Every finding on record at Stanly Manor

Based on observations and staff interviews, the facility failed to label and date open containers of food and discard expired food items in 1 of 1 walk-in cooler, and secure open food containers in the freezer, and prevent the freezer compressor from dripping condensation directly into open boxes stored under the compressor in 1 of 1 freezer.The findings included:a. The kitchen was toured on 1/5/26 with the Dietary Manager at 10:22 AM. During the observation, the walk-in cooler was observed to have an open container of liquid eggs. The container did not have a date when it was opened. The Dietary Manager reported that the eggs were used at breakfast on 1/5/26 and the cook should have labeled the open container. A container of open potato salad dated open on 12/25/25 was noted on the shelf of the walk-in cooler. The Dietary Manager reported that the potato salad was expired and should have been discarded. The Dietary Manager discarded the potato salad. During the observation of the walk-in cooler, an open bag of white chocolate chips was noted in an open plastic bag inside a box. Neither the box nor the bag were labeled with an open date. The Dietary Manager explained that the white chocolate chips were used during the holidays and were expired and should be discarded. The Dietary Manager could not recall exactly when the white chocolate chips were opened and reported the box should have been labeled.Cook #1 was interviewed on 1/5/26 at 10:28 AM and she reported she had opened the liquid eggs for breakfast this date and should have labeled the carton but forgot. [NAME] #1 reported she did not know anything about the white chocolate chips.b. The walk-in freezer was observed on 1/5/26 at 10:30 AM. During the observation it was noted that frozen hashbrowns were in an open box without a date and the bag containing the hashbrowns inside the box was open to air. An open box of bagged frozen bread was sitting under the freezer compressor. The box had frozen liquid on the top of the box, the box was open and the bread inside of a plastic bag was open to air. The Dietary Manager reported he was not aware the compressor was dripping onto the boxes and the bags with the frozen food should have been closed. A follow-up interview was conducted with the Dietary Manager on 1/8/26 at 10:10 AM. The Dietary Manager reported he typically checked the freezer and walk-in cooler daily for expired foods, but he had not been able to do that task on 1/5/26 before the tour of the kitchen. The Dietary Manager reported he expected dietary staff to label open foods, secure the food in bags, and discard expired food.The Administrator was interviewed on 1/8/26 at 11:17 AM. The Administrator reported the kitchen had monthly inspections and they had not observed any issues with open food labels or food open to air. The Administrator reported she was not aware the freezer compressor was dripping on boxes stored under the compressor and she expected a work order to be completed. The Administrator reported the Dietary Manager had returned from vacation on 1/5/26 and had not had the opportunity to check the freezer and the walk-in cooler before the tour of the kitchen. The Administrator reported she expected the dietary staff to label open food, discard expired food, and secure open food in bags.

Based on observation, record review, and interviews with hospital system's transportation staff (Driver #1), Passenger Services Manager and Nurse Practitioner (NP), the facility failed to leave Resident #45 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #45 was being transported to dialysis in a hospital system owned transport van. Driver #1 made a sudden stop which caused Resident #45 to slide forward out his wheelchair onto the van floor when his seatbelt loosened. Driver #1 pulled the van into the median of the road and attempted to transfer Resident #45 back into his wheelchair. When Driver #1 was unsuccessful in transferring Resident #45 back to his wheelchair, she continued to transport Resident #45 to the dialysis center while the resident was seated on the floor of the transportation van. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if the resident sustained any injuries. Resident #45 did not sustain any injury, however there was a high likelihood of serious injury after sliding out of his wheelchair onto the floor of the vehicle when the driver had to suddenly apply brakes to avoid hitting pedestrians. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #45). The immediate jeopardy began on 2/9/24 when Resident #45 was not physically assessed for injury before being moved and was transported to dialysis while seated and unsecured on the floor of the transportation van. The immediate jeopardy was removed on 10/15/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm that is immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: The Motor Vehicle Accident and Emergency Reporting procedure updated 6/23/23 included a policy that stated health care passenger service drivers would report a motor vehicle accident or medical/vehicle emergencies immediately. The supervisor should be called (number listed) to resolve any urgent or emergency situations concerning the driver, the delivery or pick-up of passengers, and vehicle related problems at any time. The procedures included if patient starts to slide or shift while in wheelchair during transport - driver must pull over when safe to do so and seek help. i.e. Call 911 - fire department, pull vehicle onto the shoulder of the road; assess patient and/ passenger to determine if emergency medical assistance was needed and if patient or passenger was injured, report this to your supervisor immediate so an online incident report can be done via CARE Event (A Care Event is an incident/accident report that involves resident safety). Resident #45 was admitted to the facility on [DATE] with diagnoses that included generalized weakness, end stage renal disease and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was cognitively intact. The MDS further indicated he required substantial/maximum assistance (helper does more than half of the effort) to go from a lying position to sitting, utilized a manual wheelchair and received dialysis. An interview was conducted with Resident #45 on 10/11/24 at 5:00 PM. Resident #45 stated he recalled an incident in which he slid from his wheelchair in the transportation van while going to his dialysis appointment. He further stated the brakes [when the driver applied brakes, it] threw him out of the chair. Resident #45 revealed he had gotten help from emergency medical service (EMS) staff to get back into his wheelchair. He stated Driver #1 slammed on brakes and he did not touch his seatbelt. Driver #1's witness statement dated 2/9/24 at 2:45 PM read Driver #1 was driving down [Highway] 52 South towards the dialysis center. Some pedestrians started to run out in the front of her and Driver #1 had to put on brakes suddenly. Somehow the seatbelt came loose, and Resident #45 slid out of wheelchair onto the floor. Driver #1 pulled into the median to check on Resident #45 and attempted to get him up. Resident #45 stated he wanted to stay there and just take him on to his appointment. Once at dialysis, Driver #1 asked for help from dialysis staff. The Dialysis Staff said they could only help if Resident #45 was visible in the building. Driver #1 called 911 to help. Resident #45 stated he was not hurt to the medic on the phone, and they came and got him back in the chair. Driver #1 took Resident #45 in dialysis center for his appointment. Interview with Driver #1 on 10/10/24 at 4:09 PM revealed she could not recall the date of the incident but recalled a van incident that occurred with Resident #45. She stated she was transporting Resident #45 to dialysis when she observed 2 pedestrians that appeared to be darting in the roadway. She slammed on brakes. When she slammed on the brakes, Resident #45 slid from his wheelchair, his seatbelt came loose and he landed on the van floor. She indicated it was the force of the van stopping that made the resident's seatbelt come loose and Resident #45 landed on the van floor. She stated she stopped the van and tried to put Resident #45 back in his chair. She could not get him in the chair, and he stated he did not want help. Driver #1 stated she was close to the dialysis center, so she drove Resident #45 while he was seated on the floor of the transportation van. She indicated she should have contacted 911 to get Resident #45 back into his wheelchair and not drive with him on the floor of the van. Following the incident, she received education to call 911 if a fall happened on transport and she shouldn't move a resident. She further stated she had seen the video of the incident as there was a camera on the transportation vans. An observation of video footage (visual and audio) of the van incident dated 2/9/24 was conducted with the Administrator on 10/11/24 at 2:31 PM. The video footage revealed a date of 2/9/24 and began at 11:43 AM. The camera was mounted in the front of the van and provided a view toward the rear of the van. Resident #45 originally seated behind the driver in the middle isle of the van. At 11:49 AM in transport, Resident #45 was observed to lean forward as his seatbelt was observed to come from his right side (where it was fastened) to his left. Resident #45 was observed to lean to his right side then slide forward out of his wheelchair in the aisle and then fall to his right. After falling to his right, Resident #45 was no longer visible through the video (behind passenger seat). His wheelchair could still be seen in the upright position. Driver #1 was observed to stop the transportation van in the road's median and stated someone ran out in front of her. Driver #1 then exited the driver's seat and entered the side door of the transportation van. She was overheard to tell Resident #45 You going to have to help me out now. Resident #45 was heard telling Driver #1 she was going to have to get some help. Driver #1 was observed to attempt to get the resident back up into his wheelchair as evidenced by picking him up under both arms. Resident #45 was observed sliding back out of his wheelchair back onto his bottom to the floor of the transportation van. Driver #1 then positioned Resident #45's back against his wheelchair while he was seated on the floor while telling him to hold on. Driver #1 was further observed to get back in the driver's seat. She stated she would drive slow. She also stated Resident #45 shouldn't have taken his seatbelt off. Driver #1 transported Resident #45 to the dialysis center. At 11:53 AM Driver #1 was observed pulling into the dialysis center parking covered parking deck. Resident #45 could be heard breathing heavy and moaning. Driver #1 was observed to go into the dialysis center, and then shortly after came back out to the transportation van. Within distance of the surveillance video, Driver #1 was observed to make a phone call at 11:55 AM (not within distance to overhear conversation). Driver #1 was observed to meet emergency medical services (EMS) upon arrival at 12:08 PM. Two EMS personnel were observed to assist Resident #45 back into his wheelchair at 12:10 PM. EMS were observed not to take vital signs or check Resident #45 for injuries. After EMS transferred Resident #45 into his wheelchair they exited the transportation van. Driver #1 was observed taking Resident #45 into the dialysis center at 12:12 PM. According to contact with the local EMS agency on 10/22/24, a report was not made. EMS attendants observed in the video footage did not document the event. Interview with Passenger Services Manager on 10/11/24 at 2:00 PM revealed when an incident occurred during transport, the driver should contact dispatch office. After watching the video footage she indicated following the incident, Driver #1 should have contacted 911 to assist her transferring Resident #45 back into his wheelchair. Driver #1 should not have attempted to transfer Resident #45. She indicated that due to the investigation, Driver #1 was reeducated regarding the seatbelt strap, transporting a secured resident and contacting 911 for assistance. She further indicated it was not part of the procedure to drive with a resident on the floor of the van unsecured. On 10/14/24 at 9:03 AM the Unit Manager stated she had not completed an incident report for the fall but did put the incident in a care event. She continued that generally, when a resident had a fall, the facility would assess the resident before moving them. Assessing the resident prior to getting him up was to ensure there were no fractures or anything that could cause more damage if moved. Interview with the Nurse Practitioner on 10/14/24 at 11:00 AM initially indicated she did not believe the resident had the dexterity to unhook his seatbelt. She stated there should be an assessment of the resident before he was assisted up from the floor of the transportation van. The assessment would have included his level of consciousness, a quick neurological check to see if moving all extremities, baseline mentation, looking for trauma, blood, bruising or any signs of injury. A body assessment should have been completed to identify any abrasions that could have occurred due to the incident. Resident #45 was not someone who could be lifted because Resident #45 cannot assist. An interview with Director of Nursing Services, on 10/14/24 at 3:26 PM was conducted. She stated she had seen the video of the incident involving Resident #45 while he was being transported to his appointment. She further revealed Driver #1 would not have been able to assess the resident due to not being licensed. She indicated Driver #1 also continued to transport Resident #45 following the fall while he was seated on the floor of the transportation van. Driver #1 should have contacted 911 for assistance. Interview with the Administrator on 10/14/24 at 2:12 PM stated she was not clinical and was not involved with Resident #45's assessment following the incident Driver #1 should have not attempted to pick up Resident #45 from the floor of the van and should not have continued to transport Resident #45 while seated on the floor of the transport van. Resident #45 should be assessed before he was moved, and she assumed EMS would have assessed him. The facility was notified of immediate jeopardy on 10/11/24 at 7:17 PM. The facility provided the following immediate jeopardy removal plan. Identify those recipients wo have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 2/09/24 Resident #45 was at the dialysis clinic when the Administrator was notified by a staff member that Resident #45 experienced a fall while in van transport. Driver #1 did not notify the facility administrator nor her supervisor, the Passenger Services Manager, about the accident. On 2/09/24 the Administrator contacted the Passenger Services Manager to begin an investigation and require education of Driver #1. On 2/09/24 Driver #1 put on the brakes suddenly and Resident #45 slid from his wheelchair onto the floor. Driver #1 stated that she did attempt to get Resident #45 up however Resident #45 stated to just to leave him on the van floor and take him to the Dialysis Clinic. Driver #1 then proceeded to call 911 for assistance. Driver #1 asked Resident #45 if he was ok and Resident stated that he was. Resident #45 stated to 911 personnel that he was not hurt, and they moved him back to the wheelchair. After Resident #45 was transferred to his chair by EMS (Emergency Medical Services) staff, Resident #45 stated that he had to go to the restroom Resident #45 required assistance prior to being dialyzed, Driver #1 transported Resident #45 back to the facility to receive care and Driver #1 then transported Resident #45 back to the Dialysis Clinic to be dialyzed without further incident. Driver #1 returned Resident #45 to the facility after dialysis was completed. There was no documentation that the nurse assigned to Resident #45 completed an assessment after incident on 2/9/24. Resident #45 was assessed by physician on 2/10/24 not related to this incident and no injuries were noted. The Passenger Services Manager provided documentation to validate that Driver #1 received education on the following policies and procedures on 2/13/24 and on 3/2/24: Expectations of Passenger Services Drivers', Mobile Cellular Device, Proper Transport Loading and Unloading Wheelchair Patients, General Safety, Motor Vehicle Accidents& Emergency Reporting Procedures to the facility administrator. On 10/14/24, the Passenger Services Manager notified the facility administrator that on 2/12/24 and 2/13/24, the Lead Driver accompanied Driver #1 on transportation routes and provided one-to one re-training as assigned by the Passenger Services Manager. Driver #1 reported back to work on 2/12/24. The Passenger Services Manager provided documentation to validate that Driver #1 received related education on the following policies and procedures: General Safety, Motor Vehicle Accidents & Emergency Reporting Procedures, Expectations of Passenger Services Drivers, Proper Transport Loading and Unloading Wheelchair Patients and Mobile Cellular Device to the facility administrator. Documentation of training and acknowledgment was signed on 2/13/24. On 3/2/24 Driver #1 was re-educated again on the following Policies and procedures: General Safety, Motor Vehicle Accidents & Emergency Reporting Procedures, Expectations of Passenger Services Drivers, Proper Transport Loading and Unloading Wheelchair Patients and Mobile Cellular Device and documentation of training was provided to the facility administrator. Documentation of training and acknowledgment was signed on 3/2/24. All residents who use wheelchair transportation services for medical appointment[s] are at risk of experiencing an adverse outcome as a result of this deficient practice. Current residents who had been transported by the transportation service within the last 30 days were interviewed on 10/12/24 and 10/13/24 by members from the IDT team, specifically the Resident Liaison, Rehab Manager, Activity Director and LPN/Unit Coordinator regarding any incidents or accidents where the resident was not immediately assessed for injuries occurred in transport. For current residents who were not able to be interviewed, the assigned transportation companions were interviewed 10/12/24 and 10/13/24 and no evidence of any additional deficient practice during transport was reported where drivers moved residents after an incident without being first assessed by 911 personnel or licensed nurse/physician. The Passenger Services Manager was interviewed by the facility Administrator on 10/11/24 and 10/13/24 related to any events of deficient practice reported from all drivers within the last 30 days which required immediate assessment for injuries. The Passenger Services Manager reviewed incident reports and communicated directly with all drivers providing services to the facility and found no evidence of any deficient practice during transport review period reported. The Passenger Services Manager also asked all drivers, including Driver # 1, if there were any accidents/incidents that occurred on transport that were not reported in the last 30 days and the drivers' responses indicated that there had not been any accidents/incidents that had not been reported during review period. On 10/13/24, the Passenger Services Manager confirmed with the facility administrator that interviews; and a review of transportation records for that past 30 days found no evidence of deficient practice with drivers providing service to residents at the facility. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility will take immediate action by informing Hospital system transportation services to remove Driver #1 from transporting facility residents to any off-campus appointments, Effective at 8:40 pm on 10/11/24. On 10/12/24, the Passenger Services Manager and the Facility Administrator reviewed the policy, Motor Vehicle Accident & Emergency Reporting Procedure and found the policy did not address skilled nursing facility residents and the policy section regarding emergencies was revised on 10/14/24 to reflect that for skilled nursing home residents, drivers are not to move patient until assessed by EMS or licensed nurse/physician, as listed below: Medical/Vehicle Emergencies: If patient starts to slide or shift while in wheelchair during transport - Driver must pull over when safe to do so and seek help. i.e. Call 911 - fire dept. Each driver has a cell phone provided and other communication devices which are owned and managed through Mobile Medical Services not the facility. Pull vehicle onto the shoulder of the road Evacuate Patients and or passengers from the vehicle quickly and safely if vehicle is on fire Administer first aid and use fire extinguishers as appropriate Do not move patient. Patient must be accessed by Emergency Medical Services (EMS) or licensed nurse/physician Drivers will immediately notify the Passenger Services Manager in the event of an incident/accident during transport Call Atrium Health Security or contact 9-1-1 as needed for emergency help and update Mobile Medicine Passenger Services Dispatch at (704)512-7920 If patient or passenger is injured, report this to your supervisor immediately so an online incident report can be done via CARE Event (A Care Event is an incident/accident report that involves resident safety) Driver must remain with patients and/or passengers until all are transported to an emergency care facility if necessary Have Atrium Health Security notify supervisor and department head as needed On 10/14/24 the facility administrator notified the Passenger Services Manager to immediately notify the facility administrator or charge nurse in the event of an incident/accident during transport. All current van drivers will receive education by 10/14/24. Any current van drivers who do not receive education by 10/14/24 (due to FMLA, leave, etc.) will be required to complete education prior to working a scheduled shift. All van drivers hired after 10/14/24 will be required to complete this training and education upon hire. The education will be required during annual orientation. Beginning 10/12/24, the Passenger Services Manager will immediately notify and provide all transportation services incident reports involving nursing home facility residents to the Administrator and Director of Nursing to ensure that timely resident assessments post medical/vehicle emergencies are completed. The alleged date of immediate jeopardy removal was October 15, 2024. On 10/16/2024 the facility's immediate jeopardy removal was validated by the following: The facility provided documentation to support immediate jeopardy removal including education provided by the Passenger Services Manager to the current drivers. Drivers were interviewed and they reported the procedure to follow if a resident falls on the van, including pulling the van over as soon as possible, calling 911 to request an assessment of the resident by an EMT, contacting the dispatcher to report the accident or incident. Drivers verbalized they were not to move the resident until an EMT, nurse, or physician had assessed the resident for injuries. The immediate jeopardy was removed on 10/15/2024.

Based on observations, record review, review of audio/video footage, and Nurse Practitioner (NP), Passenger Services Manager, resident and staff interviews, the facility failed to provide safe transportation for Resident #45 in the hospital system transportation van to the dialysis center. On 2/9/24 while en route Driver #1 stopped abruptly, and Resident #45 slid out of his wheelchair to the floor of the van. Driver #1 was unable to assist Resident #45 back into his wheelchair and proceeded to drive to the dialysis center with Resident #45 sitting on the floor of the van. In addition, on 8/12/24, Driver #1 failed to ensure the lift gate was in the elevated position before unloading Resident #62 from the back from the van. Driver #1 stood behind Resident #62's wheelchair and wheeled Resident #62 towards the back of the van and lift gate. Driver #1 fell out of the back of the transportation van and Resident #62 and his wheelchair rolled out of the back of the transportation van and landed on top of Driver #1. There was a high likelihood of a serious adverse outcome or injury when the manufacturer's instructions for securing and unloading residents from the transportation van are not followed. This was for 2 of 5 residents reviewed for accidents (Resident #45 and Resident #62). Immediate jeopardy began on 2/9/24 when Resident #45 fell to the floor of the transportation van while being transported to his dialysis appointment. Immediate jeopardy began on 8/12/24 for Resident #62 when Driver #1 wheeled the resident out of the back of the van with the lift gate in the grounded position. Immediate Jeopardy was removed on 10/15/24 when the facility implemented an allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place are effective. The findings included: Review of manufacturer's instructions for the hospital system transportation van wheelchair securement system titled B Secure the Passenger included (undated): 1. Attach lab belts - use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrest to ensure proper fit around occupant. a. on the aisle side, attach belt with female buckle to rear tie down pin connector to ensure buckle rest on passenger hips. b. on the window-side attach belt with male tongue to rear tie-down pin connector and insert into female buckle 2. Attach shoulder belt - extend shoulder belt over passengers' shoulders and across upper torso and fasten pen connector onto lap belt Note: combination lap/shoulder belts serve as both window and window-side lab belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. 1. Resident 45 was admitted to the facility on [DATE] with diagnoses that included generalized weakness, end stage renal disease and hypertension. Resident #45 was not on prescribed an anticoagulant (blood thinner). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was cognitively intact. The MDS further indicated he required substantial/maximum assistance (helper does more than half of the effort) to go from a lying position to sitting. Resident #45 utilized a manual wheelchair for mobility and had no falls since admission. Review of Resident #45's nursing notes for the month of February 2024 did not reveal any documentation regarding him sliding from his wheelchair while on the transportation van. Review of a dialysis center Social Worker note dated 2/9/24 at 1:08PM stated gave emergency contact to call to inform him that Resident #45 had a fall (while) being transported to treatment today. The SNF Post Fall Debrief and Checklist dated 2/9/24 had no time entered for the incident and the location was identified as the transportation van. Nurse #1 was identified as the assigned nurse. The brief description of the event stated, Resident #45 was noted to be on transport to an appointment when Resident #45 slid out of the wheelchair going down the road. Medics assisted Resident #45 back into his wheelchair. The medication factors, factors that may have contributed to Event, Care planning and Behavioral factors were left blank. The document indicated that the Nurse Practitioner (NP) was notified on 2/9/24 with no time of contact, and Resident #45's family was notified on 2/9/24. The form was completed by the Unit Manager on 2/9/24. Review of the witness statement written by Driver #1 dated 2/9/24 at 2:45PM revealed Driver #1 was driving down [name of highway] towards the dialysis appointment. Some pedestrians started to run out in front of her and Driver #1 had to put on brakes suddenly. Somehow the seat belt came loose, and Resident #45 slid out of wheelchair onto the floor. Driver #1 pulled into the median to check on Resident #45 and attempted to get him up. Resident #45 stated he wanted to stay there and just take him on to the appointment. At dialysis, Driver #1 asked for help, and they said they could only help if Resident #45 was visible in the building. Driver #1 called 911 to help. Resident #45 stated he was not hurt to the medic on the phone, and they came and got him back in the wheelchair. Driver #1 took Resident #45 in for his appointment. Resident #45 asked them to take him to the restroom. They said they could not so, they brought him back out so Driver #1 could take him back to the facility to change and use the bathroom. Once that was done, Driver #1 returned him to this appointment. Review of dialysis nursing note dated 2/9/24 at 4:37PM stated Resident #45 slid out of his wheelchair in the transportation van with no apparent injury. EMS was called to assist in lifting the resident. The resident denied any problems or discomfort. Interview with Driver #1 on 10/10/24 at 4:09PM revealed she could not recall the date of the incident but recalled a van incident that occurred with Resident #45. Driver #1 stated she was transporting Resident #45 to dialysis when she observed 2 pedestrians that appeared to be darting in the roadway, and she slammed on the brakes. When she slammed on the brakes, she observed through her rearview mirror, Resident #45 slid from his wheelchair, his seatbelt (combination lap/shoulder belt) came loose, and he landed on the van floor. Driver #1 stated she pulled over into the median, stopped the van and went to assist Resident #45. She stated when arrived at Resident #45 he was positioned on the floor face up with his head toward his chair and his legs towards the driver's seat. Resident #45's head was close to the van door and his wheelchair remined upright. Driver #1 indicated she tried to put Resident #45 back in his wheelchair and she could not. Resident #45 stated he did not want help with getting back in his wheelchair. Driver #1 stated she was close to the dialysis center, so she drove Resident #45 there while he was seated on the floor of the transportation van. Driver #1 also could not recall if she communicated the incident to anyone in the facility. An interview was conducted with Resident #45 on 10/11/24 at 5:00 PM. Resident #45 stated he recalled an incident in which he slid from his wheelchair in the transportation van while going to his dialysis appointment. He further stated the brakes [when the driver applied brakes] threw him out of the wheelchair. Resident #45 revealed he had gotten help from emergency medical service (EMS) staff to get back into his wheelchair. He stated Driver #1 slammed on brakes and the resident did not touch his seatbelt. Interview with Unit Manager on 10/11/24 at 11:11AM indicated she recalled being at the nursing station 2/9/24 when she overheard Driver #1 talking with staff members (could not recall names) about Resident #45 sliding out of his wheelchair during transport. The Unit Manager stated she questioned Driver #1 about the incident and Driver #1 stated Resident #45 had slid out of his wheelchair on his way to his dialysis appointment that day. Driver #1 explained that during the transport, someone ran across the road, and she had to slam on the brakes to avoid them. When Driver #1 slammed on the brakes, Resident #45 was holding onto his lunch bag, and when he got pushed forward, his lunch bag and hand unhooked his seatbelt. She indicated Driver #1 stated when Resident #45 slid to the floor, Driver #1 pulled over into the median, and she asked was Resident #45 ok. Driver #1 indicated she couldn't get him up and Resident #45 told her he wanted to go to dialysis. Driver #1 contacted Emergency Medical Services (EMS) when she arrived at the dialysis center, and they assisted Resident #45 back into his wheelchair. The Unit Manager recalled Driver #1 bringing Resident #45 back to the facility that day from the dialysis center for incontinence care and then transporting him back to the dialysis center. The Unit Manager stated she believed she asked Driver #1 about the situation after she came back from the dialysis appointment and not when she brought Resident #45 back for incontinence care. She stated she filled out the SNF post fall debrief and checklist form dated 2/9/24, contacted the NP and Resident #45's family member. She recalled telling the current interim Director of Nursing (DON), Regional Facility Consultant #1 and the Administrator about Resident #45 having a fall while on the van. She stated she put a note in the flow sheet and documented that she contacted the provider but had not completed a detailed note about the incident. In another interview with the Unit Manager on 10/11/24 at 11:53 AM, the unit manager indicated she followed up on the incident on 2/12/24. She stated she did not include interventions on the SNF post fall debrief and checklist form because she didn't deal with transportation. She further indicated Driver #1 was not employed by the facility and she was not sure what interventions the transportation department put into place. The unlicensed Administrator provided a copy of an email dated 10/11/24 at 11:09AM requesting a copy of the care event related to the van incident on 2/9/24 from Passenger Services Manager. The response email dated 10/11/24 included the Corporate Risk Management Care Event dated 2/9/24 which stated Resident #45 slid out of his wheelchair during transport. Driver #1 advised that she had to brake suddenly, and Resident #45 slid out of his chair. The reporting employee was identified as the Passenger Services Manager. The Corporate Risk Management Care Event indicated there was no harm to Resident #45. Interview with the Passenger Services Manager on 10/11/24 at 2:00PM revealed when an incident occurred during transport, the transporter/Driver should contact dispatch and in a lot of cases contact the family. The driver would also need to make contact with the Passenger Services Manager and provide information as it related to the incident immediately. A witness statement would also be requested. The Passenger Services Manager stated she included information regarding incidents on the transportation van in a care event (information regarding incidents on the transportation van). She further revealed she would conduct an internal investigation to identify what occurred and what could be done differently to prevent a recurrence. The Passenger Services Manager stated typically when she entered a care event she would alert the facility of the incident as well. She recalled Driver #1 notified her that Resident #45 had a fall during transport on 2/9/24. The Passenger Services Manager created a care event and obtained a statement from Driver #1. She could not recall if she notified the facility. She stated she was unsure if Resident #45 had any injuries due to the accident. The Passenger Services Manager explained during her investigation she reviewed the audio/video footage of the incident. The Passenger Services Manager stated she recalled hearing a click when Driver #1 fastened the combination lap/shoulder belt on the audio/video footage which led her to believe Driver #1 secured Resident #45 properly. However, she also stated the shoulder belt strap could have been more secure around Resident #45 due to her observing slack when she observed the video footage. The Passenger Services Manager indicated Driver #1 should have tightened the shoulder belt after connecting the device. In the video, Resident #45's lap belt inclusive of shoulder belt were observed to come off of Resident #45 (unfastened) and he slid out of his wheelchair onto the van floor. She indicated that due to the investigation Driver #1 was reeducated regarding the combination lap/shoulder belt, not transporting residents while unsecured and contacting 911 for assistance. The Passenger Services Manager further indicated it was not part of the procedure to drive with a resident on the floor of the transportation van. The Passenger Services Manager indicated in her internal investigation she did not make observations of the wheelchair to identify any potential malfunction or damage due to the incident. She stated it would be the facilities responsibility to assess the Resident's wheelchair after the event. An observation of audio/video footage of the van incident dated 2/9/24 was conducted with the Administrator present on 10/11/24 at 2:31 PM. The video footage revealed a date of 2/9/24 and began at 11:43 AM. The camera was mounted in the front of the van and provided a view toward the rear of the van. Driver #1 was observed to get Resident #45 off the lift and roll him onto the back of the transportation van. She was further observed to attach the base of the wheelchair to tie downs and then place the combination lap/shoulder belt around Resident #45. Driver #1 pulled the shoulder strap and integrated lab belt from the left side of the van and connected the belt to the right side of Resident #45 (no sound heard). The shoulder strap was observed to be loose as the shoulder belt was not snug around Resident #45's torso. (Slack was observed where the shoulder strap would retract). Driver #1 was not observed to check or adjust the lap or shoulder belt. Resident #45 was seated behind Driver #1 in the middle aisle of the van. At 11:49 AM Resident #45 was observed to lean forward as his lap belt inclusive of shoulder belt, were observed to unfasten, going from his right side (where it was fastened) to his left. Resident #45 was observed to lean to his right side then slide forward (feet first) out of his wheelchair into the van's aisle and then fall to his right side. Resident #45's wheelchair was observed to remain upright with tie downs still attached. After falling to the floor, Resident #45 was no longer visible on the video and Driver #1 was observed to stop the transportation van in the highway's median and stated someone ran out in front of her. Driver #1 then exited the driver's seat and entered through the side door of the transportation van. She was overheard telling Resident #45, You going to have to help me out now. Resident #45 was heard telling Driver #1 she was going to have to get some help. Driver #1 was observed to attempt to get the resident back up into his wheelchair by picking him up under both arms. Resident #45's was observed sliding onto his bottom on the floor of the transportation van. Driver #1 then positioned Resident #45's in a sitting position with his back against his wheelchair while he was seated on the floor and telling him to hold on. Driver #1 was observed to get back in the driver's seat and stated she would drive slowly. She also stated Resident #45 shouldn't have taken his seat belt off and Resident #45 did not respond. Driver #1 transported Resident #45 to the dialysis center. At 11:53 AM Driver #1 was observed pulling into the dialysis center's covered parking deck. Resident #45 could be heard breathing heavy and moaning. Driver #1 was observed to go into the dialysis center, and then shortly after came back out to the transportation van. Driver #1 was observed to make a phone call at 11:55 AM (not within distance to overhear conversation). Driver #1 was observed to meet emergency medical services (EMS) personnel upon arrival at 12:08 PM. Two EMS personnel were observed to assist Resident #45 back into his wheelchair at 12:10 PM And Driver #1 was observed taking Resident #45 into the dialysis center at 12:12 PM. In a continued interview with the Unit Manager on 10/14/24 at 9:03AM. She stated she didn't overhear Driver #1 speaking of the incident until she returned with Resident #45 at the completion of his dialysis treatment. The Unit Manager stated she contacted Facility Consultant #1 as soon as she was made aware. She stated Regional Facility Consultant # 1, requested that she ask further questions about what occurred and had her reach out to Driver #1's supervisor to let them know about the van incident and obtain a statement. The Unit Manager revealed she communicated to the Passenger Services Manager on 2/9/24 that she wanted them to do an incident report/care event, and the Passenger Services Manager indicated they would handle the situation. The Unit Manager indicated she did not complete an incident report. During an interview on 10/14/24 at 11:00AM the Nurse Practitioner (NP) initially indicated she was not made aware of Resident #45's fall while being transported to his dialysis appointment. She stated she was made aware (Friday or Wednesday) of last week. After a review of the SNF Post Fall Debrief Checklist report completed by the Unit Manager dated 2/9/24 the NP stated she may have been contacted but it wasn't to the extent of the resident sliding from his wheelchair, not being assessed and transported to his dialysis appointment while seated on the floor of the transportation van. The NP stated the Unit Manager might have notified her, but the NP indicated she would have thought she would have remembered being contacted if she was provided with the details of the incident. Looking at how the SNF Post Fall Debrief Checklist was written, it sounded as if the resident was just assisted back to his wheelchair. The NP further indicated she did not believe Resident #45 had the dexterity to unhook his seatbelt. Interview with Regional Facility Consultant #1 on 10/14/24 at 2:00PM revealed she was notified by the Unit Manager by phone 2/9/24 that Resident #45 had a fall on the transportation van while being transported to his dialysis appointment. The Regional Facility Consultant #1 told the Unit Manager to contact the Passenger Services Manager to notify her to obtain a statement from Driver #1, an incident report, and their course of action or plan. She further stated she had email communication with transportation (not named) on 2/9/24 at 4:40PM regarding Resident #45 sliding out of his wheelchair while on route to the dialysis center. Regional Facility Consultant #1 explained as corporate support she provided support and direction to make sure regulatory procedures were followed. She indicated it would be her expectation that administration followed up about the incident to ensure procedures were followed. Regional Facility Consultant #1 indicated she notified the Passenger Services Department that a care event would be put into the system and the Passenger Services Department would need to put in a care event as well. Regional Facility Consultant #1 stated she did not follow up about incident after she provided the facility direction on what information they would need. Regional Facility Consultant #1 indicated she had not contacted the Passenger Services Manager to discuss the details of the investigation or identify what corrective measures were put into place. Interview with the Director of Nursing Services on 10/14/24 at 3:26PM was conducted. She stated she had reviewed the audio/video footage of the incident involving Resident #45 while he was being transported to the dialysis center. She indicated in the video she observed Resident #45 seatbelt come off and Resident #45 go to the floor of the transportation van. The Director of Nursing Services indicated Driver #1 also continued to transport Resident #45 following the fall while he was seated on the floor of the transportation van. Interview with the unlicensed Administrator on 10/14/24 at 2:12PM revealed she became aware of the van incident on 2/9/24 through a staff member (name unknown). The unlicensed Administrator stated she did not provide guidance to nursing staff because Resident #45 was not in the building when the fall occurred. She indicated she contacted the Passenger Services Manager on 10/11/24 to get a statement and a copy of the incident report/care event. The unlicensed Administrator confirmed a post-fall investigation was not completed and she had not contacted the Passenger Services Manager to discuss the details of the investigation or identify what corrective measures were put into place. 39613 2. Resident #62 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was cognitively intact. He was not receiving an anticoagulant. He did not have any impairment to his upper and lower extremities. Review of Passenger Services Liftgate Use and Patient Safety Check (no date) supplied by the Passenger Services Manager revealed the following: I. Vehicle Liftgate Use & Safety Checks- - Always ride liftgate up when getting ready to offload patient - Ensure liftgate is in the upward position prior to attempting to unload patient - Do not ride liftgate up or down with the patient on lift II.Passenger Safety (Unload) - - Always ride the liftgate up when getting ready to offload patient - Ensure liftgate is in the upward (level with the floor in the rear of the van) position prior to attempting to unload patient and that the liftgate is level with floor of vehicle - Get in front of patient and push wheelchair onto liftgate and secure wheelchair by locking wheelchair brakes Review of Passenger Services Safety Briefing (no date) supplied by the Passenger Services Manager revealed the following: - To ensure the lift gate is in the upward position prior to attempting to offload a patient, always ride the lift gate up after entering from the rear of the vehicle. Review of the video and audio recording (which was center- rear facing) from the hospital owned transportation van dated 8/12/24 revealed the following: - At 6:08 PM the hospital owned transportation van, driven by Driver #1, returned to the facility with Resident #62's responsible party, Resident #62, and another resident. Resident #62 was observed in his wheelchair with his shoulder securement strap resting across his left upper arm. - At 6:09 PM to 6:10 PM, Driver #1 disconnected Resident #62's shoulder securement strap and Resident #62 remained in his wheelchair while another resident was being unloaded by Driver #1 via the lift gate. - At 6:12 PM Driver#1 returned to the hospital owned transportation van and entered from the rear. The lift gate was observed to be on ground level. Driver #1 unsecured Resident #62's wheelchair securement straps from behind. - At 6:13 PM Driver #1, who was behind Resident #62, was observed pulling Resident #62 backwards towards the rear of the hospital owned transportation van. As Driver #1 crossed the threshold at the rear of the hospital owned transportation van, an audible alarm sounded, and indicator lights lit up red and flashed, which indicated the liftgate was not in the upward position and there was a risk of falling out of the rear of the van. Driver #1 proceeded to fall out of the back of the hospital owned transportation van. She let go of Resident #62's wheelchair as she was falling backwards out of the hospital owned transportation van. Resident #62 was seated in his wheelchair and remained in motion rolling backwards out of the hospital owned transportation van. Driver #1's arm was observed to come up to meet the back of Resident #62's wheelchair as Resident #62 and his wheelchair proceeded to roll off the back of the hospital owned transportation van. Resident #62 continued rolling backwards in his wheelchair and his legs were seen coming up in the air as his chair exited the rear of the hospital owned transportation van and pivoted to where the resident was still seated but facing upwards. Resident #62 then was observed to be slightly unseated from his wheelchair. The wheelchair wheels were observed to be hanging off the back of the hospital owned transportation van. Driver #1 ceased to be in the field of vision. Driver #1 and Resident #62 could be heard yelling/calling out for help. Resident #62's wheelchair wheels were suspended in air and still spinning. - At 6:14 PM to 6:16 PM facility staff were observed exiting the facility and saw Driver #1 lying on her back on the lift gate on the ground and Resident #62 in his wheelchair tilted to the left resting on Driver #1 and ran back inside to get help. More staff responded and came out to assist. The Unit Manager also responded. Staff were observed standing over Driver #1 and Resident #62. The Unit Manager was observed entering the hospital owned transportation van from the side entrance and walking to the rear of the hospital owned transportation van towards the lift gate. The Unit Manager was observed bending over and grabbing the wheelchair legs while other staff were observed assisting Driver #1 from underneath Resident #62 and his wheelchair. Resident #62's wheelchair was then placed to the left side of the hospital owned transportation van. Driver #1 was observed to stand and stretch. Staff continued to stand as Resident #62 was being assessed. Resident #62 was assisted by staff back to his wheelchair and taken back inside the facility by staff. An observation was completed on 10/11/24 at 4:55 PM of the Administrator obtaining the measurement of the back of the transportation van where Resident #62 fell backwards in his wheelchair to where he and his wheelchair landed measured three (3) feet and ten (10) inches. Review of the Care Event (incident report) notification completed by the Passenger Services Manager dated 8/12/24 revealed the following information: Event Description- Driver was unloading patient from wheelchair van. Patient fell out of the wheelchair as driver was exiting patient from vehicle. Driver statement will be sent. Date Occurred: 8/12/24. Incident Location (facility): Hospital System- Health Mobile Medicine. Extent of Harm: Mild Harm. Event Type: Fall. Review of Driver #1 witness statement dated 8/12/24 read in part: Driver #1 was unloading two patients. Driver #1 unloaded the first patient and took them inside the building. Driver #1 returned to the hospital owned transportation van on the passenger side, where the door was already opened, and unlocked the seatbelt and the wheelchair securement straps. Driver #1 was behind the wheelchair to pull it back to the rear of the hospital owned transportation van not realizing the lift gate was down on the ground and not in the level position. The safety beeper went off. At that point, Driver #1 was too far back and fell backwards, still holding on to the wheelchair. Driver #1 let go of the wheelchair, so it stayed on the hospital owned transportation van but was tilted back. Driver #1 balanced and held the wheelchair up with her feet as long as she could and called out for help. When Driver #1 strength gave out, the patient and wheelchair fell back onto Driver #1 body breaking the fall. Driver #1 braced his [the resident] upper body with her left arm and hand until help arrived. An interview with Driver #1 on 10/10/24 at 4:33 PM revealed that she and Resident #62 fell out of the back of the hospital owned transportation van on 8/12/24. Driver #1 explained she went to unload Resident #62 from the hospital owned transportation van after unloading another resident. Driver #1 stated she entered the hospital owned transportation van from the rear and proceeded to unsecure Resident #62 from the wheelchair securement straps from behind. Driver #1 explained she remained behind the wheelchair of Resident #62 and wheeled him backwards towards the lift gate area. Driver #1 voiced she did not realize the lift gate was down. Driver #1 continued to explain while moving Resident #62 towards the lift gate area, walking backwards as she was pulling Resident #62 in his wheelchair backwards, Driver #1 verbalized the alarm/sensor sounded as she crossed the threshold at rear of the van. Driver #1 stated the alarm sound startled her. Driver #1 proceeded to explain she fell backwards out of the hospital owned transportation van taking the wheelchair with Resident #62 with her as she fell . Driver #1 further stated she held the wheelchair with Resident #62 in the air with her feet and hands as long as she could (no timeframe given) and hollered for help. Driver #1 expressed she started to fatigue and the wheelchair with the resident fell on top of her as she laid on the lift gate which was at ground level. Driver #1 voiced Resident #62 did not hit the ground, because she had absorbed his fall. A telephone attempt was made on 10/11/24 at 11:05 AM to speak with the responsible party for Resident #62 without success. Review of the post fall evaluation completed by the Unit Manager dated 8/12/24 revealed the following: Fall Occurrence: August 12, 2024. Day of Week of Fall Occurrence: Monday. Location of Fall Occurrence: Exterior. Description of Fall Activity: Other. Assistive Device: Lift and Walker. Post Fall Injury: No apparent injury. Post Fall Notification (date/ time/ name): August 12, 2024/ 7:25 PM/ Nurse Practitioner. Outcome of Notification: No new order received. Date/ Time of Family Notification/ Family Contact: August 12, 2024/ 7:25 PM/ onsite discussion with responsible party. Post Fall Analysis (current interventions in place): wheelchair for locomotion, wheelchair locked when not in use, non-skid footwear. Review of the Unit Manager nursing progress note dated 8/12/24 read in part: Resident #62 observed laying on back on top of Driver #1 on the lift of the hospital owned transportation van with wheelchair laying on top of Resident #62. The lift gate was resting flat on the ground. Driver #1 stated she broke his fall. Staff came in from the back of the hospital owned transportation van and pulled the wheelchair off of the resident and were able to position resident to where the driver could slide out from under him. Staff assessed Resident #62 for injury with no apparent injuries noted. Staff assisted Resident #62 to his wheelchair and assessed head for injury, none noted. Nurse Practitioner (NP) was made aware and going to complete full assessment of resident for injury. Responsible party made aware and appreciative of care. An interview with the Unit Manager was completed on 10/11/24 at 11:34 AM. The Unit Manager stated she was in her office working and a family member or visitor was leaving out of the facility. The Unit Manager proceeded to state the family member or visitor started hollering her name. The Unit Manager responded and ran towards the front entry hallway per the request. The Unit Manager explained when she arrived at the front entrance door, the lift was down on the back entry of the hospital owned transportation van and Driver #1 was lying flat on her back with her feet against the back of the hospital owned transportation van (bumper area), Resident #62 was on top of Driver #1 on his back, the wheelchair was half on top of him/ half under him somehow. The Unit Manager recalled she immediately went to remove the wheelchair from on top of resident. She stated she could not remove the wheelchair from on top of Resident #62, so she went in the hospital owned transportation van through the side entrance to remove the wheelchair from the top angle. The Unit Manager voiced she was able to remove the wheelchair and get it upright inside the hospital owned transportation van. The Unit Manager stated she exited the hospital owned transportation van with the wheelchair [TRUNCATED]

Based on observation, record review, and staff, family, resident and Nurse Practitioner (NP) interviews, the facility failed to obtain a referral, schedule or arrange an audiology appointment, or and screening for a resident with sensory neural hearing loss whose hearing aids did not fit properly for 1 of 1 resident (Resident #45) reviewed with hearing loss. The findings included: Resident #45 was admitted to the facility on [DATE] with a diagnosis that included cognitive decline and asymmetrical sensory-neural hearing loss. The care plan dated 1/22/24 indicated Resident #45 had a hearing deficit due to hearing loss as evidence by wearing bilateral hearing aids. The goal stated Resident #45 would understand verbal communication as evidence by appropriate response. The interventions included involve in activities that don't depend on hearing, parties, craft games, and small groups. Speak clearly/distinctly, adjust tone and volume of voice as necessary and monitor for changes in condition. A nursing note dated 2/8/24 indicated Resident #45 arrived at the facility via stretcher accompanied by Emergency Medical Services following a hospitalization . Resident #45 was alert, oriented and able to verbalize his needs. The note continued that Resident #45 was hard of hearing (HOH) and had hearing aids. A Speech Therapy note dated 3/6/24 included Resident #45 required written down information (visual cues), as Resident #45 was extremely HOH and hearing aids did not work. Review of Occupational Therapy note dated 3/8/24 stated Resident #45 asked, can you put my hearing aids in. The note did not indicate if Resident #45's hearing aid were put in. Review of a Social Worker (SW) note written by the previous SW dated 8/7/24 stated Resident #45 was watching television with the volume loud as he was HOH. The note continued that Resident #45 had a new roommate who was trying to visit with his wife but was unable to due to Resident #45's loud television. Resident #45 gave the Social Worker permission to turn volume down but seemed aggravated. Resident #45 was alert and appeared oriented. It was a difficult to converse with Resident #45 due to him being extremely HOH. Resident #45 asked the Social Worker to write a question on paper and he answered them appropriately. An interview was attempted with the previous SW. He was unable to be reached by phone. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was cognitively intact. Resident #45 was further coded as having moderate hearing loss and was using hearing aids. An observation of Resident #45 on 10/7/24 at 4:50 PM revealed him to be watching television with headphones. The headphones were held to his ears with tape attached across both earlobes. The tape was holding in place the wires attached to the earbuds. An interview and observation was conducted (via writing) with Resident #45 on 10/10/24 at 1:40 PM. Resident #45 was observed to be watching television in his room with earphones taped in his ears. Resident #45 revealed he had hearing aids, but no one knew how to put them in. Resident #45 stated he could not put them in himself because his hands didn't work like they used to. Resident #45 stated his hearing aids were in a basket on his nightstand. Observation of Resident #45's nightstand revealed a basket with random items. At the bottom of the basket was a chargeable hearing aid case. There were 2 hearing aids observed in the unplugged chargeable hearing aid case. During an interview with the SW on 10/10/24 at 2:04 PM revealed Resident #45 was hard of hearing and required staff to increase their tone or write to him. Resident #45 used headphones (earbuds) to watch TV because he needed the TV loud to hear it. The SW was not aware of any issues regarding Resident #45's hearing aids not working properly. She indicated if a resident had a referral for an outside appointment, it would be scheduled by transportation department. An interview with Resident #45's family member on 10/11/24 at 9:04 AM indicated he had spoken with the facility (name of staff and date unknown) regarding his family member's hearing aids. He stated when he visited the hearing aids were not in Resident #45's ears. He stated he had communicated to the facility (name of staff and date unknown) that they would have to be taken into the store they were purchased, because the store could service the device by turning the volume up or down and changing the filters. He indicated he did not believe the facility had taken the hearing aids to be serviced. He recalled having to take the device to the store to have the filters changed but he could not recall the date. An interview and observation with Nursing Assistant (NA) #3 on 10/10/24 at 1:44 PM revealed Resident #45 was very hard of hearing. She stated he had to get headphones for his television because he had it too loud. Resident #45 did have hearing aids, and they worked. Resident #45 was unable to put his hearing aids in without assistance. She indicated she has tried to put them in Resident #45's ears but they were weirdly shaped and sometimes she couldn't. She stated she has communicated to nurse (name unknown) that Resident #45's hearing aids were difficult to put in. She indicated she recalled the nurse coming in the room and trying and being unsuccessful. She stated his hearing aids did not use batteries but were kept in a charging device. NA #3 stated the last time she worked with Resident #45 she recalled putting in his hearing aids after Resident #45 requested them for a dialysis appointment. She further indicated she might be putting them in his ears wrong. During the observation of Resident #45's hearing aids, NA #3 stated the part that sat in the cartilage of Resident #45's ear did not fit correctly so they won't stay in his ears. An interview with NA #1 on 10/10/24 at 2:37 PM revealed Resident #45 was very hard of hearing and wore hearing aids. She stated when working with him she had not tried to help him put his hearing aids in. Resident #45 has issues with his hands and was not able to put his hearing aids in himself. She further indicated he had not been wearing them and she wasn't sure if it was the responsibility of the nurse or the NA to put them in. She had to get really close to Resident #45 for him to hear, and stated he always said he can't hear anything. NA #1 indicated NAs would look at the resident summary to identify what was required for each resident but could not recall if Resident #45's summary indicated apply hearing aids. Nurse #2 was interviewed on 10/10/24 at 2:03 PM and revealed she was assigned to Resident #45. She stated Resident #45 did have hearing aids but due to not working with Resident #45 for a week she was unsure of when the last time he wore them. Resident #45 was unable to put his hearing aids in himself. Nurse #2 indicated she had never put them in due to it being an NA responsibility. An interview with NA #4 on 10/10/24 at 3:16 PM indicated Resident #45 did not wear hearing aids. She stated he wore earbuds to watch television. There was tape on the earbuds to keep them from falling out of Resident #45's ears. She indicated it was her second day and this was her first time working with Resident #45. She indicated she was unsure if there was a guide that identified what the resident's activities of daily living needs were as she was new and still taking direction from NA#5. Resident #45 was very hard of hearing. She indicated she had to almost holler at him for Resident #45 to hear her. An interview with NA #5 on 10/10/24 at 3:32 PM revealed she recalled being assigned to Resident #45. She stated she had not seen Resident #45 with hearing aids and had not observed hearing aids in his room. Resident #45 had told her he was hard of hearing and that he preferred for staff to get close to his ear when speaking to him. NA #5 stated the electronic medical record would identify if a resident wore hearing aids or had to have hearing aids applied. She had not observed in the medical record that Resident #45 had hearing aids or needed assistance applying them. An interview with Nurse #5 on 10/10/24 at 3:20 PM indicated he had worked with Resident #45. He further revealed he had not seen Resident #45 with hearing aids. Nurse #5 stated Resident #45 did wear headphones when he watched TV because he needed it to be loud. The tape on his ears were to hold the headphones in place. When speaking to Resident #45 he had to speak very loudly so Resident #45 could hear him. He stated if hearing aids were not documented in the resident record on the Treatment Administration Record (TAR) or care plan, he wouldn't have looked for them. An interview with the Interim Director of Nursing on 10/10/24 at 2:16 PM indicated Resident #45's hearing aids were placed in his ears when staff could get them in his ears. She recalled having a hard time putting Resident #45's hearing aids in one day when he had an appointment to dialysis. The Interim Director of Nursing couldn't get them in and had to request assistance from another nurse. She indicated it was the NAs that would be tasked with putting in his hearing aids. She did not get a referral for Resident #45's hearing aids or notify the physician because a nurse (name unknown) was able to get them in. Issues with hearing aids should be brought to the attention of administration so the SW could do something like get an appointment. She was unsure if the concerns with Resident #45 made it to the SW. The unlicensed Administrator was interviewed on 10/10/24 at 2:06 PM. She stated Resident #45 wore earphones when he watched television. She stated she had not personally assisted Resident #45 with applying his hearing aids. From staff communication, Resident #45 did not always wear his hearing aids, but she was unsure of the cause. The unlicensed Administrator just understood he didn't like to wear them. She revealed if Resident #45's hearing aids were not fitting appropriately the facility should have gotten him an appointment and discussed the hearing aids with the Resident's family, especially if it was hindering Resident #45's care. The unlicensed Administrator recalled the SW discussing the hearing aids with the resident's family but was unaware if there was a note about the discussion. An interview with the NP on 10/14/24 at 11:00 AM revealed she recalled Resident #45 being hard of hearing. She indicated she did not recall any issues regarding his hearing aids. Resident #45 did not have the dexterity (skill in performing task, especially with the hands) to put in his own hearing aids. The NP stated if the hearing aids were not working or not fitting properly Resident #45 should have been sent out for a referral or at least be evaluated.

Based on observations, record review,and pharmacist and staff interviews, the facility failed to label and date an opened vial of Purified Protein Derivative (PPD) stored in 1 of 1 medication room refrigerator reviewed for medication storage. The findings included: A review of the manufacturer's recommendation for Purified Protein Derivative (PPD) storage, PPD vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. An observation was completed of the medication room refrigerator with the Interim Director of Nursing (DON) on 10/10/24 at 10:03 AM revealed an opened PPD vial in a plastic pouch. The affixed sticker had a dispensed date of 08/2/24. There was no open date or discard date marked on the box/pouch. During an interview with the Interim DON on 10/10/24 at 10:07 AM, the Interim DON verbalized the nurses, and the pharmacist had access to the medication room refrigerator. The Interim DON verbalized she was surprised to see the opened and unlabeled PPD solution had not been discarded. The Interim DON verbalized the pharmacist finished checking the cart and medication room refrigerator last on 10/07/24. The Interim DON removed the PPD solution in question. An interview with the Pharmacist on 10/11/24 at 1:19 PM revealed the Pharmacist inspected the medication room, treatment carts, and medication carts monthly. Last time she conducted her inspection was 10/07/24. The Pharmacist stated that any vial, once opened, should be labeled with open and discard date.

Based on observation, record review and staff interview, the facility failed to post cautionary and safety signage indicating the use of oxygen outside resident rooms for 3 of 3 sampled residents reviewed for respiratory care (Resident #40, Resident #41 and Resident #56). The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnosis of tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe or trachea). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was rarely/never understood and rarely/never made decisions. The respiratory treatment while a resident was oxygen therapy. A physician's order for Resident #40 dated 10/10/24 revealed to keep the resident's oxygen saturation above 90% and wean to maintain saturation of >90% via tracheostomy collar. During an observation on 10/07/24 at 12:55 PM, no signage for oxygen use was found anywhere near Resident #40's room entrance. Resident #40 was observed on oxygen via tracheostomy collar at 5 liters per minute. An interview conducted with the Interim Director of Nursing (DON) on 10/11/24 at 4:21 PM revealed the facility consolidated all the residents to halls 400, 500, and 600. Resident #40 moved from 300 hall to 400 hall last week. The Interim DON expressed that before the transfer occurred, the staff went around the facility to ensure oxygen signs were in place at each resident's room requiring oxygen use. The Interim DON verbalized whoever nurse admitted a resident requiring oxygen should make sure necessary items were prepared. An interview conducted with the unlicensed Administrator on 10/16/24 at 4:43PM revealed staff had moved all residents to halls 400, 500 and 600 on 10/04/24. The unlicensed Administrator further revealed staff did not have the chance to make sure cautionary oxygen signage was placed in all residents' rooms that were ordered oxygen. All residents that receive oxygen should have a cautionary signage. 31146 2. Resident #41 was admitted to the facility on [DATE] with a diagnosis that included respiratory failure and seizure disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 was severely cognitively impaired, received tracheostomy care (a hole that surgeons make through the front of the neck and into the windpipe or trachea) and oxygen (O2) therapy. Review of physician order dated 10/1/24 indicated a modification. The order sated oxygen adult low flow nasal cannula/O2 at 5 liters per minute (lpm) continuous with 28% humidification via trach for hypoxia prevention. Observation on 10/8/24 at 9:19AM revealed Resident #41in his bed receiving oxygen via tracheostomy. There was no cautionary signage indicating the use of oxygen on Resident #41's door. An observation of Resident #41 on 10/9/24 at 10:45AM revealed him receiving oxygen via tracheostomy. There was no cautionary signage indicating the use of oxygen on Resident #41's door. Interview and observation with Nurse #6 on 10/9/24 at 2:54PM stated she believed it would be the responsibility of the nurse to place oxygen signage on residents' doors. She stated it should be done upon admission or when the resident received an order to use oxygen. Upon observation of Resident #41's room she stated the resident did use oxygen and did not have signage identifying the use of oxygen. Interview and observation with the Interim Director of Nursing on 10/9/24 at 2:58PM revealed it was the responsibly of the admitting nurse or the responsibility of the nurse working when the resident obtained an order for O2 to apply cautionary signage. She further revealed oxygen signage was kept in the oxygen storage room. Upon observation of Resident #41's room the Interim Director or Nursing indicated there was not signage and there should have been signage. She stated the error occurred with they recently moved several residents to consolidate halls. The signage must not have followed the residents. An interview conducted with Unlicensed Administrator on 10/16/24 at 4:43PM revealed staff had moved all residents to halls 400, 500 and 600 on 10/04/24. The Unlicensed Administrator further revealed staff did not have the chance to make sure cautionary oxygen signage was placed on all resident rooms that were ordered oxygen. All residents that receive oxygen should have cautionary signage. 3. Resident #56 was admitted to the facility on [DATE] with a diagnosis that included acute respiratory failure with hypoxia. Review of the admission MDS assessment dated [DATE] revealed Resident #56 was moderately cognitively impaired and had oxygen in use upon admission. Review of Resident #56 physician order dated 10/1/24 stated oxygen adult low flow nasal cannula 3-7. May increase flow rate to 3 to keep saturation of peripheral oxygen (spO2) greater than 90% and wean as tolerated to maintain spO2 at 90% or greater. Observation of Resident #56 on 10/8/24 at 8:48AM revealed him to be seated in his wheelchair with nasal cannula applied with oxygen running. There was no cautionary signage to Resident #54's room identifying oxygen was in use. Interview and observation with Nurse #6 on 10/9/24 at 2:54PM stated she believed it would be the responsibility of the nurse to place oxygen signage on residents' doors. She stated it should be done upon admission or when the resident received an order to use oxygen. Upon observation of Resident #56's room she stated the resident did use oxygen and did not have signage identifying the use of oxygen. Interview and observation with the Interim Director of Nursing on 10/9/24 at 2:58PM revealed it was the responsibly of the admitting nurse or the responsibility of the nurse working when the resident obtained an order for O2 to apply cautionary signage. She further revealed oxygen signage was kept in the oxygen storage room. Upon observation of Resident #56's room, the Interim Director or Nursing indicated there was not signage and there should have been signage. She stated the error occurred with they recently moved several residents to consolidate halls. The signage must not have followed the residents. An interview conducted with Unlicensed Administrator on 10/16/24 at 4:43PM revealed staff had moved all residents to halls 400, 500 and 600 on 10/04/24. The Unlicensed Administrator further revealed staff did not have the chance to make sure cautionary oxygen signage was placed on all resident rooms that were ordered oxygen. All residents that receive oxygen should have cautionary signage.

Based on record review, observations and staff interviews, the facility failed to label the gastrostomy feeding formula with the flow rate and the time the formula was hung for 1 of 1 resident reviewed for tube feeding (Resident #40). The findings included: Resident #40 was admitted to the facility on [DATE] with diagnoses which included anoxic brain injury, tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe or trachea), persistent vegetative state, percutaneous endoscopic gastrostomy (medical procedure where a tube is inserted through the abdominal wall and into the stomach) tube placement. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was rarely/never understood and rarely/never made decisions. The nutritional approach while a resident was via feeding tube. Review of Resident #40's care plan revealed the resident required a permanent feeding tube for the provision of nutrition. The goal for Resident #40 was to maintain adequate nutritional and hydration status as evidenced by stable weight, and no indicators of malnutrition or dehydration. Review of a physician order dated 11/16/23 revealed an order for Resident #40 to receive continuous feeding formula infused at 45 milliliters (ml) per hour via pump infusion. Flush enteral tube with 30 ml of water every hour via pump. The manufacturer's information stated prefilled containers can hang safely for up to 48 hours when clean technique and only one new feeding set is used. An observation conducted of Resident #40 on 10/07/24 at 12:57 PM revealed the resident's tube feeding formula labeling information was written on a cloth surgical tape which only contained the date, name of resident and initials of nurse. There was no information about the time it was hung and flow rate based on the order. The pump was running at 45 ml per hour. An interview with Nurse #2 was conducted on 10/07/24 at 1:18 PM revealed the feeding formula was hung by the nurse working on night shift. Nurse #2 verbalized the label should indicate the name of the resident, date and time tube feeding was placed, the rate, and the name or initials of the nurse. An interview with Nurse #3 on 10/11/24 at 1:09 PM revealed she worked from 7:00 PM to 7:00 AM on 10/06/24 and confirmed taking care of Resident #40. Nurse #3 said she had been labeling tube feedings as observed and nobody had said anything about what she's been doing. An interview conducted with the Interim Director of Nursing (DON) on 10/11/24 at 4:20 PM revealed the facility nurses were aware of what needed to be done. The Interim DON further stated that the facility nurses knew the policy. The Interim DON verbalized staff do things to finish quicker. An interview conducted with the unlicensed Administrator on 10/16/24 at 4:45 PM revealed she was still investigating the findings. The unlicensed Administrator verbalized that anytime there was tube feeding, it should be labeled appropriately.

Based on observations and staff interviews, the facility failed to secure residents personal health information by leaving shift report documentation and a medication cart laptop unattended with resident information exposed in an area accessible and visible to the public on 1 of 3 Medication Carts (600 Hall Medication Cart). The findings included: While walking down the 600 hall, an observation was completed on 10/10/24 at 10:36 AM of the 600 Hall Medication Cart inclusive of the medication cart laptop which was unattended. The laptop displayed resident personal health information including names, medications, and diagnoses. The 600 Hall shift report documentation was also observed to be face up which displayed resident personal health information. Staff was observed passing by the 600 Hall Medication Cart. On 10/10/24 at 10:38 AM Nurse #4 returned to the 600 Hall Medication Cart. Nurse #4 closed the laptop screen and verbalized her medication cart was locked but she forgot to close her laptop. An interview was completed with Nurse #4 on 10/10/24 at 10:39 AM. Nurse #4 stated she was retrieving dry cereal for a resident and forgot to close her medication cart laptop. Nurse #4 explained she should have closed the medication cart laptop while not in attendance. Nurse #4 also voiced she should have turned her shift report documentation over while not in attendance of the 600 Hall Medication Cart. An interview with the interim Director of Nursing (DON) was completed on 10/10/24 11:16 AM. The interim DON revealed that Nurse #4 should have locked her laptop screen prior to leaving the medication cart unattended. The interim DON further stated that the nurse should have turned over her clip board to protect resident health information. An interview with the Director of Nursing Services was completed on 10/14/24 at 4:07 PM. The Director of Nursing Services explained anytime staff were not with their medication cart the medication cart should be locked. The Director of Nursing Services continued to explain that staff should lock or lower their computer screen so that protected health information (PHI) was not exposed and shift report documentation should also be flipped over so that PHI was not exposed and no one could read as they passed by. An interview with the unlicensed Administrator was completed on 10/14/24 at 4:34 PM. She stated staff should lock or minimize their laptop screen or turn the medication cart towards the wall so the public cannot view protected health information. The unlicensed Administrator further stated that shift report documentation should be flipped over when the nurse left the medication cart unattended.

Based on record review, and staff and the Executive Director of the NC Board of Nursing Home Administrators interviews, the facility failed to have a licensed Administrator in place to oversee the daily staff and resident operations of the skilled nursing facility. This failure had the potential to affect all residents residing in the facility. The findings included: An interview was completed with the Executive Director of the NC Board of Nursing Home Administrators on [DATE] at 11:12 AM. The Executive Director of the NC Board of Nursing Home Administrators was notified on [DATE] by the unlicensed Administrator via telephone call that her license had expired on [DATE]. The Executive Director of the NC Board of Nursing Home Administrators explained the unlicensed Administrator was being honest and stated she forgot to renew her license at the end of September. The Executive Director of the NC Board of Nursing Home Administrators verbalized the unlicensed Administrator's license was originally issued on [DATE] and expired on [DATE]. The Executive Director of the NC Board of Nursing Home Administrators communicated a temporary license was issued to the unlicensed Administrator on the afternoon of [DATE] which will expire on [DATE]. A telephone interview with the unlicensed Administrator was completed on [DATE] at 11:09 AM. She explained she was under the impression the deadline for administrator license renewal was extended due to Hurricane [NAME]. The unlicensed Administrator stated she reached out to the NC Board of Nursing Home Administrators and they informed her she was not eligible for the extension due to not being in an affected area. The unlicensed Administrator stated that she had to reapply for her Administrator license and was granted a temporary license effective [DATE] with an expiration date of [DATE]. A telephone interview was completed on [DATE] at 1:45 PM with the [NAME] President (VP) for Advocate Health which includes oversight for the nursing home administrators across the hospital healthcare system. The VP for Advocate Health stated the unlicensed Administrator telephoned him on [DATE] to inform him her license had expired. He further stated the temporary license paperwork was completed the afternoon of [DATE]. The VP of Advocate Health communicated ultimately the Administrators were responsible for making sure their license remained current. The VP of Advocate Health voiced moving forward he and his administrative staff will work with the current Administrators to ensure that issue dates and expiration dates were obtained and reviewed so that all Administrators have an active license within the hospital healthcare system's skilled nursing facilities.

Based on record review, staff interview, resident interview and outside transportation vendor, the facility failed to maintain a resident's dignity when a nurse yelled and spoke rudely towards 1 of 3 resident's (Resident #3) reviewed for abuse. The findings included: Resident #3 was admitted to the facility on [DATE]. The 5- Day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact. Review of the initial allegation report (24-hour working report) dated 8/9/23 revealed an allegation of abuse. The facility became aware of the allegation on 8/9/23. There was no date documented for the date of the incident. The allegation details revealed agency staff (Nurse #1) was reported not to honor Resident #3 wishes and spoke to the resident in a rude manner. Review of the investigation report (5-day) working report dated 8/16/23 stated the date of the incident was 8/3/23 and the facility became aware of the incident on 8/9/23. The incident involving Resident #3 occurred at the central nursing station. Resident #1's cognition was documented as intact. The accused staff was identified as Nurse #1 and one witness identified as Nursing Assistant (NA) #1. The actions taken revealed agency nurse (Nurse #1) was immediately suspended and her contract term ended during the suspension and investigation. The summary of the facility investigation stated Resident #3 was interviewed by the Resident Liaison and reported agency nurse (Nuse #1) to be rude. The witness to the incident also indicated that Nurse #1 was rude and exhibited poor customer service. A witness statement written by NA #1 on 8/10/23 stated on 8/3/23 on the way out to the van with Resident #3, NA #1 and the Transportation Aide were stopped by Nurse #1. Nurse #1 advised before Resident #3 left she needed to give Resident #3 her insulin. Resident #3 told Nurse #1 she was causing her to be late. The witness statement continued that Nurse #1 lifted Resident #3's shirt and said in a very rude tone, I'm not causing you to be late. You can get your shot before you go or she could mark Resident #3 refused. Which one you want to do? Resident #3 advised Nurse #1 to give her the shot so she could go. Nurse #1 gave Resident #3 the shot and walked off. NA #1, Resident #3 and the Transportation Aide proceeded to the van to leave for the appointment and were told was cancelled due to the doctor being sick. Once Resident #3 was back off the van and headed back to her room she stated the nurse was rude and hateful to her and she didn't want her as a nurse anymore. Once Resident #3 was in her room NA #1 went to the Director of Nursing (DON) and explained the incident that took place. The DON advised she would follow up on the incident with both Resident #3 and Nurse #1 as Resident #3 had made these allegations before on staff and moving forward Nurse #1 would have someone in the room with her when caring for Resident #3 the remainder of the shift. A witness statement written by Transportation Aid on 8/15/23 stated Resident #3, the Transportation Aide and one of the NA's (name unknown) were walking towards the front door to get Resident #3 loaded for her appointment. Resident #3's nurse approached her as we were near the end of the nurse station. She told Resident #3 that she needed to give her one of her medications before we left. Resident #3 stated, can't I take it when we get back, you're going to make me late. The nurse got really irritated and yelled at Resident #3, are you refusing? Because I can definitely document that!. Resident #3 told her to just go ahead and give her the medication and that she just didn't want to be late. Nurse #1 responded with, it's not my fault you're late, you're the one that has 35 different medications to take!. Resident #3 went on to say how she had never had a nurse be so mean and argue with a patient. Nurse #1 responded, Merry Christmas and walked away! A statement written by Nurse #1 dated 8/11/23 revealed Nurse #1 didn't recall the exact date, but she was assigned to be the nurse working on 400-hall. Resident #3 had an appointment around 9:00 AM so Nurse #1 medicated her. After getting through the regular routine with Resident #3, Resident #3 stated that she wasn't doing to make it to her appointment because the provider had the times mixed up. After checking with the scheduler, it was noted that Resident #3 was on time. Upon transport wheeling her to the front, Nurse #1 noticed that she hadn't given Resident #3 her insulin. The statement continued that nurse #1 met up with Resident #3 and the transportation aid at the nursing station. Nurse #1 let Resident #3 know that she didn't give her the last medication. Resident #3 stated Nurse #1 was making her late. Nurse #1 explained that she had the medications with her, but it was up to Resident #1 if she wanted to take it. Resident #3 stated yes so it was administered. A few minutes later Resident #3 was returning to her room because the appointment was canceled due to the provider getting sick. Resident #3 was upset and made comments that Nurse #1 was mean to her and nurse #1 informed her supervisor. Nurse #1's supervisor spoke with Resident #3 and soon after came and got me and we both went to speak to Resident #3 who stated, I don't have a problem with the nurse, and I don't want to hear anything else about it. Nurse #1 finished her shift and was assigned to Resident #3 the next 2 days without any problems. Interview with NA #1 on 11/28/23 at 12:52 PM revealed on the 8/3/23 she and the Transportation Aide were on the way out to the van when Nurse #1 stopped us because she wanted to give Resident #3 an injection. Resident #3 stated you are going to make me late to my appointment. Nurse #1 asked Resident #3 did she wanted the medication or not. Nurse #1 further stated she would document refuse if Resident #3 didn't want the medication (injection). Resident #3 stated to Nurse #1 to hurry up and give her the medication. NA #1 described Nurse #1 tone as very firm and if she was a resident, she wouldn't want to be talked to the way Nurse #1 talked to Resident #3. Following the incident Resident #3 told NA #1 she didn't like how Nurse #1 had spoken to her and she didn't want Nurse #1 working with her. NA #1 stated she told the Director of Nursing (DON) on 8/3/23 the day the incident occurred. The DON stated she would address the incident. She indicated the DON had spoken with Nurse #1. Interview with Transportation Aide on 11/28/23 at 2:22 PM stated on 8/3/23 she was taking Resident #3 to an appointment with an NA (name unknown). She indicated a nurse came running up and stated she had forgotten to give Resident #3 one of her medications. Resident #3 stated she didn't want to take the medication because she didn't want to be late to her appointment. She stated the nurse told Resident #3 it wasn't her fault Resident #3 had 35 medications to take. Resident #3 stated she had never seen a nurse go back and forth with a patient. Nurse #1 told Resident #3 Merry Christmas and walked away. The Transportation Aide described Nurse #1's communication with Resident #3 as very rude. She further indicated Resident #3 appeared upset after the interaction with Nurse #1. Interview with Resident #3 on 11/28/23 at 3:04 PM revealed she did not recall the incident. Interview with the Director of Nursing (DON) on 11/28/23 at 1:49 PM indicated she recalled being approached on 8/3/23 by the nurse or a NA that Resident #3 and a nurse were arguing in the hallway. Resident #3 was going out for transport for a doctor's visit. Resident #3 was questioning whether she should take the insulin before the appointment. Nurse #1 and Resident #3 were interviewed, and the DON found Nurse #1 was inappropriate with her tone and she lacked empathy when speaking to Resident #3.

Based on record review and staff interviews the facility failed to have a Registered Nurse (RN) scheduled for 8 consecutive hours a day for 7 of 30 days (1/2/22, 1/3/22,1/8/22,1/9/22,1/15/22,1/16/22 and 1/8/23) reviewed for staffing. This failure had the potential to affect all residents in the facility. Findings included: A review of daily staffing assignment sheets and RN timecards for 1/1/22 through 1/15/22 and 1/1/23 to 1/15/23 revealed on 1/2/22, 1/3/22,1/8/22,1/9/22,1/15/22,1/16/22 there was no RN coverage in the facility. On 1/8/23 the staffing assignment sheet and RN timecard revealed an RN worked 4.5 hours out of the required 8 hours a day. A review of the posted daily staffing 1/1/22 through 1/15/22 and 1/1/23 to 1/15/23 revealed the census ranged from 42 to 46 residents. A joint interview on 5/25/23 at 12:25 PM with the Director of Nursing (DON) and the corporate Director of Nursing Services confirmed the dates listed above without an RN was accurate. The corporate Director of Nursing Services stated they had received approval in February 2022 from their corporate office to hire traveling nurses (RNs that travel to different facilities) and an international traveler RN to fill the void of the weekend RN vacancy. The DON stated that their census had been in the 40s for the last one and half years so the DON, Assistant Director of Nursing and the Minimum Data Set Nurse had counted for days during the week; Monday through Friday and had worked on some weekends but could not cover all the weekends. An interview with the Administrator on 5/25/23 at 1:32 PM stated that she had begun her role as the Administrator at the facility as of March of 2023, and we are ensuring RN coverage is consistent by utilizing traveling nurses to fill the shortage and will plan to have a secondary option to alternate nursing administration to cover the weekends.

Based on record reviews and staff interviews, the facility failed to complete quarterly assessments within the required 14-day timeframe for 2 of 18 residents reviewed for Minimum Data Set (MDS) assessments (Resident #26 and Resident #4). The findings included: a. Resident #26 quarterly MDS dated [DATE] was completed on 5/18/2023. b. Resident #4's quarterly MDS dated [DATE] was completed on 5/18/2023. The MDS nurse was interviewed on 5/25/2023 at 10:38 AM. The MDS nurse reported she had been struggling with timeliness of assessments and had other nurses helping to get the assessments caught up. The MDS nurse reported she was aware Resident #26 and Resident #4's quarterly MDS assessment was late. The Administrator was interviewed on 5/25/2023 at 1:18 PM. The Administrator reported it was not until after a mock survey conducted on 5/5/2023 that the management team realized how many assessments were late. The Administrator reported that nurses came to help with the completion of the assessments. The Administrator reported she expected the MDS assessments to be completed in a timely manner.

Based on record review, observations and staff interviews the facility failed to check the expiration dates of thickened liquids maintained in the bedside coolers for 2 of 2 residents reviewed for thickened liquids (Resident # 32 and Resident # 41) and failed to check the temperature of 5 of 5 chicken salad sandwiches prior to plating for the tray line. Findings included: 1.Resident # 32 was admitted to the facility on [DATE] with diagnoses that included post cerebral infarction dysphagia and malnutrition. A review of a significant change Minimum Data Set (MDS) dated [DATE] included that Resident # 32 had a swallowing disorder and received a mechanically altered diet. A review of a care plan for Resident # 32 updated [DATE] revealed that resident # 32 had an increased nutritional and dehydration risk related to history of dysphagia and need for a mechanically altered diet. A review of a physician (MD) order dated [DATE] included in part that Resident # 32 was to receive a puree diet with honey thick (moderately thick) liquids. A review of a note by the registered dietician (RD) dated [DATE] at 11:13 AM included in part that Resident # 32 received a dysphagia puree diet with moderately thick liquids. On [DATE] 08:19 AM an observation of Resident # 32's room revealed a blue and white cooler on the nightstand next to the bed that contained 7 pre thickened honey constancy containers inside. Three of the containers were identified to have expiration dates that included 2 clear water containers with expiration dates of [DATE] and another dated [DATE]. The cooler also contained a thickened iced tea container with an expiration date of [DATE]. The items were removed from the cooler and nursing assistant (NA) # 2 stated that she did replenish thickened liquid items at times from the containers that the dietary staff left in the nourishment refrigerator but that she never looked at the expiration dates and she would have informed the nurse and thrown the items away immediately. An interview conducted with the dietary manager (DM) conducted on [DATE] at 3:29 PM revealed that she was not aware of any expired thickened liquids brought to the nourishment refrigerator by the dietary staff daily. The DM revealed that her expectation was that all food or other items dispensed from the kitchen were to have expiration dates checked prior to being delivered to residents or resident care areas. On [DATE] at 11:28 AM an interview conducted with NA # 4 revealed that she was had removed about 3 to 4 expired thickened liquid items from the bedside cooler of Resident # 32 and threw the items away immediately. NA #4 revealed that the nurse at that time witnessed the episode but that she was not certain who the nurse was or the specific date. The nursing home administrator ( NHA) was interviewed on [DATE] at 8:25 AM. The NHA stated that it was her expectation that all bedside coolers that contained thickened liquids have at least daily checks of the expiration dates of the items and if expired items were identified the items be disposed of immediately and that the director of nurses ( DON) or NHA be notified immediately. #2. Resident # 41 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] and dysphagia. A review of a quarterly MDS dated [DATE] revealed that Resident # 41 received a mechanically altered diet. A review of MD order summary dated [DATE] included an order written [DATE] that Resident # 41 was to receive a dysphagia puree diet with mildly (honey) thick liquids. An interview conducted with the DM on [DATE] at 3:29 PM revealed that she was not aware of any expired thickened liquids brought to the nourishment refrigerator by the dietary staff daily. The DM revealed that her expectation was that all food or other items dispensed from the kitchen were to have expiration dates checked prior to being delivered to residents or resident care areas. On [DATE] at 11:28 AM an interview conducted with NA # 4 revealed that she was not aware of expired items in the blue thickened liquid items in the room of Resident # 41. NA # 4 revealed that if she had noted expired items in the cooler, she would have removed the item immediately and reported the concern to the nurse. The NHA was interviewed on [DATE] at 8:25 AM. The NHA stated that it was her expectation that all bedside coolers that contained thickened liquids have at least daily checks of the expiration dates of the items and if expired items were identified the items be disposed of immediately and that the DON or NHA be notified immediately. 3. An observation was conducted in the kitchen on [DATE], which started at 11:58 AM. During the observation the food for the resident ' s meal was checked for appropriate holding temperatures. The cook completed checking the temperatures of foods in the steam table and at 12:16 PM she and the other dietary staff started to plate and tray the resident ' s meals for lunch. The alternate for lunch was a chicken salad sandwich. There were 5 chicken salad sandwiches, they were wrapped in plastic wrap, and were in a pan placed on top of another pan with ice in it. One of the sandwiches, in the pan, had been placed on top of a clear plastic container containing a lettuce salad which was also in the pan, and the other 4 were stacked vertically so that only the bottom edge of the sandwich was in contact with the cooled surface of the pan. The Dietary Aide (DA) was observed plating the sandwich which had been sitting on top of the salad container for a resident. The DA stated they had never checked the salad of the chicken salad sandwiches. The DA was observed to check the temperature and the temperature of the chicken salad of the sandwich was observed to have been 56 degrees Fahrenheit. The DA stated she would dispose of the sandwich. She further explained the sandwiches had come right out of the refrigerator and they had been made not too long before they started the tray line for lunch. The DA was then observed checking a second sandwich which had been sitting on the chilled tray and the chicken salad of the sandwich was observed to have been 51 degrees Fahrenheit. An interview was conducted on [DATE] at 12:42 PM with the DA and she stated she should have checked the temperature of the chicken salad in the sandwiches when they did the other food temperatures prior to starting the tray line. An interview was conducted on [DATE] at 12:46 PM with the cook and she stated they had not been checking the temperature of the chicken salad sandwiches. She said the sandwiches had been made at about 11:00 AM and then had been placed in the 2-door cooler until they were brought out for the lunch line. She said the temperature of the chicken salad sandwiches should have been checked because the chicken salad is a perishable food and needed to stay cold. An interview was conducted on [DATE] at 12:48 PM with the Dietary Manager (DM) and the Dietary Consultant (DC). The DC stated the sandwiches should have been checked when the other temperatures were checked for the tray line. She further stated the chicken salad in the sandwiches should have been in the range of 32 to 40 degrees Fahrenheit. The DM stated they would keep the chicken salad sandwiches in the 2-door cooler and remove each sandwich as needed in order to keep the sandwiches at a proper temperature. During an interview conducted on [DATE] at 10:08 AM the Administrator stated her expectation was for food to be kept in the appropriate temperature range for cold and hot foods. She said the chicken salad sandwiches were out of the safe temperature range and the temperature should have been checked prior to the food being plated for the resident. She said all perishable foods should be checked for proper temperature prior to the start of the tray line and a log for temperature of all perishable foods had been implemented after the deficient practice was identified.

Based on observation, record review resident and staff interviews, the facility failed to refer a resident with identified dental needs to the dentist. This was for 1 of 2 residents reviewed for dental care. (Resident #3) Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was a Medicaid recipient and coded Resident #3's cognition as being cognitively intact. Resident #3's dental/oral status was assessed as having cavity or broken natural teeth. A review of the quarterly MDS assessment dated [DATE] coded the resident's cognition as being cognitively intact. A review of Resident #3's dental care plan with a start date of 5/19/19 revealed a plan of care that read, Resident #3 was at risk for decline in oral health due to natural teeth in poor condition with obvious caries. (Caries is identified as tooth decay) The care plan revealed a goal that Resident #3 will remain free of oral issues through next review with a review date as 11/11/21. The interventions included Refer for Dental exam per resident/resident representative preference. A care plan intervention for diet included mechanical altered regular with soft bite sized meats. A review of the facility's in-house dental clinics for 2020 were scheduled at the facility on 1/3/2020, 7/2/2020 and 7/23/2020. Resident #3 was scheduled to be seen for follow-up/dentures on 7/2/2020 and 7/23/2020 but both clinics were cancelled due to Covid-19. A review of the facility's in-house dental clinics for 2021 revealed one clinic for 7/27/21 but was canceled due to the dental provider not presenting with a negative Covid-19 Polymerase chain reaction (PCR) test. An observation and interview with Resident #3 on 10/18/21 at 11:50 AM revealed the resident had decaying front teeth. Resident #3 stated that I have not had any dental exams due to Covid, but he had told staff that he wanted to have his teeth looked at as he would like to get dentures. An interview was completed on 10/20/21 at 8:59 AM with the Transportation Coordinator (TC) who sets up all the dental services. The TC stated that she would put residents on the schedule if they would get an order from the doctor or if the dental clinics are set up, the TC would ask the resident's family if they would like to have their loved one to be seen. The TC stated if the resident was alert and oriented, we would ask the residents. The TC stated that the dental clinic that was scheduled in July of this year was cancelled as the Administrator stated the facility was not allowed to have dental clinics due to Covid. The dental clinic that was set up for 9/27/21 needed to be canceled as the facility's ownership was requiring a negative PCR Covid test for the providers. The TC stated the dental provider thought they could show their vaccination cards and therefore the clinic needed to be cancelled. An interview was completed with Resident #3 on 10/20/21 at 9:58 AM who stated that he doesn't have many upper teeth left, but the bottom teeth are Ok. Resident #3 stated that he was not in any pain and has soft foods. An interview was completed on 10/20/21 at 11:40 AM with the Administrator who was asked why there had not been in dental clinics in 2021. The Administrator stated that the corporation held a planning meeting on 4/15/21 for re-entry of dental services and the plan was not finalized until later in the year. The Administrator stated that it would be her expectation that if a referral was needed for dental services the facility could have sent Resident #3 out of the facility for dental services. A telephone interview was completed with the dental provider on 10/21/21 at 4:27 PM who stated the facility's corporation had recently made a change. The dental provider stated they had known part of the policy and thought since they were vaccinated, they could show proof of their vaccination cards, however the dental team had been turned away the day of the clinic as they did not have a PCR Covid test. An interview was completed on 10/21/21 at 9:57 AM with the Director of Nursing (DON) who stated that she had been aware many dental clinics were cancelled due to Covid-19. DON stated that it would be her expectation for Resident #3 to be free of any dental issues and to follow up with the facility's dental clinic. The DON stated that if it was an immediate need any resident would be outsourced to an outside dental clinic. The DON stated that it would be her expectation that Resident #3 would have been seen. The DON stated nursing staff could have made a referral and collaborated with the TC to ensure Resident #3 was seen. An interview was completed on 10/21/21 at 10:34 AM with the Administrator who stated it would be her expectation to follow the process that is in place and for nursing to let the dental provider know and for the facility to obtain a referral for Resident #3 to be seen timely. The Administrator stated it was her expectation that Resident #3 should have been seen for dental services. The Administrator stated that if a resident is needing any type of dental services that they could be sent out of the facility for dental services.

Based on observation, record review, resident and staff interviews, the facility failed to provide assistance with daily oral care and provide instruction on proper oral care in accordance with the resident's comprehensive care plan to ensure he maintained or improved on his ability to carry out his own oral hygiene care. This was for 1 of 1 resident with identified dental needs reviewed for activities of daily living. (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident's cognition as being cognitively intact and he was assessed in the areas of self-care for oral hygiene - the ability to use suitable items to clean teeth with set up assistance with helper sets up or cleans up and resident completes the activity. Resident #3's dental/oral status was assessed as having cavity or broken natural teeth. Resident #3 was coded as having no refusals of care. A review of the Resident #3's active dental care plan with a start date of 5/19/19 revealed a plan of care that read, Resident #3 was at risk for decline in oral health due to natural teeth in poor condition with obvious caries (caries is identified as tooth decay). The care plan revealed a goal that Resident #3 will remain free of oral issues through next review with a review date as 11/11/21. The interventions included Set up and assist as needed with daily oral care and provide instruction on proper oral care techniques as needed. An observation of Resident #3 on 10/18/21 at 11:50 AM revealed the resident had decaying front teeth. An interview was completed with Resident #3 on 10/20/21 at 9:58 AM who was asked if he had a toothbrush. Resident #3 stated he did not know where his toothbrush was. He indicated they used to bring it to him, but they had not done so in a while. Resident #3 was not able to state when the last time it was that staff had brought his toothbrush. An observation of Resident #3's bathroom sink and cabinet revealed no oral hygiene products in the bathroom and the sink, and the cabinet was empty. With Resident #3's permission, his night-stand drawer was opened and revealed no visible oral hygiene products. The resident was asked if he had a bed bath today and he stated that he had a bed bath this morning and when asked if he brushed is teeth, he stated he had not. An interview and observation were completed with Nursing Assistant (NA) #5, the NA assigned to Resident #3, on 10/20/21 at 10:06 AM. NA #5 was asked if Resident #3 brushed his teeth after his morning bed bath on 10/20/21. NA #5 revealed oral hygiene care was not completed with Resident #3 that morning because she forgot about it. NA #5 stated the toothbrush is normally set up by staff for Resident #3 and he brushed his teeth himself. NA #5 stated it had been a long time since she had personally watched Resident #3 brush his teeth. NA #5 stated Resident #3 had always been cooperative and would not refuse oral hygiene. NA#5 was asked if she knew where Resident #3's toothbrush was and she opened his night-stand drawer and found a toothbrush in the bottom of his night-stand, however she was not able to find any toothpaste and stated that she would locate some for Resident #3. NA #5 was observed placing Resident #3's toothbrush on his bedside table. An interview was completed with Nursing Assistant (NA) #4 on 10/20/21 at 10:38 AM who stated that Resident #3 was able to brush his own teeth but had refused to do so on some occasions in the past. NA #4 stated that Resident #3 had a small tube of toothpaste in his drawer on Monday 10/18/21. NA #4 stated she had not watched him brush his teeth but had set up his toothbrush for him. An interview was completed with Nursing Assistant (NA) #6 on 10/20/21 at 3:10 PM who stated that she had never watched Resident #3 brush his teeth but did set up his toothbrush for him. NA #6 was asked where the resident's toothbrush was located, and she stated usually in his drawer. NA #6 was asked if he the resident had toothpaste, and she stated he should have toothpaste in his drawer. NA #6 stated that Resident #3 never had refused cares. On 10/20/21 at 3:06 PM an observation and interview were completed with Resident #3. Resident #3's bedside table had a plastic pink kidney shaped basin with a toothbrush and toothpaste lying in the basin. Resident #3 was asked if he had brushed his teeth and he said he had. On 10/21/21 at 8:50 AM an observation and interview were completed with Resident #3. Resident #3 was lying in his bed with a plastic pink kidney shaped basin with a toothbrush and toothpaste lying in the basin. Resident #3 began to brush his teeth and opened the tube of toothpaste and put it on the toothbrush. Resident #3 brushed his teeth but did not spit out any toothpaste and had drank water which he swallowed. Resident #3 was asked if he knew what the plastic pink kidney shaped basin was for and Resident #3 stated to hold his toothbrush and toothpaste. Resident #3 was asked if he had ever spit out the water with his toothpaste into the plastic bin and Resident #3 did not respond. An interview was completed on 10/21/21 at 9:57 AM with the Director of Nursing (DON) who stated that it was her expectation that the resident have an observation by facility staff and cueing to complete the oral hygiene tasks daily. DON further stated the facility staff should provide education on the steps for oral hygiene, so the resident learned how to do proper oral care. DON stated that she felt Resident #3 could retain the steps for proper oral hygiene care if provided the education by staff. An interview was completed on 10/21/21 at 10:34 AM with the Administrator who stated it would be her expectation that the facility staff assist residents with oral care every day and follow the care plan as written.

Based on record review and staff interviews the facility failed to provide actual hours worked by nursing staff for 3 of 7 days reviewed for accurate nurse staffing hours. Findings included: A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 10/1/2021 the 7:00 pm to 7:00 am shift had 48 hours recorded for the Nurse Aides, but the actual hours were 24 hours. b. On 10/3/2021 the 7:00 pm to 7:00 am shift had 12 hours recorded for Registered Nurse and 12 hours record for the Licensed Practical Nurses, but the actual hours were 0 hours for the Registered Nurse and 24 hours for the Licensed Practical Nurses. c. On 10/5/2021 the 7:00 pm to 7:00 am shift had 48 hours recorded for Nurse Aides, but the actual hours were 36 hours for the Nurse Aides. An interview with the Unit Secretary on 10/20/2021 at 2:25 pm revealed she was responsible for filling out the Posted Nurse Staffing each morning. She stated she does not update the form when staff call out or there are changes to the schedule. The Unit Secretary stated she did not know who was responsible for updating the Posted Nurse Staffing form when staff call out or the schedule changes. During an interview with the Director of Nursing on 10/20/2021 at 3:38 pm she reviewed the Posted Nurse Staffing Forms and Nursing Schedules for 10/1/2021 to 10/7/2021. The Director of Nursing stated there were discrepancies between the Posted Nurse Staffing hours and available staff recorded on the Nursing Schedules for 10/1/2021, 10/3/2021, and 10/5/2021. The Director of Nursing stated she had not been the Director of Nursing for very long and had not had a chance to work on the process for completing the Daily Nurse Staffing Forms with the nursing staff. The Administrator was interviewed on 10/21/2021 at 10:14 am and stated she was aware of the Posted Nurse Staffing was not accurate for the Posted Daily Nurse Staffing Forms reviewed for 10/1/2021 to 10/7/2021. The Administrator stated the facility should have a process in place to ensure the Posting Daily Nurse Staffing was updated each shift with accurate information.

Based on record review and staff interviews, the facility failed to provide a CMS- SNF ABN (Centers for Medicare and Medicaid Services Skilled Nursing Facility Advanced Beneficiary Notice) prior to discharge from Medicare Part A skilled services to 2 of 3 residents reviewed for beneficiary protection notification review (Resident #17 and Resident #23). Findings included: 1.Resident # 17 was admitted to the facility 01/25/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record of Resident #17 revealed a CMS- Notice of Medicare Non - Coverage letter (NOMNC) was given to Resident #17 on 03/10/2021 which indicated that Medicare Part A coverage for skilled services would end on 03/10/2021. Resident #17 remained at the facility. A review of the medical record for Resident #17 revealed a CMS - SNF ABN form was not provided to Resident #17. An interview conducted with the facility resident liaison (RL) on 10/20/2021 at 8:54 AM and revealed that she was not aware that a SNF ABN was required for residents that remained in the facility with remaining Medicare Part A benefit days after skilled services were discontinued required a SNF ABN form. The rehabilitation manager (RM) was interviewed on 10/20/2021 at 10:05 AM. The RM revealed that she was not aware that when a resident no longer received skilled services with remaining Medicare Part A days required a SNF ABN form. On 10/21/2021 at 8:25 AM an interview conducted with the nursing home administrator (NHA) revealed that she expected SNF ABN forms be issued timely and appropriate as the regulation required. 2. Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record of Resident #23 revealed a MS- NOMNC was given to the responsible party (RP) that indicated Medicare Part A coverage for skilled services would end on 06/07/2021. Resident #23 remained at the facility. A review of the medical record for Resident #23 revealed a CMS - SNF ABN form was not provided to Resident #23 or the RP. An interview conducted with the facility RL on 10/20/2021 at 8:54 AM and revealed that she was not aware that a SNF ABN was required for residents that remained in the facility with remaining Medicare Part A benefit days after skilled services were discontinued required a SNF ABN form. The RM was interviewed on 10/20/2021 at 10:05 AM. The RM revealed that she was not aware that when a resident no longer received skilled services with remaining Medicare Part A days required a SNF ABN form. On 10/21/2021 at 8:25 AM an interview conducted with the NHA revealed that she expected SNF ABN forms be issued timely and appropriate as the regulation required.

Based on record reviews, and staff interviews, the facility failed to notify a resident representative (RP) of a worsening pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with a most recent readmission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be cognitively intact, with a Brief Interview for Mental Status (BIMS) of 13 out of 15 (cognitively intact). The MDS did not document the presence of pressure ulcers for Resident #1. A BIMS assessment completed on 5/19/2020 assessed Resident #1 to have a BIMS of 09 (moderately cognitively impaired). Resident #1 ' s medical chart was reviewed. A nursing note date 5/29/2020 written by the Staff Development Coordinator (SDC) noted Resident #1 had a new Stage 2 pressure ulcer on his buttocks that measured 1.8 centimeters (cm) by 2.3 cm by 0.1 cm. The note documented the physician (MD) and the Nurse Practitioner had been notified. The note did not document the family had been notified of the new pressure ulcer. A nursing note written by Nurse #6 dated 6/3/2020 noted Resident #1 Stage 2 pressure ulcer to the left buttocks and it measured 1.5 cm by 1.8 cm by 0.2 cm and the area around the wound was excoriated. The note did not document the family was notified of the pressure ulcer. A nursing note written by Nurse #1 dated 7/11/2020 documented Resident #1 had excoriation of his buttocks and sacrum (lower back) and the area was cleansed with soap and water and a barrier cream was applied. The note further documented Resident #1 ' s continued loose stools related to an infection and the MD had been notified. The note did not document the family had been notified of the change in skin condition. A nursing note dated 7/20/2020 written by Nurse #2 documented the deterioration of the skin on Resident #1 ' s buttocks and the appearance of a deep tissue injury that measured 3.3 cm by 2.1 cm, as well as an open areas on the coccyx that measured 3.0 cm by 1.4 cm by 0.3 cm. The note documented no signs or symptoms of infection and the area was cleansed and a dressing was applied. The note documented the MD was notified. The note did not document the family had been notified of the change in skin condition or the open pressure ulcer. A nursing note dated 7/30/2020 written by Nurse #1 documented that Resident #1 had an appointment at the wound clinic and he had returned to the facility with new MD orders. A nursing note dated 8/1/2020 written by Nurse #5 documented Resident #1 was confused off and on. A nursing note dated 8/2/2020 written by Nurse #4 documented the family had been notified Resident #1 was more confused. The note did not document the family had been notified of the pressure ulcer. Nurse #6 and the SDC were interviewed on 8/13/2020 at 2:40 PM. Nurse #6 reported she had been performing weekly wound care for all residents in the facility for the past several months. Nurse #6 reported Resident #1 had not specifically told her to not contact his family, but he was alert and oriented at that time and he was his own representative. The SDC explained if a resident was their own representative, staff did not need to call the family to notify of changes. The SCD reported Resident #1 had been alert and oriented but had a change in cognition after his hospitalization and readmission to the facility on [DATE]. The SCD reported she was not certain if Resident #1 was able to cognitively process the information regarding the breakdown of his skin. An interview was conducted with Nurse #1 on 8/13/2020 at 3:08 PM. Nurse #1 reported she had provided care to Resident #1 and had noted the change in skin condition on 7/11/2020. Nurse #1 reported that Resident #1 was his own representative and he was able to process information and he was aware that he had wounds on his buttocks. Nurse #1 reported Resident #1 was able to answer questions appropriately on 7/11/2020. Nurse #1 was unable to remember if Resident #1 specifically asked her not to call his family. A phone interview was conducted with Nurse #4 on 8/13/2020 at 10:02 PM. Nurse #4 reported she had contacted Resident #1 ' s family on 8/2/2020 because had had increased confusion. Nurse #4 reported she had not mentioned the pressure ulcers during her conversation with the family. Nurse #3 was interviewed by phone on 8/13/2020 at 10:30 PM. Nurse #2 reported she had written the note on 8/1/2020 regarding the change in the pressure ulcer on Resident #1 ' s buttocks. Nurse #3 reported she had notified the MD and completed a change in condition form for Resident #1. When asked why she had not notified the family of the change in Resident #1 ' s wound, Nurse #3 reported she read the change of condition report dated 7/20/2020 and felt that the MD had been notified and did not think the family needed notified. Nurse #3 reported she could not remember if Resident #1 was confused on 8/1/2020. Nurse #2 was interviewed on 8/14/2020 at 9:12 AM. Nurse #2 reported she had documented the pressure ulcer change on 7/20/2020 after being notified by a nursing assistant that the skin on Resident #1 ' s buttocks had changed. Nurse #2 reported that on 7/20/2020 when she provided care to Resident #1, he was confused and was unable to retain information. Nurse #2 reported she should have notified the family of Resident #1 regarding the change in skin and the pressure ulcers because Resident #1 was unable to understand her. A nursing assistant #1 (NA) was interviewed on 8/14/2020 at 9:27 AM. NA #1 reported that Resident #1 was forgetful and required instructions repeated many times. NA reported she had provided care for Resident #1 and when the skin on his buttocks opened and became dark, she notified the nurse. An interview was conducted with the resident liaison (RL) on 8/14/2020 at 10:39 AM. The RL reported Resident #1 ' s family was notified about his change in cognition and they had been interested in obtaining power of attorney forms in July 2020. The Director of Nursing (DON) was interviewed on 8/14/2020 at 1:30 PM. The DON reported she was not certain why the RP of Resident #1 was not notified of the change in his buttocks skin and the formation of pressure ulcers. The DON reported that Resident #1 had been alert and oriented and the cognitive change was recent. The DON reported if a resident was confused, she expected the family to be notified of changes in the resident condition.

Based on record review, staff, pharmacy consultant and physician interview the facility failed to initiate the facility wide antibiotic stewardship program. This was evidenced by 1 of 5 sampled residents reviewed for unnecessary medication use (Resident #12). The findings included: Review of the Infection Prevention Plan (IPP) revised (MONTH) 2019 indicated the Antibiotic Stewardship Program (ASP) was to improve the use of antibiotics to protect the residents and reduce antibiotic resistance which was crucial to the IPP. The goal of the ASP was to optimize the treatment of [REDACTED]. The components of the program included in part: 1. Leadership commitment 2. Accountability 3. Action 4. Tracking 5. Education Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. [MEDICATION NAME][MEDICATION NAME]. A record review revealed an order dated 7/13/17 [MEDICATION NAME] milligrams (mg) give half tab (125mg) every night for UTI [MEDICATION NAME] indefinitely. A urinalysis dated 3/31/19 was negative. There was no record of a urology consultation since her admitted . On 7/9/19 at 2:47pm an interview occurred with the physician. The physician was familiar with the Antibiotic Stewardship Program and stated, every patient has individual needs when it came to the use of antibiotics, however he would be researching further as to why Resident #12 was on an indefinite antibiotic. An interview with the Director of Nursing occurred on 7/9/19 at 3:14pm. The Director of Nursing (DON) stated she had been the infection control nurse since being hired in (MONTH) 2019 and that she was familiar with the antibiotic stewardship program but could not produce any antibiotic logs or protocols for the antibiotic stewardship program. The DON reviewed the antibiotic order for Resident #12 and stated, I don't see anything wrong with it. If there is an order for [REDACTED].>On 7/9/19 at 3:26pm an interview occurred with the pharmacy consultant. She reviewed for unnecessary antibiotics each month and communicated with the physician and facility when an indefinite antibiotic was being used. The pharmacy consultant provided a recommendation to the physician dated 6/26/19 to review the use of indefinite antibiotic for Resident #12. The Director of Nursing and Administrator were interviewed on 7/11/19 at 11:15am. They both were aware the facility did not utilize an antibiotic stewardship program but expected to implement and follow an infection control program per regulatory guidelines.

Based on observations, resident, staff and Physician interviews and record review, the facility failed to assess the skin around a [MEDICAL CONDITION] and observe [MEDICAL CONDITION] care (Resident #10), failed to administer continuous oxygen at the Physician ordered rate, change the oxygen tubing, change a nebulizer mask and humidification as ordered by the Physician and failed to store a nebulizer mask in a protective bag while not in use (Resident #169). The facility also failed to obtain a Physician order [REDACTED].#37) and failed to date and label oxygen tubing and humidification (Resident #270). This was for 4 of 5 residents reviewed for respiratory care. The findings included: 1. Resident #10 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the Body Assessment Schedule dated 1/3/17 read Resident #10 was to have a full skin assessment every Sunday on the 7:00 AM to 7:00 PM shift. Review of Resident #10 Physician order [REDACTED]. Review of Resident #10 annual Minimum Data Set ((MDS) dated [DATE] indicated he was cognitive intact and exhibited no behaviors. He was coded for supervision with his activities of daily living. He not coded as having a [MEDICAL CONDITION]. Review of Resident #10's care plan last revised on 5/1/19 read he was at risk for skin breakdown due to his chronic [MEDICAL CONDITION]. Interventions included a full skin assessment weekly. Review of a skin assessment dated [DATE] read no signs of skin breakdown noted. Review of a skin assessment dated [DATE] read no open wound noted. The facility provided no evidence of a skin assessment for the weeks of 5/19/19 or 5/26/19. The facility provided no evidence of a skin assessment for the weeks of 6/2/19, 6/9/19, 6/16/19 and 6/23/19. Review of a nursing note dated 6/12/19 at 5:48 AM read Resident #10 was started on an antibiotic due to an abscess on the back of his neck. Also ordered was warm compresses to the area while awake. The abscess appeared slightly red and swollen. Review of a skin assessment dated [DATE] read no skin breakdown. Skin intact. Review of a skin assessment dated [DATE] read scabbed are to back of neck, no skin breakdown noted. During an interview on 7/10/19 at 12:13 PM, Nurse #7 stated Resident #10 did his own [MEDICAL CONDITION] care and she only changed his [MEDICAL CONDITION] tie and equipment if it showed up on his TAR. She stated she did not routinely assess the skin around his [MEDICAL CONDITION] because the weekend nurse did it. During an interview on 7/10/19 at 3:00 PM, Resident #10 stated he completed his [MEDICAL CONDITION] care in the evenings before he went to bed. He stated seldom was a nurse present during his [MEDICAL CONDITION] care unless it was to change his tie. Resident #10 stated this was his third [MEDICAL CONDITION] and he very comfortable with caring for it. He stated he had taught the staff a thing or two about tracheostomies. During a telephone interview on 7/10/19 at 4:37 PM, Nurse #13 confirmed she was assigned Resident #10 on 6/2/19, 6/9/19 and 6/23/19. She stated Resident #10 was independent with his [MEDICAL CONDITION] care and she was not aware that he was scheduled to a weekly skin assessment every Sunday. Nurse #13 stated if it did not alert her on his TAR, she would not have known to complete it. Nurse #13 stated she was aware of the skin assessment schedule, but most have overlooked it on 6/2/19, 6/9/19 and 6/23/19. During a telephone call on 7/11/19 at 12:20 PM, Nurse #15 confirmed she completed the skin assessment on Resident #10 the weeks of 5/5/19, 5/12/19, 6/30/19 and 7/7/19. She stated she worked at the facility as needed on the weekends. Nurse #15 recalled Resident #10 was recently treated for [REDACTED]. She stated when she did her weekly skin assessments, she would scan his [MEDICAL CONDITION]. During an interview on 7/11/19 at 12:45 PM, Nurse #7 confirmed she worked with Resident #10 on 5/19/19. She stated she did not complete a skin assessment of his [MEDICAL CONDITION] because she was under the impression that the nurse who watched him perform [MEDICAL CONDITION] care did it. During another interview on 7/11/19 at 12:50 PM, Resident #10 stated he found a knot on the back of his neck and told the nurse. He stated the Physician came in and assessed it and ordered antibiotics. He stated the abscess was gone. During an interview on 7/11/19 at 2:03 PM, the Administrator and the Director of Nursing (DON) stated it was their expectation that a nurse observed Resident #10 perform his [MEDICAL CONDITION] care and assess the skin around his [MEDICAL CONDITION] while observing his care. The DON stated it was her expectation that Resident #10 receive a full skin assessment weekly. 2. Resident #169 was admitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #169's quarterly Minimum Data Set ((MDS) dated [DATE] indicated she was cognitively intact and exhibited [MEDICAL CONDITION]. She was coded for the use of oxygen. Review of Resident #169's care plan revised on 6/19/19 read she was at risk for shortness of breath due to [MEDICAL CONDITION]. Interventions included administering her oxygen as ordered by the Physician. Review of Resident #169's electronic medical record indicated she was sent to the hospital on [DATE] and readmitted back to the facility on [DATE]. Review of Resident #169's readmission orders [REDACTED]. During an observation on 7/8/19 at 11:32 AM, Resident #169 was sitting up in bed, She was wearing a nebulizer mask receiving a breathing treatment. The oxygen concentrator was running at 1.5 liters. The date on the oxygen tubing read 6/29/19. The date on the nebulizer mask read 6/20/19. The humidifier water bottle was dated 6/29/19. During an interview on 7/9/19 at 3:00 PM, the Physician stated it was his expectation that Resident #169 receive her continuous oxygen at the ordered rate, oxygen tubing, nebulizer tubing, nebulizer mask and humidified water be changed as ordered. He further stated the nebulizer mask should be stored in a bag when it was not in use for infection control purposes. During an observation on 7/9/19 at 3:05 PM, Resident #169 was sitting up in bed wearing her oxygen with the oxygen concentrator running at 1.5 litters. The oxygen tubing was still dated 6/29/19. Her nebulizer mask was lying on the nightstand next to her bed not secured in a bag. The mask was still dated 6/20/19. The humified water bottle was still dated 6/29/19. During an interview on 7/9/19 at 4:55 PM, Nurse #7 stated the oxygen tubing, humidified water bottle was not changed when she returned from the hospital on [DATE]. Nurse #7 stated Resident #169's nebulizer mask should have been changed 6/27/19 but apparently was not. Nurse #7 also observed Resident #169's nebulizer mask lying on her nightstand and confirmed not only should have it been changed on her readmission 7/7/19 but it should be stored in a bag when it was not in use. Nurse #7 verified Resident #169's continuous oxygen was running at 1.5 litters but ordered at the rate of 2.5 litters. Nurse #7 stated she was unsure why Resident #169's oxygen was not running at the ordered rate except to say one has to be down at eye level to ensure the ordered rate. Nurse #7 corrected the oxygen rate to 2.5 litter and stated she would ensure the oxygen tubing, nebulizer tubing and mask, the humidifier water bottle were changed immediately. During an observation on 7/10/19 at 8:45 AM, Resident #169 oxygen was running at the ordered rate of 2.5 litters, the oxygen tubing and humidified water bottle was dated changed 7/9/19. The nebulizer mask was observed inside a bag but still dated 6/20/19. During an interview on 7/10/19 at 4:40 PM, Nurse #7 stated she instructed the Treatment Aide (TA) to change out all the tubing, water and mask yesterday but apparently, she neglected to change the nebulizer mask and she had not noticed the error. Nurse #7 changed the nebulizer mask on 7/10/19 at this time. During an interview on 7/10/19 at 4:45 PM, TA #1 stated she changed the oxygen tubing and humidified water bottle on 7/9/19. She stated she also observed the nebulizer mask lying on Resident #169's nightstand but did not change it but rather returned it to the bag. She stated it was an oversight. During an interview on 7/11/19 at 2:03 PM, the Administrator and the Director of Nursing (DON) stated it was their expectation that Resident #169's oxygen be administer as ordered and tubing, mask and humified water be changed as ordered. Both also stated the expectation that the nebulizer mask be stored in a bag when it was not in use. 3. Resident # 37 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 #37's cognition was intact. Resident #37's nurse's notes were reviewed. The note dated 5/4/19 at 9:45 AM (written by Nurse # 8) revealed that Resident #37 was complaining of left sided chest pain and her oxygen saturation was 80%. Oxygen was started at 3 Liters (L) per minute and her oxygen saturation went up to 99%. The Nurse Practitioner (NP) was notified and she ordered to send the resident to the emergency room (ER) for evaluation. The note did not indicate whether the resident was admitted to the hospital or not. The note dated 5/6/19 at 1:38 PM (written by Nurse #9) revealed that Resident #37 was on oxygen and the oxygen saturation was 98%. On 7/9/19 at 8:10 AM and at 4:47 PM, Resident #37 was observed in bed with oxygen between 2 ½ - 3 Liter (L) per minute via nasal cannula. On 7/9/19 at 4:48 PM, Resident #37 was interviewed. She stated that she was using oxygen since she was readmitted from the hospital. Resident #37 was not able to remember the date of readmission. Review of Resident #37's medical records (electronic and hard copy chart) revealed no order for oxygen. On 7/9/19 at 4:49 PM, Nurse #7, assigned to Resident #37, was interviewed. The Nurse stated that Resident #37 was on oxygen since she was readmitted from the hospital. On 7/9/19 at 4:50 PM, Nurse #7 observed Resident #37's oxygen and verified that the resident was receiving oxygen between 2 ½ - 3 L per minute via nasal cannula. Nurse #7 reviewed Resident #37's medical records and she reported that the resident had no doctor's order for oxygen. The Nurse indicated that the admitting Nurse should have written the order for then oxygen. On 7/11/19 at 10:20 AM, Nurse #8 was interviewed. The Nurse remembered that Resident #37 had complained of chest pain and her oxygen saturation was low. She started the resident on oxygen at 3 L per minute via nasal cannula and she notified the NP who gave her an order to send the resident to the ER. Nurse #8 indicated that she could not remember whether Resident #37 was admitted or not. The nurse also stated that if the resident was not admitted to the hospital and she came back to the facility with oxygen, an order for [REDACTED].>On 7/11/19 at 11:01 AM, Nurse # 9 was interviewed. The Nurse verified that she was assigned to Resident #37 on 5/6/19 and the resident was on oxygen. The Nurse stated that she didn't check if Resident #37 had a doctor's order for oxygen. Nurse #9 verified that there was no note to indicate the date and time Resident #37 came back from the ER. The Nurse also indicated that the Nurse who received the resident from ER should have written the order for the oxygen. On 7/11/19 at 2:10 PM, the Director of Nursing (DON) was interviewed. The DON expected that all residents on oxygen should have an order for [REDACTED].> 4) Resident #270 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) was currently in progress. A review of the physician orders [REDACTED]. A review of the (MONTH) 2019 Treatment Administration Record (TAR) indicated the oxygen tubing and humidifier bottle was changed on 7/5/19 by Nurse #13. On 7/8/19 at 11:45am an observation was made of Resident #270 in her room with oxygen in use and tubing connecting to the humidification bottle on the oxygen concentrator. There was no label with a date on the tubing or the humidification bottle. Resident #270 indicated she did not know when the tubing or humidification bottle was last changed. An observation was made on 7/9/19 at 11:57am of Resident #270 using the oxygen and the tubing was connected to the humidification bottle on the oxygen concentrator without a label and date. The resident stated she didn't know if the tubing or humidification bottle had been changed. On 7/9/19 at 3:45pm Resident #270 was observed in her room with the oxygen in use and tubing connected to the humidification bottle and oxygen concentrator. There was no label with a date on the tubing or the humidification bottle. In an interview with Nurse #1 on 7/9/19 at 3:45pm she indicated the oxygen tubing and humidification bottle were changed every 5 days per the standing orders and were to be labeled with the date and initials of the nurse who completed the task. An observation was made, in the company of Nurse #1, in Resident 270's room, of the oxygen tubing and humidification bottle without a label or date. A phone interview was completed with Nurse #13 on 7/10/19 at 4:37pm. She stated it was an oversight not to have dated the oxygen tubing and humidification bottle for Resident #270. On 7/11/19 at 11:15am an interview with the Director of Nursing indicated she expected the oxygen tubing and humidification bottle to be labeled with a date when they are changed as ordered.

Based on observation, record review, resident interview, and staff interview, the facility failed to prevent a dependent resident from falling out of bed during incontinence care for 1 of 3 residents reviewed for falls. Resident #1 fell face down onto the floor and sustained multiple skin tears to her upper extremities, lacerations to her face requiring sutures, a facial hematoma, and increased pain for a period of 5 days requiring the administration of narcotic medication for pain management. The findings included: Resident #1 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 ' s cognition was intact. She was assessed as dependent on 2 or more staff for transfers and toileting. Resident #1 required the extensive assistance of 1 staff for bed mobility and personal hygiene. She was assessed as not steady on her feet and only able to stabilize with staff assistance for surface to surface transfers. Moving from seated to standing, walking, turning around, and moving on and off the toilet had not occurred for Resident #1 during the MDS review period. Resident #1 had impairment on both sides of her upper extremities. Her weight was 220 pounds, she was always incontinent of bladder and bowel, and she no falls since her previous MDS assessment (3/28/18). Resident #1 received scheduled pain medications, no as needed (PRN) pain medication, and no opioid medications during the review period. During the resident interview she indicated she had no pain presence during this MDS review period. The plan of care for Resident #1 included the problem/need of staff assistance for all Activities of Daily Living (ADLs) related, in part, to muscle weakness, impaired mobility, incontinence of bladder/bowel, and dementia with behaviors. This area was initiated on 4/4/18 and most recently reviewed on 6/27/18. The interventions included 2 staff in Resident #1 ' s room while personal care was provided and total dependence for transfers requiring 2 staff and a mechanical lift. The plan of care for Resident #1 also included the problem/need of the risk for falls related, in part, to poor trunk control, poor safety awareness, and muscle weakness. This area was initiated on 4/4/18 and most recently reviewed on 6/27/18. The interventions included incontinence care and transfers as directed. A review of Resident #1 ' s physician's order [REDACTED]. - Tylenol 650 milligrams (mg) every 4 hours PRN for pain or discomforts. This order was initiated on 1/21/17. - [MEDICATION NAME] (narcotic pain medication) 5-325 mg every 4 hours PRN for pain secondary to [MEDICAL CONDITION] arthritis and polyarthritis. This order was initiated on 10/2/17. An incident report dated 8/23/18 completed by Nurse #1 indicated Resident #1 had a witnessed fall on 8/23/18 at 6:30 AM resulting in moderate harm. Nurse #1 indicated she was called to Resident #1 ' s room where the resident was observed face down on the floor. Nursing Assistant (NA) #1 stated she was doing incontinence care and Resident #1 rolled out of bed. Resident #1 had injuries to her face and was sent to the Emergency department (ED) for evaluation and treatment. The post fall investigation dated 8/23/18 at 7:00 AM was also completed by Nurse #1. Nurse #1 indicated she thought the fall happened because Resident #1 had no side rails and she was a larger resident in a regular bed. Her recommendation was a bariatric bed (a larger bed frame and mattress). A nursing note dated 8/23/18 at 6:35 AM completed by Nurse #1 indicated she was called to Resident #1 ' s room by the NA (NA #1) who was doing incontinence care when the resident rolled out of bed. Resident #1 was observed by Nurse #1 lying face down with blood coming from her eye. Resident #1 was sent by Emergency Medical Services (EMS) to the ED for evaluation and treatment. The physician and Responsible Party (RP) were notified of the fall. Hospital records dated 8/23/18 indicated Resident #1 presented at the ED at 7:22 AM for evaluation after a fall. Emergency Medical Services (EMS) reported Resident #1 fell out of her bed when staff lost their balance while holding the patient and attempting to change her in bed. Resident #1 reportedly rolled out of bed, striking her head on an oxygen regulator. Resident #1 endorsed head pain that was achy/sore rated at a 6 out of 10 during evaluation in the ED. Resident #1 ' s fall was witnessed by facility staff, she had struck her head, but there was no loss of consciousness. Resident #1 was assessed with [REDACTED]. She had a hematoma (solid swelling of clotted blood within the tissues) to the head, a complex flap laceration approximately 6 centimeters (cm) above the left (L) eyelid, and a subcentimeter (less than a cm) laceration in the midline inferior (lower) of the left eye. Minimal oozing bleeding was noted from both lacerations. The laceration above Resident #1 ' s L eyebrow was assessed as a mixed laceration and skin avulsion (skin avulsion occurs when skin is forcibly detached/torn from the body during an accident or other injury) requiring 4 sutures. The laceration below Resident #1 ' s L eye required 1 suture. A CT (computed tomography) scan was conducted of Resident #1 ' s head and confirmed a L frontal preorbital (situated in front of the eye socket) soft tissue hematoma without fracture. X-rays of Resident #1 ' s left elbow and bilateral hands were completed with the results showing no fractures/dislocations. She was noted with [MEDICAL CONDITION]/[MEDICAL CONDITION] changes in the left elbow and both hands. A nursing note dated 8/23/18 indicated Resident #1 returned from the ED at 12:30 PM. Dressings were noted to her L eye due to lacerations above and below the eye. A nursing note dated 8/23/18 at 9:52 PM completed by Nurse #1 indicated the L side of Resident #1 ' s face was swelling and turning purple. The lacerations above and below the L eye were bleeding and required a dressing change. Resident #1 complained of pain all over and PRN [MEDICATION NAME] was administered. The plan of care related to Resident #1 ' s risk for falls was updated on 8/23/18 with the interventions of 2 staff assistance with all personal care and a bariatric bed. A Nurse Practitioner (NP) note dated 8/24/18 indicated the NP reviewed the summary of the medical records for Resident #1. The NP wrote that Resident #1 had a fall from her bed on 8/23/18, she hit her oxygen concentrator, and suffer multiple contusions and lacerations. Due to the facial injuries and the inability to stop the bleeding, Resident #1 was transferred to the ED. Multiple x-rays of Resident #1 ' s elbow, wrist, and hand were indicative of [MEDICAL CONDITION] changes and [MEDICAL CONDITION] arthritis with no fracture. A CT of Resident #1 ' s head and neck showed moderate L frontal preorbital facial hematoma. There was no evidence of facial fracture or cervical spine fracture. Sutures were placed on 2 lacerations. The NP indicated Resident #1 had significant difficulty with continued bleeding. She was noted to be on Xarelto (anticoagulant medication) and aspirin related to [MEDICAL CONDITION] embolism. Resident #1 was assessed by the NP while she was lying in bed. Her left eye was swollen with continued bleeding and she was unable to open the eye. A nursing note dated 8/25/18 completed by Nurse #4 indicated lacerations continued to Resident #1 ' s L eye and her face was swollen from the previous fall (8/23/18). Resident #1 complained of pain all over and PRN [MEDICATION NAME] was administered. A review of Resident #1 ' s (MONTH) (YEAR) Medication Administration Record [REDACTED]. - After Resident #1 ' s fall on 8/23/18 (8/23/18 through 8/31/18): PRN Tylenol was not administered; PRN [MEDICATION NAME] was administered 9 times (8/23 x2, 8/24, 8/25 x2, 8/26 x2, and 8/27 x2). An observation and interview were conducted with Resident #1 on 9/11/18 at 1:05 PM. Resident #1 was observed to be in a bariatric bed. Bruising that was brown and yellow in color was noted to her face and steri-strips were observed on the laceration above her L eye. Resident #1 was alert and oriented to self, but she was unable to answer any questions related to her previous fall. A phone interview was conducted with NA #1 on 9/11/18 at 9:31 AM. She indicated she had worked at the facility for about a year. NA #1 was asked how she knew how much assistance a resident required with their ADLs. She reported that there was hard copy NA care guide in each resident ' s closet. She indicated she was familiar with Resident #1 and had worked with her occasionally. NA #1 was asked how much assistance Resident #1 required with her ADLs based on her care guide. She stated she was not sure off the top of her head. She also stated she had not viewed Resident #1 ' s care plan before. This phone interview with NA #1 continued. The incident report related to Resident #1 ' s fall on 8/23/18 at 6:30 AM was reviewed with NA #1. She confirmed she was the NA who was providing incontinent care to Resident #1 at the time of this fall (8/23/18). She stated she had worked the third shift, 11:00 PM to 7:00 AM, on 8/22/18 into 8/23/18. She reported Resident #1 was the last resident she needed to provide incontinence care to that morning prior to the end of her shift. NA #1 stated that she called for a staff member to help her, she waited about 10 minutes, and then she just proceeded to provide care to Resident #1 by herself. She indicated staffing was normal for both the NAs and nurses that morning. She stated she asked Resident #1 to roll onto her side and grab hold of the side of the mattress. She indicated Resident #1 was able to roll, but she rolled too far and was not able to keep herself on the bed. NA #1 indicated she was unable to stop Resident #1 from falling and she proceeded to fall face down onto the floor. NA #1 revealed she should have waited for an additional staff member for the resident ' s safety and for her own safety. She stated that after the incident (8/23/18) the Interim Administrator/previous Director of Nursing (DON) told her to always utilize 2 staff for all personal care for Resident #1. NA #1 reported that since the fall on 8/23/18 she always had another staff member with her when she was providing personal care to Resident #1. A phone interview was conducted with Nurse #1 on 9/22/18 at 9:38 AM. She stated she was familiar with Resident #1 and confirmed she was the nurse assigned to her at the time of the fall on 8/23/18 at 6:30 AM. She reported she was called to Resident #1 ' s room via a hand held multi-way radio. She stated that when she got to the room, Resident #1 was lying on the ground, blood was coming from her face, and lacerations were noted above and below her L eye. She indicated Resident #1 was sent to the ED for evaluation and treatment. Nurse #1 stated she completed the incident report and the post fall investigation, and she believed the fall could have been prevented if Resident #1 had a larger bed. She reported that for several days after the fall, Resident #1 ' s pain was increased, and PRN [MEDICATION NAME] was administered on several occassions. She revealed this was a change for Resident #1 as PRN Tylenol normally was able to manage her pain. An interview was conducted with NA #2 on 9/11/8 at 11:23 AM. She stated she had worked at the facility for 4 years. She indicated she was very familiar with Resident #1 as she worked with her regularly. NA #2 was asked how much assistance Resident #1 required with her ADLs. She stated that Resident #1 was dependent for most ADLs other than eating. She indicated 2 staff were required for incontinence care and transfers. She explained that Resident #1 was heavy and she was not able to control her trunk. NA #2 reported that any time she performed incontinence care for Resident #1 she always asked for another staff ' s assistance so that 1 staff member could stand on each side of the bed. She indicated she has worked the third shift (11:00 PM to 7:00 AM) and the first shift (7:00 AM to 3:00 PM) and had not found it difficult to find another staff member to assist with care. She stated sometimes you just had to be patient and wait a few minutes for another NA or a nurse to be able to help you out. A phone interview was conducted with Nurse #3 on 9/11/18 at 11:55 AM. She indicated she was aware of Resident #1 ' s fall on 8/23/18 and confirmed she had worked with her after the fall. She stated that Resident #1 had severe bruising and swelling to her face, bruising to upper extremities, and sutures above one of her eyes. She additionally stated that Resident #1 had, more pain than usual. Nurse #3 reported that Resident #1 had orders for PRN Tylenol and PRN [MEDICATION NAME]. She indicated that Resident #1 normally just requested PRN Tylenol when she was having pain, but that for a few days after the fall she was requesting the PRN [MEDICATION NAME]. A phone interview was conducted with Nurse #2 on 9/11/18 at 12:20 PM. She indicated she was aware of Resident #1 ' s fall on 8/23/18. She indicated she had not seen Resident #1 after the fall until a several days later. She stated Resident #1 had sutures over the left eye and bruising on her face and arms. Nurse #2 reported she recalled that Resident #1 had increased pain after the fall and that PRN [MEDICATION NAME] was administered. She explained that PRN [MEDICATION NAME] was not frequently used for Resident #1 as her PRN Tylenol normally managed her pain. A phone interview was attempted with Nurse #4 on 9/11/18 at 11:43 AM, but she was unable to be reached. An interview was conducted with the MDS Coordinator on 9/11/18 at 10:25 AM. The care plans for Resident #1 related to ADLs and the risk for falls were reviewed with MDS Coordinator. She stated that prior to Resident #1 ' s fall on 8/23/18 the care plan, the NA care guide, and the bowel and bladder guide had not been specific about the amount of assistance and/or staff required for Resident #1 ' s incontinence care. She explained that prior to the fall (8/23/18) Resident #1 fluctuated between extensive to dependent and 1 to 2 staff for physical assistance with incontinence care. She reported that Resident #1 ' s care plan had an intervention that stated 2 staff members were to be in Resident #1 ' s room during personal care. The MDS Coordinator explained that this intervention was related to behavioral issues for the resident and not intended to specify that 2 staff were required to provide physical assistance. She acknowledged that this intervention on the care plan was not followed on 8/23/18 as NA #1 was the only staff member in Resident #1 ' s room at the time of the fall. The MDS Coordinator verified that after the 8/23/18 fall, the care plan, NA care guide, and bowel and bladder guide were all updated to specify that 2 staff ' s physical assistance was required for all of Resident #1 ' s personal care. An interview was conducted with the Interim Administrator (former DON) on 9/11/18 at 1:20 PM. The current DON sat in on the interview. Resident #1 ' s 8/23/18 fall was reviewed with the Interim Administrator and the DON. The Interim Administrator verified that as a result of the 8/23/18 fall, Resident #1 sustained multiple skin tears, facial lacerations requiring sutures, a facial hematoma, and increased pain for a period of 5 days (8/23/18 through 8/27/18) requiring narcotic medication for pain management. The Interim Administrator stated she believed the root cause of the fall was that Resident #1 required 2 staff ' s assistance for incontinence care primarily related to Resident #1 ' s size. She acknowledged that Resident #1 additionally had muscle weakness and poor trunk control which limited her ability to assist the staff. The Interim Administrator stated that following the 8/23/18 fall Resident #1 ' s care plan, NA care guide, and bowel and bladder guide were updated to specify that 2 staff ' s physical assistance was required for all of Resident #1 ' s personal care needs. She explained that prior to the 8/23/18 fall, these three documents (care plan, care guide, bowel and bladder guide) had not specifically stated that 2 staff were required to provide incontinence care for Resident #1. The Interim Administrator indicated that a bariatric bed was implemented for Resident #1 as a precautionary measure after the 8/23/18 fall, but she had not believed this was the root cause of the fall. She explained that Resident #1 was overweight, but that she adequately fit in a regular bed, there was no indication of her discomfort in the bed, and no recent falls to suggest that a bariatric bed was needed. The current DON confirmed her agreement with the Interim Administrator ' s root cause of the fall and the expectation that 2 staff should have been utilized to provide incontinence care to Resident #1.