry room doors which would allow her access back into the building. She further stated she saw Resident #1 leaning against the side of the building about 10 feet from the exit door. She stated he had on a white shirt and a brief. She stated the weather was not very cold and that it was not raining. She described the resident as looking lost . She stated she addressed the resident and asked if he was OK and he replied that he was fine. She further stated she did not see any sign of injury or indication of the resident being in distress. Housekeeper #1 stated she went back inside the facility and immediately found a restorative aide (restorative aide #1) on the 200 hall. She stated she and restorative aid #1 went out the laundry doors to be with Resident #1. When asked why she did not bring Resident #1 back into the building herself she stated he does not like me and I was afraid to try to make him come in. Sometimes he hits the staff. Housekeeper #1 stated she left the resident and restorative aide #1 outside while she went back into the facility to get his nurse. She stated she found the resident ' s nurse (Nurse #1) near the 200 hall nursing station. She estimated it took her about 2 minutes to enter the building and find the nurse. Housekeeper #1 stated once Nurse #1 was notified she returned to her housekeeping duties. When housekeeper #1 was questioned if she had ever seen Resident #1 try to exit the building unattended prior to this incident she stated no. In an interview on 11/13/15 at 12:25 PM restorative aide #1 stated as she was walking on the 200 hall at around 2:30 pm on 11/07/15 she was stopped by housekeeper #1 who told her that a resident was outside of the building alone. Restorative aide #1 stated she immediately exited the building through the laundry room doors with housekeeper #1 and went to stand beside Resident #1. She stated she remained with Resident #1, who showed no sign of injury or distress, while housekeeper #1 went to find a nurse. Restorative aide #1 estimated it took about 2 to 3 minutes for Nurse #1 to get outside to the resident. She further stated the nurse instructed her to go inside and get a sheet and wheelchair for the resident which she did immediately. Restorative aide #1 stated she assisted with covering Resident #1 with the sheet and wheeling him back into the building before returning to her own duties. When asked how long it took to get the resident inside once he was pointed out to her by housekeeper #1 she replied about 4 or 5 minutes. When asked why she did not just assist the resident inside herself she shook her head and stated I don ' t mess with him. He will not do what I ask and will fight me if I try to make him do something. When asked if she had seen Resident #1 attempt to leave the building before this incident, Restorative aid #1 stated staff keep a close eye on him. He will try to get up out of his wheelchair and I was told by Nurse #1 he tried to leave the building at night a few weeks ago (unsure of date). In an interview on 11/13/15 at 12:46 PM with the nursing assistant (NA #1), who worked on Resident #1's hall on 11/07/14 first shift, it was stated during the time the resident left the building it was revealed NA#1 was newly hired and had been working at the facility for 3 weeks. He stated 11/07/15 was the first day that he worked on his own (unsupervised) and he had 14 residents to care for including Resident #1. NA # 1 stated he was not aware of Resident #1 ' s wandering behaviors or any care planned interventions. NA #1 stated he was aware of Resident #1's behaviors of resisting care and being verbally and physically aggressive toward staff but he was unable to verbalize any interventions (re-approach, ask another staff member to attempt care, etc). NA #1 stated he was in room 204 on the 200 hall providing resident care from approximately 2:15 PM until 2:45 PM which is when Housekeeper #1 found the 200 hall exit door alarming. He estimated he was in room 204 for 30 minutes. NA #1 stated at some point while he was in room 204 he heard an alarm that sounded like the resident shower call bell. He stated he completed his resident care and exited the room and no longer heard the bell or alarm. NA #1 stated he was not immediately aware of Resident #1 ' s exit from the facility. He stated Resident #1 had refused his ADL care that morning. He further stated: he (Resident #1) did not seem to like me and was resistant to my attempts to provide care. I reported this to his nurse (Nurse #1). NA #1 stated he had his hands full with other residents and Nurse #1 provided most of Resident #1's care that day. NA #1 stated the last time he remembered seeing Resident #1 in the facility on 11/07/15 was about 10:00 AM when he saw the resident sitting in his room. NA #1 stated he was busy providing care to other residents and did not check on Resident #1 at a scheduled time. NA #1 stated he was unable to monitor Resident #1 due to being overwhelmed with his assignment. NA #1 was asked when the last time he saw Resident #1 in the building on 11/07/15 and his answer was I remember seeing him in his room sitting in the wheelchair around 10:00 AM. NA #1 further stated when he returned to work on Sunday 11/08/15 he was told someone had to be watching the resident full time. NA #1 stated he knew he could not watch Resident #1 all of the time while caring for 13 other residents, so he did the best he could. NA #1 reported Resident #1 was much calmer on Sunday and no incidents occurred. NA #1 confirmed Resident #1 was on every 15 minute safety/location checks on Sunday, but stated Nurse #1 did most of the checks. NA #1 was instructed by a nurse (he did not recall the nurses name), to check on Resident #1 more frequently. NA #1 stated he was better able to manage his resident assignment on Sunday. Interview on 11/13/15 at 1:15 PM with Nurse #1 who was assigned to the resident on 11/07/15 when Resident #1 left the building unattended revealed she was in room 303 hanging a tube feeding during the time the exit alarm went off. She stated that after completing the tube feeding at about 2:30 PM she walked toward the 200 hall nursing station where she overheard Housekeeper #1 tell a visitor (Resident #1's RP) this is his nurse (referring to Resident #1). Nurse #1 stated she and Resident #1's RP met in the 200 hall and the RP told her Resident #1 was not in his room. Nurse #1 stated she had last seen Resident #1 prior to his exiting the facility on 11/07/15 when she administered his 9:00 AM medications at about 9:15 AM Nurse #1 stated she and the RP went down to the main dining room where activities were ongoing. She stated the resident was not found in in activities. She further stated she and the RP checked with the PT/OT therapist and Resident #1 was not present there. She stated that while walking back toward the 200 nursing station Resident #1's RP stated she had heard an alarm that sounded different from the call bells. Nurse #1 stated she was going to the phone at the 200 hall nursing station to call a silver alert (an alert code for a missing resident) at about 2:40 PM when she was approached by the housekeeper #1. Nurse #1 stated Housekeeper #1 informed her she had found Resident #1 standing outside the building near the 200 hall exit door unattended. Nurse #1 further stated the housekeeper informed her that a restorative aid (Restorative aide #1) was with the resident and a nurse was needed to assist in getting the resident back inside the building. Nurse #1 stated she and the resident ' s RP immediately went outside to get the resident. She observed he had on a brief and a t-shirt, no shoes or socks. Nurse #1 said she did a quick assessment of the resident while outside and noted he had no injury. She said Resident #1 stated I went out to check on my truck. She further stated the resident was wrapped in a sheet and placed in a wheelchair then transported back inside the facility. Nurse #1 stated she did a complete assessment on the resident once he was back in his room and found no sign of injury. She verified vital signs were checked and normal. Nurse #1 estimated the time that the resident was returned to the facility to be at about 2:50 PM. She further stated the resident's RP stayed with him for the next hour. Nurse #1 stated she reported the incident to the Nurse Supervisor (Nurse Supervisor #1) who implemented staff checks on Resident #1's location and safety to be done every 15 minutes. Nurse #1 ended the interview by stating she recalled an incident a few weeks ago late at night on third shift when Resident #1 went to the 200 Hall door intending to exit the building but she said she was able to stop him from leaving the building during that attempt. She further stated the facility administrator and Director of Nursing (DON) had been informed of the attempted elopement on 10/26/15. She did not recall any new interventions being put into place after Resident #1 attempted to leave the facility on 10/26/15. In a telephone interview on 11/14/15 at 11:37 AM with Unit Supervisor #1 it was revealed that on 11/07/15 at around 3:00 PM it was reported to her by Nurse #1 that Resident #1 had left the facility unattended by staff between 2:00 and 2:30 PM. She further stated that by the time she was notified of the elopement, Resident #1 had already been assisted back into the facility by Nurse #1. She stated Nurse #1 reported that the resident's vital signs were stable and he showed no sign of injury although he was outside in only a t shirt and briefs. Supervisor #1 stated she went to the resident's room, assessed him herself, and found no injury. She stated the resident was confused but not agitated. Supervisor #1 further stated generally the resident is alert but confused and could be agitated at times. She said Nurse #1 had reported to her earlier in the shift that he was agitated and kept removing his personal alarm (clip on alarm). Supervisor #1 stated that the last time she recalled seeing the resident in the building that afternoon was around 12:30 PM at lunch time. Supervisor #1 verified she called the administrator, the DON, and the resident's primary physician immediately after the incident. She stated per the DON's order's the resident was placed on Q (every) 15 minute checks for location and safety. Supervisor #1 stated she was aware of Resident #1's attempt to leave the building on 10/26/15. She stated that in discussions following the incident on 10/26/15 between the administrator, social workers, and nurses it was decided the resident did not require additional care plan interventions for his safety. In an interview on 11/14/15 at 10:40 AM with the Director of Nursing (DON) it was revealed she was called by the first shift supervisor on 11/07/15 (supervisor #1) at about 2:30 PM who reported an incident of Resident #1 being found outside of the building standing against the wall stating he was looking for his truck. The DON stated Supervisor #1 reported the resident was not injured and that he been found by a house keeping staff member. The DON further stated the supervisor had informed her the resident's RP was in the facility when the event took place. The DON stated she contacted the administrator and he agreed the resident should be placed on every 15 minute checks for location and safety. The DON stated she called the supervisor (Supervisor #1) and gave instructions to initiate the every 15 minute safety/location checks. The DON further stated she notified Resident #1's physician of the incident and he gave no new orders. The DON stated she and the administrator had met with the Interdisciplinary Team on Monday 11/09/15 morning and it had been determined Resident #1 would be kept on 15 minute checks until he could be moved to the secured unit. When asked if she had been aware of any other incidents involving the resident attempting to leave the facility she stated yes I was aware of an attempt by the resident to leave the building on 10/26/15. I discussed the resident's risk of wandering with the administrator. We communicated with the resident's physician and the consensus was that the resident did not require extra care plan interventions. Nursing Note dated 11/07/15 at 6:08 PM read: Medicated x 2 this shift for increased agitation at 9 am for cursing at unseen visitor and increased anxiety about the work he needed to be doing - med was effective. Resident calmed down, was compliant with care, no further cursing. Then med again at 5:52 PM with po (by mouth) Haldol for wanting to go check on his car and arguing with his brother-in-law (no one present). Remains on q (every) 15 min. checks for location. Personal alarm in place/functioning/audible. Note was signed by Nurse #1. Resident #1's care plan for wandering and behaviors was updated 11/07/15 when a handwritten note was added to the behaviors care plan, stating 15 min checks - NSG (nursing). On 11/09/15 a handwritten note was added to the behaviors care plan stating moved to Wander guard unit. On 11/10/15 additional interventions were added to Resident #1 ' s care plan for wandering. The new interventions included: Assign staff to account for resident whereabouts at all times; Note which exits resident favors for elopement from facility; Alert staff working near those areas; Place monitoring device on resident that sounds alarms when resident leaves building; place resident in area where constant observation is possible; alert staff to resident's wandering behavior. Nursing Note dated 11/08/15 at 3:00 AM read: Resident (#1) is in bed sleeping at this time. Resident is cooperative with staff regarding taking medications and incontinence care. Bed remains in lowest position, floor mat in place, personal safety alarm in use and functioning properly. Call bell within reach. Continue monitoring. Note was signed by Nurse #2. Nursing Note dated 11/08/15 9:03 AM read: Resident (#1) remains on q (every) 15 min checks for location and safety. Spoke with RP about moving him to a room on 400 hall (Wander Guard Secured Unit) and applying wander guard (ankle alarm system) to ensure further safety. RP did not give consent at this time for the room change. Stated she wanted a meeting with Administrative staff Monday AM and to check out the 400 hall he (Resident #1) would be moved to prior to giving consent. Reiterating informed her staff would continue with the 15 minute checks Q (every) day. Note was written by Nurse #3. Nursing Note dated 11/08/15 at 11:07 AM read: Alert, oriented to self only. Resident is up in w/c (wheelchair) in dining room at this time. No exit seeking behaviors so far this shift. Resident has made no attempts to get out of chair. Note continues and concludes with Continues on q (every) 15 minute checks for location. Note was signed by Nurse #1. Nursing Note dated 11/09/15 7:26 PM read: Resident continues to attempt to leave building stating he is going to go take care of that cardboard. Demonstrating verbal and combative behaviors with female staff during times of increased anxiety. PRN (as needed) administration at (4:00 PM) during stated time of increased anxiety. Informed from management that (RP) would be coming tonight to approve transfer to 400 hall (Secured Unit) or take resident home with her. Expected time of visit between (7:00 PM) and (10:00 PM). Will continue to monitor. Note was signed by Nurse #4. Social Worker Note dated 11/10/15 at 10:22 AM, written by Social Worker #2, read: Resident has had several exit seeking behaviors within the last several weeks with the last documentation being 11/07/15. Note was signed by the facility Social Worker #1. Nursing Note dated 11/10/15 at 10:36 AM resident moved to room 403A (Secured Unit) per staff request, family informed by staff. Note was signed by Social Worker #2. Nursing Note dated 11/10/15 5:09 PM read: Spoke with (Resident #1's RP) at this time and made her aware that a room change had been made to resident and that a wander guard (ankle security alarm) has been put into place at this time. Will continue to monitor resident at this time. Note was signed by Nurse #5. In an interview on 11/13/15 at 1:40 PM with Social Worker #1 it was revealed that on admission a Risk assessment dated [DATE] had evaluated the resident as an elopement risk. Social Worker #1 stated the resident had been care planned for wandering and attempts to exit the building after the 5/19/15 assessment. She stated once the resident was seen by psychiatry and medication was begun his behaviors improved. I did not see documentation in the Nursing Notes or hear discussion in the Interdisciplinary Team meetings to indicate he was showing exit seeking behaviors. When asked if she was aware of Resident #1's attempt to exit the building on 10/26/15 she stated yes. She said: I did not get involved in making determinations about whether he was safe in the unsecured part of the facility that is up to (the administrator). She further stated she was involved in communicating with the resident's RP to convey the need to move him to a secured location after he left the facility unattended on 11/07/15. In an interview on 11/13/15 at 1:55 PM with Social Worker #2, who wrote a Social Worker Note dated 11/10/15 which stated Resident has had several exit seeking behaviors within the last few weeks the last documented episode being 11/07/15. When asked about the documentation of exit seeking behaviors within the last few weeks in her own note, she stated: that was a typing error, the note should have been corrected to state days where it states weeks. When asked about her role in evaluating the resident for Wandering and elopement risk as outlined in the Resident's care planned intervention of Social Services to evaluate resident she stated she read the nursing notes and monitored the resident. In an interview by telephone on 11/13/15 at 2:30 PM Nurse #2 stated she had worked with Resident #1 about once a week and stated she had not observed the resident trying to exit the building. She stated the nursing staff have to watch him (Resident #1) closely because he can become confused and agitated at times. She verified she was aware of the every 15 minute safety/location checks the resident was ordered to be on until he was secured in the Wander Guard Unit. In a telephone interview on 11/14/15 at 12:05 PM with the Geriatric Psychiatry Nurse Practitioner (NP #1) who worked directly with Resident #1 to assist in treatment of [REDACTED]. She stated she was in contact with the facility during Resident #1's early days of admission and after evaluation she and the psychiatric physician had determined the facility was capable of caring for the resident and at no risk to other residents. She stated she had been informed of Resident #1's attempt to leave the building on 10/26/15 and of his most recent exit of the facility on 11/07/15. She stated that after his attempt to leave the building on 10/26/15 she had been under the impression the staff had increased monitoring of the resident's location. She further stated she felt increased monitoring was sufficient to maintain the resident's safety. NP #1 stated she was surprised to hear that Resident #1 had exited the building without supervision on 11/07/15. She stated she felt medication changes that had been implemented over the past months had been sufficient to control Resident #1's behaviors. NA #1 further stated that over the past 5 months the resident had stabilized with his behaviors and had not exhibited any exit seeking behaviors until the incident on 10/26/15. In a telephone interview on 11/14/15 at 1:27 PM with Resident #1's physician stated he was aware of the resident ' s attempt to leave the building on 10/26/15 and did not recall considering the resident to be a safety or flight risk. He stated if I had thought the resident needed further interventions to insure his safety I would have written orders for them. The physician did not recall any concerns with Resident #1's safety or risk of wandering. He stated I don ' t remember what I did concerning these incidents. The MD stated if I had considered sending him to the hospital to be evaluated for behavior and medication management, I would have written an order. Interview, observation and tour of facility at 10:15 AM on 11/13/15 with facility administrator revealed the location of Resident #1's room (#403) on 11/07/15. Room #403 was observed to be midway between the 200 hall nursing station and the 200 hall fire exit door. The fire exit door was about 20 feet from room 203 ' s door. The facility administrator opened the 200 hall exit door and pointed out the area where Resident # 1 was found standing outside of the facility on 11/07/15 which was next to the back side of the building approximately 10 feet from the 200 hall exit door. The area where the resident was found was grassy, on the back side of the building, and surrounded on 2 sides by building wings. It was noted that the 200 hall exit door alarmed properly when opened. The administrator stated he was informed of the 11/07/15 incident involving Resident #1 leaving the building by Nurse Supervisor #1 around 2:45 PM on 11/07/15. He stated he instructed Supervisor #1 to inform Resident #1's physician and initiate every 15 minute safety/location checks on Resident #1 immediately. He further stated the resident remained on the 15 minute checks until 11/09/15 at 8:00 PM when he was moved to a room on the facility ' s secured unit. The administrator stated the resident would have been moved sooner but his RP did not want him moved. He stated the resident's RP stated she would rather take the resident home than have him moved to the unit. He further stated the RP was given until 11/09/15 at 8:00 PM to come to the facility and pick him up. He stated she did not take the resident home so he was moved to the secured unit for his safety. He stated the resident's RP was notified prior to the resident's relocation. Observation was made on 11/13/15 at 10:35 AM of the secured unit. The facility administrator was present during the observation. Observation of the unit revealed it was secured by double doors that opened onto the interior of the building next to the 200 nursing station. Resident #1 was observed in room 403 resting in bed with a bed alarm in place. The resident was observed to be confused but showed no sign of agitation or aggressive behaviors. It was noted the resident had a wander guard bracelet in place on his left ankle. The facility administrator explained the ankle bracelet functioned by triggering the unit exit doors to lock when it came within 10 feet of the doors. The unit exit doors were tested with a wander guard ankle bracelet and found to lock when the bracelet came within 10 feet of the door sensor. The administrator stated that residents in the secured unit were required to wear the ankle alarm bracelet 24 hours per day except when ADL care or skin assessments required its removal. He stated staff were required to remain with any resident while their ankle alarm was not in place. He further stated the residents in the secured unit were assessed every shift by the primary care nurse to ensure their ankle alarm bracelet was in place. In a continuation of the interview on 11/13/15 at 11:50 AM with facility administrator he was asked why additional interventions were not care planned for Resident #1 after the resident ' s attempt to leave the facility which was documented in nursing notes on 10/26/15 at 2:27 AM. His reply was that he was aware of the incident but felt the resident was safe without adding additional interventions. He further stated normally the resident did not attempt to leave the building. In an additional interview on 11/14/15 at 2:05 PM with the facility administrator it was revealed that he was aware of Resident #1's attempt to exit the facility unsupervised on 10/26/15, was aware of the physical and verbal behaviors the resident directed toward staff at times, and was aware that no new care planned interventions had been put in place after the resident attempted to leave the facility on 10/26/15. He stated he did not consider additional interventions to be needed at that time. The administrator further acknowledged the resident had left the facility unattended on 11/07/15 around 2:30 PM. He stated: He (Resident #1) will need to remain in the Wander Guard Unit in order to insure his safety from exiting the building. The Administrator was notified of the Immediate Jeopardy on 11/13/15 at 5:45 PM. The facility provided the following Credible Allegation on 1/14/15 at 2:30 PM. Corrective action which will be accomplished for those residents found to be affected by the deficient practice: The resident #1 was

Based on record review, observations, staff and physician interviews, the facility failed to notify the physician a pressure ulcer was getting worse from 11/24/14 to 12/03/14 for 1 of 2 residents reviewed for physician notification (Resident #36). Findings included: Resident #36 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) completed on 8/18/14 indicated short and long term memory problems. Decision making was severely impaired and there was no rejection of care listed. Extensive care of two persons' physical assist was required with bed mobility and transfers. No pressure ulcer was indicated to the head; however at risk for pressure ulcer development was indicated. The Care Area Assessment completed on 8/18/14 specified Resident #36 required staff assistance with all transfers, turning and repositioning due to at risk for pressure ulcers. No pressure ulcer to the head was indicated. A review of the care plan dated 8/21/14 indicated as a problem impaired thought process with short and long term memory loss, difficult in making needs known and self care deficit related to decline in condition and decreased mobility. A review of nurse's notes dated 8/25/14 read "Unable to keep abrasion/skin tear to back of head with a dressing on it related to continuous movement of head." A review of the weekly skin assessment record dated 9/2, 9/9, 9/16, 9/23/14, revealed the skin assessments were signed as completed. No pressure ulcer or changes in skin condition to the back (posterior) of Resident #36's head was indicated. The skin assessment records dated 9/30 and 10/7/14 were not signed as completed. A review of the nurse's note dated 10/14/14 indicated the Nursing Assistant (NA) while the resident was turned on his side, noticed an opened area to the back of Resident #36's head. The area was documented as opened, with drainage, measured 3.5 cm (centimeter) in diameter, cleaned with normal saline, a sponge dressing applied and the treatment nurse (Nurse #2) notified. A review of the wound/skin record completed by Nurse #2 revealed a stage II pressure ulcer to the back of the head was identified on 10/14/14 that measured 1.5 cm (centimeter) length x 2 cm width, no odor, red wound bed with normal brown surrounding skin color and brown edges with [MEDICATION NAME] every three days. A review of the weekly skin assessment record completed on 10/14/14 by Nurse #2 was initialed as completed A review of the physician order [REDACTED]. Pat dry, apply [MEDICATION NAME] dressing every 3 days and as needed until resolved." A review of the nurses' notes indicated "10/27/14 received treatment to Stage II area to back of head, area is without hair due to constant movement from resident, wound bed 0.8 cm x 0.9 cm with [MEDICATION NAME] dressing applied", "11/4/14 received treatment to posterior head and [MEDICATION NAME] dressing applied, wound bed pink with surrounding pink skin where hair has been rubbed away, wound measures 1.5 cm x 2.0 cm which is an increase since last measured", "11/5/14 Resident #36 continues to rub head against Geri chair and causing worsening of wound on his occipital (head) lobe, nursing will do a referral to occupational therapy for possibilities of positioning device, have occipital wound due to constant rubbing his head against back of Geri chair when up in chair", "11/6/14 responsible party notified of use of Broda chair starting today for one week trial to promote improved positioning while out of bed and of stage II to back of head and ongoing treatment", "11/7/14 constantly turns head side to side", "11/10/14 treatment received to stage II with [MEDICATION NAME] dressing but resident is constantly moving and rubs the dressing off his head after a little while, wound bed is dark pink surrounded by light pink colored skin, size of wound has not changed since last measured." The quarterly MDS completed on 11/11/14 Resident #36 was indicated with no problems with mental status. Extensive assistance of two persons' physical assist was required with bed mobility and transfers. Rejection of care was indicated as occurred 1 to 3 days. A stage 2 pressure ulcer was listed dated 10/14/14, described with granulation tissue-pink or red tissue with shiny, moist and granular appearance. Ulcer care and treatment included: pressure reducing device for chair/bed, turn/reposition, nutrition/hydration, pressure ulcer care, application of dressings and apply ointments/medications. The care plan updated on 11/18/14 indicated to continue with the current care plan - referring to the previous care plan dated 8/21/14. Approaches for care for pressure ulcer directed to "Measure wound at least once a week, record appearance, report any decline in wound status to physician, administer treatments as ordered by physician and document, use pillows, air mattress and other supportive devices to assist with positioning." The care plan did not specifically indicate a pressure ulcer to the back of the head. A review of the nurse's notes documented "11/20/14 treatment to posterior head area measured 1.5 cm x 2 cm no bleeding or drainage, [MEDICATION NAME] dressing applied to head - head is elevated off chair to reduce friction." A review of the wound/skin record completed on 11/24/14 by the treatment nurse (Nurse #2) documented a stage II 1.5 cm x 1.8 cm with no odor, red wound bed and pink surrounding tissue with continued [MEDICATION NAME] dressing, as the plan of care. The facility was unable to provide a skin assessment for Resident #36 completed for 12/1/14. On 12/3/14 at 10:30 am, during an observation, Nurse #3 asked Resident #36 to lift his head from the pillow, to relieve pressure. The resident opened his eyes, attempted to lift his head from the pillow but did not completely lift his head off the pillow. He required the assistance of NA #2 to lift and hold his head, while Nurses #3 provided care to the pressure ulcer on the back of his head. The area was observed to be blackened in the center of the wound bed with surrounding pink skin tissue. The edges of the blackened matter were embedded into the wound completely. As Nurse #3 cleansed the wound, the blackened matter continued in the center of the pressure ulcer fixed to the wound. No odor or drainage was observed. A review of the wound/skin record assessment completed by the Director of Nursing (DON) on 12/4/14 revealed the pressure ulcer to the back of the head worsened which read "Response to treatment: deteriorated, stage: unstageable, 1.2 cm length x 1.5 cm width, wound bed: minimal eschar, with surrounding skin color pink." A review of the nurse's note dated 12/4/14 completed by the DON in part read "Reassessed wound on resident's occipital (head) area, an area of dark eschar was noted in the middle of wound bed. Physician to be notified for change in treatment orders. Resident continue with constant moving of his head from side to side causing frequent dislodging of dressings. Nursing staff to replace dressing if it is noted to come off." A review of the physician orders [REDACTED]. Stop Santyl application once eschar has come off. Reassess daily." On 12/4/14 at 9:11 am, in an interview, the treatment nurse (Nurse #2) stated she was responsible for doing skin assessments and wound measurements for all residents. She stated because the [MEDICATION NAME] dressing would come off the back of Resident #36's head continuously and the resident would also pull it off; she questioned if the treatment was working due to the resident would move his head back and forth on the pillow while in bed, causing the [MEDICATION NAME] not to stay on. She stated she discussed the concern with the DON and ways were discussed such as roll a sheet up and put behind his neck to elevate his head off of the pillow/Geri chair; however she did not consult with the physician for further guidance. Nurse #2 did not indicate how long she questioned if the treatment was working or why she did not consult with the physician for further guidance. She added prior to the development of the pressure ulcer, she did not have knowledge the resident constantly turned his head back and forth while in the bed and Geri chair. The treatment nurse stated she last saw the pressure ulcer to the back of his head on 11/24/14, per her wound assessment and she documented it was healing as evidence by pink tissue and no odor. She indicated she had not seen the pressure ulcer again until 12/4/14, because she was on a leave of absence from 12/1 - 12/3/14. She stated in her absence, the unit manager or the DON were responsible for completing the skin measurements, per past instructions received from of the DON. On 12/4/14 at 10:00 am, in an observation, accompanied by the DON and the treatment nurse, revealed a pressure ulcer to the back of Resident #36's head, with blackened matter embedded into the center of the wound bed and surrounding wound tissue pink. On 12/4/14 at 10:10 am, in an interview, the DON stated the pressure ulcer to the back of the head was unstageable and she expected the physician to have been notified on 12/3/14, when Nurse #3 assessed a change in the physical description from pink to darken. She stated the wound measurement was not obtained because she instructed the nursing staff the treatment nurse is expected to do them, however the treatment nurse was out on leave of absence from 12/1 to 12/3/14, and the measurements should have been obtained on 12/2/14 by her (DON), to ensure consistency and prevent discrepancies in measurement, in the absence of the treatment nurse. On 12/4/14 at 11:32 am, in an interview, the unit manager stated she became aware of the pressure ulcer to the back of Resident #36's head on 10/14/14. She stated in the absence of the treatment nurse, the unit manager or the DON is responsible for completing skin assessments and wound measurements. She indicated in absence of the treatment nurse on 12/1 to 12/3/14, she did not complete a skin assessment or measurement, nor was she aware there was a change in the status of the pressure ulcer. She added if she had been made aware there was a change in the pressure ulcer, she would have obtained measurements and notified the physician for any new orders or guidance. On 12/4/14 at 4:15 pm, during a pressure ulcer observation, accompanied by the DON she assessed the pressure ulcer to the back of the head as "Black in the center of the wound bed, with surrounding pink tissue." On 12/4/14 at 4:30 pm, in an interview, Nurse #3 indicated while providing care to the back of the resident's head on 12/3/14, she observed the area (back of head) blackened in the center of the pressure ulcer. She indicated she did not notify the physician because she did not think there was a change in the pressure ulcer. On 12/4/14 at 4:34 pm, in an interview, Resident #36's physician stated he expected to be notified by the nursing facility within 24-48 hours for chronic concerns and acute concerns immediately to ensure if there was a change or worsening in the resident's condition, medical guidance was provided related to care and treatment.

Based on observations, record review and staff interviews, the facility failed to update the care plan for a resident with a sacral pressure ulcer to address repetitive head movement, and failed to care plan preventive measures to prevent an ulcer to the back of the head from worsening for 1 of 2 residents care plans reviewed for pressure ulcers (Resident #36). Findings included: Resident #36 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) completed on 8/18/14 indicated short and long term memory problems. Decision making was severely impaired and there was no rejection of care listed. Extensive care of two persons' physical assist was required with bed mobility and transfers. No pressure ulcer was indicated to the head; however at risk for pressure ulcer development was indicated. The Care Area Assessment (a tool used for identifying care problems) completed on 8/18/14 specified Resident #36 required staff assistance with all transfers, turning and repositioning due to at risk for pressure ulcers. The resident also required the staff assistance to move sufficiently, to relieve pressure over any one site and with all transfers, turning and repositioning. No pressure ulcer to the head, or repetitive movement was indicated. A review of the care plan dated 8/21/14 indicated as a problem impaired thought process with short and long term memory loss, difficult in making needs known and self care deficit related to decline in condition and decreased mobility. The care plan in part read "Provide incontinence care timely and ensure skin clean and dry, measure wound at least once a week - record appearance, amount and odor of any drainage and report decline in wound status to the physician when available, administer treatment as ordered by the physician and document, and use pillows, air mattress, other supportive devices to assist with positioning and avoid restrictive clothing." A review of the nurse's note dated 10/14/14 indicated while performing incontinence care, the Nursing Assistant (NA) while the resident was turned on his side, noticed an opened area to the back of Resident #36's head. The area was documented as opened, with drainage, measured 3.5 cm (centimeter) in diameter, cleaned with normal saline, a sponge dressing applied and the treatment nurse (Nurse #2) notified. The quarterly MDS completed on 11/11/14 indicated no problems with mental status. Extensive assistance of two persons' physical assist was required with bed mobility and transfers. Rejection of care was indicated as occurred 1 to 3 days. A stage 2 pressure ulcer was listed dated 10/14/14, described with granulation tissue-pink or red tissue with shiny, moist and granular appearance. Ulcer care and treatment included: pressure reducing device for chair/bed, turn/reposition, nutrition/hydration, pressure ulcer care, application of dressings and apply ointments/medications. The care plan updated on 11/18/14 indicated to continue with the current care plan - referring to the previous care plan dated 8/21/14. Approaches for care for pressure ulcer directed to "Measure wound at least once a week, record appearance, report any decline in wound status to physician, administer treatments as ordered by physician and document, use pillows, air mattress and other supportive devices to assist with positioning." The care plan did not specifically indicate a pressure ulcer to the back of the head, measures or interventions to address the repetitive head movements. On 12/3/14 at 10:50 am, in an interview, the Director of Nursing (DON) stated "Resident #36 pressure ulcer to the back of his head was acquired in the facility." She indicated the resident had a history of [REDACTED]. She added the facility had attempted a Geri chair, Brodachair and currently an air mattress to allow freedom of the head from a surface; however the resident constantly continued to move his head from side to side when in the bed and Geri chair. She added the resident was resistant with being turned and repositioned every two hours by the staff. The DON indicated the care plan did not reflect the resident constantly turning and repositioning his head while in the bed and the Geri chair, nor, Resident #36 removal of the dressings from the back of his head himself; however she expected the care plan to reflect such. On 12/3/14 at 3:06 pm, in an interview, the DON, accompanied by the MDS nurse stated she (DON) did not expect Resident #36 to go two weeks without a skin assessment being completed. She stated a skin assessment should have been completed on 9/30 and 10/7/14. She elaborated because the treatment nurse was on leave from 12/1 - 12/3/14, the skin assessment still should have been completed on 12/1/14 however the record did not reflect such. The MDS nurse indicated she became aware of the stage II pressure ulcer to the back of the head on 10/14/14. She also stated she was aware the resident constantly turned and repositioned his head from side to side while in the bed and Geri chair. The MDS nurse indicated she did not care plan specifically; related to the stage II pressure ulcer to the back of the resident's head or the constant turning of his head from side to side while in the bed and Geri chair. She concluded she completed a generic care plan for pressure ulcers.

Based on record review, observations, staff and physician interviews, the facility failed to complete weekly skin assessments and closely monitor the progress of a worsening pressure ulcer and also failed to put interventions in place to relieve pressure for 1 of 2 residents reviewed for pressure ulcers (Resident #36). Findings included: Resident #36 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) completed on 8/18/14 indicated short and long term memory problems. Decision making was severely impaired and there was no rejection of care listed. Extensive care of two persons' physical assist was required with bed mobility and transfers. No pressure ulcer was indicated to the head; however at risk for pressure ulcer development was indicated. The Care Area Assessment (a tool used for identifying care problems) completed on 8/18/14 specified Resident #36 required staff assistance with all transfers, turning and repositioning due to at risk for pressure ulcers. The resident also required the staff assistance to move sufficiently, to relieve pressure over any one site and with all transfers, turning and repositioning. No pressure ulcer to the head, or repetitive movement was indicated. The Braden scale (an assessment tool used for predicting pressure ulcer risk) completed on 8/11/14 scored a 13; indicative of moderate risk. A review of the nurses notes documented on "8/14/14 involuntary movement", "8/15/14 attempted (Resident #36) to help with positioning in bed by grabbing the headboard and pulling himself up when being pulled up in bed", "8/18/14 difficultly to keep resident positioned due to involuntary movement" and "8/19/14 grabbed head board and pulled self up in bed when staff indicated they were going to do it." A review of the care plan dated 8/21/14 indicated as a problem impaired thought process with short and long term memory loss, difficult in making needs known and self care deficit related to decline in condition and decreased mobility. The care plan in part read "Provide incontinence care timely and ensure skin clean and dry, measure wound at least once a week - record appearance, amount and odor of any drainage and report decline in wound status to the physician when available, administer treatment as ordered by the physician and document, and use pillows, air mattress, other supportive devices to assist with positioning and avoid restrictive clothing." A review of nurse's notes dated 8/25/14 read "Unable to keep abrasion/skin tear to back of head with a dressing on it related to continuous movement of head." A review of the weekly skin assessment record dated 9/2, 9/9, 9/16, 9/23/14, revealed the skin assessments were signed as completed. No pressure ulcer or changes in skin condition to the back (posterior) of Resident #36's head was indicated. The skin assessment records dated 9/30 and 10/7/14 were not signed as completed. A review of the daily staffing nursing assignment sheet dated 10/7/14 for the 400 hall read "400 hall do own treatments." Nurse #1 was the primary nurse for this day. A review of the nurse's note dated 10/14/14 indicated while performing incontinence care, the Nursing Assistant (NA) while the resident was turned on his side, noticed an opened area to the back of Resident #36's head. The area was documented as opened, with drainage, measured 3.5 cm (centimeter) in diameter, cleaned with normal saline, a sponge dressing applied and the treatment nurse (Nurse #2) notified. A review of the wound/skin record completed by Nurse #2 revealed a stage II pressure ulcer to the back of the head was identified on 10/14/14 that measured 1.5 cm (centimeter) length x 2 cm width, no odor, red wound bed with normal brown surrounding skin color and brown edges with [MEDICATION NAME] every three days. A review of the weekly skin assessment record completed on 10/14/14 by Nurse #2 was initialed as completed A review of the physician order [REDACTED]. Pat dry, apply [MEDICATION NAME] (a wafer type that contains gel forming agents, that provide a moist healing environment, autolytic debridement and insulation) dressing every 3 days and as needed until resolved." Autolytic debridement refers to the body's own enzymes and moisture to provide rehydration, soften and eventually liquefy hard eschar (dry or dark scab or falling away of dead skin) and slough (indicative of tissue damage). A review of the nurses' notes indicated on "10/27/14 received treatment to Stage II area to back of head, area is without hair due to constant movement from resident, wound bed 0.8 cm x 0.9 cm with [MEDICATION NAME] dressing applied", "11/4/14 received treatment to posterior head and [MEDICATION NAME] dressing applied, wound bed pink with surrounding pink skin where hair has been rubbed away, wound measures 1.5 cm x 2.0 cm which is an increase since last measured", "11/5/14 Resident #36 continues to rub head against Geri chair and causing worsening of wound on his occipital (head) lobe, nursing will do a referral to occupational therapy for possibilities of positioning device, have occipital wound due to constant rubbing his head against back of Geri chair when up in chair", "11/6/14 responsible party notified of use of Broda chair starting today for one week trial to promote improved positioning while out of bed and of stage II to back of head and ongoing treatment", "11/7/14 constantly turns head side to side", "11/10/14 treatment received to stage II with [MEDICATION NAME] dressing but resident is constantly moving and rubs the dressing off his head after a little while, wound bed is dark pink surrounded by light pink colored skin, size of wound has not changed since last measured." The quarterly MDS completed on 11/11/14 Resident #36 was indicated with no problems with mental status. Extensive assistance of two persons' physical assist was required with bed mobility and transfers. Rejection of care was indicated as occurred 1 to 3 days. A stage 2 pressure ulcer was listed dated 10/14/14, described with granulation tissue-pink or red tissue with shiny, moist and granular appearance. Ulcer care and treatment included: pressure reducing device for chair/bed, turn/reposition, nutrition/hydration, pressure ulcer care, application of dressings and apply ointments/medications. The care plan updated on 11/18/14 indicated to continue with the current care plan - referring to the previous care plan dated 8/21/14. Approaches for care for pressure ulcer directed to "Measure wound at least once a week, record appearance, report any decline in wound status to physician, administer treatments as ordered by physician and document, use pillows, air mattress and other supportive devices to assist with positioning." The care plan did not specifically indicate a pressure ulcer to the back of the head. A review of the nurse's notes documented "11/20/14 treatment to posterior head area measured 1.5 cm x 2 cm no bleeding or drainage, [MEDICATION NAME] dressing applied to head - head is elevated off chair to reduce friction." A review of the wound/skin record completed on 11/24/14 by the treatment nurse (Nurse #2) documented a stage II 1.5 cm x 1.8 cm with no odor, red wound bed and pink surrounding tissue with continued [MEDICATION NAME] dressing, as the plan of care. The facility was unable to provide a skin assessment for Resident #36 completed for 12/1/14. On 12/3/14 at 10:15 am, in an interview, Nurse #3 indicated Resident #36 could move his upper body independently but could not move his lower body. On 12/3/14 at 10:20 am, during an observation, Resident #36 was observed in the bed positioned on his back with his head on the pillow, looking up at the ceiling and the head of bed was at elevated 75 degrees. The resident was not observed turning his head from side to side while in the bed. The resident was lying on an air mattress. On 12/3/14 at 10:30 am, during an observation, Nurse #3 asked Resident #36 to lift his head from the pillow, to relieve pressure. The resident opened his eyes, attempted to lift his head from the pillow but did not completely lift his head off the pillow. He required the assistance of NA #2 to lift and hold his head, while Nurses #3 provided care to the pressure ulcer on the back of his head. The area was observed to be blackened in the center of the wound bed with surrounding pink skin tissue. The edges of the blackened matter were embedded into the wound completely. As Nurse #3 cleansed the wound, the blackened matter continued in the center of the pressure ulcer fixed to the wound. No odor or drainage was observed. On 12/3/14 at 10:50 am, in an interview, the Director of Nursing (DON) stated "Resident #36 pressure ulcer to the back of his head was acquired in the facility." She indicated the resident has a history of constantly moving his head from one side to the other. She added the facility had attempted a Geri chair, Brodachair and currently an air mattress to allow freedom of the head from a surface; however the resident constantly continued to move his head from side to side when in the bed and Geri chair. She added the resident was resistant with being turned and repositioned every two hours by the staff. The DON indicated the care plan did not reflect the resident constantly turning and repositioning his head while in the bed and the Geri chair, nor, Resident #36 removal of the dressings from the back of his head himself; however she expected the care plan to reflect such. On 12/3/14 at 12:23 pm, in an interview, Nurse #3 stated residents' skin assessments are completed weekly according to the skin assessment record, where one documents the completed skin assessment. She added new admission residents were completed by the primary floor nurse and the treatment nurse was responsible for completing weekly skin assessments and treatments. Nurse #3 concluded in the absence of the treatment nurse, the primary floor nurse was responsible for completing the skin assessment and any needed treatment. On 12/3/14 at 3:06 pm, in an interview, the DON, accompanied by the MDS nurse stated she (DON) did not expect Resident #36 to go two weeks without a skin assessment being completed. She stated a skin assessment should have been completed on 9/30 and 10/7/14. She elaborated because the treatment nurse was on leave from 12/1 - 12/3/14, the skin assessment still should have been completed on 12/1/14 however the record did not reflect such. The MDS nurse indicated she became aware of the stage II pressure ulcer to the back of the head on 10/14/14. She also stated she was aware the resident constantly turned and repositioned his head from side to side while in the bed and Geri chair. The MDS nurse indicated she did not care plan specifically; related to the stage II pressure ulcer to the back of the resident's head or the constant turning of his head from side to side while in the bed and Geri chair. She concluded she completed a generic care plan for pressure ulcers. A review of the wound/skin record assessment completed by the DON on 12/4/14 revealed the pressure ulcer to the back of the head worsened which read "Response to treatment: deteriorated, stage: unstageable, 1.2 cm length x 1.5 cm width, wound bed: minimal eschar, with surrounding skin color pink." A review of the nurse's note dated 12/4/14 completed by the DON in part read "Reassessed wound on resident's occipital (head) area, an area of dark eschar was noted in the middle of wound bed. Physician to be notified for change in treatment orders. Resident continue with constant moving of his head from side to side causing frequent dislodging of dressings. Nursing staff to replace dressing if it is noted to come off." A review of the physician orders [REDACTED]. Stop Santyl application once eschar has come off. Reassess daily." On 12/4/14 at 9:11 am, in an interview, the treatment nurse (Nurse #2) stated she was responsible for doing skin assessments and wound measurements for all residents. She stated because the [MEDICATION NAME] dressing would come off the back of Resident #36's head continuously and the resident would also pull it off; she questioned if the treatment was working due to the resident would move his head back and forth on the pillow while in bed, causing the [MEDICATION NAME] not to stay on. She stated she discussed the concern with the DON and ways were discussed such as roll a sheet up and put behind his neck to elevate his head off of the pillow/Geri chair; however she did not consult with the physician for further guidance. Nurse #2 did not indicate how long she questioned if the treatment was working or why she did not consult with the physician for further guidance. She added prior to the development of the pressure ulcer, she did not have knowledge the resident constantly turned his head back and forth while in the bed and Geri chair. The treatment nurse stated she last saw the pressure ulcer to the back of his head on 11/24/14, per her wound assessment and she documented it was healing as evidence by pink tissue and no odor. She indicated she had not seen the pressure ulcer again until 12/4/14, because she was on a leave of absence from 12/1 - 12/3/14. She stated in her absence, the unit manager or the DON were responsible for completing the skin measurements, per past instructions received from the DON. On 12/4/14 at 10:00 am, in an observation, accompanied by the DON and the treatment nurse, revealed a pressure ulcer to the back of Resident #36's head, with blackened matter embedded into the center of the wound bed and surrounding wound tissue pink. On 12/4/14 at 10:10 am, in an interview, the DON stated the pressure ulcer to the back of the head was unstageable and she expected the physician to have been notified on 12/3/14 when Nurse #3 assessed a change in the physical description from pink to darken. She stated the wound measurement was not obtained because she instructed the nursing staff the treatment nurse is expected to do them, however the treatment nurse was out on leave of absence from 12/1 to 12/3/14, and the measurements should have been obtained on 12/2/14 by her (DON), to ensure consistency and prevent discrepancies in measurement, in the absence of the treatment nurse. On 12/4/14 at 10:29 am, in an interview, accompanied by the DON, Nurse #4 who was assigned to do skin assessment/treatment on 10/7/14, acknowledged she was responsible for the skin assessments/treatments of residents, however she was not responsible for Resident #36. Nurse #4 revealed she wrote on the staff assignment sheet "400 hall nurse to do own treatment." The staffing schedule revealed Nurse #4 communicated "400 hall do own treatment." On 12/4/14 at 11:32 am, in an interview, the unit manager stated she became aware of the pressure ulcer to the back of Resident #36's head on 10/14/14. She stated in the absence of the treatment nurse, the unit manager or the DON is responsible for completing skin assessments and wound measurements. She indicated in absence of the treatment nurse on 12/1 to 12/3/14, she did not complete a skin assessment or measurement, nor was she aware there was a change in the status of the pressure ulcer. She added if she had been made aware there was a change in the pressure ulcer, she would have obtained measurements and notified the physician for any new orders or guidance. On 12/4/14 at 12:42 pm, in an interview, NA #3 who worked on 9/30/14 from 11pm - 7am, stated she recalled giving the resident a bed bath, however did not recall observing any skin concerns. On 12/4/14 at 1:17 pm, in an interview, NA #4 who worked on 9/30/14 from 3pm - 11pm, stated she did not recall observing any opened skin areas while providing care. On 12/4/14 at 2:25 pm, in an interview, NA #5 who worked on 10/7/14 from 3pm - 11pm indicate she did not observe any opened skin areas while providing care. On 12/4/14 at 2:33 pm, in an interview, NA #1 who worked on 10/7/14 from 11pm - 7am stated while providing incontinence care, when she turned and repositioned Resident #36, she observed an open skin area to the back of his head with blood at the site. She stated prior to her observation of the opened area to the back of the head, the resident would not keep a pillow under his head and would rub his head against the sheet of the bed continually when in the bed and in the Geri chair. She stated she did not report this to a nurse because she assumed, the nursing staff was aware the resident would continually rubbed his head against the bed sheet and Geri chair, and would not keep the pillow under his head. NA #1 concluded she notified the nurse on duty related to the opened area, however did not recall the name of the nurse. NA #1 did not indicate if there was a dressing was in place. A review of the nurse's note for 10/7/14 did not reveal a nursing entry related to NA # 1' s report. Nurse #7 who worked on 10/7/14 from 11pm - 7am was unable to be interviewed. On 12/4/14 at 2:50 pm, in an interview, the MDS nurse stated she was aware Resident #36 moved his head from side to side, including general involuntary movements. She stated she did not update the care plan to specifically address interventions to maintain his head from developing a pressure ulcer. She stated she developed the care plan to reflect general interventions for at risk for pressure ulcer preventions. She concluded she was aware the resident would not keep the pillow under his head and moved his head constantly from side to side while in the bed and in the Geri chair. On 12/4/14 at 4:15 pm, during a pressure ulcer observation, accompanied by the DON she assessed the pressure ulcer to the back of the head as "Black in the center of the wound bed, with surrounding pink tissue." On 12/4/14 at 4:30 pm, in an interview, Nurse #3 who worked on 9/30/14 from 7am - 7pm, stated she did not recall doing the skin assessment for Resident #36 scheduled on 9/30/14, nor did she receive any reports from the NAs of any skin concerns. She further indicated while providing care to the back of the resident's head on 12/3/14, she observed the area (back of head) blackened in the center of the pressure ulcer. She indicated she did not notify the physician because she did not think there was a change in the pressure ulcer. On 12/4/14 at 4:34 pm, in an interview, the physician stated he expected to be notified by the nursing facility within 24-48 hours for chronic concerns and acute concerns immediately to ensure if there was a change or worsening in the resident's condition, medical guidance was provided related to care and treatment. On 12/5/1/4 at 1:52 pm, in an interview, Nurse #1 who worked on 10/7/14 from 7am - 7pm stated she was aware on 10/7/14 the treatment nurse (Nurse #4) did not complete the skin assessment or treatments as documented on the staffing assignment sheet for the 400 hall. Nurse #1 acknowledged she was supposed to do Resident #36's skin assessment. She concluded if she did not sign the treatment record, then the skin assessment was not completed.