Every finding on record at Summerstone Health and Rehabilitation Center

Based on record review and interviews with resident, family member, facility staff, agency staff and law enforcement, the facility failed to protect a resident's right to be free from misappropriation of property when $200 was transferred out of a resident's online banking account into Nurse Aide (NA) #2's personal bank account. This deficient practice affected 1 of 3 residents reviewed for misappropriation of property (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact.Review of a Police Incident/Investigation Report indicated on 04/09/26 the Director of Nursing (DON) and the Administrator reported the theft of $200 from Resident #1's online banking account that occurred on 04/03/26. The report further documented that law enforcement dispatched a police officer to the facility and contact was made by the police officer with Resident #1. The police officer observed the online banking transaction on Resident#1's telephone.On 05/07/26 at 9:42 am a telephone interview was conducted with the Police Officer. He reported he was called by the Administrator on 04/09/26 for an allegation of a resident who had been defrauded of $200. The Police Officer stated he went to the facility and met with Resident #1. He stated Resident #1 reported she was missing $200 from her bank account and he viewed the transaction data on Resident #1's telephone screen. The transaction was dated 04/03/26 and was processed via an online banking application from Resident #1 to NA #2. He stated he confirmed NA #2 was working with Resident #1 on 04/03/26. On 05/06/26 at 11:13 am a telephone interview was conducted with Resident #1. Resident #1 stated on 04/09/26 she noticed $200 was withdrawn from her bank account. The withdrawal was processed via an online banking application with a transaction date of 04/03/26. She requested her family member review the account information to confirm the discovery. Once confirmed, Resident #1 notified the bank by telephone. An inquiry was initiated by the bank. Resident #1 reported she was advised by bank staff a cellular telephone device transaction dated 04/03/26 for $200 went from Resident #1's online bank account into NA #2's online bank account. Resident #1 reported she was not acquainted with NA #2 and did not loan or give NA #2 permission to withdraw the money. Resident #1 revealed her telephone was password protected and she had not shared the password with anyone. Resident #1 stated her family member called the facility and advised the DON of the incident. Resident #1 shared she felt devastated and violated by this incident. Resident #1 stated within a few hours she was visited by a policeman and gave a report. Resident #1 added the $200 was returned to her account by NA #2 on 04/09/26 via the online banking application. An interview was conducted on 05/06/26 at 11:33 am with Resident #1's family member who revealed she reported to the DON on 04/09/26 that Resident #1 noticed $200 missing from her bank account. The family member stated she was asked by Resident #1 to confirm the $200 was withdrawn. The family member was able to confirm that a telephone transaction dated 04/03/26 was processed. A telephone interview was conducted with NA #2 on 05/06/26 at 4:19 pm. NA #2 stated she worked at the facility for 3 weeks and was assigned to Resident #1's care on 04/03/26. NA #2 stated she told Resident #1 about her financial concerns including her inability to pay her power bill. NA #2 reported Resident #1 offered to let her borrow $200. NA #2 stated Resident #1 used her telephone and completed a transaction via her online banking application and transferred $200 to NA #2's bank account. NA #2 reported the agreement was NA #2 would return the funds in the future. NA #2 stated she was aware that she should not have taken money from Resident #1. An interview was conducted with the DON on 05/05/26 at 3:53 pm. The DON stated on the afternoon of 04/09/26 she was informed by Resident #1's family member that an unauthorized online banking transfer was sent from Resident #1's online banking account to NA #2's bank account. The DON reported that she immediately notified the Administrator and the staffing agency Chief Executive Officer (CEO). The DON stated NA #2 was immediately removed from the schedule and did not return to the facility. On 05/06/26 at 8:24 am a telephone interview was conducted with the CEO for the staffing agency that NA #2 was employed by in April 2026. She stated on 04/09/26 the DON from the facility called to report a misappropriation of resident property allegation by NA #2. The CEO reported she was advised NA #2 had allegedly taken $200 from Resident #1 via an online banking application. She stated she called and spoke with NA #2 on 04/09/26 at 4:39 pm. The CEO indicated NA #2 admitted taking the $200 from Resident #1 via an online banking application. The CEO reported NA #2 stated Resident #1 offered to allow her to borrow the funds. She further reported that NA #2 stated she had already returned the funds to Resident #1's online banking account. The CEO stated that NA #2 admitted she was aware that she should not have asked to borrow money from Resident #1.The facility's investigation report dated 04/15/26 completed by the Administrator indicated on 04/09/26 at 2:30 pm the facility became aware of an allegation of misappropriation of Resident #1's property in the amount of $200. A family member reported an unauthorized transaction dated 04/03/26 from Resident #1's bank account into NA #2's bank account. Local law enforcement was notified on 04/09/26 at 3:00 pm. The allegation was substantiated and A #2's employment was terminated by the agency. An interview with the Administrator was conducted on 05/06/26 at 11:20 am. He reported on 04/09/26 he was notified by the DON of an allegation of misappropriation of Resident #1's property in the amount of $200. The Administrator stated he notified local law enforcement, and a police officer came to the facility. A report was given by Resident #1 to the police officer. The Administrator stated he did not know how this occurred and that actions were taken to prevent further issues. The facility provided a corrective action plan that was not acceptable to the State Agency as it did not contain sufficient evidence of systemic measures and monitoring to prevent future incidents of misappropriation of resident property.

Based on observations, record reviews, and resident and staff interviews, the facility failed to provide nail care for 1 of 3 dependent resident reviewed for activities of daily living (ADL) (Resident #104).Findings include:Resident #104 was admitted on [DATE] with diagnoses including diabetes and bilateral hand contractures.A Physician order dated 8/25/25 indicated that Resident #104 needed daily nail cleaning and weekly trimming was to be done on the 7:00 AM to 7:00 PM shift for diabetic care. A review of the Medication Administration Record for March 2026 indicated that diabetic care should be done daily on the 7:00 AM to 7:00 PM shift including fingernails should be cleaned daily and trimmed as needed. The feet should be kept clean and dry and assessed for injury and the need for toenails to be trimmed. The MAR was initialed as nail care being assessed each day as completed through 3/19/26.Resident #104's quarterly Minimum Data Set (MDS) dated [DATE] specified the resident had intact cognition, limited range of motion to bilateral hands, use of hand guards and had no rejection of care. Resident #104 required dependent care for hygiene and nail care.A review of the quarterly care plan dated 3/9/26 indicated Resident #104 received minimum to maximum assistance for ADL care from staff for bathing, range of motion, set up for feeding, hygiene, toileting, nail and skin care. Resident #104 was not care planned for any rejection of care. An observation and interview on 3/16/26 at 9:50 AM, revealed Resident #104's fingernails on both hands were long, dirty, had brown matter under the thumbs and a whitish substance underneath the 2nd, 3rd and 4th fingers of both hands. The left thumbnail was orange in color. The resident stated it had been a long time since his nails were cleaned or cut on either hand and reported that staff did not offer nail care. An observation on 3/17/26 at 11:20 AM showed Resident #104's nails were long and dirty with brown matter under the thumb nails on both hands, white matter under the others. An interview with NA #6 on 3/17/26 at 11:30 AM indicated that she had not given the resident a bath because he was already up when she got there. She stated he was bathed by the 7:00 PM to 7:00 AM shift and put it into his electric wheelchair because he got up early, and she had not noticed his nails needed to be cleaned.An interview and observation with Nurse #3 who was assigned to Resident #104 on 3/18/26 at 9:30 AM revealed that the physician orders read that Resident #104 was to have his nails cleaned daily and trimmed weekly and as needed. She indicated that due to his contractures it was difficult to trim them but agreed they did need to be cleaned and trimmed. The March 2026 MAR was reviewed with Nurse #3 during the interview, and the MAR was not initialed on 3/18/26 for diabetic care including fingernails being cleaned and trimmed daily. Nurse #3 further stated she had not looked at Resident #104's nails that morning.An interview with Nurse Aide (NA) #4 on 3/19/26 at 9:28 AM was assigned to Resident #104 on 3/18/25 and 3/19/26 on the 7:00 AM to 7:00 PM shift. She stated she did not bathe Resident #104 on 3/18/26 or 3/19/26 because she thought night shift (7:00 PM to 7:00 AM) had done so. Resident #104's fingernails were observed during the interview, and she agreed they needed to be cleaned and trimmed and had not been cleaned by 7:00 PM to 7:00 AM shift. NA #4 indicated that Resident #104 was diabetic and she could not trim his nails but could soak and clean them. NA #4 reported that Resident #104 did not refuse care. The NA further stated the nurse would have to trim Resident #104's nails because he had diabetes.A phone interview on 3/19/26 at 10:56 AM with NA #5 revealed she was assigned to Resident #104 on 3/18/26 from 7:00 PM to 7:00 AM on 3/19/26. NA #5 reported she bathed the resident that morning (5:30 AM), but stated she was unable to clean or trim his nails due to his contracted hands into fists. She did not indicate that she had reported the condition of the nails to nursing.On 3/19/26 at 3:30 PM a joint interview was conducted with the Director of Nursing (DON) and the Administrator. The DON reported that the Administrator trimmed the resident's nails the previous day and stated the resident was a messy eater, making it difficult to keep his hands clean, but the aides giving care should be making sure the residents hands and nails are trimmed are clean. The Administrator stated the DON had talked with him regarding Resident #104's nail care and he understood the importance of maintaining the resident's diabetic nail care and would ensure the nail care was completed.

Based on record review, observations, and resident and staff interviews, the facility failed to apply palm guards as ordered for 1 of 1 dependent resident reviewed for limited range of motion (Resident #104).Findings include: Resident #104 was admitted on [DATE] with diagnoses of bilateral hand contractures (permanent tightening of muscles, tendons, or ligaments causing joint stiffness and restricted movement).A review of the therapy discharge note dated 9/12/25 indicated that the resident had met maximum potential and he needed to wear palm guards every day to maintain maximum mobility and prevention of skin irritation.An order dated 9/8/25 indicated that Resident #104 was to wear palm guards as tolerated 6 hours daily, removing them during range of motion exercises, eating and activities of daily living care. Resident #104's care plan dated 3/9/26 identified limited physical mobility related to bilateral hand contractures and use of bilateral palm guards to be worn 6 hours each day and removed for range of motion and activity of daily living (ADL) care. A review of the care plan dated 2/3/26 indicated Resident #104 had limited physical mobility related to bilateral hand contractures. Interventions included to do range of motion to bilaterally contracted hands and apply bilateral hand guards worn 6 hours daily or as tolerated, and to do daily hygiene reporting any skin issues to nursing.Resident #104's most recent quarterly Minimum Data Set, dated [DATE] documented intact cognition, functional limitation in range of motion in both upper extremities, and dependent care for bathing, toileting, transfers and dressing, set up for eating and mouth care, minimum assistance for positioning. There were no behaviors or rejection of care. The Medication Administration Record (MAR) for March 2026 indicated the resident was to wear palm guards up to 6 hours daily as tolerated, as donned/doffed by nursing following ROM and hygiene, and with daily skin checks. The palm guards were signed off as applied at 9:00AM from 3/1/26 through 3/18/26.An observation and interview with Resident #104 on 3/16/26 at 9:50 AM revealed contractures to bilateral hands that were in loose-fisted positions. When asked if he had a hand roll or splints, Resident #104 stated he had palm guards but had not worn them in a long time. There were no palm guards observed in Resident #104's room. Resident #104 stated that he had not declined to wear them and added that they didn't hurt him and he would wear them as ordered if they prevented his contractures from worsening. A second observation of Resident #104 on 3/17/26 at 11:20 AM revealed the palm guards ordered were not on his hands and were not seen in the room.A third observation of Resident #104 on 3/18/26 at 4:12PM AM revealed the ordered palm guards were not on his hands and were not seen in the room. An interview with the Unit Manager (200 hall) on 3/18/26 at 12:10 PM revealed the nurse aides usually applied the palm guards for Resident #104 after care and the nurses were supposed to make sure they were applied.An interview was completed with Nurse #1 on 3/18/26 at 2:12 PM and included a review of Resident #104's MAR. After looking at the MAR Nurse #3 confirmed she had not initialed the MAR for the palm guards on 3/18/26 and she had not completed her treatments yet. Nurse #1 indicated the nurse aides were supposed to place the palm guards on Resident #104 when they got him up and bathed him. Nurse #1 was unable to say when she last saw Resident #104 wearing the palm guards.An interview with Nurse Aide (NA) #1 in Resident #104's room, on 3/19/26 at 9:28 AM, stated she had not seen Resident #104's palm guards in a long time. NA #4 then stated she knew Resident #104 used to wear the palm guards, but they must have gotten lost. NA #4 did attempt to look for the palm guards but could not locate them.An interview with the Therapy Director on 3/19/26 at 11:30 AM revealed Resident #104 was given palm guards for both hands to be worn daily on 8/26/25. The Therapy Director indicated that Resident #104 was discharged from therapy on 9/12/25, and it was the nursing staff's responsibility to make sure the palm guards were placed on both hands as ordered. The Therapy Director stated a functional maintenance program was established and staff were trained on the application of palm guards.An interview with the Director of Nursing (DON) on 3/19/26 at 3:30 PM revealed that she was not informed that Resident #104's palm guards were missing. The DON stated she would expect the staff to continue implementing active therapy orders and would check with the therapy department to see if the resident was supposed to have the palm guards. She then indicated the palm guards were to be applied after care and kept on at least 6 hours daily. On 3/19/26 at 3:30 PM, the Administrator stated the DON had talked with him regarding Resident #104's palm guards and that he was working with therapy to resolve the issue.

Based on observation, record reviews, and resident and staff interviews, the facility failed to obtain routine dental services when requested for a resident with missing upper teeth for 1 of 1 sampled resident reviewed for dental care (Resident #9).The findings included: Resident #9 was originally admitted to the facility on [DATE] with diagnoses which included end-stage renal disease. Review of the Swallowing assessment dated [DATE] revealed Resident #9 had no swallowing disorders and received a diet of regular consistency and thin liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact and had no dental problems or significant weight loss. Resident #9 received dialysis services. Resident #9's active care plan revealed no information related to dental care. A review of Resident #9's medical record from 1/23/25 through 3/16/26 revealed no evidence of the resident receiving dental services since her admission to the facility. During an observation and interview on 3/17/26 at 11:08 a.m., Resident #9 was noted with no upper teeth. The resident stated that she had two teeth in the left, upper back side of her mouth that needed to be extracted before she could be fitted for a partial denture. The resident did not indicate difficulty with chewing her food and did not currently have any mouth pain; but has had some pain in the past from the remaining two upper back teeth. Resident #9 revealed that since her admission to the facility she had not been examined by a dentist. She stated that she made requests to several nurses (unable to recall names) to see a dentist, but the nurses would always inform her the dentist's visits at the facility were during the time she was at the dialysis center. The resident's scheduled dialysis treatments were on Mondays, Wednesdays, and Fridays. An interview was conducted on 3/19/26 at 10:53 a.m. with the Appointment Schedular. She stated that the process for obtaining dental services included: the contracted dentist examined residents at the facility during scheduled visits every three months and the date of the visit was determined by the dental provider. However, if a resident requested to be examined by a dentist, the resident's name would be added to the list of residents' to be seen during the next scheduled dental visit unless the resident required an emergency dental visit. If an emergency dental appointment was needed or if a resident was unable to meet with the dentist during on-site visits, she would schedule a dental visit with the contracted dentist's office or the first available dental practice. The facility would be responsible for transporting the resident to and from the dental office. The Appointment Schedular revealed she was not informed by any of the facility's nurses that Resident #9 requested a dental appointment. During a follow-up interview on 3/19/26 at 1:30 p.m., the Appointment Schedular stated that after the interview with this Surveyor, she reviewed the dental appointment records and contacted the visiting dentist's office. She confirmed Resident #9 had not been seen by a dentist since her admission to the facility and was not included on the list of residents scheduled to be examined by the dentist during his most recent on-site visit at the facility on 1/30/26. As a result, she instructed the facility's current Social Worker (began working at the facility the prior week and would be responsible for maintaining names of residents to be examined by the dentist) to include Resident #9's name on the list of residents to be examined by the dentist during the next dentist's visit (exact date determined by the dental office) to the facility. During an interview on 3/19/26 at 4:27 p.m., the Administrator acknowledged Resident #9 should have received dental services since her admission to the facility and when the resident requested.

Based on observation, record review and staff interviews, the facility failed to ensure nurse staffing sheets were accurate for 4 of 7 days reviewed for nurse staffing information (2/2/26, 2/9/26, 2/22/26, and 3/16/26). The findings included:The daily posted nurse staffing sheet for 2/2/26 revealed 9 Licensed Practice Nurses (LPNs) and 22 Nurse Aides (NAs). The nursing staff assignment sheet dated 2/2/26 revealed 6 Licensed Practical Nurses (LPNs) and 27 Nurse Aides (NAs) worked. The daily posted nurse staffing sheet for 2/9/26 revealed 8 LPNs and 24 NAs worked. The nursing staff assignment sheet dated 2/9/26 revealed 3 LPNs and 11 NAs worked. The daily posted nursing staffing sheet for 2/22/26 revealed 10 LPNs and 27 NAs worked. The nursing staff assignment sheet dated 2/22/26 revealed 11 LPNs and 23 NAs worked. The daily posted nursing staffing sheet for 3/16/26 revealed 10 LPNs worked. The nursing staff assignment sheet dated 3/16/26 revealed 11 LPNs worked.An interview was conducted with the Director of Nursing (DON) on 3/19/26 at 2:20 PM. She stated she was responsible for both the nursing staff schedules and completion and posting of the daily staffing posting sheet as the facility did not have a Staff Scheduling Coordinator. She stated if a nursing staff member called out or left early the daily staffing posting sheet should have been adjusted. The DON stated that the difference between LPNs scheduled and posted was because a Registered Nurse was counted as an LPN. The DON stated she was unaware the posting sheets were not correct for 2/2/26, 2/9/26, 2/22/26, and 3/16/26. She stated that currently she does not have someone reconcile the nurse staff schedules with the daily posting nurse staffing sheet. During an interview on 3/19/26 at 2:40 PM, the Administrator stated the Director of Nursing was responsible for posting and updating the daily nurse staffing sheets. He was unable to give a reason for the staff sheets not being filled out correctly. The Administrator stated he was not involved in the staff posting sheets; however, he would expect them to display the correct information.

Based on record review and staff, Nurse Practitioner (NP), and Responsible Party (RP) interviews, the facility failed to protect a cognitively impaired resident, Resident #6, when he was allowed to exit the facility through the locked main entrance door. Nurse Aide (NA) #1 unlocked and opened the door for Resident #6 and allowed him to leave the facility, in the dark, on the evening of 1/26/25. Resident #6 was found in the parking lot of a restaurant near a gas station 1.4 miles from the facility. There were multiple roads between the facility and where the resident was found including a divided 4 lane road, a 4-lane highway, sidewalks, posted speed limits of up to 45 miles per hour, in 38-degree Fahrenheit weather while wearing shoes, pajamas, a coat, and a hat. Upon being unable to locate Resident #6 Nurse #1 failed to immediately implement and activate the elopement process, which included notifying the police, when she became aware Resident #6 had left the building. After the facility initiated the elopement process, the resident was discovered by police who returned the resident to the facility. Due to the facility's noncompliance through allowing the resident to exit the facility followed by the failure to immediately contact the police, the resident's cognitive impairment, exposure to cold weather, time of day when the resident exited the facility, distance traveled by the resident, and having to traverse on sidewalks, possibly the road, and cross multiple roads there was the high likelihood of serious harm. The deficient practice was found for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia and congestive heart failure. The resident was discharged on [DATE]. The admission wandering assessment dated [DATE] showed Resident #6 scored a two on the wandering risk assessment, which is low risk for elopement. The care plan dated 1/22/25 revealed Resident #6 was a wanderer and at risk for elopement due to wandering behavior and being disoriented due to new placement at the facility with a goal to minimize risks for elopement through current interventions over the next 90 days. Interventions included redirection away from exits as needed, provide diversional activities, and notifying the Director of Nursing (DON) of any exit seeking behaviors. During an interview with Nurse #2, Nursing Supervisor, on 2/25/25 at 3:07 pm, she indicated she completed Resident #6's care plan and that all residents who have at risk for elopement added to their care plans scored something other than zero on their assessment. She reported that Resident #6 had been admitted less than a week and had exhibited no exit-seeking behaviors. Nurse #2 stated, Resident #6 would be seen walking up and down the halls at times or sitting in the common area watching television. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment and wandering behaviors were indicated for 1 to 3 days. The MDS also indicated Resident #6 ambulated independently. A handwritten, undated, statement by NA #1 documented, around 11:00 pm, Resident #6 walked up and asked NA #1 to let him out of the building which NA #1 did because NA #1 thought Resident #6 was visiting. NA #1 wrote Resident #6 told NA #1 he had fallen asleep and that he needed to get home to [NAME]-Salem. NA #1 also wrote that they both walked together to the main entrance and the NA opened the door. Resident #6 then walked out of the building. During a phone interview with NA #1 on 2/25/25 at 2:25 pm, NA #1 reported not letting any residents out of the building. NA #1 reported seeing Resident #6 leaving the building around 11:00 pm but did not let Resident #6 out and was unaware who may have unlocked the door. NA #1 explained not recognizing Resident #6 as living at the facility because the NA had never worked with him, so the NA did not stop Resident #6 from leaving. NA #1 also indicated it wasn't unusual to see visitors coming and going at all times during the night, so the NA didn't question seeing someone leaving at that time. NA #1 indicated noticing Resident #6 was wearing dark shoes, a coat, and a hat the night of 1/26/25. NA #1 added not noticing Resident #6 was wearing flannel pajamas the night of 1/26/25. NA #1 explained the contradiction between the written statement provided regarding Resident #6 leaving the building compared to information shared during the interview was because the facility had NA #1 write what was in the written statement. A handwritten statement, undated, by Nurse #1 read, she saw Resident #6 walking down the hall toward the lobby. Nurse #1 indicated she redirected Resident #6 by having him follow her back toward his room. Nurse #1 wrote she went into the room next door to assist that resident and when she came out of that room several minutes later, she didn't see Resident #6 in the hallway anymore. Nurse #1 reported after looking for him around other units, she was advised by NA #1 that the NA saw the resident and that the NA let Resident #6 out of the building assuming he was a visitor. Nurse #1 documented all of the staff began searching for the resident and the Nursing Supervisor (Nurse #2) called the police and the DON (Director of Nursing). During an interview with Nurse #1 on 2/25/25 at 3:10 pm, she stated she was assigned to Resident #6 for the 7pm-7am shift on 1/26/25. Nurse #1 indicated Resident #6 liked to walk a lot but she had not seen him show any exit-seeking behaviors such as attempting to open outside doors. Nurse #1 reported she saw Resident #6 walking toward the lobby area from the 300 hall around 11:00 pm wearing his flannel pajamas and shoes. She indicated he wasn't wearing a hat or coat when she saw him walking in the hallway. Nurse #1 stated she had Resident #6 follow her back down the 300 hall toward his room where Nurse #1 left him as she went into Resident #6's neighbor's room to assist. Nurse #1 indicated that Resident #6 didn't seem distraught or express to her anything was wrong. Nurse #1 reported several minutes later, she came out of the room and noticed Resident #6 was not in the hallway anymore, so she looked in Resident #6's room, assuming he may have gone to bed, and then proceeded to look in all the rooms on the 300 hall without finding Resident #6. Nurse #1 then stated she expanded her search to other units before meeting NA #1 on the 100 hall who told her the NA let someone who matched the description of Resident #6 out of the building earlier. Nurse #1 explained the NA was unable to provide her with the exact time of when the resident had left the facility. Nurse #1 then reported she went out the front door and proceeded to look for Resident #6 throughout the facility parking lot, both the whole front and then the back lot where employees park, and to the street in front of the building before returning to the facility. Upon returning inside the facility Nurse #1 explained she went to find Nurse #2, Nursing Supervisor, to let her know Resident #6 was missing. Nurse #1 stated she searched for Resident #6 outside for only 5-10 minutes before coming back in. She stated she didn't think about finding the Nursing Supervisor first to let her know before searching outside herself because she was anxious to find Resident #6. Nurse #1 stated she hoped the resident would be right outside on the sidewalk, which led to looking in the parking lot, and then she went to the street. An incident note, which was documented in the nurses' notes, dated 1/27/25 at 6:44 am made by Nurse #2 stated on the evening of 1/26/25 around 11:30 pm, Resident #6 was let outside of the building by a Nurse Aide (NA) #1. Nurse #1 had stated she went outside looking for the resident for about 30 minutes prior to telling the supervisor that a resident was out the facility. She stated she then came back into the building, went to the nurses' station on 100 hall and informed the Nursing Supervisor that a resident had left the building, and she could not find him. Nurse #2 wrote she called the (Director of Nursing) DON, and 911 who was informed of the resident missing from the facility with a detailed description of him and what he was wearing when he was last seen. The staff was alerted that a resident was missing from the facility. The DON called Nurse #2 while she was in her car and said the police had found the resident and he was safely brought back to the facility. During an interview with Nurse #2 on 2/25/25 at 3:07 pm, she stated she was the Nursing Supervisor, and she was made aware of Resident #6 exiting the building by Nurse #1 right before midnight on 1/26/25. Nurse #2 stated Nurse #1 told her she had been searching for Resident #6 for 30 minutes outside and had not been able to locate him. Nurse #2 reported, following the elopement policy, she immediately notified all staff to begin looking for Resident #6 and also notified the DON who advised her to call 911 immediately, which she did. Nurse #2 stated she got in her own car and began driving around the area near the facility looking for Resident #6. Nurse # 2 explained looking for a resident in her own car was not part of the policy, but she was hoping it would result in finding the resident quicker. Nurse #2 reported the DON called her on her cell phone while she was driving, advised her the police had located the resident, and had just returned him to the facility. Nurse #2 stated she returned to the facility and completed an assessment of Resident #6. A police report dated 1/27/25 read police were dispatched at 12:04 am after a staff member called stating an aide let a resident out of the building. Staff made the dispatcher aware Resident #6 had cognitive impairments. Resident #6 was located on NC Hwy 66 near the gas station and was transported back to the facility. The report further stated, NA #1 told the police the NA did not know Resident #6 was a resident at the facility and thought he was letting out a family member after visiting. NA #1 informed the police the doors to the facility were locked and only staff members open the doors. The report also documented the facility searched for Resident #6 for approximately 30 minutes after being made aware the resident had left the building. The resident was unharmed and required no medical attention. The time Resident #6 was returned to the building was not documented. During an interview with the responding Police Officer on 3/3/25 at 4:35 pm, he indicated he was dispatched at approximately midnight on 1/26/25 and advised there was a resident missing from the facility. He stated Resident #6 was found around a fast food restaurant and gas station approximately 1 1/2 miles away from the facility and was wearing a hat, shoes, long pajamas and a dark overcoat. He stated Resident #6 appeared unharmed and told him he needed to get home to [NAME]-Salem. The officer reported he spoke with NA #1 after returning Resident #6 to the facility who told the officer he let Resident #6 out by accident thinking he was a family member there visiting. The officer added that he was told by an unnamed staff member that the facility had been searching for Resident #6 for about 30 minutes before dialing 911. Observation of the facility layout from Resident #6's room to the door where the resident was allowed egress revealed the following: a right turn has to be made when coming out of Resident #6's room, followed by a short walk in the 300 hall until a mid-point in the hall, and then a right turn must be made to the middle hall. From the middle hallway the front common areas can be accessed, to the left of the common areas, there was a double door entrance which had locks controlled by a magnetic lock system, and there was a visible keypad which allowed the magnetic lock to be disengaged by entering a code which would allow the two automatic doors to be opened. Observation of Google map on 2/25/25 at 4:25 pm revealed the following information about the roads located between the facility and where the resident was discovered by the police. Upon exiting the facility and going through the parking lot there was a two-lane road with a sidewalk on each side of the road, a left turn on the two-lane road would take an individual to an intersection of a 4-lane divided road, where there was also a sidewalk on each side of the road. A right turn would be needed at the 4-lane intersection to travel in the direction of where the resident was found. The 4-lane road had a posted speed limit of 40 miles per hour, had streetlights, and traveled through a mostly wooded area with one commercial building. There was an intersection with a 4-lane highway where a left turn would need to be made to get onto the 4-lane highway with a posted speed limit of 45 miles per hour. There were sidewalks on each side of the 4-lane highway. According to the police report and police interview, Resident #6 was discovered at a closed fast food restaurant parking lot near a gas station on the other side of the 4-lane highway. According to the map, the distance between the facility and the restaurant and gas station where Resident #6 was found was 1.4 miles. A review of the data from the National Weather Service (NWS) web site the hourly temperatures beginning at 10:54 pm on 1/26/25 were as follows: 10:54 pm-38 degrees, 11:54 pm-40 degrees, 12:54 am-40 degrees, and 1:54 am-38 degrees. There was no precipitation documented. A progress note by the facility's Nurse Practitioner dated 1/27/25 read that Resident #6 had a normal exam and he had no signs of any injury related to the elopement. During an interview with the Nurse Practitioner (NP) on 2/25/25 at 4:20 pm, he stated he saw and examined Resident #6 on the morning of 1/27/25. He reported an exam with no injuries as a result of the elopement. When asked if he thought there was a higher likelihood of harm to Resident #6 based on his current physical condition and cognition he stated, although Resident #6 could ambulate independently, he had only seen the resident once before and didn't feel like he had enough information yet to make that determination. During an interview with both the Director of Nursing (DON) with the Regional Nurse Consultant (RNC) present on 2/25/25 at 4:45 pm the DON stated she reported to the facility as soon as Nurse #2 alerted her Resident #6 had exited the building. The DON stated NA #1 should have never unlocked the door to let anyone out who was unfamiliar without verifying the person was not a resident. The DON also stated Nurse #1 should have immediately implemented the elopement process which stated the secondary search procedure is to be initiated by the Nursing Supervisor in charge which would have been Nurse #2. The Nursing Supervisor, in turn, would notify all staff of a missing resident, contact the DON, and then the police. Nurse #1 did not follow procedure when she failed to alert her supervisor immediately after she was unable to locate Resident #6 on her unit and learned he had left the building. The RNC also stated the facility immediately began a plan of correction for all staff members regarding the elopement process. The facility's Administrator was notified of immediate jeopardy on 2/25/25 at 6:04 pm. The facility implemented the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #6 is an [AGE] year-old male who was admitted on [DATE] with falls, balance issues, and vascular dementia. Resident #6's Brief Interview for Mental Status (BIMS) was 8 which suggests moderate cognitive impairment. On admission Resident #6 scored a two on the wandering risk assessment, which is low risk for wandering. A low risk indicates the resident has not exhibited wandering behaviors and has no history of wandering. Resident #6's care plan indicated he was at risk for falls, risk for elopement, and was displaying inappropriate behaviors. During Resident #6's stay at the facility, he showed no signs of wandering or exit seeking behaviors according to nurse notes and staff interviews, he was ambulatory in his room only. He did have behaviors such as urinating in the trash can, on his bed, and on his floor, in his room. On 1/26/25 around 11:30pm, Resident #6 walked up to Nurse Aide (NA) #1 and asked to let him out of the building. NA #1 thought Resident #6 was a family member visiting a resident. Resident #6 stated to NA #1 he fell asleep at facility, he lived in [NAME]-Salem and needed to go home. Nurse Aid #1 walked Resident #6 to the main entrance, manually unlocked the front door by turning the knob, opened the door, and Resident #6 walked out of the facility. According to Nurse Aid #1 Resident #6 was wearing a white short- sleeve tee shirt, a plaid button-down long sleeve shirt, a black coat, long pajama pants, and hard bottom black shoes. During the time Resident #6 was let out of the facility by NA #1 he was not identified as a wandering risk during this time as an elopement risk, therefore he was not in the elopement book. According to Nurse #1 Resident #6 was wearing long pants, a coat, a shirt, and shoes during her shift that evening which began at 7:00pm. Interview with Nurse #1, I do not know what time it was when I realized Resident #6 was missing but it was some time after 10:30pm. Nurse #1 immediately went to Resident #6's room and he was not there. Nurse #1 then walked down the hallway to the living room near the main entrance and did not see Resident #6. She then walked to 200 hall and he was not there. Nurse #1 then saw NA #1 and asked if Resident #6 had been seen in the facility. NA #1 then told Nurse #1 Resident #6 was mistaken for a visitor and let out the main entrance per the resident's, who thought was a visitor, request. Nurse # 1 immediately unlocked the front door and exited the main entrance to find Resident #6. Nurse #1 left the property on foot and searched to the main road but did not visualize Resident #6. Nurse #1 came back to the facility and reported to the Night Shift Supervisor immediately the missing resident. The Night Shift Supervisor then activated code pink (the facility's code for a missing resident), this was around 11:55pm. The Night Shift Supervisor called the Director of Nursing and local police department. Nurse # 1 contacted the Responsible Party and made her aware. Resident #6 was returned to the facility at 12:30am on 1/27/25 by the local police department. According to local police, Resident #6 was found 1.4 miles away from the facility at a gas station trying to make a phone call. The resident was placed on 1:1, an intervention where 1 staff member is assigned to 1 Resident. Resident #6 was not able to verbalize where he had been or what he had done when he returned to the facility. A head-to-toe assessment was completed by Nurse #1 on duty at 12:40am. Resident #6's skin was intact and all vital signs were stable. The resident's Provider was notified. New orders received to place resident on 1:1 and place an elopement transmitter to the left lower extremity, the careplan, and Kardex were updated to reflect the elopement risk and the elopement transmitter. Resident #6's Responsible party was made aware. The three elopement books were also updated to reflect Resident #6 was an elopement risk. Resident #6 discharged on [DATE] to home with his family. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 1/27/25 the Director of Nursing (DON) identified current residents who were potentially impacted by this practice by completing a 100% audit on all current residents to ensure they were all present and accounted for. The audit was completed on 1/27/25. The results concluded: 107 of 107 residents were present and accounted for in the facility. On 1/27/25 the DON identified current residents who were potentially impacted by the deficient practice by completing a 100% audit on all current residents to ensure wandering assessments were accurate and residents identified as at risk or high risk to wander had appropriate interventions including: elopement transmitters, updated information in the elopement books, and or 1:1. This was completed on 1/27/25. The results concluded: 107 of 107 residents had correct wandering assessments completed. There were elopement books located at each nurse's station and front desk with pictures of residents and physical description. On 1/27/25 3 of 3 elopement books were checked by the Activities Director to ensure they were up to date for all current residents that had been identified as potential to elope and they were accurate and up to date. 107 of 107 current residents had elopement risk audits completed on 1/27/25 by the Director of Nursing to ensure they were completed accurately. The results revealed no negative findings. All risk assessments had been completed accurately. All new admission risk assessments will be reviewed daily Monday through Friday in the clinical meeting to ensure risk assessments are completed accurately. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 1/27/25, the Staff Development Clinician (SDC) initiated an in-service for all staff (including agency) on the Elopement Prevention policy. This training will include all current staff including agency. This training included: -When a resident is assessed as being high risk for elopement a transmitter bracelet is placed on the resident. Staff should check the placement of the transmitter bracelet and battery. The task of batteries being checked by using the transmitter checking device is assigned to the floor nurses on the unit then documented in the Medication Administration Record (MAR) every shift. -New admissions with high risk or at risk to wander will be monitored or placed with a sitter until they can be re-evaluated by the Interdisciplinary Team and an appropriate intervention is implemented which can include: continued sitter, application of elopement transmitter device, careplan and Kardex will be updated to reflect and information added to elopement books. -Risk assessments will be completed on admission, quarterly and/or as needed on all residents. -Any resident identified to be at High Risk for elopement or wandering will be discussed with the interdisciplinary team, documentation of interventions noted, and the careplan updated to reflect interventions, and the elopement books will be updated to reflect resident is and elopement risk. -Location of the three elopement books and when and how to reference them. -Never let a person out of the facility unless you reference the elopement book and ask nurse if the person can exit the facility. Initial Search Procedure -As soon as a resident is noted to be missing ALL staff will search their assigned areas and report to the nursing station. All other areas will then be checked including but not limited to linen rooms, storage rooms, general baths, bathrooms and closets. -If the resident is not located during the initial search then initiate a secondary search. -Secondary Search Procedure: -The charge nurse will assign staff members to search the outdoor facility grounds and report back to charge person. -If the resident has not been found on the secondary search in the facility and facility Grounds, the person in charge will notify the local police or sheriff department. Inform them a search is in progress and request search assistance. This will be done immediately after confirming the secondary search is unsuccessful. - This search should be completed timely and involve all members of the team so that more ground can be covered in a shorter time period. The search for a resident should not be for more than 30 minutes without activating police involvement -The Charge Nurse will assemble all staff at the Nurses' station by announcing over the paging system Missing Resident. This should be completed timely. The Director of Nursing will ensure that any of the above identified staff who do not complete the in-service training by 1/28/25 will not be allowed to work until the training is completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing and Unit Manager will audit all admission and readmission risk assessments beginning 1/29/25 weekly for 2 weeks and then monthly for 3 months using the Quality Assurance Elopement Tool. This tool will consist of accurate completion of risk assessment on admission, identification of high or at risk to wander residents, and as changes occur, elopement transmitter is in place, care plan and Kardex revised, and if the elopement book has been updated to reflect elopement risk. Staff knowledge checks will also be completed beginning 1/29/25 using the Mock Elopement Drill Knowledge Checks Audit Tool weekly x2 weeks and monthly x3 months. 5 Random employees from all different departments will be asked when and how to implement code pink for missing residents. These knowledge checks will include: Have you been educated on code pink initial search to start immediately with all staff searching assigned areas and reporting to charge nurse; Have you been educated on code pink secondary search which is when a resident is not found inside the facility timely; When should you call code pink; Who should be involved in code pink; Should you let a person out the door if you don't know if he or she is a resident or visitor, What do you do? Reports of the results will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is implemented and effective. Compliance will be monitored through an ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, Minimum Data Set (MDS) Coordinator, Therapy, Health Information Manager, and the Dietary Manager. The alleged IJ removal date is 1/29/25. The alleged date of compliance will be 2/4/25. On 2/25/25, the facility's corrective action plan was validated on-site by record review, observations, and interviews. Individual interviews of current staff members working all reported to have completed the elopement process training dated 1/27/25. Record review of the in-service documents dated 1/27/25 and 1/28/25 noted the DON and the Staff Development Coordinator completed the in-person training. Signed staff rosters were reviewed with no issues or concerns. Interviews conducted with multiple staff members revealed they had received training about the elopement process and were able to identify what processes to put into place in the event a resident cannot be located. All new staff members will also complete the training before their first shift at the facility. Observation of the three elopement books showed they were current and now also included photographs of residents. Review of audits showed the facility completed new wandering assessments on all residents. The facility's immediate jeopardy removal date of 1/29/25 was validated. The date of compliance was validated as 2/4/25.

Based on observations and staff interviews, the facility failed to label, date, safely store food including an open box of unsealed corn on the cob, and discard expired food items that included a plastic container of partially used ice cream stored in the freezer of 1 of 1 walk-in freezers. The findings included: Accompanied by the facility's Dietary Manager, an observation was made of the walk-in freezer on [DATE] at 11:31 AM. The following items were stored in the freezer: - One undated box of corn on the cob that was open to air in its original unsealed plastic bag - One opened and undated box of turkey sausage - One opened and undated box of hot dogs - One opened and undated box of hamburger patties - One plastic container of vanilla ice cream partially used and dated [DATE] The Dietary Manager was interviewed on [DATE] at 11:35 AM. She stated she had been in the role of manager for a couple weeks, but she had educated staff on the expectation that all food should be labeled, dated, and stored correctly. She stated containers of food that had been partially used should be dated and discarded after 3 days. On [DATE] at 3:03 PM the Director of Nursing was interviewed. She stated that all foods in storage should be dated. If they have been opened, then they should have been wrapped and placed in another container and used in the timeframe specified for that product. The Administrator was unreachable by phone for interview after multiple attempts.

Based on record review and interviews with staff, Nurse Practitioner (NP), and the resident's representative, the facility failed to allow a resident with behaviors to remain in the facility and to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 1 resident (Resident #205) reviewed for facility initiated discharge. Findings included: Resident #205 was admitted to the facility on [DATE] with the diagnosis of dementia and repeated falls. The admission Minimum Data Set (MDS) dated [DATE] for Resident #205 documented the resident had an intact cognition. The active diagnosis was dementia. Social Worker #1's note dated 9/24/24 at 3:59 pm documented she sent a referral for Resident #205's admission to a sister facility's memory care unit in another town for possible admission. The note indicated the Social Worker would continue to follow-up. Social Worker #1's note dated 9/24/24 at 5:09 pm documented an email was received from the sister facility for Resident #205's admission and they had no bed in the memory care unit at that time. The note indicated the Social Worker would continue to look for placement. Resident #205 had a significant change MDS dated [DATE] for cognitive decline and falls. Resident #205 had severe cognitive impairment. Resident #205 was coded with no behaviors, rejection of care, or wandering. The resident had 2 or more falls without injury since the previous MDS assessment. The NP documented in Resident #208's progress note dated 12/3/24 that he saw the resident for her monthly chronic conditions visit. The Resident's Representative had not conveyed any concerns. Nursing staff reported the resident had intermittent severe behavioral disturbance including exit seeking and was a fall risk. The resident was assessed and noted to have notable cognitive gaps (deficits). The plan for psychiatric conditions included major depressive disorder with psychotic episodes and the resident was restarted on Seroquel at bedtime. The NP will continue to collaborate with in-house psychiatry. The resident was clinically stable at the time of this encounter. Resident #205's discharge form documented she was transferred on 12/19/24 to a local nursing facility with a memory care unit. The form was signed by Nurse #4. The form was not signed by the resident's representative. There was no physician documentation in the medical record that indicated the specific resident needs the facility could not meet, the facility's efforts to meet those needs, or the services the receiving facility would provide to meet the needs of the resident which could be met at the current facility. On 1/9/25 at 8:46 am Nurse #4 was interviewed. Nurse #4 stated Resident #205's representative was not available (at the facility) at the time of discharge on 12/19/24 to sign the discahrge form. She was informed by Social Worker #1 that all paperwork had been completed. On 1/9/25 at 9:46 am a follow up interview was conducted with Nurse #4. Nurse #4 stated Resident #205 was discharged on [DATE] to a local nursing facility with a memory care unit. Social Worker #1 completed the paperwork. Nurse #4 stated she did not know why the Resident's Representative was not present at the time of discharge. The Resident's Representative normally signed the discharge paperwork. Nurse #4 stated Social Worker #1 informed her that the discharge paperwork was completed. Nurse #4 stated, I understood that the Resident's Representative knew about the discharge to a memory care unit. Nurse #4 indicated Social Worker #1 reported to her that the Resident's Representative had not wanted the resident discharged to the facility after the discharge had taken place. Nurse #4 stated the resident had declined quickly from dementia. She was combative, confused, and was frequently wandering and falling. The resident required increased supervision, including one on one, and was not safe without supervision. The NP was aware. On 1/9/25 at 12:05 pm an interview was conducted with Resident #205's Resident's Representative. The representative stated that she was notified by Social Worker #1 back in August 2024 that the resident would require a higher level of care with a memory care unit. The Resident's Representative was provided with 3 facilities that had a memory care unit. The Resident's Representative stated the 3 facilities had a 1-star rating (nursing home rating from 1 to 5 with 1 being the lowest), she observed the facilities, and declined the choices. The Resident's Representative stated that the facility discussed on multiple occasions that the resident needed a higher level of care, and that care could not be safely provided at this facility. Resident #205's Representative stated she provided one facility name in [NAME] to Social Worker #1 that she would agree to discharge the resident. The Resident's Representative stated in November 2024 she was approached about the discharge to a higher level of care/memory care unit again by Social Worker #1 and she (the Resident's Representative) asked for the resident to remain at the facility. In December 2024 she received a call from Social Worker #1 that the resident had been discharged to one of the three facilities the Resident's Representative was provided back in August 2024. The Resident's Representative stated she was not advised prior to the day of discharge that Resident #205 was being discharged to another facility with a memory care unit. She was notified on the day of discharge. When the Resident's Representative informed Social Worker #1 that she had refused this facility, the Social Worker denied being told that. Resident #205's Representative stated the resident remained at the new facility for a week and was discharged to and currently at hospice. On 01/08/25 at 12:36 pm the Nurse Practitioner (NP) was interviewed. The NP stated due to Resident #205's decline from dementia and frequent falls, the facility could not meet the needs of the resident. The resident required and was provided one on one supervision for wandering and behaviors. The Resident's Representative agreed that the resident required a higher level of care. The resident was discharged to a facility with a memory care unit for increased supervision. The Director of Nursing (DON) was interviewed on 1/9/25 at 10:10 am. The DON stated she remembered Resident #205's discharge was agreed upon with the Resident's Representative and Social Worker #1 and was not facility initiated for a higher level of care. She was discharged to another facility with a memory care unit. The DON stated all discharge paperwork would be in Resident #205's record. The DON had no other documentation, and Social Worker #1 was no longer employed at the facility and her phone number was disconnected. The DON believed there was a verbal consent by the Resident's Representative for discharge to a facility with a memory care unit. On 1/19/25 an interview was attempted with Social Worker #1 who was no longer with the facility. The phone number was disconnected. On 1/19/25 at 2:41 pm an interview was conducted with the Business Office Manager. The Business Office Manager stated Resident #205 was discharged to another facility in agreement with the Resident's Representative. Social Worker #1 would have completed the paperwork. She further stated that this discharge not a facility-initiated discharge. On 1/9/25 at 3:51 pm an interview was conducted with the Discharge Planner. The Discharge Planner stated she was aware that Resident #205's Resident's Representative spoke with Social Worker #1 about the planned discharge to another facility with a memory care unit to meet the resident's needs. The Discharge Planner stated the Resident's Representative agreed with the discharge to another facility with a memory care unit if it was in close proximity to her so she was able to visit the resident. The Discharge Planner stated she thought the Resident's Representative changed her mind on which facility after the discharge reported by the Social Worker. She was aware the Resident's Representative reported her disapproval.

Based on record review, and staff and family interviews, the facility failed to ensure a safe and orderly discharge when a resident was discharged home without a referral for home health services for 1 of 2 residents reviewed for discharge (Resident #356). The findings included: Resident #356 was admitted to the facility on [DATE] with diagnoses including stroke. A review of the physical therapy discharge summary dated 10/10/24 indicated Resident #356 was ambulatory and able to walk 150 feet with supervision, able to climb 12 steps with supervision, and independent in mobility. The discharge recommendation was for home health services to continue physical therapy at home. A review of occupational therapy discharge summary dated 10/10/24 indicated Resident #356 was independent in toileting hygiene, toileting transfer, and required supervision with bathing and dressing. The discharge recommendation for home health services to continue occupational therapy at home. A review of physician order dated 10/11/24 revealed a discharge order for Resident #356 to discharge home with family with home physical therapy and occupational therapy services. Review of the discharge summary dated 10/11/24 indicated that Resident #356 was discharged from the facility on 10/11/24. The discharge summary was signed by Social Worker #2. The discharge summary indicated no home services were requested. An interview was conducted with Resident #356's family member on 1/17/25 3:26 pm. She indicated Resident #356 was discharged home on 10/11/24 with no home health orders from the facility and she felt the discharge was not a safe discharge. An interview was conducted with the Director of Rehabilitation services on 1/9/25 at 9:45 am. She indicated she met with Resident #356 to discuss his discharge planning needs prior to discharge. Resident #356 was cognitively intact and voiced that he wanted to be discharged . The Director of Rehabilitation further indicated she and Resident #356 agreed to move forward with the discharge plan to return home with family and to continue therapy at home. The Director of Rehabilitation revealed she made the Discharge Planner and additional interdisciplinary team members aware of the recommendation for home physical and occupational therapy. An interview was conducted with Social Worker #2 on 1/9/25 at 9:10 am. She indicated she was aware of the physician's discharge order on 10/11/24 which ordered home physical and occupational therapy. She further revealed that she did not follow through with the order as she thought the discharge order was standard for all residents and that the family had indicated they were planning to move and unsure of the new address. An interview was conducted with the Nurse Practitioner on 1/9/25 at 2:19 pm. He indicated he wrote the order to discharge Resident #356 home with home health physical and occupational therapy services and the Social Worker should have made the referral as ordered. An interview was conducted with the Administrator on 1/10/25 at 2:08 pm. She indicated the Social Worker should have followed the physician's discharge order to refer Resident #356 for home health services.

Based on record review and interviews with staff, Nurse Practitioner, and the resident, the facility failed to provide care in a safe manner when a dependent resident rolled off her bed onto the floor during incontinence care. The resident was not injured. The deficient practice affected 1 of 7 residents reviewed for accidents (Resident #18). Findings included: Resident #18 was admitted to the facility on [DATE] with the diagnosis of osteoarthritis. Resident #18 had a significant change Minimum Data Set, dated dated dated [DATE] for mobility decline, pressure ulcer, and a fall. The resident required extensive assistance with bed mobility and was always incontinent of bowel and bladder. The care plan for Resident #18 dated 11/26/24 documented the resident had an increased risk for falls and required assistance with her activities of daily living for bed mobility, transfers, bathing, and personal hygiene. Resident #18's nurses' note dated 11/29/2024 at 7:36 am documented by Nurse #4 documented the resident fell from her bed to the floor. Nursing Assistant (NA) #3 informed Nurse #4 she was attempting to provide care to the resident, turned her, and the resident fell off the bed onto the floor. The resident was assessed and she complained of pain in her head and her right hip. The on-call physician was notified, an order was given to send the resident to the Emergency Department (ED) for assessment. Resident #18's change in status note dated 11/29/2024 at 6:05 am written by Nurse #4 documented the resident had fallen. At the time of evaluation, the resident's vital signs were: Blood Pressure (BP): 109/67, Pulse (P): 60, Respiratory Rate: 18, Temperature: T 98.1, oxygen saturation- 98.0 % on room air and Mental Status Evaluation: No changes observed A fall incident report for Resident #18 dated 11/29/24 was documented by Nurse #4. Resident #18 fell out of bed during care provided by NA #3. The staff was educated on resident bed mobility during care. The resident was sent to the ED. On 1/8/25 at 11:46 am Nurse #4 was interviewed. Nurse #4 stated she remembered Resident #18 and the fall incident on 11/29/24. Nurse #4 stated NA #3 was assigned and reported to her that when care was provided to Resident #18 the NA turned the resident and the resident rolled out of bed. Nurse #4 was not aware whether there were any side rails. The resident required maximal assistance in bed for turning and the NA should have 2 staff to prevent rolling out of bed when turning a dependent resident. Resident #18 was assessed and had no apparent injury and had no complaints. The resident was sent to the hospital for evaluation. Nurse #4 stated she asked NA #3 what happened, and the NA stated she provided care by herself and when she turned the resident for care she rolled out of bed onto the floor. Nurse #4 stated she provided the NA education to use 2 staff for a dependent resident. The Director of Nursing (DON) was informed. The physician was notified, and the resident was sent to the Emergency Department (ED) for an evaluation. The resident returned from the ED the same day and had no injury. Attempts were made to interview NA #3 by phone on 1/09/25 and 1/10/25. A voice mail was left but NA #3 did not return the calls. On 1/9/25 at 2:42 pm an interview was conducted with Resident #18. Resident #18 stated she remembered when she fell out of bed. Resident #18 stated when the NA was providing care she placed her on the side of the bed (the resident pointed to the right side of her bed) and I fell off. She further stated I was not hurt. The resident did not remember if the bed was raised for care. Resident #18's ED after visit summary dated 11/29/24 documented the resident was evaluated after a fall. A CAT (radiograph of the brain) scan of head showed no injury. The resident had pain in both knees and an x-ray was completed. The results were negative for injury. The resident had a history of osteoarthritis to both knees. The resident was sent back to the facility. A nurses' note dated 11/29/24 documented Resident #18 complained of right hip pain and had an x-ray completed at the facility after return from the ED. The x-ray result showed no fracture. There was moderate osteoarthritis of the hip joint. On 1/9/25 at 1:04 pm an interview was conducted with the DON. The DON was aware that Resident #18 had rolled out of bed during care by NA #3. The DON stated NA #3 was provided education. On 1/9/25 at 12:10 pm an interview was conducted with the Nurse Practitioner (NP). The NP stated he was not aware Resident #18 had rolled out of the bed. The NP stated the resident complained of left hip pain and an x-ray was done 11/30/24. The x-ray result was osteoarthritis, no injury. He further stated that the resident long standing pain from osteoarthritis in both hips and knees.

Based on observations, staff interviews, and facility record reviews, the facility failed to keep a urinary catheter bag and/or its tubing from touching the floor to reduce the risk of infection for 1 of 2 residents (Resident #9) reviewed for urinary catheters. The findings included: Resident #9 was admitted to the facility on [DATE] from a hospital. Her cumulative diagnoses included neuromuscular dysfunction of the bladder and a history of a urinary tract infection. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. No behaviors nor rejection of care were reported. The assessment indicated Resident #9 required set-up or clean-up assistance for eating and personal hygiene, substantial to maximum assistance for bathing and bed mobility, and was totally dependent on staff for toileting and chair to bed to chair transfers. The MDS reported Resident #9 had an indwelling urinary catheter. Resident #9's care plan included an area of focus related to the resident having an indwelling urinary catheter due to her neuromuscular dysfunction of the bladder (Initiated on 12/9/24; Revision on 12/10/24). An initial observation and interview was conducted on 1/6/25 at 3:10 PM as Resident #9 was sitting in her wheelchair with a urinary catheter collection bag hanging from the back of her wheelchair. At the time of this observation, 2 to 3 inches of the bottom of Resident #9's urinary catheter bag and approximately 10 inches of the catheter tubing were lying on the floor. When asked about the use of the indwelling urinary catheter, the resident reported she had the catheter prior to admission to the facility. Resident #9 added that she was prone to developing urinary tract infections. On 1/7/25 at 9:25 AM, the resident was again observed to be sitting in her wheelchair. The urinary catheter bag was hanging from the back of the wheelchair and positioned so that the catheter bag was 1 inch from the floor. However, 3-4 inches of the urinary catheter tubing was again observed to be lying on the floor. An additional observation was conducted on 1/9/25 at 8:18 AM as approximately 5 inches of the bottom of Resident #9's urinary catheter bag was lying directly on the floor in front of the resident's wheelchair. The catheter bag was not attached to the wheelchair at the time of this observation. An interview was conducted with Nurse Aide (NA) #1 on 1/9/25 at 8:20 AM. NA #1 reported she was assigned to care for Resident #9. During the interview, the NA was asked about the positioning of resident's catheter bag lying on the floor without being attached to the wheelchair's frame. The NA stated she knew this was the case and had told the nurse about it. She reported the resident would be going out for an appointment later this morning and needed to have the catheter bag covered and the bag/tubing secured. When asked if the catheter bag and/or tubing should be on the floor, the NA stated Resident #9's wheelchair was low, so the catheter bag sometimes ended up on the floor when she was sitting in the wheelchair. On 1/9/25 at 8:23 AM, the facility's Staff Development Coordinator (SDC) joined the conversation as she approached Resident #9's room. The SDC confirmed she was also the facility's Infection Preventionist. Upon inquiry, the SDC stated she was heading into Resident #9's room to take care of her urinary catheter and tubing. Upon informing the SDC of the previous observations made on 1/6/25 and 1/7/25, the SDC was asked if the resident's urinary catheter bag and/or tubing should be on the floor. The SDC stated, No. An interview was conducted with the facility's Director of Nursing (DON) on 1/9/25 at 11:40 AM. During the interview, the observations of Resident #9's catheter bag and/or tubing lying on the floor were discussed. In response, the DON stated she would have preferred for the NA to take care of this issue when it was first identified. Upon further inquiry as to whether a urinary catheter bag and/or its tubing should be on the floor, the DON stated, No, never.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 29 opportunities, resulting in a medication error rate of 10.3% for 2 of 4 residents (Residents #32 and #86) observed during the medication administration observation. The findings included: 1-a. On 1/7/25 at 7:35 AM, Nurse #1 was observed as she prepared and administered 9 medications to Resident #32. The medications administered included one 81 milligram (mg) aspirin chewable tablet. A review of Resident #32's medication orders revealed the resident had a current order for one-81 mg aspirin EC [Enteric Coated] Tablet Delayed Release to be given as one tablet by mouth one time a day (ordered on 12/31/24). An interview was conducted on 1/7/25 at 3:55 PM with Nurse #1. During the interview, the discrepancy in the formulation of the 81 mg aspirin tablet administered to Resident #32 was discussed. Upon review of Resident #32's medication order, Nurse #1 confirmed she gave one-81 mg chewable aspirin tablet to Resident #32 instead of the enteric coated/delayed release formulation ordered for this resident. 1-b. On 1/7/25 at 7:47 AM, Nurse #1 was observed as she completed the administration of Resident #32's scheduled medications. At that time, Resident #32 reported he had pain and requested a pain medication. Nurse #1 returned to the medication cart and reviewed the resident's medication profile. Upon review, the nurse reported Resident #32 had an order for 650 milligrams (mg) acetaminophen to be given to the resident as needed (PRN) for pain. Nurse #1 was observed as she prepared and administered the PRN acetaminophen to Resident #32. A review of Resident #32's medication orders revealed the resident had a current order for 325 mg acetaminophen to be given as 2 tablets (total dose of 650 mg) every 8 hours as needed for pain. Further review of Resident #32's Medication Administration Record (MAR) revealed there was documentation which indicated 650 mg acetaminophen had previously been administered to Resident #32 on 1/7/25 at 6:04 AM. The resident also received the PRN dose of 650 mg acetaminophen observed and documented as given by Nurse #1 on 1/7/25 at 7:52 AM. The second dose of 650 mg acetaminophen was administered to the resident only 1 hour and 48 minutes after the first dose he received earlier that morning (instead of 8 hours later). An interview was conducted on 1/7/25 at 3:55 PM with Nurse #1. During the interview, Nurse #1 reviewed Resident #32's Medication Administration Record (MAR). The nurse stated that if she had known that a dose of acetaminophen was already given to the resident at 6:04 AM that morning, she would not have given him a second dose. The nurse reported she would have told the resident he had already received the medication and if his pain was not adequately managed, she may have consulted with his provider. 1-c. On 1/7/25 at 7:55 AM, Nurse #2 was observed as he prepared to administer 8 medications to Resident #86. The medications administered included one tablet of 81 milligram (mg) delayed release (DR) aspirin. A review of Resident #86's medication orders included a current order for one-81 mg aspirin EC [Enteric Coated] Tablet Delayed Release to be given as one tablet by mouth one time a day (ordered on 11/1/24). As Nurse #2 pulled Resident #86's medications from the medication (med) cart, he placed the tablet(s) and capsule(s) into a small medication (med) cup. In the process of pulling the medications scheduled for administration, Nurse #2 identified two stock medications that were not stored on the med cart. On two separate occasions, the nurse locked the med cart and went to obtain the medications needed from the medication storeroom and/or other med carts. Nurse #2 took the small med cup (containing the tablets and capsules pulled thus far) with him each time he left the med cart. Upon his last return to the medication cart, the med cup was observed to be missing the one-81 mg EC Delayed Release tablet of aspirin previously pulled for administration to Resident #86. Nurse #2 was not aware of the missing tablet. On 1/7/25 at 8:30 AM, Nurse #2 reported he was ready to administer the medications prepared for Resident #86. The nurse locked his medication cart and computer screen, picked up the med cup containing the tablets and capsules (but without the aspirin tablet), then left the med cart and headed to the resident's room. At that time, a request was made for the nurse to return to the med cart. Upon his return to the med cart, the nurse was asked if the aspirin tablet that he had pulled was in the med cup. The nurse reviewed the medications in the med cup and confirmed the aspirin tablet was no longer in the cup. Nurse #2 stated he did not know what happened to the aspirin tablet. He reported he would need to pull another 81 mg aspirin EC tablet from the cart for administration to the resident. Nurse #2 was observed as he obtained an 81 mg EC aspirin tablet from a stock bottle on the med cart, added it to the med cup, and administered the medications to Resident #86. An interview was conducted on 1/8/25 at 9:22 AM with the facility's Director of Nursing (DON). During the interview, the medication administration observations were discussed. The DON reported she would expect the nursing staff to be following the 5 rights of medication administration, including the right dosage and dosage form. She also confirmed that if there was an order for a medication to be given, she would expect it to be given. With regards to the PRN acetaminophen being given too soon for Resident #32, the DON stated, that shouldn't have happened. She reported if the computer software failed to automatically indicate when the last dose of a PRN medication was given, the nurse was expected to check the documentation to determine if enough time had elapsed to administer another dose.

Based on observations, interviews with the staff, Nurse Practitioner (NP), and dispensing pharmacist, and hospital and facility record reviews, the facility failed to correctly transcribe an order to administer the full course of an antibiotic treatment to a resident upon her return from a hospital stay for a urinary tract infection (UTI). This occurred for 1 of 3 residents (Resident #27) reviewed for antibiotic use. The findings included: Resident #27 was admitted to a hospital from 12/7/24 to 12/10/24. A review of the resident's hospital Discharge Summary dated 12/10/24 reported Resident #27 had been admitted to the hospital with symptomatic acute cystitis with hematuria (a bladder infection with visible blood present in the urine) and associated weakness. The Discharge Summary indicated, Due to her prior history of ESBL [Extended-spectrum beta-lactamases] she was placed on ertapenem [an intravenous antibiotic generally reserved for pathogens that are resistant to other antibiotics]. Urine culture did confirm ESBL E. coli [a strain of bacteria that produces enzymes which make an infection more difficult to treat]. The resident's hospital Discharge Summary noted she would be discharged from the hospital on fosfomycin [an oral antibiotic] to start on 12/11/24 and repeat dose 3 days later. Resident #27's hospital Discharge Medication List dated 12/10/24 included in part: fosfomycin (3 gram pack) with instructions to take 3 grams by mouth every 3 days for 2 doses. Start date: 12/11/24; End date: 12/15/24. Resident #27 was discharged from the hospital to the facility on [DATE]. A review of the resident's admission orders included an order transcribed into the resident's electronic medical record (EMR) on 12/10/24 by Nurse #3 for the following: fosfomycin oral packet 3 grams to be given as 3 grams by mouth one time a day for ESBL for one (1) administration (Start Date 12/14/24). The order did not include initiating a dose of fosfomycin on 12/11/24. An interview was conducted on 1/8/25 at 3:28 PM with Nurse #3. Nurse #3 was identified as the staff member who transcribed the order for fosfomycin into the facility's computer software on 12/10/24 upon Resident #27's admission to the facility. When asked, the nurse pulled up the resident's hospital discharge medication (med) list for review. He confirmed her Discharge Medication (med) List indicated two doses of fosfomycin were to be administered every 3 days upon discharge from the hospital with a start date of 12/11/24 and end date of 12/15/24. Nurse #3 also confirmed the order he transcribed into the computer system on 12/10/24 had a start date of 12/14/24 (not 12/11/24). The nurse was unable to explain why he incorrectly transcribed the order for fosfomycin to include only one dose instead of two. A review of the resident's December 2024 Medication Administration Record (MAR) revealed only one dose of fosfomycin was administered to Resident #27 after her admission to the facility. This one dose of fosfomycin was documented as administered on 12/14/24. Resident #27's admission Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired cognition. The resident's care plan included an area of focus which read, I am at increased risk for UTI [urinary tract infection] due to history of recurrent urinary tract infections. Hx [History] of ESBL (Date Initiated 12/10/24). On 1/6/25, the resident's Nurse Practitioner (NP) ordered a urinalysis with a culture and sensitivity test. A culture and sensitivity test is a lab test that identifies the specific type of bacteria causing an infection and then identifies which antibiotics are most effective against the bacteria present. The urinalysis report dated 1/7/25 noted the urine sample was positive for several factors suggestive of a UTI (including urine white blood cells and urine bacteria). An interview was conducted on 1/8/25 at 10:57 AM with the NP assigned to care for Resident #27. At the time of the interview, the NP had access to Resident #27's EMR. During the interview, the NP was asked how many doses of fosfomycin were intended to be given to the resident upon her admission to the facility. He confirmed he had understood the hospital recommended two doses of fosfomycin should have been given to the resident (one dose on 12/11/24 and one on 12/14/24). Upon further inquiry, the NP stated he absolutely would have wanted 2 doses of fosfomycin to be administered to the resident after her admission to the facility. During the interview, the NP stated he saw Resident #27 on 1/3/25 and noted the family reported she had increased confusion. For this reason, he was concerned the resident may have a UTI and ordered a urinalysis and urine culture be sent out. The NP reported he was primarily waiting for the culture results to come back from the lab before he considered initiating an antibiotic. A telephone interview was conducted on 1/8/25 at 3:58 PM with a pharmacist at the facility's contracted dispensing pharmacy. When asked about Resident #27's fosfomycin, the pharmacist reported one (1) dose of 3 grams oral fosfomycin was dispensed and delivered from the pharmacy for Resident #27 on 12/10/24. When asked, the pharmacist reported a second dose of fosfomycin was not requested by the facility (or dispensed) for Resident #27. An interview was conducted with the facility's Director of Nursing (DON) on 1/9/25 at 11:40 AM. During the interview, the DON was informed of the concern related to the facility's failure to administer the full course of fosfomycin treatment ordered for Resident #27's UTI. During a follow-up interview conducted on 1/9/25 at 1:05 PM, the DON confirmed the resident was supposed to receive two doses of fosfomycin upon admission to the facility. She reported the provider was called and the NP decided he wanted to order another dose of fosfomycin for the resident at this time. A telephone follow-up interview was conducted on 1/9/25 at 2:34 PM with the NP. During the interview, the NP reported Resident #27's lab report from her urine culture came back inconclusive, so he decided to order the second dose of fosfomycin initially missed upon her admission to the facility. When asked, the NP reported he did not think missing this second dose of fosfomycin after her admission to the facility resulted in harm to the resident.

Based on observations, interviews with staff, and record reviews, the facility failed to: 1) Store a medication in accordance with the manufacturer's storage instructions on 1 of 3 medication (med) carts observed (200 Hall Med Cart); and 2) Remove and dispose of expired medications observed to be stored in the drawer of 1 of 3 med carts observed (300 Hall Med Cart). The findings included: 1. According to the manufacturer, intact (unopened) bottles of latanoprost eye drops should be stored under refrigeration at 36 degrees Fahrenheit (o F) to 46 o F. An observation of the 200 Hall Med Cart was conducted on 1/9/25 at 2:10 PM in the presence of Nurse #4. The observation revealed an unopened 2.5 milliliter (ml) bottle of latanoprost eye drops was stored on the med cart. The pharmacy label on the latanoprost eye drops indicated the medication was dispensed from the pharmacy on 1/7/25 for Resident #76. A pharmacy auxiliary sticker placed on the container of the medication read, Refrigerate until opened. Upon inquiry, the nurse confirmed the eye drop bottle was unopened and should have been stored in the refrigerator. 2. An observation of the 300 Hall Med Cart was conducted on 1/9/25 at 2:25 PM in the presence of Nurse #5. The observation revealed one-300 milliliter (ml) bottle, and one-240 ml bottle of Magic Mouthwash (a compounded medication) were labeled by the pharmacy as having been dispensed for Resident #418 on 12/21/24. The expiration date on the pharmacy label of both bottles indicated the medication had an expiration date of 1/4/25. An auxiliary sticker placed on the 240 ml bottle of Magic Mouthwash read, Keep in refrigerator Do not Freeze. Upon inquiry, Nurse #5 confirmed both bottles of the Magic Mouthwash should have been stored in the refrigerator. He also acknowledged the pharmacy labeling on both bottles indicated the medication was expired. An interview was conducted on 1/9/25 at 3:10 PM with the facility's Director of Nursing (DON). During the interview, the medication storage observations were discussed. When asked, the DON reported she would expect the nursing staff to pay attention to any special instructions for the storage of medications when they were delivered from the pharmacy, including whether the medication should be refrigerated. Additionally, expired medications needed to be removed from the med cart.

Based on observations, record review, and staff interviews, the facility failed to implement their infection control policy and procedure for hand hygiene when a nurse failed to perform hand hygiene after removing gloves while providing wound care for Resident #408. This occurred for 1 of 2 nurses observed for infection control practices (Nurse #3). The findings included: The facility's policy entitled Hand Hygiene last revised on 10/2022 indicated that hand hygiene included after contact with body fluids or excretions, non-intact skin, wound dressings, and after removing gloves. If gloves are worn for a procedure, hand hygiene is to be completed before putting gloves on and after removal and deposit of gloves in appropriate container. The use of gloves does not replace hand hygiene. An observation was completed on 1/08/25 at 10:37 AM of Nurse #3 performing wound care on Resident #408. Nurse #3 positioned the treatment cart outside of Resident #408's room. After he donned a gown and gloves to perform wound care, due to Resident #408 being on enhanced barrier precautions, Nurse #3 entered the resident's room and positioned him on his left side. Nurse #3 then began removing the soiled dressing from the resident's lower right back. The nurse discarded the dressing in the trash, removed his gloves and exited the room. He did not cleanse his hands after removing his gloves. At the treatment cart, Nurse #3 used his unclean hands and removed a small stack of 4x4 gauze, a bottle of wound cleanser, and 4 skin prep swabs from the drawer on the wound care cart. He then donned a clean pair of gloves. When Nurse #3 returned to the bedside he laid the stack of 4x4 gauze and the 4 wound prep swabs on Resident #408's bed. Nurse #3 cleaned the resident's wound and used one skin prep swab to wipe along the edges of the resident's wound. After cleaning the wound Nurse #3 picked up the unused gauze from the bed and threw it in the trash. He then picked up the unused skin prep swabs in his gloved hands and placed them back in the drawer of the treatment cart. He then removed his gloves and placed them in the trash. Without washing his hands, he then donned another pair of clean gloves as Nurse #5 entered Resident #408's room to complete the wound care procedure. Nurse #5 cleaned the bedside table with a disinfecting wipe and laid down a barrier once it dried. He then gathered the supplies needed, green foam sponge with clear occlusive dressing packet and scissors, to reapply the negative pressure dressing for the resident. Nurse #5 cut the green sponge to fit the size of the wound opening and placed it in the wound bed. He then cut the occlusive drape and placed it over the foam. Nurse #5 then cut a small hole in the drape and placed the suction tubing over the opening. He connected it to the vacuum canister and turned it on. Nurse #3 assisted in handing supplies to Nurse #5 throughout the application of the new dressing change. Nurses #3 and #5 then gathered up all used supplies and threw them in the trash. They removed their soiled gloves and washed their hands. Then Nurse #5 cleaned his scissors and laid them on a paper towel on the wound care cart to dry. On 1/08/25 at 11:10 AM Nurse #3 was interviewed. He stated it was his usual practice to place a barrier down to lay supplies on before beginning wound care. He stated he was not sure why he did not place a barrier down when removing Resident #408's dressing during the procedure. He further stated that he thought he could return unused wound care supplies to the wound care cart if they were unopened. He was not aware he had not cleaned his hands after removing gloves and putting on a clean pair of gloves. The Director of Nursing (DON) and Administrator were interviewed on 1/08/25 at 11:18 AM. The DON stated staff were to follow the policy for providing wound care to residents. She further stated that she expected staff to wash their hands prior to wound care, in between glove changes, and after wound care is completed. She stated that she expected staff to throw away wound care supplies that came in contact with the resident's environment. The Administrator agreed that those were her expectations as well.

Based on record review, resident, and staff interviews the facility failed to ensure the Resident's right to file a grievance and receive a written decision regarding the grievance investigation. This occurred for 1 of 1 resident reviewed for the grievance process (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was cognitively intact. An interview was conducted with Resident #61 on 10/24/2023 at 9:27 a.m. and he revealed he had shared a grievance about the quality of food at the facility and the inconsistent times meal trays were delivered. He added he filed a grievance with the head dietary staff member on several occasions. He was unsure of her name. He stated he had not been informed of the outcomes of the grievance. A review of the facility grievance log was conducted for the period of July 2023 through October 25, 2023. There was not a grievance for Resident #61 for food quality or time variations in meal tray delivery. An interview was conducted with Dietary Aid #1 on 10/26/2023 at 1:54 p.m. and she revealed she had worked with Resident #61 several times regarding his meals, his likes, and his dislikes. She stated he had told her he had a grievance regarding fruit, the quantity of the food, the quality of the food, and other areas. She added, in response to the Resident's grievance she began to check his tray at each meal to ensure he received preferences. She stated she was not sure of what happened when she was not at work. She revealed she had not shared the Resident's grievance with the Dietary Manager, Social Worker, or Administrator. She revealed she had received education on the facility grievance process. She added she documented the Resident's food preferences on his meal ticket but had not reported the other areas he had shared with her. An interview was conducted with the Dietary Manager on 10/26/2023 at 2:02 p.m. and she revealed she was familiar with Resident #61 but had not been informed the Resident had voiced a grievance about several concerns. She stated it was her expectation that a grievance form be completed when a grievance was shared with a member of her staff. An interview was conducted with the Administrator on 10/26/2023 at 2:16 p.m. and she stated she had not been made aware Resident #61 had been placing oral grievances with Dietary Aid #1. She added it was her expectation that a grievance be completed in written form and filed on behalf of a resident if they place an oral grievance with the staff member.

Based on resident interview, staff interview, and record review the facility failed to protect resident's right to be free from abuse for 1 of 2 residents reviewed for physical abuse from Resident #48 (Resident #25). On 10/16/23 Resident #48 struck Resident #25 on the nose after a verbal altercation. The findings included: Resident #48 was admitted to facility on 2/1/23 with diagnoses that included schizophrenia, unspecified dementia of unspecified severity with agitation, psychotic disturbance, and mood disturbance. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 had moderate cognitive impairment. He had no behavior during the MDS review period. Resident #48 required the supervision to limited assistance of one person for walking in room, walking in corridor, and locomotion on/off the unit. Resident #48's Care Plan updated on 6/6/23 included the focus area, I have potential to demonstrate physical/ verbal behaviors related to history of confrontation with fell ow residents. At times, I am argumentative toward the roommate. The interventions for Resident #48 included, in part, I will not harm self or others x 90 days, analyze key times, places, circumstances, triggers, and what de-escalates behavior and document, cognitive assessment, monitor/document/report to MD of danger to self and others, psychiatric/psychogeriatric consult as indicated, staff to check on resident frequently to promote safety. The plan of care for Resident #48 also included the focus area, When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Resident #25 was admitted on [DATE] from an acute hospital with diagnoses which included: multiple fractures of pelvis, bipolar disorder, current episode mixed, severe, without psychotic features Alzheimer's disease, unspecified dementia with other behavioral disturbance, delusional disorders, atrial fibrillation, and moderate protein-calorie malnutrition. Reside #25 did not reside in the facility at the time of the survey. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was admitted on [DATE] with severely impaired cognition. She was total dependent with one-person physical assist with activities of daily living. Review of Resident #25's care plan dated 7/20/23 included the focus area of potential to demonstrate verbally abusive behaviors related to dementia. At times she yelled out and cursed at the staff. The interventions for Resident #50 included, in part, she would try to control verbally abusive behavior for 90 days. Staff were to analyze key times, places, circumstances, triggers, and what de-escalated behavior and document. Assess and anticipate the Resident's needs: food, thirst. toileting needs, comfort level, body positioning, and pain. Staff were to provide positive feedback for good behavior. Emphasize the positive aspects of compliance and intervene before agitation escalates. Guide away from source of distress and engage calmly in conversation; If response was aggressive, staff were to walk calmly away, and approach later. The facility investigation file for an allegation of resident abuse related to the incident between Resident #25 and Resident #48 on 10/16/23 was reviewed. The report revealed Resident #25 and Resident #48 were in the commons after lunch. The residents were observed talking loudly to themselves. Per the investigation report a written statement by a nurse aide who witnessed the interaction between Resident #48 and Resident #25 revealed Resident #48 told Resident #25 to shut up and they argued. The investigation report revealed a nurse aide went over to intervene and before she could get there Resident #48 struck Resident #25 in the face. The nurse aide separated the residents. Resident #48 had a small amount of blood coming from her nose. She was removed from the common area and assessed. Resident #48 was removed from the area and placed on 1:1 monitoring. The investigation report documented the results of a facial x-ray for Resident #25 was negative for fracture. Review of a 24-hour report dated 10/16/23 revealed an allegation Resident #48 had hit Resident #25 in the face in the commons area on 10/16/23. Resident #48 was placed on 1:1 for an undefined duration. Resident was scheduled for a tele visit at 4:45 PM and a psychiatric consult for that day. The 24-hour report was signed by the Administrator on 10/16/23. The allegation type was classified as resident abuse. A review was completed of the 5-working day investigation report dated 10/20/23. The review revealed the allegation of resident abuse when Resident #48 hit Resident #25 in the face on 10/16/23 was investigated and unsubstantiated. The summary of the investigation documented Resident #25 was sitting in the dayroom talking to herself when Resident #48 heard her say shut up and he went over and hit her. The residents were separated, and Resident #48 was placed on 1:1. Resident #25 was evaluated, and an x-ray was ordered. In-house psych services and the nurse practitioner were contacted for Resident #48 for a change in condition. Resident #48 was evaluated by psych services on 10/16/23 and received an order to increase his Risperdal due to increased impulsivity. The Administrator documented negative facial bone x-ray results were reviewed by the nurse practitioner. She further documented no signs of mental anguish, no facial bruising or swelling. The investigation report included Resident #48 would remain on 1:1 until his mood stabilized. The Administrator concluded she was unable to substantiate the allegation of physical abuse based on Resident #48's diagnosis of schizophrenia and dementia with agitation and psychotic disturbance as well as his cognition, his triggers and impulsivity. She added due to Resident #48 talking to himself it was unclear what voices he heard or what the voices may have instructed him to do.

Based on record review, observations, staff, and resident interviews the facility failed to accurately code Minimum Data Set assessments in the areas of Accidents and Nutrition for 2 of 6 residents reviewed (Resident #41 and #61). The findings included: 1. Resident #41 was admitted to the facility on [DATE]. A review of the fall incident reports revealed Resident #41 had a fall on 7/5/2023. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had severe cognitive impairment and required assistance of one staff member for activities of daily living (ADL) care needs. She was only able to stabilize with staff assistance during transfers and while walking. She was coded to have no falls since the prior assessment. An interview was conducted with MDS Coordinator #2 on 10/26/2023 at 4:25 p.m. She reviewed the MDS dated [DATE] and stated She had completed the MDS assessment. She then revealed the Resident was coded to have not had a fall since the prior assessment dated [DATE]. She reviewed the fall incident report dated 7/5/2023 and stated the assessment was inaccurate and should have reflected the fall. 2. Resident #61 was admitted to the facility on [DATE] with diagnoses that included a fracture to the spine and atrial fibrillation. A review of Resident #61's weight history revealed an admission weight of 128 pounds (lbs.) on 6/6/2023. On 7/1/2023 Resident #61 was discharged to an acute care hospital. On 7/13/2023 Resident #61 was readmitted to the skilled nursing facility. On 7/26/2023, Resident #61 had a documented weight of 116.9 lbs. in the electronic medical record. This was a weight loss of 8.67%. since admission. There were no other weights for the month of July, prior to the 7/26/2023 weight. A review of a dietary assessment dated [DATE], written by a corporate dietary consultant, documented Resident #61 had 5% or more weight loss in the last month and was not on a prescribed weight loss regimen. A progress note on the assessment read: Resident #61 had a weight loss of 9.3% x 30 days. A review of quarterly Minimum Data Set (MDS) dated [DATE], under the section titled nutrition, documented Resident #61 did not have weight loss of 5% over one month or 10% over 6 months. This assessment was completed by MDS coordinator #2. An interview was conducted with MDS Coordinator #2 on 10/26/2023 at 4:30 p.m. She reviewed the MDS dated [DATE], under the section titled Nutrition, and stated it was documented the Resident did not have weight loss over 5% in one month or 10% in 6 months. She reviewed the weight loss documented in the electronic medical system and stated the Resident had weight loss of 8.67% prior to the assessment dated [DATE] and the assessment should have reflected the weight loss.

Based on record reviews and staff interviews, the facility failed to prevent a significant medication error when an additional dose of an intravenous (IV) antibiotic was administered to 1 of 1 sampled resident (Resident #27) reviewed. Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included: intraspinal abscess and granuloma, bacteremia, and methicillin-resistant staphylococcus aureus (MRSA). The physician's order dated 9/25/23 indicated the pharmacy would adjust the intravenous (IV) vancomycin (antibiotic) dosage for Resident #27 based on the lab results of the vancomycin troughs (lowest level of the antibiotic while in the therapeutic range). A Trough level was to be drawn 30 minutes before the next dose was due and helped determine if the next dose needed to be adjusted, depending on the results. In some cases, the next dose could be skipped, or the dose would be decreased for patient safety. The care plan dated 9/26/23 revealed Resident #27 received antibiotic therapy related to diagnoses of MRSA, bacteremia, and spinal abscess. Interventions included: administering medication as ordered; monitoring every shift for adverse reactions; and reporting pertinent laboratory results to the physician. The admission Minimum Data Set, dated dated dated [DATE] indicated Resident #27 was cognitively intact and received intravenous antibiotic medication. Resident #27's October 2023 medication administration record (MAR) was reviewed. The physician's order for Resident #27 to receive 750mg (milligram) vancomycin, intravenously every 12 hours (9:00 a.m. and 9:00 p.m.) was changed to 1500mg/15ml vancomycin intravenously, daily (9:00 a.m.) on 10/21/23. The medication was documented on the MAR as administered by Staff Nurse #1 at 9:00 a.m. on 10/21/23. Review of the nurse's note dated 10/22/23 indicated Pharmacy was notified that Resident #27 mistakenly received an additional dose of vancomycin on 10/21/2023, during the evening shift. The pharmacist ordered a hold on the 10/22/23 dose and to check the Trough level on 10/23/2023. The on-call nurse practitioner was notified and instructed the staff to follow the pharmacist's orders. During interviews on 10/24/23 at 10:40 a.m. and 10/26/23 at 1:31 p.m., Resident #27 revealed she received an additional dose of her IV medication on Saturday (10/21/23).When asked if she knew which medication and how often it was given that day, the resident stated she received the medication twice on Saturday and the medicine was that up there pointing to the empty bag hanging from the IV pole next to the resident's bed. Written documentation on the empty bag read: Vancomycin 1.5g (grams) per 300ml (milliliters) was written on the empty IV bag. Resident #27 stated that two female staff (unsure of names) were in her room looking at the IV pump when she overheard one of them state she's already had one dose. The resident insisted no one ever informed her that she received an additional dose of her medication. An interview was conducted with the Nurse Practitioner (NP) on 10/26/23 at 2:19p.m. The NP stated that he was notified on 10/23/23 the Resident #27 may have received an additional dose of vancomycin on 10/21/23. He revealed on 10/21/23 the on-call provider was notified the resident received 1500 ml (milliliters) of vancomycin twice that day (10/21/23) and was ordered to hold the next day's dosage. He concluded he was not aware of any harm to the resident as result of the additional dose; the resident's creatinine clearance was normal based on her weekly laboratory results. During an interview on 10/26/23 at 3:37 p.m., Staff Nurse #1 stated Resident #27 had an order for IV vancomycin and was to receive a vancomycin Trough on Mondays and Thursdays (30 minutes before her morning dose); and depending on the Trough results, pharmacy would either increase or decrease the dosage and/or frequency. On 10/21/23, the order was for the resident to receive 1500 ml via IV, once per day which was administered at 9:00 a.m. However, when she (Staff Nurse #1) was to administer the vancomycin to the resident on 10/22/23 at 9:00 a.m., she noticed the empty vancomycin bag hanging from the IV pole in the resident's room. She contacted the second shift nurse who informed her that she (Staff Nurse #2) administered the vancomycin to the resident the night of 10/21/23 at 9:00 p.m. Staff Nurse #1 stated she reminded Staff Nurse #2 the resident was only to receive the vancomycin once a day, at 9:00 a.m. Staff Nurse #1 revealed she stopped the IV and notified the pharmacy who gave the order to hold the vancomycin (10/22/23) until the Trough was completed on 10/23/23. The on-call NP was notified and gave the order to follow the pharmacy order follow-up with the Trough on 10/23/23. The manager on duty was notified and instructed Staff Nurse #1 to follow the orders. Staff Nurse #1 also indicated that because of this incident all of the facility's licensed nursing staff and medication aides received an in-service on medication errors. During an interview on 10/27/23 at 8:50 a.m., Staff Nurse #2 acknowledged she administered 1500 ml vancomycin, intravenously to Resident #27 at 9:00 p.m. on 10/21/23. She confirmed she was notified via phone by Staff Nurse #1 that she (Staff Nurse #2) shouldn't have administered the vancomycin at 9:00 p.m. on 10/21/23 because the order had changed. Staff Nurse #2 indicated she was reprimanded and was in-serviced on medication errors. On 10/26/23 at 5:11 p.m., the Director of Nursing stated she was made aware Resident #27 had received an additional dose of the vancomycin medication. She indicated the resident was monitored and her vital signs were checked every day. The facility submitted the following corrective action plan with a completion date of 10/23/23. 1.Corrective action for resident(s) affected by the alleged deficient practice: On 10/22/2023 Resident #27 was identified to have received an additional dose dose of Intravenous (IV) Vancomycin. Resident was assessed on 10/22/2023. Nurse Practitioner (NP) on call was notified. Pharmacy called and new orders received to hold the Vancomycin 10/22/2023 dose. Resident made aware. Responsible Party updated. Resident #27 was monitored per policy for any negative outcomes. There was no negative outcome for resident #27. On 10/23/2023 at the 3pm IDT meeting, the interdisciplinary team reviewed components of the plan of correction for resident #27 and any other potentially affected residents. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: On 10/23/2023 the Director of Nursing identified residents that were potentially impacted by this practice by completing a 100% audit on all current residents with Intravenous (IV) Medications for accuracy of medication administration. This was completed on 10/23/2023. The results included: 3 of 3 residents with IV medications received medication as ordered. On 10/23/2023 the DON implemented corrective action for those residents which included: no corrective action needed, no deficient practice. On 10/23/2023 All nurses and med aids were interviewed to ensure they administered all medications and treatments per order on 10/21/2023. The results included all reviewed medications or treatments were administered per orders. No corrective action needed, no deficient practice. 3. Measures/Systemic changes to prevent reoccurrence of alleged deficient practice: Education: On 10/23/2023, the Staff Development Clinician began in-servicing all Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) , and medication aids, (including agency) on Medication Error policy. This training included all current staff including agency. This training included: Following the 6 rights The right person The right medication The right dose The right time The right route The right documentation The Director of Nursing ensured that any of the above identified staff who did not complete the in-service training by 10/23/2023 would not be allowed to work until the training is completed. 4. Monitoring Procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. The Interdisciplinary team met on 10/23/2023 to review the components of the plan of correction at daily stand-down. This meeting consisted of the facility QAPI team members. The DON or designee will monitor medication/ treatment order administration weekly for 2 weeks and monthly for 3 months for using the Quality Assurance (QA) monitoring tool. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, Minimum Data Set Coordinator, Therapy, Health Information Management, and the Dietary Manager. Date of Compliance: 10/23/2023 The facility's corrective action plan was validated on 10/27/23 by the following: Record review of in-services given to staff and audits completed by staff management. Validation was also evidenced by interviews of nursing staff. The facility's education was reviewed and included documentation of completion. The facility's audits were also reviewed. There was documentation that audits had been completed. Staff members from various were interviewed and reported that they had attended in-service training on medication errors. The staff attendance was verified on the attendance logs. Training included How to Avoid Medication Errors during administration. The 6 rights: the right patient, right route, right drug, right dose, right time, and the right documentation. The completion date of 10/23/23 for the corrective action plan was validated.

Based on observation, staff and resident interviews and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and interventions put into place after recertification surveys completed on 5/27/21 and 7/21/22. The deficiencies were in the areas of abuse, accuracy of assessments, residents are free from significant med errors, and accurately coding Minimum Data Set assessments and were recited on the the recertification survey of 10/27/23. The continued failure of the facility during three consecutive federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This citation is cross referenced to: 1. F600 Based on resident interview, staff interview, and record review the facility failed to protect resident's right to be free from abuse for one of one resident reviewed for physical abuse (Resident #25) from Resident #48. On 10/16/23 Resident #48 struck Resident #25 on the nose after a verbal altercation. The facility was cited during the 5/27/21 recertification survey for failure to provide incontinent care for 1 of 1 sampled resident who required extensive assistance and who had requested incontinent care on 2 occasions because she had soiled herself. 2. F641 - Based on record review, observations, staff, and resident interviews the facility failed to accurately code Minimum Data Set assessments in the areas of Accidents and Nutrition for 2 of 6 residents reviewed (Resident #41 and #61). The facility was cited during the 7/21/22 recertification survey for failure to accurately code the Minimum Data Set (MDS) assessment in the areas of weight loss and medications for 2 of 33 residents reviewed. During the current survey, the facility failed to obtain a physician's order for an indwelling catheter. The facility was cited during the 5/27/21 recertification sand complaint investigation survey for failure to accurately code the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for unnecessary medications. 3. F760 - Based on record reviews and staff interviews, the facility failed to prevent a significant medication error when additional doses of an intravenous (IV) antibiotic was administered to 1 of 1 sampled resident (Resident #27) reviewed. The facility was cited during the 7/21/22 recertification survey the facility failed to hold the administration of antihypertensive medications when a resident ' s blood pressure / heart rate were outside of the parameters indicated by his physician orders. During the current survey, the facility failed to ensure residents were free of significant med errors. During an interview with the Administrator on 10/27/23 at 4:00 PM, the Administrator stated the QAA Committee met monthly and identified, developed, and implemented plans of action to correct identified quality deficiencies. The Administrator also stated that after the previous recertification survey, corrective actions were put in place and until this survey, she felt the facility was in substantial compliance regarding a former citation.

Based on resident and staff interviews, Nurse Practitioner (NP) and hospital radiologist interviews, and record reviews, the facility failed to transfer a resident safely from her recliner to the bathroom toilet with the assist of one while using a sit-to-stand lift for 1 of 2 residents reviewed for accidents (Resident #4). Resident #4 experienced a fall when the nurse aide did not fasten the sling's chest support strap securely in accordance with the manufacturer's instructions and did not use the leg straps attached to the lift resulting in the resident falling from the lift to the floor. Resident #4 was sent out to the hospital for evaluation / treatment and was found to have a right acetabular roof/iliac bone fracture (the main weight-bearing area of the hip joint) and 3 lumbar vertebral fractures (two fractures on the 3rd lumbar vertebra or L3; and one fracture on the 4th lumbar vertebra or L4). The lumbar vertebrae are 5 bones located at the bottom section of the spine (lower back) and are identified as L1 to L5. Resident #4 reported her pain level after the fall as an 8 to more than 10 (with 0 indicative of no pain and 10 representative of the worst pain possible). Immediate Jeopardy began on 1/2/23 when Resident #4 was transferred by a nurse aide with a sit-to-stand lift without either the chest support strap or leg straps being securely fastened, resulting in her falling to the floor and sustaining multiple fractures. Immediate Jeopardy was removed as of 1/19/23 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's Instructions for Use for the facility's sit-to-stand lift (dated October 2019) included directions for the safe use of the lift. The instructions read in part, To fasten the [chest] support strap securely, press the buckles (if available) or hook and loop strap (if available) together. The strap shall be tight, but comfortable for the resident Remember to tighten the strap once the resident becomes raised from the chair .The sling support strap will help to support the resident in the sling during the raising procedure. The strap also retains the sling in the correct position around the resident. Additionally, the manufacturer's instructions included a boxed warning in bold print which read, Warning: The sling chest support strap must always be applied and fastened when using the sling. The role of the lower leg straps attached to the lift were also described in the instructions as follows: [The lower leg straps are an] Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support. They pass around the knee supports, then around the resident's lower calves. To fasten, click the strap into it's socket as with a seatbelt. Ensure that the straps are firm but comfortable for the resident. Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included a history of acute respiratory failure with hypoxia (low oxygen level in the blood). A review of Resident #4's Care Plan included the following area of focus, in part: -- I have an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance (Date Initiated: 2/2/18; Revision on: 10/26/22). The 10/26/22 revision indicated a sit-to-stand lift with a large sling was required for transfers. Resident #4's Occupational Therapy Treatment Encounter Notes included a notation authored by the facility's Occupational Therapist (OT) on 11/2/22 at 1:50 PM. The note read in part: .Pt [Patient] educated regarding need to use knee strap during use of stand up (sit-to-stand) lift for toileting tasks, as pt has refused to allow staff to use same in past due to c/o [complaints of] pain. OT educated pt regarding allowing OT to pad strap to increase comfort and allow proper support. Pt agreeable to same. Pt educated regarding staff inability to use stand up machine (sit-to-stand lift) without proper strapping due to heightened fall risk. Resident #4's level of pain was documented in her electronic medical record (EMR) 0 to 4 times a day during the two week period prior to her fall using the numeric pain scale rating ranging from 0 to 10. From 12/18/22 to 1/1/23, there were the 34 documented reports of the resident's pain level which included: --On 12/19/22 at 9:23 PM, the resident's level of pain was documented as 3; --On 12/26/22 at 8:23 PM, the resident's level of pain was documented as 2; --On 12/27/22 at 10:27 PM, the resident's level of pain was documented as 3; --On 12/28/22 at 8:10 PM, the resident's level of pain was documented as 3. Thirty (30) of the 34 reports of the resident's level of pain were documented as 0 from 12/18/22 and 1/1/23. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #4 had intact cognition. She was totally dependent on staff for transfers and required two plus (2+) persons physical assist. Resident #4's EMR included a Change in Condition report dated 1/1/23 at 8:16 PM which indicated the resident was sent out to the hospital Emergency Department (ED) for evaluation and treatment due to chest pain and shortness of breath. A Nursing Note dated 1/2/23 at 3:32 AM reported the resident returned to the facility on [DATE] at 3:00 AM with a diagnosis of a urinary tract infection (UTI) and fungal infection. The note reported an antibiotic and antifungal medication were prescribed. The resident was reported as still complaining of difficulty breathing. Her oxygen saturation level (O2 sat) was 93% on 3 liters / minute of supplemental oxygen. A Fall Report dated 1/2/23 at 5:37 PM and authored by the facility's Director of Nursing included a description of an incident involving Resident #4 which read, The resident was being transferred to the bathroom by two CNAs [Certified Nurse Aides] on the stand up [sit-to-stand] lift. The resident was holding on to the lift properly but suddenly she was observed falling, so the CNAs lowered her to the floor. The resident had a syncope episode [temporary loss of consciousness]. Resident stated that she had fainted. The Fall Report indicated the Immediate Action Taken as: The nurse was noted by CNAs that the resident had been lowered to the floor after fainting. The nurse assessed the resident and she was lifted off the floor by [brand name of a total mechanical lift]. No injury noted but received orders to send to hospital for evaluation. The Fall Report indicated no injuries were observed at time of incident. The resident's level of pain was reported to be 0. An interview was conducted with Resident #4 on 1/17/23 at 12:00 PM as she recalled the incident of 1/2/23 when she had a fall in the bathroom. The resident reported the Nurse Aide (NA) who assisted her to the bathroom was new and this was her first day working at the facility. When asked to detail what occurred on the day she fell , the resident again reported she had a new NA working with her on that day. She did not recall the NA's name. The resident stated she was being transferred from the recliner to the toilet in her bathroom. The resident then stated, The girl didn't fasten the center strap (referring to the chest support straps on the sling). She reported I told her she didn't hook the cross-straps on me. Resident #4 reported only the two long straps that connected each side of the sling to the lift were used for the transfer. However, the cross straps which secured the sling to her (the resident's) chest were not used. Resident #4 stated during the transfer, she slipped a little and felt weak, then fell to the ground. Resident #4 reported her back hurt and stated, They had to call the fire truck to get me off of the floor. Upon further inquiry, the resident reported the sit-to-stand lift (not a total mechanical lift) was always used to transfer her but she reiterated the NA who transferred her did not use the straps like they were typically used. When specifically asked, the resident reported she did not actually faint or lose consciousness during the transfer on 1/2/23. Resident #4 reiterated she just felt weak when she fell in the bathroom. A telephone interview was conducted on 1/17/23 at 4:02 PM with NA #1. NA #1 was identified as the agency (temporary staff) nurse aide who was assigned to care for Resident #4 on first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only shift she worked at the facility. NA #1 reported, No one gave me rounds I did not know anything about the resident. The NA stated she did not have access to the residents' electronic Kardex (an electronic record which provided details of the type of care a resident required) or any other information typically available via the electronic Kiosk (a computer terminal) until the end of her shift. NA #1 reported she had to ask residents and other staff for information about resident care. NA #1 stated right before dinner, Resident #4 needed to use the bathroom. The NA reported she understood the resident usually kept a sit-to-stand lift inside her bathroom but it was not there so she had to go to another hall to get a lift for the transfer. NA #1 recalled the leg straps on the lift were attached to the lift but they were in knots and tied up to the machine. The NA stated she was able to use the strap of the sling under the arms only but did not provide additional details about whether or not the chest support strap was secured. The NA then reported she began to transfer Resident #4 from her recliner to the bathroom. NA #1 stated, She was hanging on fine. Then the NA noticed the resident appeared to be getting weak so she grabbed her from behind and slid her down to the floor. She stated the resident did not faint or lose consciousness. NA #1 reported another NA (NA #2) had been in and out of the resident's room during the transfer and reported that NA was in the room just as the resident fell to the floor. NA #1 then stated, When this lady fell , I caught her and put her on the floor. The NA recalled Resident #4 complained of pain so she put a pillow behind her legs and back and had the resident lean on her leg for support. When EMS arrived, the Emergency Medical Technicians (EMTs) transferred the resident off of the floor and onto the stretcher. A telephone interview was conducted on 1/18/23 at 9:27 AM with NA #2. NA #2 was identified as an agency (temporary staff) nurse aide who worked on the first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only time she worked at the facility. NA #2 reported her assignment was to provide showers for the residents. When asked about the incident involving Resident #4, the NA reported a nurse had told her the resident needed to use the bathroom and asked her to go in and check on her. NA #2 stated she went into the room and the resident confirmed she wanted to use the bathroom so the NA went and told NA #1 the resident needed assistance. NA #2 also went into the room to help with the transfer but recalled before lifting the resident up, she noticed the resident was on supplemental oxygen. However, the oxygen tubing was not long enough to reach the bathroom. She told NA #1 to wait while she found a longer oxygen tube. When NA #2 returned to the resident's room, she observed that NA #1 had already hooked the resident up to the sit-to-stand lift and began the transfer to the bathroom. NA #2 reported she observed NA #1 trying to lower Resident #4 to the toilet but she was not close enough (the legs on the base of the sit-to-stand lift were not open) and she was not able to transfer her successfully. NA #2 also observed the resident did not have the harness (sling) fastened and her legs had not been secured with the leg straps on the lift. NA #2 stated she tried to help slide the resident down while attempting to hold on to the harness. The NA explained the resident was losing the harness (sling) because it had not been fastened. The resident was still holding on to the lift's metal bars as she fell . She did not observe Resident #4 to lose consciousness. After the resident reached the floor, the harness (sling) was disconnected from the lift. NA #2 stated while NA #1 tried to stabilize the resident with her leg, she saw the NA's knee was into the resident's back. After the fall, NA #1 went out of the room to get help while NA #2 hooked up the resident's supplemental oxygen. NA #2 reported Resident #4 complained of pain in her back, legs, and feet. The resident rated her pain as more than 10. When EMS arrived, NA #2 resumed her other duties. An interview was conducted on 1/17/23 at 3:30 PM with Nurse #1. Nurse #1 was identified as having worked on 1st shift (7:00 AM to 7:00 PM) on 1/2/23 at the time of Resident #4's fall. When asked to recall the details of his involvement with Resident #4 on 1/2/23 (the date of her fall from the lift), Nurse #1 reported he was not in the room at the time of the fall and was actually in the process of sending another resident out to hospital. After Resident #4's fall, he reported both he and the Unit Manager went into Resident #4's room. He observed the resident sitting on the bathroom floor with an NA still holding on to her and the resident was still holding onto the sit-to-stand bars. He could not recall noticing which lift or sling straps were fastened at that time because his focus was on the resident. Nurse #1 recalled the resident was complaining of back pain and he reported the Unit Manager told him to go ahead and get her ready to be sent out to the hospital. He called EMS and accompanied them down to Resident #4's room when they arrived. The EMS team transferred the resident off of the floor and onto the stretcher for transport to the hospital. An Interdisciplinary Team (IDT) progress note authored by Nurse Practitioner (NP) #1 and dated 1/2/23 at 8:33 PM reported the resident was sent to the hospital ED for pulsating sensation in abdomen as reported by nursing. The note reported this feeling was not new however prior workup had been unremarkable. The NP also wrote, Of note, staff report that patient had a witnessed fall during transfer with lift, no notable injuries, no acute reports of pain . however reports that it felt like 'she swallowed her heart.' Sent to ER [emergency room ] at request of patient. This writer spoke with MD [Doctor] at [name of hospital] who states that patient is still being worked up. Resident #4's hospital records included the following: - An ED Provider Note dated 1/2/23 at 7:23 PM. The note indicated Resident #4 presented to the ED for evaluation of injuries sustained in a fall. The note reported, She had a witnessed ground-level fall in the restroom at her skilled nursing facility earlier today. The patient states that she felt generally weak and then fell to the ground. There was not a loss of consciousness. She states that she hit her head and back against the ground and is complaining of diffuse pain, but mostly headache and back pain. EMS [Emergency Medical Services] was called, patient was subsequently transported to our emergency department for further evaluation. - On 1/2/23 at 8:30 PM, computerized tomography (CT) of the resident's thoracic (12 vertebrae located in the upper and middle part of the back) and lumbar spine was performed with a comparison to a CT of the resident's abdomen and pelvis conducted on 11/22/21. The findings were reported by Radiologist #1. The radiology report noted the presence of a fracture cleft (a possible indication of a compression fracture) through the superior (upper) aspect of the 3rd lumbar (L3) vertebral body, a left L3 transverse process (a wing-shaped protrusion on the vertebra) fracture, and a minor superior endplate (a transitional area where the vertebral body and disc between the vertebrae come together) compression fracture deformity of the L4. A chronic healed L2 compression fracture deformity was also included in the findings. On 1/2/23 at 8:27 PM, a CT of Resident #4's chest, abdomen and pelvis was completed. The radiology findings reported the resident had an acute nondisplaced fracture through the right acetabular roof / iliac bone. Additional radiology tests conducted of the resident's lower extremities noted the resident had osteopenia. - Resident #4's hospital Discharge Summary dated 1/4/23 at 12:11 PM reported the resident was admitted to the Trauma Service for further management and monitoring. The hospital records reported Orthopedic Trauma was consulted for her right acetabular roof and iliac bone fracture with the fracture managed non-operatively. Neurosurgery was consulted for the lumbar spine fractures, which were also managed without surgical intervention. Resident #4 was fitted in a Thoracic-Lumbar-Sacral Orthosis (TLSO) brace used to limit motion of the thoracic, lumbar and sacral regions of the spine and upright imaging was obtained. The resident's spine was cleared for mobility while wearing the TLSO brace. The resident's hospital Discharge Summary also reported the resident was discharged back to the facility on [DATE] after receiving treatment for her injuries present on admission. These injuries were noted on the Discharge Summary to include an acute nondisplaced fracture of the right acetabular roof / iliac bone fracture and fractures of the L3 vertebral body, left L3 transverse process and L4 superior endplate. The resident's discharge medications included 325 milligrams (mg) acetaminophen to be given as two tablets by mouth every 8 hours as needed (PRN) for pain, headache, or fever; and 50 mg tramadol (an opioid pain medication) to be given as one tablet by mouth twice daily as needed. Resident #4 was readmitted to the facility on [DATE]. A review of the resident's medications orders dated 1/4/23 included 325 mg acetaminophen to be given as two tablets by mouth every 8 hours as needed for pain, headache, or fever; and 50 mg tramadol to be given as one tablet by mouth twice daily as needed. A review of Resident #4's January 2023 Medication Administration Record (MAR) revealed the resident received one dose of acetaminophen on 1/5/22 at 4:34 AM for a documented level of pain rated as 6 on a scale of 0 to 10 (with 0 indicative of no pain and 10 representative of the worst pain possible). Resident #4 also received PRN tramadol in accordance with the physician's orders on 1/5/23 at 10:03 AM for a pain level of 7. The medication was reported to have been effective. The resident's EMR included a Comprehensive Encounter notation dated 1/5/23 and authored by NP #2. The NP reported Resident #4 was seen on this date for a post hospitalization visit due to a witnessed fall. The notation read, in part: .Patient seen today for post hospitalization for a witnessed fall resulting in closed nondisplaced dome fracture of right acetabulum and iliac bone fracture with recommendations of non-surgical conservative treatment, WBAT [weight bearing as tolerated] to BLE [bilateral lower extremities], and lumbar spine fractures. Patient fitted for a TLSO for L3 vertebral body fx [fracture], L3 transverse process fracture, and L4 superior end plate fx . Further review of Resident #4's January 2023 MAR revealed the resident received PRN medication on each of the following dates / times: --1/8/23 at 9:20 AM for a pain level of 8. The medication was reported to have been effective. --1/9/23 at 9:24 AM for a pain level of 4 and at 9:12 PM for a pain level of 10. The medication was reported to have been effective on both occasions. --1/10/23 at 10:21 AM for a pain level of 9. The medication was reported to have been effective. --1/11/23 at 5:28 PM for a pain level of 9. The medication was reported to have been effective. A notation made in Resident #4's EMR indicated the resident was seen by NP #1 on 1/12/23 at 11:49 AM. The note read, in part: Patient returned from [hospital] stay on 1/4/23 following a fall and found to have lower back compression fx and fx to sacral [the portion of the spine between the lower back and tailbone]. Has prn order for tramadol q12h [every 12 hours as needed], using occasionally. Pain to lower back controlled, patient is not routinely using recommended back brace bc [because] she is spending majority of time in bed .patient states that she is doing fair without acute concerns . A follow-up interview was conducted with Resident #4 on 1/18/23 at 10:57 AM. When asked how she was doing, the resident responded by stating she was not doing good. The resident reported she was receiving therapy and with their help, she sat of on the side of the bed. Upon further inquiry, the resident stated she was glad to sit up for a short time but reported it was painful. During the interview, the resident was asked to rate her level of pain. She reported having pain all the time and rated the level of pain as an 8 to more than 10. The resident reported the pain medications prescribed for her were helpful in reducing the pain. When asked, the resident confirmed during the 1/2/23 transfer (when she fell from the lift) her sling was loose, the cross straps were not secured, and no leg straps were fastened on her legs. Resident #4 added, I told the lady it usually takes two [staff] but she didn't say nothing. An interview was conducted on 1/18/23 at 2:50 PM with the facility's Maintenance Director. During the interview, the Maintenance Director reported safety checks were done on all lifts once weekly on Fridays. He stated he inspected all mechanical lifts on 1/3/23 (after Resident #4's fall). When asked, the Director reported on 1/3/23 he noticed the leg straps on one of the sit-to-stand lifts were tied up in knots so he replaced those straps. An interview was conducted on 1/18/23 at 10:10 AM with NP #1. During the interview, the NP recalled she had given the order to send Resident #4 to the hospital on 1/2/23. She reported that initially when she gave the okay to send her out, she understood it was due to breathing issues. NP #1 stated the resident did have chronic pain. The NP also acknowledged she conducted a visit with the resident on 1/12/23. The hospital radiology reports were discussed during the interview and included the finding of osteopenia. When asked, the NP reported both osteopenia (reduced bone mass, but less severe than osteoporosis) and osteoporosis place a resident at an increased risk of sustaining any type of fracture as compared to someone else with normal bone density. A telephone interview was conducted on 1/18/23 at 12:49 PM with NP #2. During the interview, the NP reported she saw Resident #4 on 1/5/23 after the resident returned to the facility. The NP stated during her visit, the resident did not have a lot of pain while lying in bed. The NP thought unless the resident was moving, her pain should be controlled. Upon inquiry, NP #2 reported Resident #4's fractures could possibly take 8-10 weeks to mend. In the meantime, unless therapy was working with the resident it was best for her to lay in bed. When asked, the NP reported even a hard sit could potentially cause fractures for someone with osteopenia or osteoporosis. An interview was conducted on 1/19/23 at 7:45 AM with the facility's Director of Nursing (DON). When asked, the DON reported as long as she had been working at the facility, the facility's policy was for two staff members to be present for all transfers using a sit-to-stand or total mechanical lift. On 1/19/23 at 9:45 AM, the Administrator requested an observation be conducted as she and two facility staff members attempted to re-enact Resident #4's 1/2/23 fall from the sit-to-stand lift. The Administrator stated the re-enactment was based on information provided by Resident #4. She reported Resident #4 stated the cross-straps (chest support straps) of the sling itself were not fastened during the transfer, the leg straps were not used, and only the two straps (one on each side) of the sling were fastened to the lift . Based on the re-enactment conducted and observed on 1/19/23 at 9:45 AM, the Administrator questioned whether the resident would have been able to fall from the sit-to-stand lift. However, when asked, the Administrator confirmed neither of the NAs who worked with the resident on 1/2/23 (the time of the fall) had participated in a re-enactment of the transfer. She reported one NA said she would come in and do the re-enactment but she did not. The other NA declined to participate. When the Administrator was asked if there was question about the resident having experienced a fall from the lift and sustaining fractures, the Administrator responded by saying she was not certain the resident actually sustained her fractures from the 1/2/23 incident. An interview was conducted on 1/19/23 at 11:07 AM with the facility's Occupational Therapist (OT). This OT was identified as having worked with Resident #4 in November and December 2022 to determine the safety of lifts used to transfer the resident. During the interview, the OT was asked about her work with Resident #4. The OT reported the resident basically got agitated when staff used the knee (leg) strap for her when using the sit-to-stand lift. The OT reported she educated the resident that the leg straps were used for her safety. She stated Therapy provided the resident with sheepskin to use on the back of the lift's leg straps so they would be more comfortable. During the interview with the OT, inquiry was made as to why it was important for the sit-to-stand leg straps to be utilized during a transfer. The OT responded by saying that if the resident was not able to maintain her grasp for any reason (such as a weak spell), she could slide down and out of the machine without the leg straps. She stated the leg straps would be an extra measure for her safety. When asked what the OT's thoughts were with regards to a resident being transferred with a sit-to-stand lift without using leg straps and with the chest support strap either loose or not being used at all, the OT responded, Oh no, it's not safe. The hospital radiologist was interviewed by telephone on 1/20/23 at 2:59 PM. During the interview, the radiologist confirmed he reviewed Resident #4's thoracic / lumbar films. The radiologist reported the resident's L3 and L4 lumbar vertebral fractures were unhealed and likely acute fractures. He stated, a fracture of this nature was likely something recent. At that time, Resident #4's fall on 1/2/23 was described to the radiologist. When asked if the resident's lumbar fractures could be the result of her fall on 1/2/23, the radiologist stated, they certainly could be. Upon request, the facility provided documentation of a Review to Ensure Quality (initiated on 1/4/23) for review on 1/17/23 at 2:00 PM. This review indicated the facility began an investigation of Resident #4's fall on 1/4/23. The initial report indicated an investigation was needed because Resident complained of feeling weak and her legs gave way during transfer in sit to stand lift. Immediate education that was being initiated included Mechanical lift education; Agency orientation checklist; and Nursing admin (administrative) staff on agency orientation checklist being completed before agency staff can work in facility. The Root Cause Analysis statement read: The resident was being transferred when she had an emergent situation where she went unconscious causing her to have decreased alertness and compromising her mobility. The plan for correcting the specific area of concern identified and process that led to the concern included a 4-point plan that addressed: 1) Corrective action for resident involved; 2) Corrective action for potentially impacted residents; 3) Systemic changes; and 4) Quality Assurance. The date of completion for the systemic changes involving the in-service training of nursing staff was 1/18/23. The Administrator was notified of immediate jeopardy on 1/18/23 at 1:40 PM. The facility provided an acceptable credible allegation on 1/18/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 01/02/2023 Resident #4 received injury during a lift transfer resulting in injury. On 01/04/2023, the Administrator, Director of Nurses, Staff Development, Rehab Manager, MDS, Unit Manager and the Clinical Nurse Consultant began identification of residents that were potentially impacted by this practice. This audit was completed by reviewing current residents who were identified as requiring transfer utilizing of the sit to stand and hoyer lift on 100/200 halls and if the transfer device was appropriate. This audit was completed on 01/05/2023. The Director of Nurses and the Clinical Nurse Consultant began updating the care plan to ensure it included the required number of individuals to complete a safe transfer and the proper device that needed to be used. This care plan update was completed on 01/05/2023. Since 1/05/2023, the Director of Nurses, Rehab team and the nurse management team have reviewed residents at the time of admission, quarterly and with significant changes to ensure that lift status and number of staff needed for transfer was documented on the care plan for the resident. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 01/04/2023, the Director of Nurses and Staff development coordinator began in-servicing all licensed nurses and certified nursing assistants (full time, part time, prn and agency employees) on Mechanical Lift Safety Education which included education on how to use the lift, how many caregivers are required to use the lift, and what to do if there is a problem with the lift. This was completed on 01/18/2023. After 01/18/2023, this in-servicing was incorporated into all new hire orientation for nurses, certified nursing assistants and agency staff that are allowed to use the lift. The training included both sit to stand and mechanical lift manufactured. Additionally, on 01/04/2022, the Director of Nurses began validation of competency of certified nursing assistants and nurses (agency and non-agency) on use of the lift. This was completed on 01/18/2023. Competency was continued during the orientation process for new hires and as a part of the agency training. Agency staff are not allowed to use lifts until they have received training. They received education on this restriction at the beginning of their first shift in the facility. Once they are properly trained on lift use they are allowed to use lifts according to facility policy. Supervisory staff are notified when an agency staff member has been trained. On 01/16/2023, the Director of Nurses or a designee began weekly monitoring (which included facility staff and agency staff) to identify if training had been completed, on how to use the lift and if the correct number of caregivers were used to complete the transfer. These audits included actual observation of staff (including agency) carrying out transfers. There were no concerns identified from any of the audits that were completed. The Director of Nurses has ensured that all licensed nurses and certified nursing assistants (full-time, part time, as needed and agency) employees who do not complete the in-service training will not be allowed to work until the training is completed. The Director of Nursing accomplished this by: making sure that the written agency orientation packet is provided to the agency staff prior to their first shift in the facility. The facility leaves the packets near the time clock and will follow up by phone when [NAME] [TRUNCATED]

Based on resident and staff interviews and record review, the facility failed to provide agency Nurse Aides (NA #1 and NA #2) with orientation and training to meet individual residents' care needs, including education and verification of the NA's competency on the safe use of the facility's mechanical sit-to-stand lift. One (1) of 2 residents reviewed for accidents (Resident #4) experienced a fall when the nurse aide did not fasten the sling's chest support strap in accordance with the manufacturer's instructions and did not use the leg straps attached to the lift. The resident fell from the lift to the floor. The resident was sent out to the hospital for evaluation / treatment and was found to have a right acetabular roof/iliac bone fracture (the main weight-bearing area of the hip joint) and 3 lumbar vertebral fractures (vertebrae located in the lower back). Immediate Jeopardy began on 1/2/23 when two new agency NAs (NA #1 and NA #2) began working at the facility without receiving orientation, training, and verification of their competency to transfer a resident safely with a sit-to-stand lift, resulting in her falling to the floor and sustaining multiple fractures. Immediate Jeopardy was removed as of 1/19/23 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's Instructions for Use for the facility's sit-to-stand lift included directions for the safe use of the lift. The instructions read in part, To fasten the [chest] support strap securely, press the buckles (if available) or hook and loop strap (if available) together. The strap shall be tight, but comfortable for the resident Remember to tighten the strap once the resident becomes raised from the chair .The sling support strap will help to support the resident in the sling during the raising procedure. The strap also retains the sling in the correct position around the resident. Additionally, the manufacturer's instructions included a boxed warning in bold print which read, Warning: The sling chest support strap must always be applied and fastened when using the sling. The role of the lower leg straps attached to the lift were also described in the instructions as follows: [The lower leg straps are an] Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support. They pass around the knee supports, then around the resident's lower calves. To fasten, click the strap into it's socket as with a seatbelt. Ensure that the straps are firm but comfortable for the resident. Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included a history of acute respiratory failure with hypoxia (low oxygen level in the blood). A review of the resident's Care Plan included the following area of focus, in part: -- I have an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance (Date Initiated: 2/2/18; Revision on: 10/26/22). The 10/26/22 revision indicated a sit-to-stand lift with a large sling was required for transfers. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #4 had intact cognition. She was totally dependent on staff for transfers and required two plus (2+) persons physical assist. A Fall Report dated 1/2/23 at 5:37 PM and authored by the facility's Director of Nursing included a description of an incident involving Resident #4 which read, The resident was being transferred to the bathroom by two CNAs [Certified Nurse Aides] on the stand up [sit-to-stand] lift. The resident was holding on to the lift properly but suddenly she was observed falling, so the CNAs lowered her to the floor. The resident had a syncope episode [temporary loss of consciousness]. Resident stated that she had fainted. The Fall Report indicated the Immediate Action Taken as: The nurse was noted by CNAs that the resident had been lowered to the floor after fainting. The nurse assessed the resident and she was lifted off the floor by [brand name of a total mechanical lift]. No injury noted but received orders to send to hospital for evaluation. The Fall Report indicated no injuries were observed at time of incident. The resident's level of pain was reported to be 0. Resident #4's hospital Discharge Summary dated 1/4/23 at 12:11 PM reported the resident was discharged back to the facility on [DATE] after receiving treatment for her injuries present on admission. These injuries were noted on the Discharge Summary to include an acute nondisplaced fracture of the right acetabular roof / iliac bone fracture and fractures of the L3 vertebral body, left L3 transverse process and L4 superior endplate. Resident #4 was readmitted to the facility on [DATE]. An interview was conducted with Resident #4 on 1/17/23 at 12:00 PM as she recalled the incident of 1/2/23 when she had a fall in the bathroom. When asked to detail what occurred on the day she fell , the resident reported she had a new NA working with her on that day. She did not recall the NA's name. The resident stated she was being transferred from the recliner to the toilet in her bathroom. The resident then stated, The girl didn't fasten the center strap (referring to the chest support straps on the sling). She reported I told her she didn't hook the cross-straps on me. Resident #4 reported only the two long straps that connected each side of the sling to the lift were used for the transfer. However, the cross straps which secured the sling to the resident's chest were not used. Resident #4 stated during the transfer, she slipped a little and felt weak, then fell to the ground. When specifically asked, the resident reported she did not actually faint or lose consciousness during the transfer on 1/2/23. Resident #4 reiterated she just felt weak when she fell in the bathroom. A follow-up interview was conducted with Resident #4 on 1/18/23 at 10:57 AM. When asked, the resident confirmed during the 1/2/23 transfer (when she fell from the lift) her sling was loose, the cross straps were not secured, and no leg straps were fastened on her legs. Resident #4 added, I told the lady it usually takes two [staff] but she didn't say nothing. A telephone interview was conducted on 1/17/23 at 4:02 PM with NA #1. NA #1 was identified as the agency (temporary staff) nurse aide who was assigned to care for Resident #4 on first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only shift she worked at the facility. NA #1 reported, No one gave me rounds I did not know anything about the resident. The NA stated she did not have access to the residents' electronic Kardex (an electronic record which provided details of the type of care a resident required) or any other information typically available via the electronic Kiosk (a computer terminal) until the end of her shift. NA #1 reported she had to ask residents and other staff for information about resident care. Attempts made to conduct a follow-up telephone interview with NA #1 were unsuccessful. A telephone interview was conducted on 1/18/23 at 9:27 AM with NA #2. NA #2 was identified as an agency (temporary staff) nurse aide who worked on the first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only time she worked at the facility. When asked, NA #2 reported the orientation she received at the facility consisted of a walk-through of the facility conducted at the start of her shift. She stated other new NAs were included in this walk-through to let them know where everything was. The NA reported she did not receive an orientation packet. NA #2 also stated that although she had asked for access to the residents' Kardex and other information available from the Kiosk so she could do her charting, she did not receive access to these records until late in the shift. An interview was conducted on 1/18/23 at 11:09 AM with the facility's Staff Development Coordinator (SDC). The SDC reported she was new to the facility with a start date of 12/29/22. Upon inquiry, the SDC reported the facility had a structured orientation process for new employees and agency staff conducted by the Human Resources (HR) staff member. This orientation process was already in place when the SDC started in her position. An interview was conducted on 1/18/23 at 1:00 PM with the HR staff member who was identified as being responsible for the facility's orientation of new staff (both employees and agency). During the interview, the HR staff member reported the orientation process for new NAs was a two-day orientation. Day 1 of the education included general information about the company and facility. Day 2 of the education was provided for nurses and NAs covering more clinical information. Upon inquiry, the HR staff member reiterated both new facility staff employees and new agency staff attended this orientation prior to working their first shift. She also reported there was a Skills Checklist that was typically signed off on by either the facility's Director of Nursing (DON) or SDC. A review of Day 2's printed orientation packet included information on the use of lifts. This information included the following statement in bold print which read, Before you lift: Must have a spotter before lifting a resident with either lift. Total or stand aide [sit to stand lift]. Additional written information provided indicated a skills check off and return demonstration on the use of lifts. A notation on the skills checklist indicated this form was required to be completed within 10 days of hire. An interview was conducted on 1/18/23 at 5:00 PM with the facility's DON. During the interview, the DON was asked about the orientation provided to agency NAs. The DON clarified that only agency staff coming from one specific agency (not the agency employing NA #1 or NA #2) went through the 2-day orientation previously discussed with the HR staff member. She reported the Unit Manager typically stayed in the facility and provided a more condensed orientation and information on The [Company] Way for new agency staff coming from the other agencies (such as NA #1 and NA #2). She reported, Agency staff can't start working at the facility without the orientation. Upon request, the orientation and training material for NA #1 and NA #2 was provided for review on 1/18/23 at 4:07 PM by the facility's Unit Manager. The packet of information was entitled, Agency Nurse Aide Orientation. This packet included the following, in part: --An outline of the topics covered in the information packet included Falls and the Content read: In each resident's Kardex under Safety, will be listed fall prevention information. You are responsible for knowing what these are. Residents should be rounded on frequently. --Another topic in the outline was entitled, Lists and how residents transfer and noted the following: We have lifts stored in clean utility. Lift pads are kept in the storage closet on the floor. Residents who require a lift for transfers will be noted in the resident's Kardex. It also read in bold print: Agency aides must not operate a mechanical lift. If you are assigned to a resident that needs a lift, the facility aide will operate the lift and the agency aide will assist as a spotter. Remember: It is your responsibility to know what lift is required to transfer a resident. You will know this by checking the Kardex as seen below [referring to a sample diagram]. You can access a residents Kardex on the [computer terminal] by logging into the resident's chart . --A skills checklist for a sit-to-stand lift was also included in the orientation packet. Nothing was checked as completed. The checklist was signed only by the Unit Manager and dated 1/2/23. --A Mechanical Lift Transfer Safety and Change in Condition Education Packet for nurses and NAs noted in bold print, **Prior to performing a transfer, it is important that you always completed the following: One bullet point listed read, When using any lift, 2 caregivers [in bold print] must be present during the lift. One operating the lift and the other acting as a spotter. This is important to protect the resident from potential injury such as hitting their leg on the lift mast, etc. All of the training material in both NA #1 and NA #2's training / orientation packet was signed by the Unit Manager and dated 1/2/23. However, neither NA #1 or NA #2 signed any of the orientation training information or checklists included in her orientation / training packet. An interview was conducted on 1/18/23 at 5:10 PM with the facility's Unit Manager. The Unit Manager reported, That day [1/2/23] was hectic with several people being oriented. The Unit Manager recalled she did provide an orientation to the building and walked around with the new agency staff on 1/2/23. The Unit Manager also stated she asked the orientees to sign the forms in their orientation packet. NA #1 and NA #2 did not sign any documents in their orientation packets before they left their shift on that date. It was noted NA #1 and NA #2's lift checklists were not completed. The Unit Manager reported she would normally try to orient the new agency staff before the start of their shift but 1/2/23 was a very busy day with a lot going on so she had to get the NAs on the floor as soon as possible. A follow-up interview was conducted on 1/19/23 at 12:50 PM with the Unit Manager. The Unit Manager reported each of the NAs were supposed to come to her to complete the orientation packets at some point during their shift, but NA #1 and NA #2 did not come back to do so on 1/2/23. During a second follow-up interview conducted on 1/19/23 at 2:33 PM with the Unit Manager, she reported, We verbalized the orientation materials but did not do the lift checklist as a return demonstration. An interview was conducted on 1/19/23 at 7:45 AM with the facility's Director of Nursing (DON). During the interview, the orientation and training of agency NAs were discussed. The concern identified with the facility's failure to provide and/or document orientation, training and competencies provided for the two agency NAs (NA #1 and NA #2) working when Resident #4 fell to the floor was discussed. The DON stated she understood the concern. The DON reported she should have followed-up with the new SDC at the facility to ensure a process for the orientation of the new agency NAs was in place. Upon request, the facility provided documentation of a Review to Ensure Quality (initiated on 1/4/23) for review on 1/17/23 at 2:00 PM. This review indicated the facility began an investigation of Resident #4's fall on 1/4/23. Immediate education that was being initiated included Mechanical lift education; Agency orientation checklist; and Nursing admin [administrative] staff on agency orientation checklist being completed before agency staff can work in facility. The plan for correcting the specific area of concern identified and process that led to the concern included a 4-point plan that addressed: 1) Corrective action for resident involved; 2) Corrective action for potentially impacted residents; 3) Systemic changes; and 4) Quality Assurance. The date of completion for the systemic changes involving the in-service training of nursing staff was 1/18/23. The Administrator was notified by telephone of immediate jeopardy on 1/26/23 at 5:35 PM. The facility provided an acceptable credible allegation on 1/27/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 01/02/2023 Resident #4 received injury during a lift transfer resulting in injury. On 01/04/2023, the Director of Nurses, Rehab Manager, and the Clinical Nurse Consultant began identification of residents that were potentially impacted by the alleged deficient practice. The alleged deficient practice includes: agency nurse aides who did not have proper orientation and training to meet the care needs of residents and verification of competency which would include safe use of the facility's mechanical lift. This audit was completed by reviewing current residents on 100/200 hall who were identified as requiring transfers utilizing a lift. This audit was completed on 01/05/2023. The Director of Nurses and the Clinical Nurse Consultant began updating the care plan to ensure it included the required number of individuals to complete a safe transfer and the proper device to be used. This care plan update was completed on 01/05/2023. Since 1/05/2023, the Director of Nursing and assessment nurses and therapy have reviewed residents on admission, quarterly and with significant changes to ensure that care plans include the use of lift and number of nursing assistants that should assist with transfers. This information is also included on all care guides Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 01/04/2023, the Director of Nurses and Staff development coordinator began in-servicing all licensed nurses and certified nursing assistants (full time, part time, prn and agency employees) on Mechanical Lift Safety Education which included education on how to use the lift, how many caregivers are required to use the lift, and what to do if there is a problem with the lift. This was completed on 01/18/2023. After 01/18/2023, this in-servicing was incorporated into all new hire orientation for nurses, certified nursing assistants and agency staff that are allowed to use the lift. The training included both sit to stand and total mechanical lifts. All facility lifts are by the same manufacturer Additionally, on 01/04/2023, the Director of Nurses began validation of competency of certified nursing assistants and nurses (agency and non-agency) on use of the lift. This was completed on 01/18/2023. Competency was continued during the orientation process for new hires and as a part of the agency training. Facility and Agency staff are not allowed to use lifts until they have received training and have validated competency. Competency is validated by noting the NA identifying the proper transfer technique and the proper device needed for the resident, the use of the transfer device and ensuring that all safety mechanisms related to the device are used properly, as well as return demonstration. Transfer status is located on the Kardex for each resident and is found in PCC. Every employee including agency receives a login with PCC access at the start of their shift. They receive education on this restriction at the beginning of their first shift in the facility. Once the staff member is properly trained on lift use, they are allowed to use lifts according to facility policy. Supervisory staff are notified when an agency staff member has been trained. The facility Scheduler and Educator keeps a record of all trained staff and ensures the staff member on the schedule has been trained. If a schedule modification is made, the Educator and Supervisor on Duty are notified by the scheduler and the Educator or designee completes the staff member's training and competency before the start of their shift. The current education is that an agency NA can use the lift with any other NA if both are properly trained. A list of all trained staff, including agency, is kept by the scheduler and the Educator and is updated as new staff are educated. On 01/16/2023, the Director of Nurses or a designee began weekly monitoring (which included facility staff and agency staff) to identify if training had been completed on how to use the lift, and if the correct number of caregivers were used to complete the transfer. These audits included actual observation of staff (including agency) carrying out transfers, as well as Sit to Stand Staff Knowledge checks. The facility will perform 2 transfer observations per week for three weeks and then monthly times 2 months. There were no concerns identified from any of the audits that were completed. The Director of Nurses has ensured that all licensed nurses and certified nursing assistants (full-time, part time, as needed and agency) employees who do not complete the in-service training will not be allowed to work until the training is completed. The Director of Nursing, nurse managers, Educator and Scheduler accomplished this by: making sure that the written agency orientation packet is provided to the agency staff prior to their first shift in the facility. The facility leaves orientation packets near the time clocks for the Supervisor and will follow up by phone, as needed, to notify the Supervisor that a new agency employee requires education that needs to be completed before they can begin the shift. The Supervisor will ensure that the packet is reviewed. This process of notifying the on shift Supervisor is performed by the Scheduler, Educator and Director of Nursing or designee prior to the start of the employees (agency employee) first shift. All employees must complete general orientation prior to working with residents. Transfer status is located on the Kardex for each resident and is found in PCC. Every employee including agency receives a login for PCC access at the start of their shift. This training is included in the orientation process. Completed 01/18/2023. This in-service was incorporated into the new employee facility orientation for all licensed nurses and certified nursing assistants (full time, part time, prn and agency employees). This began on 1/16/2023 and will continue. Completed 01/18/2023 Date of IJ removal-01/19/2023 The facility's credible allegation of immediate jeopardy removal was validated on 2/2/23. The validation was evidenced by review of facility and agency licensed nursing staff and nurse aides' (NAs) training and education files regarding both initial education and re-education of proper use of all mechanical lifts in the facility, demonstration of mechanical lifts used, re-demonstration of mechanical lift use and a written quiz related to use of mechanical lifts. Both facility and agency licensed nursing staff and NAs on all units were interviewed and were able to verbalize the mechanical lift education they received prior to returning to work or prior to beginning to work at the facility. Immediate Jeopardy was removed on 1/19/23.

Based on observation, record review, resident and staff interviews, nurse practitioner interview, the facility failed to safely transfer a resident utilizing a mechanical lift. Resident #1 sustained a mildly displaced fracture of the distal diaphysis of the tibia (a fracture occurring at the ankle end of the tibia) and a nondisplaced fracture of the distal fibula (the smaller bone than the tibia and runs beside it, the lower end of the fibula forms the out part of the ankle joint) of indeterminate age for 1 of 2 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, and [CONDITION(S)]. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] coded Resident #1 as being severely cognitively impaired. The resident required extensive assistance of two persons for transfers. Resident #1's care plan dated 9/2/22 documented she had an activities of daily living (ADLs) self-care performance deficit. Interventions included a full mechanical lift for all transfers with a medical sling. Resident #1 had a care plan focus area for inappropriate behaviors: kicking, cursing, refusing care, yelling at staff, and scratching staff was identified with interventions which included administering medications as ordered, anticipate resident's needs, when possible, approach in a calm manner and assess for underlying causes of frustration/behaviors such as: hunger, thirst, discomfort, toileting needs, pain, and intervene when possible. A health status note written by the Unit Manager (UM) dated 10/10/22 read in part; resident yelling when right foot touched with noted discoloration and slight swelling after kicking staff member. Resident unable to describe incident and was in no immediate distress. A health status note dated 10/10/22 read in part; resident yelling when right foot touched with noted discoloration and slight swelling after kicking staff member. Resident unable to describe incident and was in no immediate distress, on-call (Nurse Practitioner) to be (NP was in the facility) notified with continued monitoring. Findings of Resident #1's right foot X-ray completed on 10/10/22 revealed prominent osteopenia was present; hammertoe deformities were present and an old appearing fracture involving the distal tibial metaphysis (the area at the ankle end of the tibia). No displacement seen; soft tissue swelling was noted. No definite fractures or dislocations of the right foot could be identified. A nurses note dated 10/11/22 written by the UM noted Nurse Practitioner (NP) in room and resident yelling when right lower leg is touched or moved. NP to evaluate and notify family. A new X-ray was ordered on 10/11/22 of the right tibia/fibula (tibia is the shinbone, the large of the two bones in the lower leg & fibula is the smaller bone than the tibia and runs beside it, the lower end of the fibula forms the out part of the ankle joint) with the following results; mildly displaced fracture of the distal diaphysis of the tibia (a fracture occurring at the ankle end of the tibia) and a nondisplaced fracture of the distal fibula of indeterminate age. A NP note written on 10/11/22 read in part; X-ray results for Resident #1 shows mildly displaced fracture of the distal diaphysis of the tibia and non-displaced fracture of the distal fibula of indeterminate age, bony structure is osteoporotic. Called residents daughter/responsible party (RP) and provided update. RP agreed to send to Emergency department for evaluation. Called facility back and provided update to unit manager. A health status note written by the UM dated 10/11/22 revealed new orders from the NP to send to the Emergency Department (ED) for evaluation and treatment. NP to notify family. A review of an ED report dated 10/11/22 read in part Resident #1 had entered with a right ankle X-ray taken of the right tibia fibula reveals a mildly displaced fracture of the distal diaphysis of the tibia (a fracture occurring at the ankle end of the tibia) and a nondisplaced fracture of the distal fibula of indeterminate age. A health status note dated 10/12/22 read in part; revealed Resident #1 returned to the facility on [DATE] from the hospital. Once in residents room Resident #1 was placed in bed using a mechanical lift without incident. Right leg with soft cast on and wrapped with gauze from base of right toes to knee. Toes are warm to touch. Will continue to monitor and observe of evident of pain. A review of the statement written by NA #1 dated 10/10/22 read in part; I was preparing to transfer Resident #1 to the bed. A I was preparing to transfer her I put the bed in the lowest position and locked and nothing around the area. I reached down to hold onto Resident #1 and told her to give me hug, as she likes giving hugs. I placed my foot between her legs and feet. As I placed her into bed, she started to kick which is normal for Resident #1 and yelled my leg, my foot. I was asking Resident #1 what was wrong but that is all she said, so I ran and got a nurse. Her Kardex says full mechanical lift not pivot. The reason I picked her up is I was just not thinking. I should have looked at her Kardex. An observation of Resident #1 on 10/26/22 at 1:11 PM was completed. Resident #1 was in her room in bed with a cast on right foot. Resident was feeding herself and unable to answer any questions. An interview was completed with the Unit Manager (UM) on 10/26/22 at 1:17 PM who was asked about Resident #1's injury to her leg. The UM stated that it was due to an improper transfer and explained that Nurse Aide (NA) #1 had transferred Resident #1 from her shower chair into her bed when Resident #1 kicked NA #1. The UM explained that Resident #1 was to be transferred by a mechanical lift. UM stated she was notified by the Nurse Aide (NA) #1 that Resident #1 was complaining of pain on her right lower extremity. UM stated the NP was in the facility and the UM and NP went to assess the resident and at that time they looked at Resident #1's foot and did not notice any abnormalities except the foot was a little red and the NP ordered an X-ray. The UM stated they asked Resident #1 if she was in pain, and she was not. Education was then completed with the nursing staff on proper transfers. An interview was completed on 10/26/22 at 1:51 PM with the Interim Director of Nursing (DON) who recalled Resident #1's injury happened by a transfer where Resident #1 kicked her kicked her leg out but Resident #1 had not displayed any behaviors during the transfer. The DON stated she recalled that the NA who transferred Resident #1 had asked her to give NA #1 a hug (the DON stated the resident likes to give hugs) and had lifted Resident #1 up into bed and when doing so, the DON stated, Resident #1 kicked out her leg and when doing so I think kicked NA #1 leg. The DON stated that Resident #1 should have been transferred by a mechanical lift and by 2 people. The DON explained that when something like this would happen, we had to complete an investigation to see what happened related to the resident's injury. The DON stated the SW had interviewed residents who were alert and oriented to see if they had any concerns related to staff hurting them or had treated them poorly and any concerns with safety. The SW interviews revealed no concerns. The DON stated that skin assessments had been completed on resident's who were not able to answer interview questions and skin assessments had not revealed any concerns. The DON stated that we had educated the NAs on the importance of using the Kardex (desktop file system that gives a brief overview of each patient) to find out specifically how to care for a resident as well as how to transfer residents. The DON stated that NA #1 was suspended while an investigation was completed. The DON stated that Resident #1's first X-ray which was completed on 10/10/22 revealed an old fracture but revealed there was no new fracture. The DON explained that on 10/11/22 there was a noticeable change in Resident #1's right leg and the swelling was more prominent on her lower right leg above her ankle. An X-ray was ordered, and it came back that she had a right fracture at the end of the tibia/fibula and was sent out to the hospital. An interview was completed with Nurse Aide #2 on 10/26/22 at 2:15 PM who stated that when she would transfer Resident #1, she would use a mechanical lift and always two people. Nurse #2 stated that if Resident #1 was demonstrating behaviors we would try and soothe her and explain what we are doing for her. An interview was completed with the SW on 10/26/22 at 2:31 PM who stated that regarding Resident #1 she had assisted with the investigation by interviewing residents who were cognitively intact and asked them if they felt safe, if they had any concerns with staff, if they felt safe being transferred, was there always two people if using a mechanical lift. The SW stated there were no concerns from residents. An interview was completed with the Senior Quality Assurance Nurse Consultant (NC) on 10/26/22 at 3:13 PM who stated that the NA#1 was performing a transfer and the resident's leg kicked out during the transfer and Resident #1 said ouch. NA #1 notified her nurse, and the NP was in the building who responded and looked at Resident #1's leg. The NC stated, that from our investigation there was nothing unusual about the transfer and could not say that it was an improper transfer. The NC stated that they had NA #1 complete a reenactment in the room and had it set up as when Resident #1 was transferred. The NC stated that NA #1 did transfer Resident #1 as a one person transfer and did not follow Resident #1's care plan but nothing significant happened during the transfer that would cause the resident's leg to kick out and there were no behaviors exhibited by Resident #1. The NC stated that she could not say that if a mechanical lift was used would her leg still have kicked out. The NC stated a full investigation was completed including skin assessments, interviews, and education. The CC stated that the facility completed a plan of correction and were in there third week of monitoring per the plan of correction. An interview was conducted on 10/26/22 with NA #1 at 3:42 PM. NA #1 stated that on 10/10/22 she was transferring Resident #1 from her shower chair to the bed. NA #1 stated that Resident #1 likes to give me hugs as it helps her relax and I had given her a hug and transferred her at the same time. NA #1 stated that it was her fault. Resident #1 stated that her bed was in the lowest position and locked but during the transfer was kicking both feet, there was nothing around her that she could have kicked and did not feel her connect with something like her leg hitting something. NA #1 stated she laid her on the bed and afterwards Resident #1 said her leg. NA #1 stated she immediately got a nurse. NA #1 stated that she had worked with Resident #1 before but had never transferred her and did not know she was a mechanical lift and did not look at the Kardex. NA #1 stated Resident #1 was very light, but it was inappropriate for me not to use a mechanical lift and did not ask anyone if she was a mechanical lift. NA #1 stated Resident #1 was not exhibiting any behaviors during the transfer. An interview was completed with Nurse #1 on 10/26/22 at 6:31 PM who stated that she was working the night Resident #1 went to the hospital and spoke to EMS. Nurse #1 stated that she informed EMS that she had a negative X-ray on 10/10/22 and 10/11/22. A telephone interview was completed with a former NA #3 on 10/27/22 at 11:04 AM who stated that she had given Resident #1 a shower on 10/10/22 and when she was bringing Resident #1 back to her room NA #1 offered to assist Resident #1 putting her back to bed. NA #3 stated NA #1 told NA #3 when she transferred Resident #1, she used a stand to pivot transfer instead of a mechanical lift. NA #3 stated she was not in the room during the transfer. NA #3 stated that when she had given Resident #1 a shower, she had not observed anything unusual (such as bruising, falls, bumping into walls) with Resident #1 and explained she was fine during her shower, her mood was fine and there were no behaviors present. A telephone interview was completed with the former NP on 10/27/22 at 12:04 PM who treated Resident #1 regarding her leg injury. NP stated that she based her treatment plan off the X-ray and that is all the information she had. NP stated that it would be speculation on her part but would say that her osteopenia could have been a contributing factor to her injury. The facility provided the following corrective action plan with a completion date of 10/17/22. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident was assessed by the NP. Pain was assessed and managed. Care plan was reviewed, and the plan of care was accurate according to the resident's care status. Care plan was updated with new changes. Therapy assessed the resident for any new recommendations. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 10/10/2022, 100% of current residents that were able to be interviewed, were asked if transfers were completed according to their plan of care. This was completed by the Unit Support Nurse. Results included: All residents who had been transferred according to their plan of care. Additionally, skin observations were completed on current residents on the aid's assignment that were not interviewed. These residents were assessed to identify any [CONDITION(S)] or signs/symptoms of pain related to transfers according to the plan of care. Results included: No residents were identified as having transfers that were not completed according to the plan of care. On 10/10/2022 the DON implemented corrective action for those residents which includes: No corrective action was needed. On 10/13/2022 the Director of Nursing completed 5 random observations of transfers with and without the lift from 10/13/2022 - 10/17/2022. There were no concerns with any of the transfers. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 10/10/2022, the Director of Nursing in-serviced all Licensed Nurses (RN's & LPN's) and CNA's Full time, Part time, and PRN staff (including agency) on Safe Transfers. This training will include all current staff including agency. This training included: Safe Transfers Utilizing the Kardex When to utilize the Kardex Abuse training. The DON or designee will complete skills check and observation of lift transfers monthly and report any concerns to the QA list. As of 10/17/2022, the Director of Nursing will ensure that any of the above identified staff who does not complete the in-service training by 10/17/2022 will not be allowed to work until the training is completed. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. The DON or designee will monitor safe transfers weekly for 5 weeks and monthly for 2 months to ensure safe transfers are being completed. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Diet Manager. 5. Root Cause(s) of the event. Circle all that apply and describe below. Regulation, Care plan and other Root Cause Analysis statement (summarize investigation results regarding why it occurred). Consider using 5 whys process: Unintentional incident during resident transfer with factors related to severe osteopenia, [CONDITION(S)], and bony structures are osteoporotic. Resident disposition of being fragile and high risk for spontaneous fractures from September 11,2022. Root cause was reviewed 10/10/22 - 10/13/ 022. Presented to QA on 10/13/22. Date of compliance as of 10/17/22 and ongoing The plan of correction was reviewed and validated 10/27/2022 by interviews with the Senior Quality Assurance Nurse Consultant (NC), Director of Nursing, Unit Manager, Social Worker, nursing staff, including Nurse #1, Nurse Aide #1, Nurse Aide #2, and Nurse Aide #3. Included in the validation was a review of the plan of correction, educational in-services. The educational in-services included a power point titled 'Resident Transfer Safety Education Packet' which included a visual power point instruction on how to access the Kardex system and to review the instructions for each resident to assist with transfers. A review of the monitoring and audits was review which included a total mechanical lift competency checklist which was given to staff as part of the monitoring process. An interview was completed with Nurse Aide #2 on 10/26/22 at 2:15 PM who stated that we need to check the Kardex system to see how a resident is to be transferred if we are not familiar with the transfer. An observation of a transfer was completed on 10/26/22 at 5:46 PM with NA #1 and NA #4 in room 106 bed A of a resident who was a mechanical lift. The resident was transferred by two people who had used a sling from the resident's bed to her wheelchair. There were no concerns with the transfer. NA #4 was asked how she knew how to transfer a resident and she stated that we are to check the Kardex system for each resident on how a resident was to be transferred and with how many people and the type of sling used in a mechanical lift. An interview was conducted on 10/26/22 with NA #5 at 6:06 PM who stated that he would always check the Kardex and the instructions regarding the transfer status for each resident. An interview was completed Nurse #2 at 6:08 PM who stated that had monitor transfers to ensure the resident was being transferred the correct way. An interview was conducted with two alert and oriented residents on 10/26/22 at 6:15 PM to 6:23 PM. There were no concerns with how they were being transferred using a mechanical lift. An interview was completed with the DON on 10/26/22 at 6:22 PM who stated that part of her monitoring process for observing mechanical lifts includes waiting outside the hallway to ensure a second person was always present for the mechanical lift. If a staff member did not have two people, I would tell them they cannot transfer that person. The DON stated there had been no concerns with staff not utilizing two persons during a mechanical lift. A phone interview was completed with Nurse #1 on 10/26/22 at 6:31 PM who stated that she has had training on transfers and will monitor staff transferring utilizing a two person lift and would assist staff if necessary if a NA needed additional help. During an interview with the NC and the Administrator on 10/26/22 at 6:45 PM there had been no further incidents of staff failing to utilize the correct transfer for a resident after the compliance date on 10/17/22. Based on the corrective action plan the facility was in compliance for F689 as of 10/17/22.

Based on record review, staff interviews, Nurse Practitioner, and Medical Director interviews, the facility failed to notify the physician of critical laboratory results. Resident #46's blood sugar was critically low at 37 milligrams/deciliter (mg/dl) on [DATE] and critically low at 25 mg/dl on [DATE] through laboratory work. These results were not acted on by the facility, daily insulin continued, and no further blood sugars were done. This deficient practice occurred for 1 of 2 residents reviewed for notification of changes (Resident #46). Immediate jeopardy began on [DATE] when nursing staff failed to identify critical laboratory results resulting in the lack of physician notification and was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was prescribed insulin with regular blood sugar checks during previous admission. A hospital discharge summary dated [DATE] included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated [DATE] also included an order to draw a complete blood count (CBC), basic metabolic panel (BMP), and [CONDITION(S)] stimulating hormone (TSH) on [DATE]. Resident #46's bloodwork dated [DATE] showed a critical low blood sugar value of 37 milligrams/deciliter (mg/dl) (normal level ,d+[DATE] mg/dl). Per laboratory report, multiple, unsuccessful attempts were made to contact the facility staff about this critical value. This result was released to the electronic medical record and faxed to the facility on [DATE] at 3:28pm. Review of the medical record for Resident #46 revealed there was no documentation the physician was notified of the critically low blood sugar on [DATE]. Review of Resident #46's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's laboratory results for the BMP dated [DATE] showed a critical low blood sugar of 25 mg/dl. Per report, this critical result was called Nurse #9 on [DATE] at 5:02pm by lab technician #1. This result was released to the electronic medical record and faxed to the facility on [DATE] at 5:02 pm. Review of the medical record for Resident #46 revealed there was no documentation the physician was notified of the critically low blood sugar on [DATE]. During an interview with lab technician #1 on [DATE] at 2:47 pm, he stated that he was never able to reach a staff member on [DATE] to relay critical sugar results but did reach Nurse #9 on [DATE] and informed him of the current critical level of 25 (mg/dl), as well as the previous result of 37 (mg/dl) at that time. He also stated that, if he was unable to reach a staff member by phone, per the laboratory policy, he would release the results to the facility's system to be flagged and would continue to try to reach the facility by phone. During an interview with Nurse #9 on [DATE] at 9:45 am, he stated that he had no recollection of ever receiving a phone call from the lab regarding critical lab results for Resident #46. When asked about critical lab results, he stated he would contact the on-call provider, get any orders that may be needed, and then place a printed copy of the results in the doctor's folder for him/her to sign off on when they come into the facility next. He again stated that he did not recall receiving any phone calls about any critical results on [DATE]. During an interview with the Nurse Practitioner on [DATE] at 3:35 pm, the state surveyor notified her of critical lab results from [DATE] and [DATE]. She stated that she was not aware of any critical blood levels for Resident #46. She stated the phone number to contact the on call doctor was available 24 hours a day. She also stated, along with immediate verbal notification, there was a folder where the staff will put any critical lab value reports for her to review upon next visit to the facility. She also stated that she was in the facility on [DATE] and there were no critical levels in her folder for her to review. During an interview with the Medical Director on [DATE] at 5:02 pm, the state surveyor notified him of critical lab results from [DATE] and [DATE]. He stated the phone number to contact him or whomever was on call for him is available 24 hours a day. He also stated, along with immediate verbal notification, there was a folder where the staff will put any critical lab value reports for him or his staff to review upon next visit to the facility. The Administrator was notified of immediate jeopardy on [DATE] at 11:16am. The facility provided a credible allegation of immediate jeopardy removal dated [DATE]. Credible Allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident # 46 was deceased on [DATE] and is no longer a resident of the facility. On [DATE], the Nurse Consultant completed an audit of 100% of all current resident's lab values to identify if there were any alert lab values that were not communicated to the Nurse Practitioner or Medical Provider for the last 60 days. The audit revealed eleven alert lab values were reviewed. Six alert lab values had provider notification upon receipt. The Director of Nurses and the Assistant Director of Nurses immediately notified the Medical Director and Individual providers on [DATE] of the five required alert lab values that were not previously communicated at the time of the lab results. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On [DATE] the Director of Nurses and Assistant Director of Nurses began in servicing of all licensed nurses (full time, part time, and prn including agency nurses) on Critical Labs. Staff were educated on how critical labs are received, to promptly notify the physician and/or on call of all critical labs, document notification in the electronic record, and to notify the resident and RP of the critical labs. The DON will ensure that any licensed staff who has not completed the in-service training on [DATE], will not be allowed to work until the critical lab training is completed. The critical lab in-service will be incorporated into the new employee facility orientation program for both facility and agency licensed staff. On [DATE], the DON was notified of the responsibility to ensure the critical lab in-service will be incorporated into the new employee facility orientation program for both facility and agency licensed staff by the Clinical Nurse Consultant. Date of IJ removal [DATE] The credible allegation of immediate jeopardy removal was verified on [DATE] as evidenced by onsite validation through record review, and staff interviews. A review of facility in-service materials titled Critical Lab Education, Changes in Condition, and Preventing Errors on Admission were reviewed for content. Staff were interviewed to validate in-service completion on signs and symptoms of [CONDITION(S)] and physician notification regarding critical lab results. The DON, assistant DON, the floating DON, and the corporate nurse met with all floor nurses and assessed all current residents to identify any signs and symptoms of [CONDITION(S)]. Per their assessment, no current residents were identified having any signs and symptoms of [CONDITION(S)]. The immediate jeopardy was removed on [DATE].

Based on record review, staff interviews, Nurse Practitioner, and Medical Director interviews, the facility failed to monitor blood sugar levels for a resident with insulin-dependent diabetes (Resident #46). The facility administered long acting insulin without monitoring the resident's blood sugar. On [DATE], Resident #46's blood sugar was critically low at 37 milligrams/deciliter (mg/dl) and, on [DATE], it was critically low at 25 (mg/dl) through laboratory work. These results were not acted on by the facility, daily insulin continued, and no further blood sugars were done. This deficient practice occurred for 2 of 3 sampled residents. Also, the facility failed to assess, notify the physician, and obtain orders to treat an open area on the right lower leg and left lower leg for 1 of 4 residents reviewed for pressure ulcers (Resident #15). Immediate jeopardy began on [DATE] when staff gave Resident #46 his first insulin dose without knowing his current blood sugar level and was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The facility was also cited at a scope and severity of D for example #2 (Resident #15). The findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was on insulin with regular blood sugar checks during previous admission. A hospital discharge summary dated [DATE] included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated [DATE] also included an order to draw a complete blood count, basic metabolic panel, and [CONDITION(S)] stimulating hormone on [DATE]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for monitoring blood sugar levels. During an interview with Nurse #8 on [DATE] at 10:05 am, she stated she completed Resident #46's admission upon arrival. She stated she faxed the hospital discharge medication orders to the pharmacy and then hand-entered the same orders into the computer system which the on-call doctor approved remotely and then the pharmacy filled the order. She stated she was aware a resident on insulin needed regular finger stick blood sugar checks but did not remember whether or not she entered that into the system as he came with a lot of orders that day. She stated she would have entered blood sugar test strips and treatment orders separate from the pharmacy order. Resident #46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . His MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's bloodwork dated [DATE] showed a critical low blood sugar value of 37 milligrams/deciliter (mg/dl) (normal level ,d+[DATE] mg/dl). Per laboratory report, multiple, unsuccessful attempts were made to contact the facility staff about this critical value. Blood work was drawn again on [DATE] because no one documented that it was done on [DATE]. Resident #46's bloodwork dated [DATE] showed a critical low blood sugar of 25 mg/dl. Per report, this critical result was called Nurse #9 on [DATE] at 5:02pm by the technician who completed the test. During an interview with the lab technician on [DATE] at 2:47 pm, he stated that he was never able to reach a staff member on [DATE] to relay critical sugar results but did reach Nurse #9 on [DATE] and informed him of the current critical level of 25 (mg/dl), as well as the previous result of 37 (mg/dl) at that time. He also stated that, if he was unable to reach a staff member by phone, per the laboratory policy, he would release the results to the system to be flagged and would continue to try to reach the facility by phone. During an interview with Nurse #9 on [DATE] at 9:45 am, he stated that he had no recollection of ever receiving a phone call from the lab regarding critical lab results for Resident #46. He stated that he was aware Resident #46 was on insulin. He stated that if blood sugars are done then they are put on the resident's medication administration record. He did not recall doing any fingerstick blood sugar tests on Resident #46 since he was admitted on [DATE]. He also stated Resident #46 ate pretty good while he was there. He added that he was not working on that hall when Resident #46 was admitted and wasn't responsible for entering his initial orders into the system. He was unsure who was assigned to him. Record review showed a Nurse Aide #4 documented that Resident #46 was seen awake and sipping on water and stated he was fine on [DATE] at 3:30 am when she made rounds. Multiple attempts to reach Nurse Aide #4 were unsuccessful. On [DATE] at 10:15 am, a review Resident #46's meal intake report for [DATE]-[DATE] showed he consumed ,d+[DATE]% of his meal one time and ,d+[DATE]% one time. All other meals were either < 25% or meal was refused. During an interview with the floating Director of Nursing on [DATE] at 3:10pm she stated you should never give insulin without knowing what the current blood sugar level is. She added that how orders are entered into the system and the lack of monitoring blood sugars was something the facility will be working on and will be included in their interdisciplinary meetings. During an interview with the Nurse Practitioner on [DATE] at 3:35 pm, the state surveyor notified her that there were no blood sugar checks. She stated the importance of finger stick sugar checks in the presence of insulin and added that you should never administer insulin if you don't know what the current sugar level is. She stated that she was not aware of any critical blood levels for Resident #46. She stated he was newly admitted and she had not had a chance to evaluate him yet. She also stated that she was in the facility the previous day and there were no critical levels in her folder for her to review. She also stated that she expected all staff, including agency staff, to take care of the residents, for nurses to know current sugar levels prior to administering insulin, and to be able to recognize [CONDITION(S)] signs. During an interview with the Medical Director on [DATE] at 5:02 pm, the state surveyor notified her that there were no blood sugar checks. He stated there should be regular finger sticks with all residents who have insulin-dependent diabetes. He stated he was not aware of any critical blood sugar levels. He stated that it was vital to be aware of a resident's blood sugar levels when administering insulin. The Administrator was notified of immediate jeopardy on [DATE] at 11:16am. The facility provided a credible allegation of immediate jeopardy removal dated [DATE] at 7:52pm. Credible Allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident # 46 was deceased on [DATE] and is no longer a resident of the facility. On [DATE], the Nurse Consultant completed an audit of 100% of all current insulin dependent diabetic residents to identify if they have orders for accuchecks and if they had any critical sugar labs. This audit was completed on [DATE]. The audit identified that 19 of 19 current insulin dependent diabetic residents had orders for accuchecks. No corrective actions were required. Additionally, 0 of 0 current insulin dependent diabetic residents had a critical sugar lab in the last 60 days. No corrective actions were required. All current insulin dependent diabetic residents blood sugars are being monitored as ordered. On [DATE], the Director of Nurses and the nurse management team began an audit of residents who were potentially affected by the noncompliance by completing an audit of all new admissions/readmissions for the month of [DATE], to identify any new admissions/readmissions who are insulin dependent diabetic residents to ensure no orders for accuchecks on the discharge summary were not entered at the time of the admission. The audit was completed on [DATE]. The audit identified 18 total admissions. 2 of 18 admissions were insulin dependent diabetics with orders for accuchecks. The 2 admissions identified as insulin dependent diabetics at admission did have orders for accuchecks with blood sugars that are being monitored as ordered. No corrective actions were required. On [DATE], the Director of Nursing and Assistant Director of Nurses met with all floor nurses and assessed all current residents to identify any signs and symptoms of [CONDITION(S)]. No current residents were identified having any signs and symptoms of [CONDITION(S)]. No other residents were impacted. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On [DATE] the Director of Nurses and Assistant Director of Nurses began in servicing all licensed nurses and certified nursing assistants (full time, part time, and prn including agency nurses) on changes in condition which includes [CONDITION(S)] and decreased meal intake. The education also included identifying signs and symptoms of [CONDITION(S)], assessment monitoring including blood sugar levels, following the diabetic protocol for [CONDITION(S)], notification of physician of signs and symptoms and documentation of assessment and actions taken in the medical record. On [DATE] the Director of Nurses and Assistant Director of Nurses began in servicing of all licensed nurses (full time, part time, and prn including agency nurses) on Critical Labs. Staff were educated on how critical labs are received, to promptly notify the physician and/or on call of all critical labs, document notification in the electronic record, and to notify the resident and RP of the critical labs. All critical lab results are currently phoned to the nurse from a lab representative. If the lab is unable to reach the nurse at the facility, the lab representative will contact the on-call nurse to report the critical lab result. The lab manager has been provided the phone number for the nurse on-call phone number by the DON [DATE]. The lab representative facility contacts will be updated to include the nurse on-call phone number by the DON on [DATE]. The on-call nurse will then be responsible for following up to ensure the following occurs: Physician and/or on call is notified of the critical lab results, documentation of the result in the electronic record, and to notify the resident and RP of the critical labs. On [DATE], the Director of Nursing and Assistant Director of Nurses also began in servicing of all licensed nurses (full time, part time, and prn including agency nurses) on the admissions process and review to ensure one nurse enters the orders into the EMR and a second nurse verifies the orders for accuracy. The nurses were also educated on the need to obtain blood sugar monitoring orders for all insulin dependent diabetics and those on diabetic medications. This will be reviewed for all new admissions/readmissions and those with new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The DON will ensure that all licensed nurses (full time, part time, and prn including agency nurses) who does not complete the in-service training will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses (full time, part time, and prn including agency certified nursing assistants and nurses). Date of IJ removal [DATE] 2. Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had moderately impaired cognition and required extensive assistance to total dependence with ,d+[DATE] people for his activities of daily living. He had no skin impairment. A review of the care plan included a focus on incontinence with risk for skin breakdown initiated on [DATE] and anticoagulant therapy with an intervention to inspect skin and report abnormalities to nurse. A Weekly Skin assessment dated [DATE] revealed no new areas. On [DATE] at 11:43 AM, an observation was made of Resident #15 sitting in his wheelchair. A bordered gauze dressing with visible dark drainage was observed to the left lower leg. A [MEDICATION(S)] dressing was observed to the right lower leg with a date of [DATE]. Resident #15 did not know why the bandages were on his legs. A record review revealed no documentation or orders for the areas to Resident #15 ' s right and leg lower legs. On [DATE] at 11:49 AM, a second observation was made of Resident #15 ' s lower legs. The resident still had the bordered gauze dressing to the left lower leg and the [MEDICATION(S)] dressing dated [DATE] was still in place to the right lower leg. On [DATE] at 8:25 AM, Nurse #7 stated she didn ' t know anything about the areas or dressings to Resident #15 ' s lower legs. Nurse #7 removed the dressing to the left lower leg and a small open area was observed with a small amount of drainage noted. The right lower leg also had a small open area present. A nurses noted dated [DATE] at 8:25 AM by Nurse #7 read, this nurse noted open area to BLE (bilateral lower extremities). Area cleansed with normal saline and dry dressing applied. Physician notified and wound care requested to assess. Orders received. A review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 10:54 AM, an interview was conducted with the Director of Nursing who stated when a resident develops a new area on their skin, the staff member that identifies the area should document it in the medical record with the description, notify the physician and family and put a treatment order in place if needed.

Based on record review, consultant pharmacists, Nurse Practitioner and Medical Director interviews, the facility failed to complete an evaluation of Resident #46's medication regimen that identified the need to monitor insulin administration. Resident #46's initial medication regimen review did not identify the inadequate monitoring of insulin administration. Resident #46 received daily insulin without blood sugar testing and experienced critically low blood sugars identified through bloodwork. This was for 1 of 3 residents reviewed for pharmacy services. Also, the facility failed to retain the consultant pharmacist's findings, recommendations, and provider response in the resident's medical record or within the facility so the records were readily available for 6 of 13 residents whose medications were reviewed (Resident #24, #15, #4, #65, #168, and #218). And the facility failed to act on the Pharmacy Consultant recommendations to complete an abnormal involuntary movement (AIMS) assessment for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. Immediate jeopardy began on [DATE] when consultant pharmacist #1 reviewed Resident #46's medications and failed to recognize there were no physician orders for blood sugar testing with the administration of insulin and was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The facility was also cited at a scope and severity of E for example #2 (Resident #24, #15, #4, #65, #168, and #218) and for example #3 (Resident #22). The findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses including Covid, left [CONDITION(S)] and insulin-dependent diabetes mellitus. He was on insulin with regular blood sugar checks during previous admission. Resident #46 died in the facility on [DATE]. A hospital discharge summary dated [DATE] included an order for long-acting basal insulin 20 units daily (long-acting means insulin enters bloodstream in ,d+[DATE] hours from administration time and can last up to 24 hours in the body) and blood sugar test strips to check blood sugars four times daily as directed. The hospital discharge summary dated [DATE] also included an order to draw a complete blood count, basic metabolic panel, and [CONDITION(S)] stimulating hormone on [DATE]. A physician's order dated [DATE] was insulin degludec (long-acting insulin) 100 unit/milliliter-inject 20 units subcutaneously one time a day for diabetes mellitus. There were no orders for monitoring blood sugar levels. The initial pharmacy review dated [DATE], completed by consultant pharmacist #1 showed no medication issues with Resident #46's current insulin orders. The review did not acknowledge the insulin. Consultant pharmacist #1 was unable to be interviewed. During an interview on [DATE] at 3:20 pm, consultant pharmacist #2 stated that consultant pharmacist #1 completed the initial medication reviews for the new admissions to the facility. She stated that they do not receive fingerstick blood sugar orders. They only receive medication orders and that is what they review and base their recommendations on. She stated that the facility was responsible for ordering and keeping up with fingerstick orders. When asked if blood sugars were something they would monitor during their pharmacy reviews, she stated no, she probably would not look at those. She stated the review was based on medication orders only. During an interview with the Nurse Practitioner on [DATE] at 3:35 pm, she stated that she was not aware that Resident #46 was not receiving any fingerstick blood checks. She stated he was newly admitted and she had not had a chance to evaluate him yet. She also relayed the importance of finger stick sugar checks in the presence of insulin and she would expect finger stick blood sugar results to be on the resident's medication administration record for review. She added that you should not administer insulin if you don't know what the current sugar level is and that insulin is adjusted based on the daily blood sugar results. The Administrator was notified of immediate jeopardy on [DATE] at 12:37pm. The facility provided a credible allegation of immediate jeopardy removal dated [DATE]. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident # 46 was deceased on [DATE] and is no longer a resident of the facility. On [DATE], the Pharmacy Director completed an audit of 18 residents who were potentially affected by the noncompliance by completing a comprehensive review of all new admissions/readmissions for the month of [DATE]. The audit consisted of a review of insulin dependent diabetics to ensure orders for diabetic monitoring are in place. The pharmacy consultant also reviewed current lab results. Recommendations based on this review were sent to the physician by the nurse supervisor on [DATE]. These recommendations may include: additional labs, order changes, or additional diabetic monitoring. There were no other residents impacted. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. As of [DATE], the nurse consultant educated the pharmacy director on the need for all pharmacist consultants to review new admissions and readmissions to conduct comprehensive review that includes reviewing discharge summaries and comparing pre-hospital admission diabetic monitoring with readmission orders for monitoring and blood work orders and ensuring that the facility is providing comprehensive services for those residents with diabetic needs. In cases of irregularities identified, the consultant pharmacist will notify facility clinical leadership for immediate follow-up to the medical provider. Pharmacy consultants will review all discharge summaries for new admissions and readmissions. In the event the pharmacy review identifies any insulin dependent diabetics, the consultant must review all orders to ensure orders for diabetic monitoring are in place. Additionally, the pharmacist consultant will review current labs and make recommendations to the physician if order changes, additional labs or additional diabetic monitoring is required. This will be completed at the time of the initial review to ensure residents with diabetes are receiving a comprehensive review with the necessary care and services, monitoring for their diabetes. On [DATE], The Regional Director of Operations had a conversation with the pharmacy director detailing the process for ongoing monitoring for those residents with diabetic needs, specifically closer monitoring of chart information for new admissions and readmissions, to include reviewing the facilities practices for providing care and services. Previous pharmacy audits did not include review of blood work or orders for insulin dependent diabetics. The Pharmacy Director will in-service all consultant staff that are assigned reviews for the facility on [DATE]. The Pharmacy Director will provide the completed in service packet the facility leadership to ensure the training has been completed and for review. The pharmacy director will ensure that any consultant pharmacists who does not complete the in-service training will not be allowed to review charts for the facility until the training is completed. This in-service was incorporated into the new pharmacy employee orientation for the above identified staff including the agency staff orientation. IJ Removal [DATE] The credible allegation of immediate jeopardy removal was verified on [DATE] as evidenced by onsite validation through record review, and staff interviews. The facility nurse consultant met with the consulting pharmacist on [DATE] to complete an audit of current diabetic residents. They also met to discuss the need for reviewing discharge summaries for any monitoring orders for new and readmissions. The pharmacist will also review lab work and make recommendations depending on results. The facility immediate jeopardy removal was validated to be completed as of [DATE]. 2-a) Resident #168 was admitted to the facility on [DATE] with re-entry on [DATE]. His cumulative diagnoses included diabetes, hypertension, [CONDITION(S)], Alzheimer ' s disease, dementia with behavioral disturbance, major depressive disorder and anxiety disorder. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: AIMS (Abnormal Involuntary Movement Scale), GDR (gradual dose reduction). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: f/u (follow-up), AIMS. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: AIMS, documentation. No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #168 ' s ' s EMR revealed a consultant pharmacist conducted an initial MRR on [DATE]. The pharmacist ' s note from the MRR read: Initial pharmacist medication regimen review completed. Recommendations made, see report. No additional information was provided related to the consultant pharmacist ' s recommendations. The resident ' s EMR included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: AIMS, documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: Repeat, AIMS. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: clinical doc (documentation). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. No additional information was provided related to the consultant pharmacist ' s recommendations. An initial MRR was completed by a consultant pharmacist for Resident #168 on [DATE]. The pharmacist note read, Initial pharmacist medication regimen review completed. Recommendations made, see report. No additional information was provided related to the consultant pharmacist ' s recommendations. On [DATE], a monthly MRR was conducted by the consultant pharmacist. The pharmacist recommendations read: documentation. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #168 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #168 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-b) Resident #218 was admitted to the facility on [DATE]. Her cumulative diagnoses included Alzheimer ' s disease, [CONDITION(S)], and depression. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: GDR (gradual dose reduction. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: f/u (follow-up). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: APAP (acetaminophen. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: GDR. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: clinical doc (documentation). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: prn (as needed). No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #218 ' s most recent Minimum Data Set (MDS) was a significant change assessment dated [DATE]. The MDS assessment revealed she had severely impaired cognitive skills for daily decision making. The MDS reported the resident ' s medications included an antidepressant on 1 out of 7 days, an antibiotic on 7 out of 7 days and an opioid medication on 7 out of 7 days during the 7-day look back period. Further review of Resident #218 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #218 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-c) Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes, [CONDITION(S)], and an adjustment disorder with mixed anxiety and depressed mood. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat, documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: GDR, repeat. No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #4 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessment revealed she had cognitively intact skills for daily decision making. The MDS reported the resident ' s medications included insulin injection and antidepressant medication on 7 out of 7 days during the look back period. On [DATE], a monthly MRR conducted by the pharmacist included recommendations which read: labs. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #4 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE] or [DATE]. Additionally, there was no documentation in Resident #4 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-d) Resident #65 was admitted to the facility on [DATE]. Her cumulative diagnoses included [CONDITION(S)], hypertension, [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), anxiety disorder and depression. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: prn (as needed), lab. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: f/u (follow-up). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab, documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: clinical doc (documentation). No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #65 ' s most recent Minimum Data Set (MDS) was an annual assessment dated [DATE]. The MDS assessment revealed she had moderately impaired cognitive skills for daily decision making. The MDS reported the resident ' s medications included an antidepressant, antibiotic, and opioid medication on 7 out of 7 days and a diuretic on 1 out of 7 days during the 7-day look back period. On [DATE], a monthly MRR conducted by the consultant pharmacist included recommendations which read: Probiotic, inhalers, documentation. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #65 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #65 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-e) Resident #15 was admitted to the facility on [DATE]. His cumulative diagnoses included a [CONDITION(S)] disorder, hypertension, heart failure, and respiratory failure. Resident #15 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessment revealed he had moderately impaired cognitive skills for daily decision making. The MDS reported the resident ' s medications included an antidepressant, anticoagulant, and diuretic medication on 7 out of 7 days during the look back period. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab, repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #15 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE] or [DATE]. Additionally, there was no documentation in Resident #15 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-f) Resident #24 was admitted to the facility on [DATE]. His cumulative diagnoses included a history of multiple fractures, hypertension and unspecified dementia with behavioral disturbance. The resident ' s electronic medical record (EMR) revealed a consultant pharmacist conducted an initial pharmacist medication regimen review (MRR) on [DATE]. The pharmacist ' s note from the MRR included documentation which read: Initial pharmacist medication regimen review completed. Recommendations made, see report. Resident #24 ' s admission Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognitive skills for daily decision making. The resident ' s MDS assessment indicated his medications included an antipsychotic medication on 4 out of 7 days and a diuretic on 5 out of 7 days during the look back period. The resident ' s EMR included the following monthly MRRs completed by the consultant pharmacist: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation, AIMS (Abnormal Involuntary Movement Scale). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat, AIMS. Further review of Resident #24 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #24 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. An interview was conducted on [DATE] at 10:27 AM with the corporate floating Director of Nursing (DON) who served as the facility ' s Interim DON from [DATE] - [DATE]. During the interview, the float DON was asked if the consultant pharmacist recommendations, consultation reports and provider response for Resident #168, Resident #218, Resident #4, Resident #65, Resident #15, and Resident #24 were available for review. During a follow-up interview conducted with the floating DON, she reported only one Note to Attending Physician/Prescriber originating from a pharmacist MRR could be located. She stated no additional pharmacy recommendations were found in the residents ' medical records or elsewhere in the facility. An interview was conducted on [DATE] at 9:56 AM with the facility ' s consultant pharmacist. During the interview, the pharmacist was asked to describe the process used at the facility for sharing the MRR monthly recommendations with the residents' provider. The pharmacist reported she would write a progress note in each resident ' s EMR to indicate whether or not she had pharmacy recommendations. She reported some recommendations were intended for nursing staff and these would go into a Nursing Note. Other pharmacy recommendations were intended for the provider. The pharmacist reported she would typically send all of her notes and recommendations via email to the DON and Regional Nurse Consultant and would flag important or urgent issues. The pharmacist stated it was up to the DON to print and distribute/delegate the Nursing Notes. The pharmacist reported she has asked the facility to upload the pharmacy recommendations with responses from the provider into each resident ' s EMR. When asked, the consultant pharmacist reiterated she would expect the pharmacy recommendations with the provider ' s response to be scanned into each resident ' s electronic medical record. A telephone interview was conducted on [DATE] at 2:00 PM with the facility ' s Nurse Practitioner (NP). During the interview, the NP described the process employed for receiving the pharmacist's recommendations, reviewing, and responding to them. She reported she received the pharmacist ' s recommendations when the DON put them in her book. The NP stated she typically reviewed the recommendations, noted what she wanted to be done, and gave them back to the DON. The NP reported the DON would enter any order changes into the resident ' s EMR. After that, it was the NP ' s understanding that the DON would give these reports to medical records to be scanned in to the resident's EMR. An interview was conducted on [DATE] at 3:55 PM with the facility ' s Interim DON. During the interview, the DON reported he was aware of the concern regarding the pharmacist ' s recommendations and provider responses not being available for review. The DON indicated he would expect the regulations to be followed. 3. Resident #22 was admitted to the facility on [DATE] with diagnoses that included a cerebral infarction, [CONDITION(S)] disease, depression, dementia, and anxiety. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had severe cognitive impairment with inattention, disorganized thinking and verbal behaviors directed towards others. The assessment documented she received an antipsychotic 6 days and an antidepressant 7 days of the 7-day lookback period. The antipsychotics were on a routine basis only. A review of the electronic medical record for Resident #22 revealed an initial admission AIMS was completed on the date of [DATE]. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 requested an AIMS due to the Resident receiving [MEDICATION(S)], an antipsychotic medication. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 repeated the request for an AIMS for the Resident. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 repeated the request for an AIMS for the Resident. A review of the electronic medical record for Resident #22 revealed a second AIMS assessment was completed on [DATE]. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 requested an AIMS due to the Resident continuing to receive an antipsychotic medication. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 repeated the request for an AIMS for the Resident due to her continuing to receive an antipsychotic medication. On [DATE] at 2:04 p.m. an interview was conducted with the Unit Manager, and she revealed she received emails from the pharmacy consultant with the nursing monthly medication regimen review recommendation and request that also stated when to conduct an AIMS assessment. She revealed she was not sure if the AIMS assessment were due every three months or six months and would need to ask her Director of Nursing because she completed the AIMS assessments when she received instructions to do so in the emails from the Pharmacy consultant and Minimum Data Set (MDS) consultant. She reviewed the chart for Resident #22 and revealed she was able to see where the Pharmacy consultant documented the request for an AIMS on [DATE], [DATE], and [DATE] and then again on [DATE] and [DATE]. She stated she had been out of work due to an illness in June, 2022 and was not sure who the request had been emailed to but the AIMS was not completed in [DATE] as requested. She revealed in [DATE] and [DATE] a different Director of Nursing (DON) had been employed and the emails were going directly to the DON. The nursing recommendations requested from the Pharmacy Consultant had begun to be sent to the Unit managers in addition to the DON to improve on the follow up. She added the second AIMS was not completed until March of 2022. An interview was conducted with the interim DON on [DATE] and he revealed the facility protocol for an AIMS assessment was to be conducted upon admission and every 6 months. He stated the facility protocol to follow up on Pharmacy consultant recommendations was for the request to be expedited as quickly as possible based on the situation and medication. He added a request for an assessment like an AIMS, the goal was for a turn around as quickly as possible, and this should be conducted before the pharmacist returns the following month.

Based on observations, record review and interviews with Registered Dietician (RD), and staff, the facility failed to implement a high calorie nutritional supplement, as recommended by the RD for a resident with a stage 4 pressure ulcer identified as underweight on admission. The resident continued to lose weight the following month which resulted in severe weight loss that was greater than 5% for 1 of 6 residents reviewed for nutrition (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 was ordered a regular diet on 6/3/22. A dietary assessment dated [DATE] revealed Resident #35 was admitted on a regular diet with thin liquids. The current by mouth oral intake was noted as adequate at 50-75%. The resident had multiple wounds. An admission Minimum Data Set assessment dated [DATE] revealed Resident #35 was cognitively intact, independent with meals, was 74 inches tall and weighed 136 pounds, did not have any swallowing disorders, and had not lost weight. The assessment did not indicate any nutritional approaches were in place. Resident #35 had a stage 4 pressure ulcer that was present on admission. A note by the Registered Dietician (RD) dated 6/14/22 at 1:39 PM read, in part, underweight BMI (body mass index). Tolerates regular diet, fair intake. Patient declined RD recommended tube feeding in hospital to assist to improve high protein intake. Recommend provide nutrition supplement to meet nutrition needs. Start Med Pass 2.0 (a high calorie, high protein nutritional supplement) 90 milliliters by mouth three times a day to provide an additional 540 kilocalories and 23 grams of protein. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35 ' s weights documented in the electronic health record were 136.2 pounds on 6/12/22 and 127.4 pounds on 7/11/22. A note by the RD dated 7/15/22 at 8:02 PM read, in part, 6.6 percent weight loss x 30 days. Recommend provide nutrition supplement to meet nutrition needs. Start Med Pass 2.0 90 milliliters by mouth three times a day. A review of the July 2022 physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/17/22 at 11:52 AM, Resident #35 was interviewed. He stated he was a chef at a nice restaurant and the food in the facility was terrible up to a couple of days ago. He stated no one had ever asked him about food likes/dislikes. On 7/17/22 at 11:52 AM, an interview was conducted with the Dietary Manager. She stated she came back to work at the facility on 7/3/22 and menus changed 7/6/22 due to a change in the food caterer. She stated she had not spoken to Resident #35 about food preferences, and she did not think food preferences were maintained. She added she could find no record of food preferences for Resident #35. She stated he got a daily menu that was placed on his breakfast tray, and he could choose what he wanted to eat the following day. On 7/20/22 at 10:17 AM, the RD was interviewed. She stated she visited Resident #35 on 6/14/22 and identified him as high risk because of medical conditions and wounds. She added the Med Pass to meet increased nutritional needs. She stated when she made recommendations, she emailed them to the Administrator, the Director of Nursing and the Dietary Manager. She stated she didn ' t know why the Med Pass didn ' t get implemented in June, but she added there was some turnover in the facility including the Administrator, Director of Nursing, and the Dietary Manager, all in the last couple of months. When she saw Resident #35 again in July, she noticed the Med Pass 2.0 wasn ' t ordered and recommended it again. On 7/20/22 at 11:16 AM, an observation was made of wound care to Resident #35 ' s sacral wound. The wound was large and covered the entire sacral area and beyond. On 7/21/22 at 11:13 AM, the Director of Nursing was interviewed. He stated recommendations from the dietician should be put into place.

Based on observations, staff interviews and record reviews, the facility failed to provide orientation and education to nursing staff on the availability of individual blood glucose monitors (glucometers) assigned to each resident requiring blood glucose monitoring. The facility also failed to provide education on how to disinfect a shared glucometer used for multiple residents in accordance with the manufacturer's instructions. This was evident for 1 of 1 nurse (Nurse #1) observed who was new to the facility and worked independently as a hall nurse assigned to care for residents. Immediate jeopardy began on 9/27/21 when Nurse #1 (an Agency nurse) did not receive an orientation to the facility and began blood glucose testing for 6 residents on her assigned hall using a shared glucometer without cleaning the glucometer between residents with an Environmental Protection Agency (EPA)-registered disinfectant. Immediate jeopardy was removed on 9/30/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete facility employee and Agency staff in-service orientation and training. The findings included: This tag is cross referenced to: F880 - Based on observations, staff interviews, and record review, the facility failed to use an approved disinfectant product and procedure to clean and disinfect a shared blood glucose meter (glucometer) used for 6 of 6 residents required to have their blood glucose checked (Resident #1, #2, #3, #4, #5 and #6). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an EPA-approved disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of blood borne infections. An interview was conducted on 9/29/21 at 10:45 AM with the facility's Scheduler. The Scheduler reported she was responsible for scheduling both nurses and nursing assistants. While the facility employed some of their nursing staff, the Scheduler reported she utilized five temporary staffing agencies to help meet the staffing needs of the facility on an as needed basis. An interview was conducted on 9/29/21 at 11:35 AM with the facility's Director of Nursing (DON). The DON was asked about the orientation process utilized for both staff and Agency nurses. She reported the facility had a form she used to orient Agency nurses. The DON stated she herself tried to complete this orientation on the first day a new Agency nurse came in prior to the start of his/her shift. If she was not able to conduct the orientation, one of her staff nurses or a Unit Manager would go over the form with the new nurse. The DON reported Nurse #1 was, a last minute fill-in for the shift and she had not been made aware this Agency nurse was coming in to work her first shift at the facility. A review of the form entitled, Agency Nurse and Nursing Student Orientation was conducted. The form included content on each of the following topics: Medication Administration; Treatments; Emergency Situations; Documentation; Falls; Elopement; Restraints; Injuries of Unknown Origin and Abuse Prevention/Investigation; Pressure Ulcers; Medications; and Personal Protective Equipment. Neither blood glucose monitoring nor the disinfection of glucometers were included on this form. A follow-up interview was conducted on 9/29/21 at 12:04 PM with the DON in the presence of the facility's Quality Assurance (QA) Clinical Consultant. When asked, the DON reported the outline provided would typically have been completed for each Agency nurse prior to the start of his/her first shift. However, she confirmed Nurse #1 did not receive the orientation as outlined on this form. A second follow-up interview was conducted on 9/30/21 at 11:45 AM with the facility's DON. During the interview, the DON reported she would expect all of the facility's staff nurses to complete an orientation prior to working independently on the residents' halls. The DON also stated she would expect to be notified if a new Agency nurse was going to be coming in to work at the facility so either the DON or a designated staff member could talk with the nurse to review the facility's orientation packet. On 9/29/21 at 1:30 PM, the facility's Regional Vice President, QA Clinical Consultant, and DON were informed of the immediate jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 9/29/21 at 7:40 PM. The allegation of immediate jeopardy removal indicated: The facility failed to provide orientation and education to Nurse #1 (an Agency nurse) on the availability of individual glucometers assigned to each resident requiring blood glucose monitoring. The facility also failed to educate Nurse #1 on how to disinfect a shared glucometer according to manufacturer's instructions when used for multiple residents. Component 1: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 9/28/21 residents #1, #2, #3, #4, #5, and #6 had their blood sugar checked using the same glucometer that had not been disinfected with an approved EPA agent between residents. Once the facility was notified of the deficient practice, the Licensed Practical Nurse Unit Support Nurse (LPN) promptly removed the glucometer from the cart. The LPN Unit Support Nurse checked each medication cart to ensure there were no glucometers on the cart. No glucometers were found on the cart. Additionally, on 9/28/21 the LPN verified that each resident (#1, #2, #3, #4, #5, and #6) had their own individual glucometer in their room. If a new admission comes in and needs an individual glucometer, the cleaned and sanitized glucometers are located in the unit medication rooms. Additionally, on 9/29/21, the scheduler reviewed the schedule for the next 7 days and identified different agency nurses or medication aides that are already scheduled to work. The DON, ADON, has reached out to these nurses to provide them with the orientation packets that includes the importance of using a resident's individually assigned glucometer and the need to disinfect using an EPA registered chemical. 100% of all agency nurses that are scheduled for 9/29/21 have been educated utilizing agency orientation packet including the importance of using a resident's individually assigned glucometer and the need to disinfect using an EPA registered chemical. The orientation material will have a copy of the Manufacturer's instructions that have the cleaning and disinfecting procedures for glucometers. No agency staff member will be allowed to work until this education is provided. Component 2: Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 9/29/21, the Director of Nurses (DON), Assistant Director of Nurses (ADON), LPN Unit Support Nurses, the HR staff member, and scheduler were educated by the Quality Assurance Nurse Consultant on the importance for ensuring that all agency staff receive the orientation packet prior to the beginning of their shift. The scheduler and/or HR staff will print education packets for agency nurses that have not previously been oriented using the education packet. These packets will be placed in the copy room in a designated box with the agency nurses name for review and signature at the beginning of their shift. The scheduler will notify the agency nurses who are scheduled for future dates that the packets are located in the designated box in the copy room and that they should be signed and placed under the DON's door, which is located across the hall from the copy room once completed. The scheduler will also provide a list of new agency staff to the facility on -call nurse each day. To ensure that this occurs, the facility on-call nurse will call the facility and talk to the agency staff member to ensure that the education packet was reviewed and signed and will address any questions that they may have. As needed agency staff are scheduled and approved by the DON, ADON, or LPN Unit Support Nurse. Additional orientation packets will be placed in the designated box in the copy room. Anytime a new agency person is sent to the facility the on-call nurse will contact them by phone and will ensure that they retrieve, review and sign the orientation packet. Component 3: Date of completion 9/30/21 On 9/30/21 from 8:02 AM through 12:15 PM, interviews were conducted with facility staff during the validation process. During an interview, the facility's Scheduler described her role in identifying when a new Agency nurse was coming to work in the facility. The Scheduler reported she was always told in advance by the temporary staffing Agency the name of the nurse who would be assigned to work a shift. She stated anytime a new Agency nurse picked up a shift at the facility, she would notify the DON and ADON. When asked, the Scheduler reported the administrative staff would be notified even if there was a last minute change in Agency nurses assigned to work at the facility. Interviews were conducted with both the DON and ADON with regards to the process of orientation for facility staff and Agency nurses. The DON and ADON confirmed they were also doing a double check of the next day's nursing staff schedule to ensure orientation and education (including infection control protocols for blood glucose monitoring) were provided to nurses before starting work at the facility. Based on the staff interviews, the credible allegation was validated and the immediate jeopardy was removed on 9/30/21.

Based on observations, staff interviews, and record review, the facility staff failed to use an approved disinfectant product and procedure to clean and disinfect a shared blood glucose meter (glucometer) used for 6 of 6 residents (Resident #1, #2, #3, #4, #5 and #6). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of blood borne infections. Immediate Jeopardy began on 9/27/21 when Nurse #1 (an Agency nurse new to the facility) began performing blood glucose testing for 6 residents on her assigned hall using a shared glucometer. Nurse #1 did not disinfect the shared glucometer between residents using an EPA-registered disinfectant. In addition, Nurse #1 was not aware facility residents each had their own individual glucometer stored in a plastic, covered container in his/her room. Immediate Jeopardy was removed on 9/30/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: A review of the facility policy entitled Glucometers (Originated January 2011; Last Revised January 2011) read, in part: It is the policy of this facility to utilize individual glucometers for each resident. The topic of Cleaning read: Anytime the glucometer is visibly soiled and PRN (as needed), it will be cleaned and disinfected per Manufacturer's guidelines. The manufacturer instructions for the glucometer used at the facility instructed the cleaning and disinfection procedure should be performed as recommended to minimize the risk of transmitting blood-borne pathogens. These instructions read in part, The meter should be cleaned and disinfected after use on each patient. The (Brand Name) multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The Cleaning and Disinfection instructions read, The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the (Brand Name) multi Blood Glucose Monitoring System. The instructions provided a list of disinfectant wipes which were shown to be safe for use with the glucometer. This list did not include alcohol wipes. A medication administration observation was initiated on 9/28/21 at 6:23 AM with Nurse #1. Nurse #1 was identified as an Agency nurse (temporary staff) who was assigned to care for residents on the 200 Hall from 7:00 PM on 9/27/21 to 7:00 AM on 9/28/21. The nurse reported she was new to the facility. Nurse #1 was observed on 9/28/21 at 6:34 AM as she picked up a glucometer stored on top of the medication cart and collected supplies to complete a blood glucose check for Resident #1. The nurse then donned gloves and entered Resident #1's room with the testing equipment. After checking the resident's blood glucose, Nurse #1 returned to the medication cart and was observed as she used an alcohol wipe to wipe off the glucometer. She placed the glucometer back on top of the medication cart. Nurse #1 was observed as she completed the medication pass. When asked, Nurse #1 stated she had completed all of the other blood glucose checks scheduled on her assigned hall. Upon further inquiry, the nurse identified the other blood glucose checks she had already completed earlier that morning. These checks included Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. As the interview with Nurse #1 continued, the nurse was asked if the glucometer observed to be used for Resident #1 was a shared meter used for all five of the other named residents. Nurse #1 reported it was and stated she assumed the facility used a shared glucometer for residents because it was the only glucometer she had seen. Upon further inquiry, the nurse was asked how she disinfected the meter between the residents. Nurse #1 reported she used an alcohol wipe as was previously observed to clean the shared glucometer between residents. Nurse #1 was also asked if there were any disinfectant wipes available on the medication cart specifically intended to clean and disinfect a glucometer. She stated she did not know. Upon request, Nurse #1 was observed as she opened the bottom drawers of the medication cart; no EPA-approved disinfectant wipes were observed to be stored on the med cart. An interview was conducted on 9/28/21 at 6:47 AM with the facility's night shift nurse supervisor. At that time, concerns regarding the use of a shared glucometer and failure to disinfect the glucometer between residents with an approved disinfectant were discussed. The nurse supervisor reported a shared glucometer would need to be disinfected using (Brand Name) disinfectant wipes. However, she reported each resident had an individual glucometer and she proceeded to point out where the glucometer would be stored in each of the residents' rooms. The nurse supervisor reported all individual glucometers were thoroughly disinfected and calibrated once a week. A review of each residents' electronic medical record revealed the following information: --In addition to the blood glucose level observed to be checked by Nurse #1 on the morning of 9/28/21, Resident #1 also had her blood glucose documented as checked by Nurse #1 on 9/27/21 at 9:19 PM. --Resident #2 did not have any additional blood glucose results documented as checked by Nurse #1. -- In addition to the blood glucose level checked the morning of 9/28/21, Resident #3 also had her blood glucose documented as checked by Nurse #1 on 9/27/21 at 10:56 PM. -- Resident #4 did not have any additional blood glucose results documented as checked by Nurse #1. -- In addition to the blood glucose level checked the morning of 9/28/21, Resident #5 also had her blood glucose documented as checked by Nurse #1 on 9/27/21 at 11:12 PM. -- In addition to the blood glucose level checked the morning of 9/28/21, Resident #6 also had her blood glucose documented as checked by Nurse #1 on 9/27/21 at 11:07 PM. An interview was conducted with the facility's Administrator, Director of Nursing (DON), and Quality Assurance (QA) Clinical Consultant on 9/28/21 at 1:55 PM. During the interview, the infection control concerns related to Nurse #1's failure to use residents' individually assigned glucometers and her failure to use an approved disinfectant on the shared glucometer used for 6 residents were discussed. The DON reported Nurse #1 was in-serviced after the infection control concerns were identified the morning of 9/28/21 regarding the need to use each resident ' s individually-assigned glucometer and use of an approved disinfectant to clean/disinfectant a glucometer. An interview was conducted on 9/30/21 at 11:00 AM with the facility's Assistant Director of Nursing (ADON). During the interview, the ADON reported only nurses and facility staff medication aides conducted blood glucose monitoring for residents. She also reported an audit of the facility's medication carts was conducted after the infection control concerns were identified on 9/28/21. This audit revealed the 200 Hall med cart (the med cart observed to be used by Nurse #1 on 9/28/21) did not contain an EPA-approved disinfectant product intended for use on glucometers. A follow-up interview was conducted on 9/30/21 at 11:45 AM with the facility's DON. During the interview, the DON reported she would expect all nurses to check residents ' blood glucose levels in accordance with physician's orders and to follow proper protocols. She reported a glucometer was kept in each resident's room with the intent for it to be used only for that resident. The DON also stated each glucometer needed to be cleaned and disinfected as needed. If any staff member had questions with regards to blood glucose monitoring or the use of a glucometer, he/she needed to reach out to a Unit Manager, ADON, or the DON for guidance. On 9/29/21 at 1:30 PM, the facility's Regional Vice President, QA Clinical Consultant, and Director of Nursing were informed of the immediate jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 9/29/21 at 7:50 PM. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: The facility failed to use an approved disinfectant product and procedure to clean and disinfect a shared glucometer used for 6 residents required to have their blood glucose checked (Resident #1, #2, #3, #4, #5 and #6). Nurse #1 (an Agency nurse) who performed the blood glucose testing was not aware facility residents each had their own individual blood glucose meter stored in a plastic, covered container in his/her room. Nurse #1 was also not trained on how to disinfect a shared glucometer according to manufacturer's instructions when used for multiple residents. Component 1: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 9/28/21, it was discovered that resident #1, #2, #3, 4#, 5# and #6 had their blood sugar checked using the same glucometer that had not been disinfected with an approved EPA agent between residents. Once the facility was notified of the deficient practice, the Licensed Practical Nurse Unit Support Nurse (LPN) promptly removed the glucometer from the cart. On 9/28/21, the LPN Unit Support Nurse checked each medication cart to ensure there were no glucometers on the cart. No glucometers were found on the cart. Additionally, on 9/28/21 the LPN verified that each resident (#1, #2, #3, #4, #5, #6) had their own individual glucometer in their room. The Director of Nurses interviewed the nurses and there were no other residents who were identified as being impacted by the deficient practice. Component 2: Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 9/29/21, the Director Nurses, Assistant Director of Nurses, Administrator, Regional Director of Operations, Quality Assurance Nurse Consultant, LPN Unit Support Nurse, conducted a root cause analysis and determined that the root cause of the deficient practice was that the scheduler didn't notify the facility on call nurse that the agency nurse would be working and required agency orientation to be completed and Nurse#1 was not aware that each resident had their own individual glucometer or of the facility glucometer disinfecting procedure. On 9/29/21, the QAPI Committee met to discuss and review root cause of analysis. The Medical Director and the [NAME] County Health Department were made aware of the deficient practice and the steps to correct the deficient practice on 9/29/21. The [NAME] County Medical Director and the Medical Director were both informed on 9/29/21 of the interventions that facility had put into place to include ensuring that each resident had their own individual glucometer and that the nurses were educated on proper steps to take for disinfecting the glucometers. There were no further recommendations from the Health Department or the Medical Director. The facility did request orders to obtain vital sign monitoring for next 72 hours for each resident. On 9/28/21, the Director of Nurses (DON) and Assistant Director of Nurses (ADON) began educating all licensed nurses and medication aides full time, part time, and PRN including agency staff on the glucometer policy to include the following: · Residents must have their own individual glucometer. · Glucometers must be cleaned and disinfected per Manufacturer ' s recommendations when visibly soiled and PRN. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. · The sanitizing wipes for cleaning and disinfecting are located in the unit medication rooms and the supply room. · Sanitized and cleaned glucometers are located in the unit medication rooms or the supply room. · The orientation material is included in the agency orientation education packet. On 9/29/21, the DON and ADON completed QA monitoring to check each medication cart to ensure there were no glucometers on the cart and that each nurse could complete a return demonstration of how to clean and disinfect the glucometers. As of 9/29/21, 100% of all nurses and medication aides have completed return demonstrations. There were no issues identified with the return demonstrations. As of 9/29/21 3pm, any employee who has not received this training will not be allowed to work until the training has been completed. This includes full time, part time, and agency staff. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all staff identified above and will be reviewed by the Quality Assurance process to verify that the change has been sustained. Component 3: Date of completion 9/30/21 On 9/30/21 from 8:02 AM through 12:15 PM, observations and/or interviews were conducted with staff and Agency nurses assigned to each of the 4 halls within the facility with regards to required infection control practices using glucometers for blood glucose checks. All nurses were aware of the facility's policy to use individually assigned glucometers for each resident requiring blood glucose monitoring and to store the individual glucometer in each resident's room. The location of EPA-approved disinfectant wipes for the cleaning and disinfection of glucometers (as needed) was also observed and discussed with each nurse. Each hall nurse was able to demonstrate and/or verbalize the instructions provided through the in-servicing received on 9/29/21 regarding these infection control practices and the glucometer's manufacturer recommendations for cleaning and disinfection. Based on the observations, staff interviews and a review of the facility's records, the credible allegation was validated and the immediate jeopardy was removed on 9/30/21.

Based on Resident interviews, staff interviews, resident observations and record review the facility neglected to provide incontinent care for 1 of 1 sampled residents (Resident #63) who required extensive assistance and who had requested incontinent care on 2 occasions because she had soiled herself. The Resident was observed crying, rocking back and forth and stated she had asked to be changed and nobody had assisted her. The findings included: Resident #63 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] revealed that the Resident had moderate cognitive impairment, required extensive assistance of one staff member with toileting and personal hygiene and two-person assistance with bed mobility and transfers. She was coded as always incontinent of bowel and bladder. A review of the care plan, revised 4/26/2021, had a focused area identified that the Resident was at risk for skin breakdown and infections due to being incontinent of urine with episodes of completely saturating and soaking through incontinence briefs. The goal was for the Resident's risk of complications related to urinary incontinence to be minimized through the current interventions for 90 days. The interventions included, assist Resident with incontinence care, Change bed linens if they are noted with any wetness from urine, change clothing as needed, check for incontinence care every two hours and as needed and provide incontinence care with each incontinent episode, thoroughly cleansing, rinsing and drying perineum. An interview with Resident #63 occurred on 5/24/2021 at 3:40 pm. The Resident stated that she had not been cleaned all day and was wet. Resident #63 went on to say that she had informed the nursing assistant (NA) that she needed help because she was wet, when the NA brought in and picked up her breakfast and lunch trays and again when she came to assist the Resident's roommate. She said she did not recall the NA's name because she was from an agency. The Resident was observed to press the call light at 3:41 PM. An observation of Resident #63 occurred on 5/24/2021 at 3:50 pm, with audible stomach noises, she passed gas and was crying, holding her stomach. The Resident was observed rocking back and forth and to say, I have been wet all day and I need to use the bedpan. Observed the call light, outside of Resident #63's room, on 5/24/2021 at 3:57 pm. The light was observed to be functioning. Observed no staff in the hallway on the 200-hall. An observation was conducted on 5/24/2021 at 4:08 pm. NA #07 provided incontinent care to Resident #63. The Resident was observed wearing a brief, saturated with urine from the front edges to the back edges. A strong urine odor was present. When the NA rolled Resident #63 to her right side, two incontinent pads beneath the Resident were observed to be wet to the edges. NA # 07 removed the Resident's clothing, changed the bedsheet, and provided incontinent care. Observed the Resident to tell NA # 05, thank you because she had been wet all day and no one would come to help her. The Resident stopped crying when incontinence care was provided without the use of a bedpan. An interview was conducted with NA #07 on 5/24/2021 at 4:10 pm as she provided incontinent care to Resident #63. She stated that she changed the bedsheet and the Resident's clothing because they were soaked with urine. On 5/26/2021 at 12:11 pm an interview with the Scheduler was conducted and revealed the assigned NA for Resident #63 on 5/24/2021 day shift, was NA # 06. She added that NA # 06 was from an agency and provided a contact phone number. A review of the 200-hall assignment sheet dated 5/24/2021 documented NA # 06 was assigned rooms 216-221. On 5/26/2021 at 12:20 pm an interview was conducted with Unit Manager #1 and she revealed that incontinence care was not documented for Resident #63 on 5/24/2021, 7 am - 3 pm shift. A telephone interview was conducted with NA # 06 on 5/26/2021 at 3:58 pm. NA #06 stated she was not assigned Resident #63 and did not provide care to the Resident on 5/24/2021. She stated her assignment was rooms 208 - 214. An interview occurred on 5/27/2021 with NA # 05 and she revealed her assignment on 5/24/2021 was rooms 208-215. She stated the assignment sheet for the 200-hall assignment, dated 5/24/2021 was accurate. She added she witnessed NA #06 exit Resident #63's room on 5/24/2021 during the meal tray pick up. An interview was conducted on 5/27/2021 at 9:17 am, with Unit Manager #1 and she revealed her expectation was for an NA to complete necessary care as assigned and if unable, to report to the charge nurse. She denied being aware of a situation or confusion with assignments on 5/24/2021. She stated, after the facilities investigation into the care provided to Resident #63 on 5/24/2021, NA #06 was not allowed to return to the facility and the agency was made aware on 5/26/2021. An interview was conducted with Resident #63 on 5/27/2021 at 9:04 am. When asked how not receiving incontinent care on day shift, 5/24/2021, made her feel, she stated, not being cleaned up, she then paused, looked down at the ground and added, why would they do that? Not come and help me? I just don't understand.

Based on record review, interviews with resident, family, staff, nurse practitioner, Orthopedic nurse practitioner and physician, the facility failed to manage residents' pain by not administering pain medication as ordered by the physician for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pain management. This resulted in Resident #1 crying and screaming into her pillow due to the pain being terrible and ultimately leaving the facility the next day against medical advice. Resident #2 experienced pain at a scale of 10+ (0 being no pain and 10 being the worst pain) and ultimately was sent to the emergency room for pain management. Immediate Jeopardy began on 12-13-19 when Resident #1, who was newly admitted to the facility with hospital discharge orders for multiple pain medications, did not receive her pain medications resulting in the resident experiencing excruciating pain and leaving the facility the next day. Resident #2's Immediate Jeopardy began on 1-1-20 when Resident #2 did not receive his pain medication because the facility ran out the medication resulting in the resident experiencing excruciating pain and the resident was transferred to the hospital emergency room to control his pain. Immediate Jeopardy was removed on 1-10-20 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put in place are effective. Findings included: 1. Resident #1 was admitted to the facility on [DATE] at approximately 6:45pm with multiple [DIAGNOSES REDACTED]. Resident #1's hospital discharge summary dated 12-13-19 revealed an order for [REDACTED]. Resident #1 left the facility against medical advice on 12-14-19 at approximately 7:00pm. There was not a care plan, or a Minimum Data Set completed. Resident #1's facility's admission nursing assessment signed by Nurse #1 dated 12-13-19 revealed Resident #1 was alert, oriented and had a pain level of zero. An interview with the admitting nurse, Nurse #1, occurred on 1-8-20 at 1:10pm. Nurse #1 said she had briefly entered Resident #1's room on 12-13-19 around 6:50pm to introduce herself and initiated the nursing assessment in the resident's electronic medical record but did not complete a full nursing assessment or ask about Resident #1's pain level. The Nurse stated, she didn't look like she was in pain. Nurse #1 stated, the resident came into the building right before the end of my shift at 7:00pm. The nurse also indicated she was not comfortable completing an admission assessment on Resident #1 because she did not have her (the resident) discharge paperwork from the hospital. Nurse #1 indicated she did not report Resident #1's admission to the on-coming nurse at 7:00pm. Resident #1 was interviewed by telephone on 1-7-20 at 11:01am. Resident #1 stated she arrived at the facility on the evening of 12-13-19 and upon arrival a staff member escorted her to her room and took her hospital discharge paperwork but she did not remember the name or title of the staff member. She also indicated a nursing assistant entered her room and obtained vital signs, but she did not see a nurse. Resident #1 said she requested to see a nurse for some pain medication several times on the evening of 12-13-19 and was not provided with either of her requests. The resident also expressed she felt neglected and described her pain as continuously excruciating and stated, I remember crying and screaming into my pillow because the pain was so terrible throughout the night of 12-13-19 and into the next day 12-14-19 for approximately 11 hours. Resident #1 stated she left the facility the next day (12-14-19) with a family member and went home. During an interview with nursing assistant (NA) #1 on 1-8-20 at 1:47pm, the NA was assigned to Resident #1 on the evening of 12-13-19 and remembered the resident using her call light two times during the shift (7:00pm-7:00am) and requesting pain medication for her back. NA #1 indicated she informed Nurse #2 and Nurse #3 of the resident's request for pain medication and Nurse #3 stated the pain medication was not available from the pharmacy. The NA revealed Resident #1 was not grimacing, grunting or crying at the time she requested pain medication. NA #1 said she had not provided any activities of daily living care to Resident #1. Nurse #2 was interviewed on 1-8-20 at 1:25pm. Nurse #2 worked from 7:00pm to 11:00pm on the evening of 12-13-19 but did not do an admission nursing assessment on Resident #1. Nurse #2 stated, (Nurse #1) admitted (Resident #1) so she would have completed the assessment. She also said she did not receive a resident report from Nurse #1 prior to starting her shift at 7:00pm. Nurse #2 revealed she briefly spoke to Resident #1 after the pharmacy called inquiring if the resident was allergic to [MEDICATION NAME]. Nurse #2 stated, I went in and asked about her allergies [REDACTED].#1 complained of pain and stated she did not administer the resident any medication. An interview with Nurse #3 occurred on 1-8-20 at 11:44am. Nurse #3 worked 11:00pm to 7:00am the night of 12-13-19 and remembered Resident #1. She revealed she did not complete an admission assessment on Resident #1 because the admitting nurse should have completed the assessment. Nurse #3 stated she did not receive a report on Resident #1 before beginning her shift. She stated (Nurse #2) didn't know much because she did not get a report from (Nurse #1). Nurse #3 indicated she did not have any interaction with Resident #1 and did not remember the resident requesting any pain medication, so she did not look to see if Resident #1 had any pain medication available. The nurse said she did not administer any medication to Resident #1 during her shift. NA #2 was interviewed on 1-9-20 at 4:10pm. NA #2 stated she worked on 12-14-19 from 7:00am to 3:00pm and was assigned to care for Resident #1. NA #2 remembered Resident #1 activating her call light a few times complaining of pain on 12-14-19. The NA said when Resident #1 would move the resident would make a grimacing face and grunt. NA #2 indicated she informed Nurse #1 several times on 12-14-19 of the resident's pain and the nurse told Resident #1 that staff was waiting for the physician to order her pain medication. The NA said she had not provided any activities of daily living care to Resident #1 because the resident did not request any care. The facility's narcotic count sheet dated 12-13-19 revealed one [MEDICATION NAME] 10-325mg tablet was removed from the medication cart by Nurse #1 on 12-14-19 at 11:00am for Resident #1. Resident #1's Medication Administration Record [REDACTED]. Nurse #1 was interviewed a second time on 1-8-20 at 1:15pm. Nurse #1 worked on 12-14-19 from 7:00am to 7:00pm and remembered Resident #1 complaining of pain. She said she informed the resident that her medications were not available from the pharmacy. Nurse #1 indicated she did not administer any medications to Resident #1. During an interview with the pharmacy manager on 1-7-20 at 1:25pm, the pharmacy manager revealed [MEDICATION NAME] 10-325mg tablet and [MEDICATION NAME] 500mg tablet were delivered to the facility at 9:45pm on 12-13-19 by the facility's back up pharmacy. He also said the rest of Resident #1's medications were not delivered to the facility until after 3:00pm on 12-14-19. During an Interview with the Quality Assurance Regional Nurse Consultant on 1/9/20 at 3:32 PM she stated it was not required, nor the facility's protocol to have nursing staff perform pain assessments every shift. She also stated, If a medication required a pain assessment prior to administration and a follow-up after administration of a pain medication, the physician's orders [REDACTED]. During an interview with the Physician Assistant (PA) on 1-9-20 at 5:40pm, the PA said she provided care to Resident #1 in the hospital post-surgery. She stated Resident #1 had a spinal fusion of her L3-pelvis area and would have been in excruciating pain and that the resident would not have been discharged without prescriptions for pain medication. The PA revealed Resident #1's mobility would have been hindered and recovery prolonged by not receiving pain medication. The Medical Director was interviewed on 1-9-20 at 3:30pm. The Medical Director said when a resident was admitted to the facility, staff would contact him or the physician assistant with the resident's information and medications that had been ordered. He also stated, admissions that happened later in the day would sometimes cause a delay in administering the admitted resident's medication but it is the facility's goal to administer medications as ordered by the physician. Resident #1's family member was interviewed by telephone on 1-10-20 at 3:10pm. The family member said upon Resident #1's admission to the facility, the resident was able to walk with assistance with moderate to severe back pain. The family member stated she received a call from Resident #1 on 12-13-19 and 12-14-19 crying and stating she did not receive any of her medications. The family member revealed she called the facility to inquire about Resident #1's medications and was informed by Nurse #1 that the facility was still waiting for the physician to order the resident's medication. The family member said she drove to the facility and took Resident #1 home against medical advice. The family member stated Resident #1 was in severe pain and could barley walk out of the facility but said she was able to give Resident #1 pain medication that the resident already had at home, which decreased the residents pain enough that the resident could sleep. A nursing note dated 12-14-19 at 7:10pm documented Resident #1 being alert, oriented and able to make her needs known and Resident #1 stating she had not been assessed in 26 hours or received any of her medications. Documentation revealed Resident #1 was ambulating down the facility hallway pushing a wheelchair with the resident's daughter present and leaving the facility in a private vehicle on 12-14-19 at 7:00pm. An interview was conducted with the orthopedic spinal physician assistant (OSPA) by telephone on 1-9-20 at 5:40pm. The (OSPA) revealed the resident would have been in excruciating pain without receiving her pain medication as ordered because of the type of surgery she received. The OSPA also said the resident's mobility would have been hindered due to the increased pain and resulted in prolonging recovery. 2. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's care plan dated 11-15-19 revealed a goal that he would verbalize adequate relief of pain or the ability to cope with incomplete relief. The interventions associated with that goal were in part; anticipate need for pain relief, evaluate the effectiveness of pain interventions, notify the physician if interventions are unsuccessful and observe for and report to the nurse any signs and symptoms of non-verbal pain. The annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was minimally cognitively impaired and coded as almost constantly in pain with decrease sleep and activities due to a pain level of 10 on a scale of 0 (no pain) to 10 (the worst pain). The MDS also revealed Resident #2 received opioid (pain medication) 7 out of 7 days. The physician orders [REDACTED].#2; [MEDICATION NAME] 500mg (milligrams) 1 tablet twice a day for muscle spasms, [MEDICATION NAME] 10mg 1 tablet 3 times a day for muscle spasms, [MEDICATION NAME] 800mg 1 tablet 3 times a day for pain, [MEDICATION NAME] 15mg 1 tablet 4 times a day for pain, [MEDICATION NAME] 5-325mg 1 tablet 4 times a day for pain until [MEDICATION NAME] 15mg is available. During an interview with Resident #2 on 1-8-20 at 8:45am, the resident revealed he had constant pain in his back due to my spine is falling apart because the discs are bad but his regularly scheduled pain medication, [MEDICATION NAME] 15mg, worked well controlling his pain. Resident #2 stated about a week ago the facility ran out of his pain medication in the morning and that it was not until the middle of the night the facility administered a different pain medication, [MEDICATION NAME] 5-325mg. The resident said he informed the nurse that [MEDICATION NAME] was not working and that he had excruciating pain. The resident described his pain at a level of 10+ all day and stated, I couldn't even get out of bed. Resident #2 said he had to go to the emergency room to receive pain relief. Nursing assistant (NA) #6 was interviewed on 1-9-20 at 3:30pm. The NA stated Resident #2 often complained of pain and that she would inform the nurse. She also stated when Resident #2 was having pain she had to assist him more with his activities of daily living because he could not move around as well. Resident #2's Medication Administration Record [REDACTED]. On 1-1-20, [MEDICATION NAME] was documented as administered to the resident at 9 am. On 1-1-20, [MEDICATION NAME] was documented as unavailable for administration to the resident at 12pm, 5pm, and 9pm. Medication Aide (MA) #1 was interviewed on 1-9-20 at 11:23am. MA #1 stated she worked with Resident #2 on 1-1-20 and the resident ran out of his [MEDICATION NAME] after she administered the 9:00am dose on 1-1-20. She stated she informed nurse #4 the resident was out of his medication. She also said the medication card had a refill request on it but as a Medication Aide she was not allowed to reorder the medication. During an interview with Nurse #4 on 1-9-20 at 8:50am, the nurse stated she was not made aware by MA #1 that Resident #2 had run out of his [MEDICATION NAME] on 1-1-20 because I was not giving medications, the MA #1 was giving medications at that time. She also said when Resident #2 complained of severe pain on 1-2-20 around 9:00pm, she realized he did not have his scheduled medication, so she called the physician to obtain orders for pain medication that was available through the facility's inventory management system ([MEDICATION NAME] 5-325mg 1 tablet 4 times a day until [MEDICATION NAME] 15mg is available) which she stated she administered at 10:00pm on 1-1-20. Nurse #4 said the resident informed her the pain medication was not controlling his pain and the resident requested to go to the emergency room . The nurse stated the resident was sent to the emergency roiagnom on [DATE] around 4:00am for severe pain. The facility's narcotic count sheet revealed Resident #2 received [MEDICATION NAME] 5-325mg 1 tab at 10:00pm on 1-1-20. A review of Resident #2's MAR for the medication [MEDICATION NAME] 5-325mg tablet revealed the medication had not been documented as administered on 1-1-20. Nurse #4's documentation dated 1-2-20 at 2:45am revealed Resident #2 was complaining of severe back pain and the pain was not relieved by the pain medication that had been administered. Documentation also revealed Resident #2 requested to go to the emergency room . Nurse #4's documentation on 1-2-20 at 3:05am revealed communication with the nurse practitioner and orders to send Resident #2 to the emergency room . The emergency department documentation dated 1-2-20 at 5:34am revealed Resident #2 was treated for [REDACTED]. Documentation also revealed Resident #2's pain had improved, and the resident was transferred back to the facility. The pharmacy manager was interviewed by telephone on 1-9-20 at 10:48am. The pharmacy manager stated they received an order for [REDACTED]. An interview with the Nurse Practitioner (NP) occurred on 1-9-20 at 12:30pm. The NP said she would not expect Resident #2 to suffer withdrawal symptoms from missing a few doses of his [MEDICATION NAME] but would expect the resident to have increased pain and more difficulty with mobility. She also stated she would not expect a resident to run out of their medication staff just has to call us, and we can fax a script over to the pharmacy. The Director of Nursing and the Corporate Nurse Consultant were notified of the Immediate Jeopardy on 1-10-20 at 12:10pm. On 1-10-20 at 11:05pm the facility provided the following credible allegation of Immediate Jeopardy removal: Resident # 1 was admitted to the facility on [DATE] at approximately 6:45 PM after hospital stay status [REDACTED]. Resident [DIAGNOSES REDACTED]. Nursing Admission Assessment completed on 12/13/2019 and indicated no pain was noted. On 12/13/2019 and 12/14/2019 resident did not receive medication as ordered. Resident discharged against medical advice on 12/14/2019. Nurse #1 on 12/13/2019 did not call pharmacy and request for back up pharmacy for medications to be delivered upon admission. On 12/13/2019 Nurse #3 did not remember any report of pain from the resident and did not give the resident any pain medication during the 11pm to 7am shift. On 12/14/2019 Nurse #2 did not call pharmacy and request for back up pharmacy for medications to be delivered. Root cause for the incident with Resident #1 is Nurse #1 did not administer pain medication due to lack of knowledge. Root cause for the incident with Resident #1 is Nurse #2 did not administer pain medication due to lack of knowledge. Root cause for the incident with Resident #1 is Nurse #3 did not administer pain medication due to lack of knowledge Resident #2. Resident #2 had an order for [REDACTED]. Resident responded pain level was 0 per electronic medication administration record. On 1/1/2020 Resident did not receive [MEDICATION NAME] 15mg at 12:00 noon, 5:00 pm and at 9:00 pm. On 1/1/2020 10:30 pm resident received pain medication [MEDICATION NAME] 5/325mg per physician orders [REDACTED]. On 1/1/2020 at 11:30pm Nurse Practitioner was notified of resident complaining of severe back pain and requesting to go to the hospital and that resident indicated that medication given to him earlier did not do anything for him. At 11:50pm resident refused Tylenol and continued to state he wants to go to the hospital. Nurse practitioner notified at 12:03am on 1/2/2020 of the above, and ordered a one-time dose of [MEDICATION NAME] 500mg and to wait 4 hours before giving another [MEDICATION NAME] 5/325mg. On 1/2/2020 at 12:10am resident received pain medication [MEDICATION NAME] 500mg. On 1/2/2020 at 2:30am resident refused pain medication [MEDICATION NAME] 5/325mg when nurse offered medication per physician orders. Resident refused and stated he wanted to go to the hospital. Nurse Practitioner was notified, and resident was transferred to the hospital on [DATE] at 2:45am. 1/3/2019 resident did not receive [MEDICATION NAME] 15mg at 12:00 noon. Root cause for the incident with Resident #2 is Nurse #1 did not administer pain medication due to lack of knowledge. Pain assessments ordered for all current residents on 1/10/2020 to be completed every shift daily by nurse. Pain assessments to be documented in the electronic Medication Administration Record [REDACTED]. All pain assessments have been completed on all current residents on 1/10/2020. The audit also ensured that pain medications are administered as ordered. Physician was notified for any resident who complained of a new onset of pain or reported severe pain that was not treated with current interventions. Any new orders for pain medications were obtained, orders faxed to pharmacy so as to obtain medication from back up pharmacy. Medications administered as ordered. All audits were completed on 1/10/2020. 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. All Full Time and Part Time and as needed (PRN) Nursing Staff (Nurses and Nursing assistants) will be educated on the following by the Director of Nursing. Education began on 1/10/2020. Education was completed on 1/10/2020 in reference to Pain management and assessment, Medication errors to include how to order and reorder medication. Education included: Pain assessment will be completed on each resident every shift by the nurse daily. Pain assessments will be completed for each new admissions or readmissions upon admission. Pain medications will be administered as ordered by physician. The monitoring will be done by the Director of Nursing or Assistant Director of Nursing Or Unit Support Nurses and will include reviewing the Point of care dashboard; Med Passes in the last 24 hours for each hall assignment every day to ensure that all medications have been administered as ordered and also by reviewing the Not Administered Med passes in last 24 hours on the dashboard checking the # of documentation saved as not administered. Changes in a patient condition occur for many different reasons. New onset of pain or complaints of pain or worsening pain unrelieved by interventions should be addressed by nurse for all resident in the facility. What to do if a resident has a new onset of pain or complains of pain or worsening pain unrelieved by interventions. If you are not a nurse, then notify the nurse immediately of the pain changes you have noticed. Even small pain changes can be very important since they may indicate bigger problems to come. Nurses should assess the patient for pain upon notification. Assessment needs will vary depending on the patient 's complaint or signs/symptoms The patient's chart should also be reviewed in order to determine if a patient had a condition that may explain the signs and symptoms they are experiencing. If interventions are available by using the standing orders, patient current orders, or items identified in the plan of care then they should be implemented as appropriate. This may include Tylenol for fever, prn pain medication etc. Administer pain medications as ordered by physician. Pain Interventions should be implemented promptly when pain change is identified. Administer pain medications as ordered by physicians. Pain Assessment results and interventions must be documented in the medical record. Immediate Notification of physician is required when there is a new onset of pain or the pain is severe and current interventions are not effective. Documentation of this notification should be completed, and new orders obtained and documented. Administer pain medications per physician orders. Phone numbers for physicians are located at the nursing stations. If a physician does not respond to an emergency or If you are unable to reach the attending physician or the physician on call, call the facility medical director within 30 minutes of contacting the primary physician. If the attending physician or medical director does not provide an appropriate response or does not call back within 30 minutes, then the nurse is to contact the Director of Nursing immediately for further instructions. Notify the responsible party and document this in the nursing notes. If the physician orders [REDACTED]. If resident refuses to be transferred to the acute care hospital or if resident representative refuses for the resident to be transferred to the acute care hospital, Physician will be notified of the refusal. Document notification of physician on such situations and follow and document physician orders [REDACTED]. Pain assessments are documented in the electronic health record. This includes nursing user defined assessments; vital signs tab, and the electronic medication records. Verbal or visual pain scales can be used to assist patients who are able to verbalize pain. Nonverbal scales are used when patients are not able to verbalize pain intensity. What to do when a drug is not available? If the medication is an OTC (over the counter drug), check the medication OTC stock supply located at each Medication room (Located at each nursing station). If you are unable to locate it there, proceed to the Central Supply Room. If you are unable to locate it there, proceed to the other medication carts to see if the OTC is available there. If the medication is still unavailable, contact the DON or Nurse Manager for further guidance. If the medication is a prescription drug, you would first check the Medispense system located at the Rehab hall nurses station medication room (100/200 hall). If the medication is not in the Medispense system, then immediately notify pharmacy so it can be obtained from back up. If the prescription medication ordered will be delayed more than one hour, notify the physician for any additional orders or directions. Medications must be given in the form ordered by the Physician unless the MD gives an order to dose differently. If at any time you have questions regarding the medication administration process, please contact the DON or Nurse Manager. Ordering Medications from the Provider Pharmacy for new admission, readmissions, new orders, and for current residents (reordering). 1) Medication orders are written on a medication order form and transmitted to the pharmacy. The written entry includes: Date ordered, Whether the order is new or a repeat order (refill). If the order is a repeat order (refill), include the prescription number. Resident's name. Medication name and strength, when indicated. Directions for use, if a new order, or direction changes to a previous order. 2) Repeat medications (refills) are ordered by peeling the top label from the unit dose card and placing it in the appropriate area and ordered as follows: a) Reorder medication (three to four) days in advance of need to assure an adequate supply is on hand. When reordering medication that requires special processing (such as Schedule II controlled substances, Department of Veterans Affairs prescriptions), order at least (seven days) in advance of need. b) The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. c) The refill order is called in, faxed, or otherwise transmitted to the pharmacy. 3) New medications, except for emergency or stat medications, are ordered as follows: a) If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within (4) hours. b) Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to pharmacy delivery. 4) Stat and emergency medications are ordered as follows: a) During regular pharmacy hours, the emergency or stat order is phoned or faxed to the pharmacy. Such medications are delivered and administered within (2) hours. If available, the initial dose is obtained from the emergency kit, when necessary. 5) When phoning or faxing a medication order to the pharmacy, the following information is given: a) Resident's name. b) Prescription number if a refill. c) Complete order if a new medication order or direction changes to a previous order. d) Name of prescriber if a new order. e) Indication for use. f) Name of person calling in order. 6) New admission orders [REDACTED] a) When calling/faxing MEDICATION ORDERS FOR [REDACTED]. b) The medication order form is also used to notify the provider pharmacy of changes in dosage, directions for use, etc. of current medications. This in service was completed by 1/10/2020. Any nursing staff (full time, part time, and PRN) who did not receive in-service training will not be allowed to work until training is completed. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees. Immediate Jeopardy Removal Date: 1/10/2020. The credible allegation for Immediate Jeopardy removal was validated on 1-11-20 at 10:00am which removed the Immediate Jeopardy on 1-10-20 as evidenced by staff interviews, in-service record reviews and observations. The in-service included information on ordering and re-ordering medications, pain assessments, pain management, type of pain and the different pain scales, what to do when a medication is not available, types of medication errors and the facility's policy and procedures on medication administration.

Based on record review, staff interview, pharmacy interview, resident interview and nurse practitioner interview the facility failed to implement effective procedures to assure pain medication was available to meet the needs of the residents. This was evident in 1 of 2 residents (Resident #2) reviewed for pain management. This resulted in Resident #2 complaining of being in excruciating pain and ultimately having to be sent to the emergency room for pain management. Immediate Jeopardy began on 1-1-20 when Resident #2 did not receive his pain medication because the facility ran out of the medication on 1-1-20 resulting in the resident experiencing excruciating pain and the resident being transferred to the emergency room for pain management. Immediate Jeopardy was removed on 1-10-20 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put in place are effective. Findings included: The facility's policy and procedure (not dated) for ordering and receiving medications from the pharmacy was reviewed and revealed in part the following: repeat medications (refills) are ordered by peeling the top label from the unit dose card and placing it in the appropriate area and ordered as follows; reorder medication 3 to 4 days in advance of need to assure an adequate supply is on hand. When reordering medication that requires special processing (such as schedule 2 controlled substances), order at least 7 days in advance of need. The refill order is called in, faxed or otherwise transmitted to the pharmacy. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 and coded as almost constantly in pain with decrease sleep and activities due to a pain level of 10 (0 no pain, 10 worst pain). The MDS also revealed Resident #2 received opioid (pain medication) during 7 out of 7 days of the look behind period. The physician orders [REDACTED].#2; [MEDICATION NAME] 500mg (milligrams) 1 tablet twice a day for muscle spasms, [MEDICATION NAME] 10mg 1 tablet 3 times a day for muscle spasms, [MEDICATION NAME] 800mg 1 tablet 3 times a day for pain, [MEDICATION NAME] 15mg 1 tablet 4 times a day for pain, [MEDICATION NAME] 5-325mg 1 tablet 4 times a day for pain until [MEDICATION NAME] 15mg is available. During an interview with Resident #2 on 1-8-20 at 8:45am, the resident stated he had constant pain in his back due to my spine is falling apart because the discs are bad but his regularly scheduled pain medication, [MEDICATION NAME] 15mg (milligrams), worked well controlling his pain. Resident #2 stated about a week ago the facility had run out of his pain medication ([MEDICATION NAME] 15mg) in the morning and that it was not until the middle of the night the facility administered a different pain medication that, the resident stated, did not control his pain. The resident described his pain at a level of 10+ all day. Resident #2 stated he had to be transferred to the emergency room to receive pain relief. Resident #2's Medication Administration Record [REDACTED]. On 1-1-20, [MEDICATION NAME] was documented as administered to the resident at 9 am. On 1-1-20, [MEDICATION NAME] was documented as not available for administration to the resident at 12pm, 5pm, and 9pm. The facility's narcotic count sheet revealed Resident #2 received [MEDICATION NAME] 5-325mg 1 tab at 10:00pm on 1-1-20. Review of the MAR for 1-1-20 revealed the [MEDICATION NAME] was not documented as administered at 10:00pm. Nurse #4's documentation dated 1-2-20 at 2:45am revealed Resident #2 was complaining of severe back pain and the pain was not relieved by the pain medication that had been administered. Documentation also revealed Resident #2 requested to go to the emergency room . Nurse #4's documentation on 1-2-20 at 3:05am revealed communication with the nurse practitioner and orders to send Resident #2 to the emergency room . The emergency department documentation dated 1-2-20 at 5:34am revealed Resident #2 was treated for [REDACTED]. Documentation also revealed Resident #2's pain had improved, and the resident was transferred back to the facility on [DATE] at 9:39am. Medication Aide (MA) #1 was interviewed on 1-9-20 at 11:23am. MA #1 worked with Resident #2 on 1-1-20 and stated the resident ran out of his [MEDICATION NAME] after she administered the 9:00am dose on 1-1-20. She stated she informed Nurse #4 the resident was out of his medication. She also said the medication card had a refill request on it but as a MA she was not allowed to reorder the medication and that was why she informed the nurse. During an interview with Nurse #4 on 1-9-20 at 8:50am, Nurse #4 stated she was not made aware Resident #2 was out of his [MEDICATION NAME] on 1-1-20 until the 9:00pm dose was to be administered. She stated she called the physician to obtain an order for [REDACTED].#4 stated Resident #2 complained about 2 hours after the new pain medication was given that the pain medication was not working and requested to go to the emergency room . She stated Resident #2 was sent to the emergency room around 4:00am on 1-2-20. The nurse stated medications were reordered through the resident's electronic medical record but if there was a MA on the medication cart, then the MA would have to inform the nurse that the medication needed to be reordered. During an interview with Nurse #5 on 1-10-20 at 12:11pm, she said if the resident ran out of their medication the nurse would first call the pharmacy to see if there were refills and if not, then the nurse could call the physician and have them fax over the script to the pharmacy and the pharmacy would have the back up pharmacy deliver the medication. The pharmacy manager was interviewed on 1-9-20 at 10:48am. The pharmacy manager stated they received an order for [REDACTED]. A review of Resident #2's MAR for 1-2-20 revealed [MEDICATION NAME] was documented as administered to the resident at 5:00pm on 1-2-20. An interview with the Nurse Practitioner (NP) occurred on 1-9-20 at 12:30pm. The NP said she would not expect a resident to run out of their medication staff just has to call us, and we can fax a script over to the pharmacy. The Director of Nursing (DON) was interviewed on 1-10-20 at 10:06am. The DON stated the nurse on duty 1-1-20 should have reordered Resident #2's [MEDICATION NAME]. She also said she had conducted an in-service in (MONTH) 2019 on ordering/reordering medications due to a similar incident in (MONTH) and would be re-educating the staff on the proper process per the facility's policy and procedures. During a telephone interview with the Director of Nursing (DON) on 1-21-20 at 2:50pm, the DON stated medications were delivered and dispensed on bingo cards and when there were 8 doses of a resident's medication left, the vertical line of the last 8 doses would be in a different color alerting the nurse to remove the re-order sticker from the card, place it on a re-order sheet and fax the re-order sheet to the pharmacy. She also stated the process for re-ordering narcotic medication was the same. The Director of Nursing and the Corporate Nurse Consultant were notified of the Immediate Jeopardy on 1-10-20 at 4:50pm. On 1-10-20 at 10:59pm the facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #2 had an order for [REDACTED]. Resident responded pain level was 0 per electronic medication administration record. On 1/1/2020 Resident did not receive [MEDICATION NAME] 15mg at 12:00 noon, 5:00 pm and at 9:00 pm. On 1/1/2020 10:30 pm resident received pain medication [MEDICATION NAME] 5/325mg per physician orders [REDACTED]. On 1/1/2020 at 11:30pm Nurse Practitioner was notified of resident complaining of severe back pain and requesting to go to the hospital and that resident indicated that medication given to him earlier did not do anything for him. At 11:50pm resident refused Tylenol and continued to state he wants to go to the hospital. Nurse practitioner notified at 12:03am on 1/2/2020 of the above and ordered a one-time dose of [MEDICATION NAME] 500mg and to wait 4 hours before giving another [MEDICATION NAME] 5/325mg. On 1/2/2020 at 12:10am resident received pain medication [MEDICATION NAME] 500mg. On 1/2/2020 at 2:30am resident refused pain medication [MEDICATION NAME] 5/325mg when nurse offered medication per physician orders. Resident refused and stated he wanted to go to the hospital. Nurse Practitioner was notified, and resident was transferred to the hospital on [DATE] at 2:45am. 1/3/2019 resident did not receive [MEDICATION NAME] 15mg at 12:00 noon. Root because for the incident with Resident #2 is Nurse #1 did not administer pain medication due to lack of knowledge of how to order and reorder narcotic medication timely, as the pain medication was not reordered in time. On 1/10/2020 a chart audit was initiated for all current residents. The audit was completed by the Assistant director of nursing, Unit Support nurses and Director of Nursing to ensure that all residents had their medications per physician order [REDACTED]. The audit also ensured that pain medications were administered as ordered. The Assistant Director of Nursing and Unit support nurses, checked all medication carts and compared to the physician orders, and ensured that all medications were available and medications administered per order. All current residents have medications available and medications administered per order. All audits were completed on 1/10/2020. 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. All Full Time and Part Time and as needed (PRN) Nursing Staff (Nurses and Nursing assistants {which includes any Nursing assistants who are medication aides}) will be educated on the following by the Director of Nursing. Education began on 1/10/2020. Education was completed on 1/10/2020 in reference to how to order and reorder medication. Education included: Pain medications will be administered as ordered by physician. The monitoring will be done by the Director of Nursing or Assistant Director of Nursing Or Unit Support Nurses and will include reviewing the Point of care dashboard; Med Passes in the last 24 hours for each assignment every day to ensure that all medications have been administered as ordered and also by reviewing the Not Administered Med passes in last 24 hours on the dashboard checking the # of documentation saved as not administered. PRN pain medications will be administered as ordered by physician. The monitoring will be done by the Director of Nursing or Assistant Director of Nursing or Unit Support Nurses and will include reviewing the Point of Care dashboard; Administered PRN medication in the last 24 hours for each assignment every day to ensure that PRN medications have been administered as ordered. What to do if a resident has a new onset of pain or complains of pain or worsening pain unrelieved by interventions. If interventions are available by using the standing orders, patient current orders, or items identified in the plan of care then they should be implemented as appropriate. This may include Tylenol for fever, prn pain medication etc. Administer pain medications as ordered by physician. What to do when a drug is not available? If the medication is an OTC (over the counter drug), check the medication OTC stock supply located at each Medication room (Located at each nursing station). If you are unable to locate it there, proceed to the Central Supply Room. If you are unable to locate it there, proceed to the other medication carts to see if the OTC is available there. If the medication is still unavailable, contact the DON or Nurse Manager for further guidance. If the medication is a prescription drug, you would first check the Medispense system located at the Rehab hall nurses station medication room (100/200 hall). If the medication is not in the Medispense system, then immediately notify pharmacy so it can be obtained from back up. If the prescription medication ordered will be delayed more than one hour, notify the physician for any additional orders or directions. Medications must be given in the form ordered by the Physician unless the MD gives an order to dose differently. If at any time you have questions regarding the medication administration process, please contact the DON or Nurse Manager. Ordering Medications from the Provider Pharmacy for new admission, readmissions, new orders, and for current residents (reordering). 1) Medication orders are written on a medication order form and transmitted to the pharmacy. The written entry includes: Date ordered, Whether the order is new or a repeat order (refill). If the order is a repeat order (refill), include the prescription number. Resident's name. Medication name and strength, when indicated. Directions for use, if a new order, or direction changes to a previous order. 2) Repeat medications (refills) are ordered by peeling the top label from the unit dose card and placing it in the appropriate area and ordered as follows: a) Reorder medication (three to four) days in advance of need to assure an adequate supply is on hand. When reordering medication that requires special processing (such as Schedule II controlled substances, Department of Veterans Affairs prescriptions), order at least (seven days) in advance of need. b) The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. c) The refill order is called in, faxed, or otherwise transmitted to the pharmacy. 3) New medications, except for emergency or stat medications, are ordered as follows: a) If needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request delivery within (4) hours. b) Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to pharmacy delivery. 4) Stat and emergency medications are ordered as follows: a) During regular pharmacy hours, the emergency or stat order is phoned or faxed to the pharmacy. Such medications are delivered and administered within (2) hours. If available, the initial dose is obtained from the emergency kit, when necessary. 5) When phoning or faxing a medication order to the pharmacy, the following information is given: a) Resident's name. b) Prescription number if a refill. c) Complete order if a new medication order or direction changes to a previous order. d) Name of prescriber if a new order. e) Indication for use. f) Name of person calling in order. 6) New admission orders [REDACTED] a) When calling/faxing MEDICATION ORDERS FOR [REDACTED]. b) The medication order form is also used to notify the provider pharmacy of changes in dosage, directions for use, etc. of current medications. This in service was completed by 1/10/2020. Any nursing staff (full time, part time, and PRN) who did not receive in-service training will not be allowed to work until training is completed. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees. Education was completed on 1/10/2020 in reference to how to order and reorder medications. This in service was completed by 1/10/2020. Any nursing staff (full time, part time, and PRN) who did not receive in-service training will not be allowed to work until training is completed. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees. Immediate Jeopardy Removal Date: 1/10/2020. The credible allegation for Immediate Jeopardy removal was validated on 1-11-20 at 10:00am which removed the Immediate Jeopardy on 1-10-20 as evidenced by staff interviews, in-service record reviews and observations. The in-service included information on ordering and re-ordering medications, what to do when a medication is not available, types of medication errors and the facility's policy and procedures on medication administration.

Based on staff and physician interviews and record review the facility failed to hold a resident's anticoagulant ([MEDICATION NAME], a blood thinner) as ordered by the physician. The resident was given two doses of [MEDICATION NAME] that was ordered to be on hold and experienced a critically high INR (International Normalized Ratio) laboratory value that required hospitalization with intervention. The intervention was Vitamin K (reverses the effect of blood thinner). This was for 1 of 3 sampled residents (Resident #1) reviewed for unnecessary medications. The findings included: Resident #1 was admitted to the facility on [DATE] with stage 3 [MEDICAL CONDITIONS], acute embolism and [MEDICAL CONDITION] of deep veins in lower extremities and long-term use of anticoagulants. There was no completed Minimum Data Set (MDS) assessment for the resident due to the resident being recently admitted to the facility. An interim care plan dated 05/16/19 specified the resident was on anticoagulant therapy and at risk for toxicity and abnormal bleeding. Interventions included: labs as ordered and report abnormal lab results to the physician. admission orders [REDACTED] - [MEDICATION NAME] (blood thinner) 5 milligrams (mg) on Monday, Tuesday, Thursday, Friday and Saturday - [MEDICATION NAME] 2.5 milligrams on Wednesday and Sunday Also, on 05/16/19 a physician's orders [REDACTED].#1's PT/INR ([MEDICATION NAME] time tests / international normalized ratio) on 05/17/19. On 05/17/19 Resident #1's PT/INR results were 27.5 seconds and 2.6 (normal range for PT is 11.4 - 14.6 seconds and INR is 0.8 - 1.2 as specified on the lab results report). Both values were high. The results were called to the physician, who ordered to continue the same doses of [MEDICATION NAME] and recheck the PT/INR on 05/20/19. On 05/20/19 Resident #1's PT/INR was rechecked, and the results were 35.2 seconds/3.6 (both high). The results were called to the physician and an order was written to hold the [MEDICATION NAME] for 48 hours and recheck the PT/INR on 05/22/19. Resident #1's Medication Administration Record [REDACTED]. According to the medical record, on 05/22/19 Resident #1 was diagnosed with [REDACTED]. Review of the MAR indicated [REDACTED]. On 05/22/19 Resident #1's PT/INR was rechecked, and the results were 34.0 seconds/3.5 (high). The results were called to the physician and an order was written to hold the [MEDICATION NAME] for 48 hours and recheck the PT/INR on 05/24/19. Resident #1's MAR indicated [REDACTED]. On 05/24/19 a nurse's progress note revealed Resident #1's urine culture results showed greater than 100,000 bacteria (indicating an infection). The physician was notified and ordered to continue administering [MEDICATION NAME] (broad spectrum antibiotic). Resident #1's PT/INR was rechecked on 05/24/19 and the results remained high (35.3 seconds and 3.6). The physician ordered to hold [MEDICATION NAME] for 48 hours (05/25/19 and 05/26/19) and recheck PT/INR after 48 hours on 05/27/19. Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Nurse #2 administered the [MEDICATION NAME] to Resident #1 on 05/25/19 and 05/26/19. On 06/04/19 at 1:25 PM Nurse #1 was interviewed on the telephone and explained that on 05/24/19 she received Resident #1's PT/INR results and notified the on-call physician that they were high. She added she received an order to hold the [MEDICATION NAME] for 48 hours. Nurse #1 explained that she attempted to hold the [MEDICATION NAME] but there was a current order to hold the [MEDICATION NAME]. She added that she was unaware the order entered in the computer was time sensitive and would come off at midnight on 05/24/19 which allowed the resident to get [MEDICATION NAME] on 05/25/19 and 05/26/19. Nurse #2 who administered [MEDICATION NAME] to Resident #1 on 05/25/19 and 05/26/19 was unable to be reached for an interview. Review of the progress notes for 05/25/19 and 05/26/19 specified the resident remained at his baseline and showed no signs or symptoms of [MEDICATION NAME] toxicity such as bruising or bleeding. On 05/27/19 Resident #1's PT/INR results were checked and noted to be critically high 62.9 seconds and 7.6. The physician was notified and ordered to hold the [MEDICATION NAME] and recheck Resident #1's PT/INR on 05/28/19. Resident #1's MAR indicated [REDACTED]. A nurse's entry dated 05/27/19 specified Resident #1's [MEDICATION NAME] was on hold due to critical INR and the resident had no concerns identified. On 05/28/19 Resident #1's PT/INR results were checked and noted to be critically high. The PT was greater than 90 seconds and the INR was not calculated (there was no indication why the value was not calculated). A physician assistant's (PA) progress note dated 05/28/19 specified an acute visit was made due to abnormal lab results. The PA documented that Resident #1 was noted to have a PT greater than 90 and the resident denied acute bleeding, abdominal pain, melena (blood in stool), no acute distress was noted on exam. The PA assessed Resident #1 and ordered to send the resident to the Emergency Department due to a critically high INR for further evaluation and possible fresh frozen plasma. A SBAR (Situation, Background, Assessment, Recommendation) note dated 05/28/19 specified Resident #1 was being transported to the Emergency Department due to elevated PT/INR results and was at high risk bleeding. There was no documented bruising or bleeding on the SBAR. The initial Emergency Department (ED) note dated 05/28/19 indicated Resident #1 was being evaluated for elevated INR and there was no active bleeding, but some bruising was noted. The ED records specified the resident had a poor prognosis due to multiple comorbidities and was treated with Vitamin K (used to reverse effects of [MEDICATION NAME]). While the in the ED on 5/28/19, the records specified Resident #1 developed multiple bruising to upper and lower extremities. Resident #1 was admitted to the hospital and his PT/INR levels returned to normal ranges after being treated with Vitamin K. On 06/04/19 at 10:24 AM the Director of Nursing (DON) was interviewed and explained that PT/INR labs were drawn in the morning as ordered by the physician and [MEDICATION NAME] was administered in the evening, once the results were received. She added that the facility waited to administered [MEDICATION NAME] until lab results were received and the physician was notified, in the event there were changes to the medication. The DON reported that the nurse was expected to follow physician orders [REDACTED]. The DON reported she was notified that Resident #1 had been given [MEDICATION NAME] in error. The DON stated she spoke with Nurse #1 and discovered the Nurse thought the medication was already on hold. The DON added that Nurse #1 did not know she needed to enter a new hold order. On 06/04/19 at 2:10 PM the physician was interviewed on the telephone and explained that she was made aware Resident #1 had received two doses of [MEDICATION NAME] totaling 7.5mg in error. She added that Resident #1 had comorbidities including terminal illness and was started on [MEDICATION NAME] for pneumonia and a urinary tract infection. She explained that those factors skewed lab values and she did not feel the labs were reliable due to comorbidities, antibiotics, dehydration and poor nutrition. On 06/05/19 at 1:45 PM the Administrator was notified via telephone of the Immediate Jeopardy. On 06/06/19 the facility provided the following corrective action plan: Resident #1 discharged to the hospital on [DATE]. On 5/28/2019, it was identified that [MEDICATION NAME] was not placed on hold per physician order [REDACTED]. Nurse did not place the order on hold for 5/25/2019 and 5/26/2019 due to lack of knowledge on placing it on hold. Resident did not receive any [MEDICATION NAME] on 5/24/2019 but received [MEDICATION NAME] 2.5 mg tablet on 5/26/2019 and [MEDICATION NAME] 5mg on 5/25/2019. PT/INR was done on 5/27/2019, results called in to physician, new orders to discontinue [MEDICATION NAME] on 5/27/2019 were placed and implemented and new order to obtain PT/INR on 5/28/2019 were ordered. PT/INR was obtained on 5/28/2019, MD was notified, and new orders to transfer resident to the ER due to abnormal PT/INR results. The root cause of the incident is Nurse #1 did not place the order on hold for 5/25/2019 and 5/26/2019 due to lack of knowledge on placing it on hold. Corrective Action for Potentially Affected Residents A complete audit of all residents on [MEDICATION NAME] was completed on 6/5/2019 by the Director of nursing to ensure that PT/INRs were completed as ordered, Physician was notified on all PT/INRs lab results, Resident representative was notified on all PT/INR lab results, Orders implemented in the electronic health record per physician orders, [MEDICATION NAME] dosing was entered correctly in the MD orders as per last order received from MD, we have no [MEDICATION NAME] orders currently on Hold, Each resident on [MEDICATION NAME] was assessed for sign and symptoms of [MEDICATION NAME] toxicity, Each resident has documented, supporting [DIAGNOSES REDACTED]. This audit revealed that 8 current residents are receiving [MEDICATION NAME] per MD orders. Each resident has a PT/INR completed as ordered by MD. Each resident has [MEDICATION NAME] dosing entered correctly in the physician orders [REDACTED]. This was completed on 6/5/2019. All residents receiving [MEDICATION NAME] were assessed for the following by the Director of Nursing or designee on 6/5/2019: [MEDICATION NAME] Toxicity · Bleeding gums, petechiae, bruising, black tarry stool, hematuria (blood in urine) fatal hemorrhage can occur) · Any area with prolonged bleeding, fever, rash, hives · Report any of the above conditions identified MD/NP immediately by phone. 0# residents were identified with any of the above signs and symptoms. The MDS Nurse Consultant audited the care plans for all residents receiving anticoagulants on 6/5/2019. All residents who are receiving anticoagulants have care plans in place. This audit was completed on 6/5/2019 The QA Nurse Consultant audited the Kardex for all residents receiving anticoagulants on 6/6/2019, to ensure that they each had the below interventions in place (The Kardex is a shortened version derived from the care plan that identifies key care needs for the residents): · Daily skin inspection. Report abnormalities to the nurse · Observe for/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. · Note the following: (Nurse): Take/give medication at the same time each day. (Nursing department): Use soft toothbrush, use electric razor, avoid activities that could result in injury, take precautions to avoid falls, Signs/symptoms of bleeding, avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. All residents who are receiving anticoagulants have inventions in place on the Kardex. This audit was completed on 6/6/2019 by the QA Nurse Consultant. Systematic Changes All FT and PT and PRN RN's, LPN's and Med Tech's will be educated on the following by the Director of Nursing. Education began on 6/5/2019. Nurses and Med Tech's: All [MEDICATION NAME] orders shall be obtained from the physician/MD. All PT/INR orders shall be obtained from the physician/MD. When an MD gives an order for [REDACTED]. Schedule the order to fire Q shift to the eMAR until the lab is collected and received back to allow time for follow up. [MEDICATION NAME] should never be restarted, once discontinued, until the MD gives an order to do so. If [MEDICATION NAME] is being discontinued, once the next PT and INR is called in, the MD or provider should be questioned if the [MEDICATION NAME] is being started back and at what dose if an order is not given. In addition to this, [MEDICATION NAME] is to be scheduled for administration at 5PM unless otherwise ordered by the MD. If you are unsure how to proceed, call the DON 24 hours a day 7 days a week. The MD must be called with all PT and INR results regardless of the lab value. All other abnormal labs should be called into the MD regardless of time of day or day of week. Residents on [MEDICATION NAME] are at risk for bleeding due to the potential for increased INR ' s. It is important that you monitor your residents on [MEDICATION NAME] for signs of [MEDICATION NAME] toxicity which are: headache, dizziness, or weakness-bleeding from shaving or other cuts that does not stop-nosebleeds-bleeding of gums when brushing teeth-vomiting blood-unusual bruising for unknown reasons-dark brown urine-red or black color in your stool-more bleeding than usual when menstruating or unexpected bleeding from the vagina-unusual pain or swelling. Residents on [MEDICATION NAME] therapy are at a higher risk for [MEDICATION NAME] Toxicity when they are placed on antibiotic therapy. If your resident is receiving [MEDICATION NAME] and begins on antibiotics, immediately notify the MD of the potential for increased INR's and request more frequent PT/INR checks while on the antibiotic. Document in the electronic medical record that: · MD notified on start of antibiotic therapy. Document what the antibiotic is that was reviewed with the MD · Review with MD current [MEDICATION NAME] dose. Document what the current dose is that was reviewed with the MD. · Review with MD most recent INR results. Document what the most recent INR result is, that was reviewed with the MD · Document any new order or lack of new orders from MD. All FT and PT and PRN, Nurses (RNs and LPN), Med Techs, and Nursing Assistants will be educated on the following by the Director of Nursing. Education began on 6/6/2019. It is important that you monitor your residents on [MEDICATION NAME] for signs of [MEDICATION NAME] toxicity which are: headache, dizziness, or weakness-bleeding from shaving or other cuts that does not stop-nosebleeds-bleeding of gums when brushing teeth-vomiting blood-unusual bruising for unknown reasons-dark brown urine-red or black color in your stool-more bleeding than usual when menstruating or unexpected bleeding from the vagina-unusual pain or swelling. Residents on [MEDICATION NAME] therapy are at a higher risk for [MEDICATION NAME] Toxicity when they are placed on antibiotic therapy. If your resident is receiving [MEDICATION NAME] and begins on antibiotics, immediately notify the MD of the potential for increased INR's and request more frequent PT/INR checks while on the antibiotic. Document in the electronic medical record that: · MD notified on start of antibiotic therapy. Document what the antibiotic is that was reviewed with the MD · Review with MD current [MEDICATION NAME] dose. Document what the current dose is that was reviewed with the MD. · Review with MD most recent INR results. Document what the most recent INR result is, that was reviewed with the MD · Document any new order or lack of new orders from MD Each Nursing Assistant will review the Kardex in the electronic medical record in point click care, prior to providing the resident care. The Kardex is a shortened version derived from the care plan that identifies key care needs for the residents. Each Nursing Assistant is required to review the Kardex of all residents assigned to their care prior to the beginning of each shift to identify care needs of the resident. If you do not see a Kardex then consult with your nurse for further care instructions. You should always follow the plan of care for the residents as outlined on the Kardex. If the resident's condition has changed, you feel that the plan is unsafe, or the resident refuses to follow the plan then you should notify the nurse for additional guidance regarding care. To access the Kardex you can click on the resident's name in the electronic health record and click on the Kardex brick. Under Resident Care tab of the Kardex, any resident on an anticoagulant will have the interventions that state: · Daily skin inspection. Report abnormalities to the nurse · Observe for/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. · Note the following: (Nurse): Take/give medication at the same time each day. (Nursing department): Use soft toothbrush, use electric razor, avoid activities that could result in injury, take precautions to avoid falls, signs/symptoms of bleeding, avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. All Nurses: Any time a Nursing Assistant or Med Tech reports to you that the resident has any abnormalities, you will assess resident immediately, notify the Physician, implement any new orders obtained, and notify the resident representative and document in the electronic health record per policy and procedure. This in service was completed by 6/6/2019. Any nurses (full time, part time, and PRN) and member of the interdisciplinary team who did not receive in-service training will not be allowed to work until training is completed. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees and will be reviewed by the Quality Assurance Process to verify that the change has been sustained. The Corrective Action Plan was validated on 06/07/19 through record reviews and staff interviews that verified a new process for discontinuing [MEDICATION NAME] was in place. Nurse and nurse aide interviews revealed knowledge of monitoring for signs and symptoms of [MEDICATION NAME] toxicity. Documentation was reviewed that validated education was provided to staff on handling of [MEDICATION NAME] orders and monitoring for [MEDICATION NAME] toxicity and reporting.

Based on observations, record reviews and interviews with staff and medical equipment representative, the facility failed to assess the use of bed rails and utilized bed rails that had a space large enough to create an entrapment hazard. As a result, Resident#1's head was entrapped in the bed rail sustaining lacerations to the nose. This was evident in 1 of 6 residents in the sample reviewed for bed rail use. 133 residents of a census of 153 residents utilized bed rails during the survey. Immediate Jeopardy (IJ) began on 01/03/13 for Resident #1 when the resident was found with his head caught in bed rail. The Administrator was notified of the Immediate Jeopardy on 01/09/13 at 5:30 PM. The Immediate Jeopardy is present and on going while the facility assesses its residents. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with numerous [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS dated [DATE] for Resident #1 indicated the bed rails were not used in bed. The MDS assessments also indicated Resident #1 required extensive assistance with bed mobility, was cognitively impaired/had short term and long term memory problems. His cognitive skills for daily decision making were severely impaired. Continued review of the MDS revealed the resident was unable to speak and had highly impaired vision. Resident #1 had functional impairment in range of motion of the upper and lower extremities. The Quarterly MDS (10/23/2012) recorded the resident's weight at 159 pounds and a height of 71 inches. The Device and Side rail Evaluation form dated 10/24/12 was reviewed. Under the Side Rail Use Justification Section revealed Resident #1 currently had ? length side rails in use on both sides of the bed. The reason for the use of the side rails was the resident ' s inability to initiate or maintain body control. Additionally, the resident was combative with ADL (Activities of Daily Living) care. The Side Rail Use Justification indicated all 4 side rails will be used to define the parameters of the bed and allow safe provision of ADL care. Review the care plans for Resident #1 dated 8/13/12, 9/25/12 and 10/24/12 revealed the care plan did not address the use of bed rails. Nurse #1's note dated 01/03/13 at 11:36 AM revealed Resident #1 was observed by staff to have his head between the bedside railings and also noted to have 2 small superficial lacerations to the sides of his nose with minimal amount of blood. Although the resident was unable to describe the pain level due to cognitive impairment, a small amount of facial grimacing was noted. First aid was administered. Slight swelling was noted, and an order was obtained for a facial x-ray. Railings were removed from the resident's bed and replaced with a low bed with bilateral floor mats. Review of the Resident Incident Report dated 01/03/13 indicated Resident #1 had a non-witnessed incident on 01/03/13 at 07:31 AM. The property involved was half length bed rails that were up at the time of the incident. The resident activity at the time of the incident was repositioning self. The incident was reported by Nurse # 2 and the report was prepared by Nurse #1. The Narrative of the incident and description of the injuries are as follows: NA #1 notified Nurse #2 that Resident #1was observed to have his head between the railings of his bed rail and was unable to move his head out of the rail on his own. It was also observed that the resident had two lacerations, one on each side of his nose with minimal amount of blood. The resident's head was manually removed from the bed rail by staff. First aid was administered. The Director of Nurses DON was on the scene. A 1 cm (centimeter) laceration to the right side of the nose and a 2 cm laceration to the left side of the nose were observed. Immediate actions taken included: the resident was assisted to a geri chair and placed at the nurse's station for observation. Pressure was applied and the bleeding was stopped. The resident's physician and family were notified. Medical risk factors possibly related to the incident included: Inability of the resident to understand directions, use of a gastrostomy tube, and incontinency. A staff interview conducted on 01/7/13 at 5:15 PM with Nurse # 1who wrote the Incident Report of 1/3/13 note revealed Nurse #1 and Nurse #2 observed Resident #1 on 1/3/13 at 7:25 AM in bed with " his head stuck between the right side rail. " When asked how many bed rails were on the bed, Nurse #1 indicated, " He had two side rails, one on each side of the bed. " When asked what type of rails Resident # 1 had, Nurse #1 indicated, " half rails. " Nurse #1 also revealed, " He was in the rail past his nose, but not blocking the nairs (sic) nares. I also noticed (Resident#1) had a superficial laceration to each side of his nose, the left side was bleeding profusely. After I got the bleeding stopped, the Director of Nurses (DON ) had come in and we (Nurse #1 and DON) were able to get his head back through the railing. " Review of the facial x-ray report dated 01/03/13 revealed no evidence of fracture. Interview with the DON on 01/07/13 at 4:15 PM indicated Resident #1was found on 1/03/13 with his head in the bed rail. The DON stated, she was making rounds around 7:30 AM when Nurse #1 informed her the resident had half of his head in the rail up to his nose. The DON further stated she went in the room and supervised two staff members ease his head out of the rail. She also indicated the Housekeeping Department switched the resident into a bed that had no rails. Housekeeping also brought up a fall mat. The DON indicated she met with the MDS Coordinator to inform her of the changes that were made, so the resident's Care Plan could be updated. When asked if an investigation of the incident had been done, the DON stated, " I did not do an investigation, because I was there. " Observations were conducted in the room of Resident #1 on 01/07/13 at 5:00 PM. The resident was out of the room. The bed had no side rails, and the left side of the bed was observed flush against the wall. There was a thick fall mat observed on the floor on the right side of the bed. Observations of the actual bed and the bed rail where Resident #1 had been found entrapped, was observed on 01/08/13 at 11:00 AM. Three Nursing Assistants, the Medication Nurse, the Unit Manager, the DON, the Housekeeping Supervisor, and the Maintenance Director were present during the observation. Measurements of the center section of the bed rail/where Resident #1's head was caught were taken by the Maintenance Director. The measurements were 7 1/2 inches in length and 7 1/8 inches in width. The Food and Drug Administration's (FDA), Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued March 10, 2006 " recommends that this space be small enough to prevent head entrapment, less than 120 mm (millimeters) ( 4 ? inches). " The bed width was 40 1/8inches from inside rail to inside rail. The matress width was 34 1/4 inches infront of the middle section of the rail.The mattress length was 75 3/4 inches. Measurement from the head board to the foot board, with the mattress at a 60 degree angle measured 80 1/2 inches. An interview was conducted on 01/16/13 at 9:45 AM with the manufacturer's representative of the bed that Resident #1's head was entrapped. The representative indicated if the resident was visually impaired, the facility could have provided padding to the open areas in the side rail so that the resident could not get his hands or arms, and in this case, his head in the top rails. On 01/08/13 at 11:10 AM a direct care staff interview was conducted with NA #1, who indicated being the first staff member who found the resident's head in the bed rail on 01/03/13 when the incident happened. The NA identified the bed and the type of bed rails (half rails) used when the resident was found on 01/03/13. The NA indicated, " I take care of him (referring to Resident #1) everyday. This is the bed, and these are the same type of rails. He had half rails. The bed was at a 60 degree angle when I found him. His head was all the way through the right rail on the right side of the bed. He prefers to lean to the right side of the bed and wants to hold on to a rail. " This information was not on any assessment or care plan. At 11:30 AM on 01/08/13 NA #1 demonstrated Resident #1's position in the bed when found entrapped in the bed rail on 01/03/13, by using a mannequin. The NA showed the back of the resident's head was laying on the bottom of the rail, and his face was facing upward. The resident's nose was touching the bottom side of the upper rail. The resident's neck was through and past the bars of the bed rail. A direct care staff interview was conducted on 01/08/13 at 12:05 PM with NA #2. When asked if she was on the scene when Resident#1was found with his head in the bed rail, she responded, " Yes I got in the room about 7:35 AM. When I went into the room, I saw (Resident #1's) head stuck between two bars on one rail. The way the rail is made it has two bars with a space between the bars. When I went in the room his head was completely through the rails. His head was back on the bottom of the rail. The upper rail was between his nose and his upper lip. The rail could have potentially blocked his airway, if the NA (referring to NA#1) had not found him on her morning round, or if he had squirmed in agitation or scared, because he is not alert, because he didn't know what was going on. He is one of the residents that constantly has to have something in his right hand to grab onto. Most of the time, it is his rails he is grabbing. When we take his hand away from the rail, he swings his hand until he finds something to grab onto. We don't know if he gets scared or agitated. It is just a known fact he does it; grabs the rails with his right hand, because he is paralyzed on the left side. NA #2 indicated NA #1, NA #3, NA#4, and Nurse # 4 were in resident's room with her. A direct care staff interview was conducted with NA #3 on 01/08/13 at 12:25 PM. When asked to describe what she observed on 01/03/13, the NA stated, (NA #1) called me into the room around 7:30 AM. I saw his (referring to Resident #1) head in the bed rail. I couldn't tell you how far his head was in the bed rail up to his nose. I couldn't handle that, so I went to go get a Nurse, but they were already coming down the hall. " A direct care staff interview was conducted with NA #4 on 01/08/13 at 2:35 PM. When asked to describe the incident the NA indicated " Around 7:15 AM -8:00 AM, I heard NA #1, and I peaked in and saw (Resident #1's) head in the rail. His head was in the rail up to his neck. I and NA #1 went to get someone, like a Charge Nurse or anybody to get his head out of the rail. His head was stuck in the center of the rail. They/several people tried to raise the rail then they tried to lower the rail. And that wasn't working. Then, I and NA #1 tried to turn his body, and that wasn't working either. I couldn't stand to see anymore, so I left and started to do my assignment. About 15 minutes later, I went down the hall, and his head was out of the rails. I don't know who took him out. " NA#1 stated at 2:50 PM on 1/8/13 that 911 had been called and later cancelled once the resident was removed from the rails. A staff interview was conducted on 01/08/13 at 5:20 PM with the MDS Coordinator regarding the medical symptoms for the use of the side rails. The MDS Coordinator indicated, " At times he is combative, and when they bathe and dress the resident, the bed rails keep him from flipping off the bed, and allows the Nursing Assistants to provide care more safely. " A direct care staff interview was conducted on 1/9/13 at 10:35 AM with Nurse #3 (who works the 11PM -7 AM shift). When asked when the Nurse saw the resident last on the shift, Nurse#3 indicated, " I saw him about 5:20 AM when I flushed his tube and cleaned his pump. He was almost in the middle of the bed. The Nursing Assistants had not done their last round yet. " A direct care staff interview was conducted on 01/09/13 at 3:00 PM with NA #5 (who was assigned to the resident and worked 11 PM -7AM on 01/02/13). When asked what time NA#5 did the last round on the resident, NA#5 indicated, " I did my last round at 5:30 AM on 01/03/13. I straightened him up in the bed and changed him. He was fine. He grabbed onto the rail like he always does. " A staff interview was conducted on 01/11/13 at 3:05 PM with the DON and Corporate MDS Assessment Nurse regarding whether the side rails for Resident #1 met the FDA Recommendations. The DON and Corporate MDS indicated, " No, the bed rails did not meet the FDA Recommendations. " 2. Based on observations, staff interviews and medical records, the facility failed to apply a physician ordered personal alarm to the resident's bed and wheelchair after a fall resulting in injury for 1 of 3 residents investigated for falls (Resident #12). Findings include: According to the Minimum Data Set ((MDS) dated [DATE] Resident #12 was admitted to the facility with cumulative [DIAGNOSES REDACTED]. The MDS indicated Resident #12 was dependent on the staff for all activities of daily living and she had impaired cognition for decision making. Resident #12 had a history of [REDACTED]. According to the care plan dated 11/08/12 Resident #12 had a history of [REDACTED]. The interventions included call bell within reach, encourage resident to ask for assistance before transferring or getting out of the wheelchair or bed. The resident required extensive assistance with all transfers from 1-2 staff members. During an observation of Resident #12 sitting in her wheelchair at the nurses' station on 01/11/13 at 1:28 PM, she was noted to have a laceration approximately 2 inches in length on her forehead with 4 sutures. Both of her eye lids were dark purple with the purple color extending below her eyes and onto her cheeks. She had redness and swelling noted to her face, nose and chin. There was no alarm noted attached to her wheelchair. A review of Nurses' Notes (NN) dated 01/06/13 at 2:40 PM revealed at 10:50 AM resident yelled and seconds later she was observed on the floor by her wheelchair by staff as they ran to her aid. The Nurse's Note revealed, " Lacerations noted to forehead and in the center of her head. Ice applied to forehead to slow bleeding and patient was placed on her side for comfort. Resident stated that she was trying to get the baby out of the bathroom. PEC (physician) was called and an order was given to send to hospital for further evaluation. The NP (nurse practitioner) also ordered upon return for a bed and chair alarm to be placed and the resident needs to be moved closer to the nurses' station." A review of a handwritten Nurses' Note (NN) dated 01/07/13 (no time indicated on the note) read in part: " ice wrap applied to decrease bleeding. Pt (patient) was sent to ER (emergency room ) for evaluation pt received 4 stitches to forehead on exam- redness around sutures-bruising around both eyes- pt in no distress " A review of a NN dated 01/07/13 at 5:14 AM read in part: " Late Entry. Ice applied for 15 minutes. Pt arrived back to facility 01/06/12 at 7:00 PM. (This note was signed by an agency nurse) " . The name was not provided. An interview with Nurse # 3 on 01/11/13 at 1:28 PM revealed Resident #12 fell the other night (Sunday 01/06/13) as she was trying to get her baby doll. Nurse # 3 continued, " the resident was in her room, we (the staff) heard her yell out and by the time we got to her room she had fallen landing on her face. She had a laceration on her forehead and the doctor who was in the building saw her and sent her to the emergency room for treatment. The PA (physician's assistant) ordered a bed alarm and chair alarm to be used for the resident when she returned from the emergency room " . She stated " I wrote the order that day, but it hasn't been done yet. I wrote the order but the central supply people have not put it (the alarms) on yet ". She also stated " I told the director of nursing (DON) and she said she would take care of it, but that was on Monday and it still was not done, so I have been keeping her at the nurses ' station so I can keep an eye on her " . Requests for a copy of the incident report and investigation and recommendation was made several times to the DON, she was unable to produce any documentation. A review of the physician's orders [REDACTED]. Bed alarm and chair alarm placed upon return " Resident returned to the facility on [DATE]. A review of a NN dated 01/07/13 at 5:38 PM revealed in part: " resident arrived back at facility alert and confused which is her baseline. Ecchymotic bruising noted to forehead along with sutures which is dressed with a band aid. Resident denies pain. Abrasion noted to the top of resident head. Resident appears neurologically intact. Resident placed in bed hob (head of bed) elevated. Ice applied for 150 (typographical error by transcriber) minutes to forehead covered in a towel. Per hospital orders suture removal in 3-5 days. Responsible party notified of resident's return back into facility. Bed in low position, call light in reach. Frequent checks made throughout shift will continue to monitor. (This Nurses note was signed by an agency nurse) " . The name was not provided. An observation on 01/11/13 at 4:55 PM of Resident #12 sitting in her wheelchair at the nurses' station revealed there was no alarm on the resident's wheelchair. There were no staff members at the nurses' station. An interview with the facility medical director on 01/11/13 at 5:49 PM revealed his expectation was that when an order was written, it would be carried out as soon as possible. He further stated the resident returned to the facility the same day she had fallen and he was concerned the alarms were not in place. An interview with the DON on 01/11/13 at 5:50 PM revealed she was aware the resident fell and was sent to the hospital. She stated " there was no incident report or investigation done because the state came in the building on Monday (01/06/13) morning and I have been busy helping the surveyors " . She further indicated she had spoken with Nurse #3 on Sunday and told her to put the alarms on the resident ' s chair and bed. She continued " I was not aware it (the alarm placement) had not been done; when I saw that she (Resident #12) did not have the alarm on her chair this morning (01/11/13) I again spoke with (Nurse #3) and told her to get it done " . She indicated it was her expectation that a physician's orders [REDACTED].

Based on observations, record reviews and interviews with staff and medical equipment representative, the facility failed to assess the use of bed rails and utilized bed rails that had a space large enough to create an entrapment hazard. As a result, Resident#1's head was entrapped in the bed rail sustaining lacerations to the nose. This was evident in 1 of 6 residents in the sample reviewed for bed rail use. 133 residents of a census of 153 residents utilized bed rails during the survey. Validation of the facility's credible allegation was conducted on 01/28/13. Residents on all halls (100, 200, 300 and 400 halls) in the facility who had use of side rails, were observed for side rail utilization which met the Food and Drug Administration (FDA) guidelines for dimension limitations. Side rail use was also observed to verify all rails were being used in accordance with the facility's Side Rail Utilization Assessment (newly developed on 01/12/13), Interdisciplinary Team recommendations, and implementation plans. Side Rail Utilization Assessments were also reviewed for new resident admissions after the survey 01/11/13. Record reviews were completed to verify rail use matched the residents' functional mobility/individual needs of the residents, and Interdisciplinary Team recommendations. Staff interviews were conducted with the maintenance team to verify necessary bed and rail changes had been completed by 01/23/13 per the Credible Allegation. Direct Care and Management Staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic changes and protocols. The Quality Assurance Audit reports since 01/11/13 were reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance. The survey found that immediate jeopardy was removed for the area of supervision to prevent accidents (F 323) on 1/23/13. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to monitor systems, complete bed replacements, and complete staff in-services. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with numerous [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS dated [DATE] for Resident #1 indicated the bed rails were not used in bed. The MDS assessments also indicated Resident #1 required extensive assistance with bed mobility, was cognitively impaired/had short term and long term memory problems. His cognitive skills for daily decision making were severely impaired. Continued review of the MDS revealed the resident was unable to speak and had highly impaired vision. Resident #1 had functional impairment in range of motion of the upper and lower extremities. The Quarterly MDS (10/23/2012) recorded the resident's weight at 159 pounds and a height of 71 inches. The Device and Side rail Evaluation form dated 10/24/12 was reviewed. Under the Side Rail Use Justification Section revealed Resident #1 currently had ? length side rails in use on both sides of the bed. The reason for the use of the side rails was the resident ' s inability to initiate or maintain body control. Additionally, the resident was combative with ADL (Activities of Daily Living) care. The Side Rail Use Justification indicated all 4 side rails will be used to define the parameters of the bed and allow safe provision of ADL care. Review the care plans for Resident #1 dated 8/13/12, 9/25/12 and 10/24/12 revealed the care plan did not address the use of bed rails. Nurse #1's note dated 01/03/13 at 11:36 AM revealed Resident #1 was observed by staff to have his head between the bedside railings and also noted to have 2 small superficial lacerations to the sides of his nose with minimal amount of blood. Although the resident was unable to describe the pain level due to cognitive impairment, a small amount of facial grimacing was noted. First aid was administered. Slight swelling was noted, and an order was obtained for a facial x-ray. Railings were removed from the resident's bed and replaced with a low bed with bilateral floor mats. Review of the Resident Incident Report dated 01/03/13 indicated Resident #1 had a non-witnessed incident on 01/03/13 at 07:31 AM. The property involved was half length bed rails that were up at the time of the incident. The resident activity at the time of the incident was repositioning self. The incident was reported by Nurse # 2 and the report was prepared by Nurse #1. The Narrative of the incident and description of the injuries are as follows: NA #1 notified Nurse #2 that Resident #1 was observed to have his head between the railings of his bed rail and was unable to move his head out of the rail on his own. It was also observed that the resident had two lacerations, one on each side of his nose with minimal amount of blood. The resident's head was manually removed from the bed rail by staff. First aid was administered. The Director of Nurses DON was on the scene. A 1 cm (centimeter) laceration to the right side of the nose and a 2 cm laceration to the left side of the nose were observed. Immediate actions taken included: the resident was assisted to a geri chair and placed at the nurse's station for observation. Pressure was applied and the bleeding was stopped. The resident's physician and family were notified. Medical risk factors possibly related to the incident included: Inability of the resident to understand directions, use of a gastrostomy tube, and incontinency. A staff interview conducted on 01/7/13 at 5:15 PM with Nurse # 1 who wrote the Incident Report of 1/3/13 note revealed Nurse #1 and Nurse #2 observed Resident #1 on 1/3/13 at 7:25 AM in bed with " his head stuck between the right side rail. " When asked how many bed rails were on the bed, Nurse #1 indicated, " He had two side rails, one on each side of the bed. " When asked what type of rails Resident # 1 had, Nurse #1 indicated, " half rails. " Nurse #1 also revealed, " He was in the rail past his nose, but not blocking the nairs (sic) nares. I also noticed (Resident#1) had a superficial laceration to each side of his nose, the left side was bleeding profusely. After I got the bleeding stopped, the Director of Nurses (DON ) had come in and we (Nurse #1 and DON) were able to get his head back through the railing. " Review of the facial x-ray report dated 01/03/13 revealed no evidence of fracture. Interview with the DON on 01/07/13 at 4:15 PM indicated Resident #1 was found on 1/03/13 with his head in the bed rail. The DON stated, she was making rounds around 7:30 AM when Nurse #1 informed her the resident had half of his head in the rail up to his nose. The DON further stated she went in the room and supervised two staff members ease his head out of the rail. She also indicated the Housekeeping Department switched the resident into a bed that had no rails. Housekeeping also brought up a fall mat. The DON indicated she met with the MDS Coordinator to inform her of the changes that were made, so the resident's Care Plan could be updated. When asked if an investigation of the incident had been done, the DON stated, " I did not do an investigation, because I was there. " Observations were conducted in the room of Resident #1 on 01/07/13 at 5:00 PM. The resident was out of the room. The bed had no side rails, and the left side of the bed was observed flush against the wall. There was a thick fall mat observed on the floor on the right side of the bed. Observations of the actual bed and the bed rail where Resident #1 had been found entrapped, was observed on 01/08/13 at 11:00 AM. Three Nursing Assistants, the Medication Nurse, the Unit Manager, the DON, the Housekeeping Supervisor, and the Maintenance Director were present during the observation. Measurements of the center section of the bed rail/where Resident #1's head was caught were taken by the Maintenance Director. The measurements were 7 1/2 inches in length and 7 1/8 inches in width. The Food and Drug Administration's (FDA), Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued March 10, 2006 " recommends that this space be small enough to prevent head entrapment, less than 120 mm (millimeters) ( 4 ? inches). " The bed width was 40 1/8 inches from inside rail to inside rail. The mattress width was 34 1/4 inches in front of the middle section of the rail. The mattress length was 75 3/4 inches. Measurement from the head board to the foot board, with the mattress at a 60 degree angle measured 80 1/2 inches. An interview was conducted on 01/16/13 at 9:45 AM with the manufacturer's representative of the bed that Resident #1's head was entrapped. The representative indicated if the resident was visually impaired, the facility could have provided padding to the open areas in the side rail so that the resident could not get his hands or arms, and in this case, his head in the top rails. On 01/08/13 at 11:10 AM a direct care staff interview was conducted with NA #1, who indicated being the first staff member who found the resident's head in the bed rail on 01/03/13 when the incident happened. The NA identified the bed and the type of bed rails (half rails) used when the resident was found on 01/03/13. The NA indicated, " I take care of him (referring to Resident #1) everyday. This is the bed, and these are the same type of rails. He had half rails. The bed was at a 60 degree angle when I found him. His head was all the way through the right rail on the right side of the bed. He prefers to lean to the right side of the bed and wants to hold on to a rail. " This information was not on any assessment or care plan. At 11:30 AM on 01/08/13 NA #1 demonstrated Resident #1's position in the bed when found entrapped in the bed rail on 01/03/13, by using a mannequin. The NA showed the back of the resident's head was laying on the bottom of the rail, and his face was facing upward. The resident's nose was touching the bottom side of the upper rail. The resident's neck was through and past the bars of the bed rail. A direct care staff interview was conducted on 01/08/13 at 12:05 PM with NA #2. When asked if she was on the scene when Resident#1 was found with his head in the bed rail, she responded, " Yes I got in the room about 7:35 AM. When I went into the room, I saw (Resident #1's) head stuck between two bars on one rail. The way the rail is made it has two bars with a space between the bars. When I went in the room his head was completely through the rails. His head was back on the bottom of the rail. The upper rail was between his nose and his upper lip. The rail could have potentially blocked his airway, if the NA (referring to NA#1) had not found him on her morning round, or if he had squirmed in agitation or scared, because he is not alert, because he didn't know what was going on. He is one of the residents that constantly has to have something in his right hand to grab onto. Most of the time, it is his rails he is grabbing. When we take his hand away from the rail, he swings his hand until he finds something to grab onto. We don't know if he gets scared or agitated. It is just a known fact he does it; grabs the rails with his right hand, because he is paralyzed on the left side. NA #2 indicated NA #1, NA #3, NA#4, and Nurse # 4 were in resident's room with her. A direct care staff interview was conducted with NA #3 on 01/08/13 at 12:25 PM. When asked to describe what she observed on 01/03/13, the NA stated, (NA #1) called me into the room around 7:30 AM. I saw his (referring to Resident #1) head in the bed rail. I couldn't tell you how far his head was in the bed rail up to his nose. I couldn't handle that, so I went to go get a Nurse, but they were already coming down the hall. " A direct care staff interview was conducted with NA #4 on 01/08/13 at 2:35 PM. When asked to describe the incident the NA indicated " Around 7:15 AM -8:00 AM, I heard NA #1, and I peaked in and saw (Resident #1's) head in the rail. His head was in the rail up to his neck. I and NA #1 went to get someone, like a Charge Nurse or anybody to get his head out of the rail. His head was stuck in the center of the rail. They/several people tried to raise the rail then they tried to lower the rail. And that wasn't working. Then, I and NA #1 tried to turn his body, and that wasn't working either. I couldn't stand to see anymore, so I left and started to do my assignment. About 15 minutes later, I went down the hall, and his head was out of the rails. I don't know who took him out. " NA#1 stated at 2:50 PM on 1/8/13 that 911 had been called and later canceled once the resident was removed from the rails. A staff interview was conducted on 01/08/13 at 5:20 PM with the MDS Coordinator regarding the medical symptoms for the use of the side rails. The MDS Coordinator indicated, " At times he is combative, and when they bathe and dress the resident, the bed rails keep him from flipping off the bed, and allows the Nursing Assistants to provide care more safely. " A direct care staff interview was conducted on 1/9/13 at 10:35 AM with Nurse #3 (who works the 11 PM -7 AM shift). When asked when the Nurse saw the resident last on the shift, Nurse#3 indicated, " I saw him about 5:20 AM when I flushed his tube and cleaned his pump. He was almost in the middle of the bed. The Nursing Assistants had not done their last round yet. " A direct care staff interview was conducted on 01/09/13 at 3:00 PM with NA #5 (who was assigned to the resident and worked 11 PM -7 AM on 01/02/13). When asked what time NA#5 did the last round on the resident, NA#5 indicated, " I did my last round at 5:30 AM on 01/03/13. I straightened him up in the bed and changed him. He was fine. He grabbed onto the rail like he always does. " A staff interview was conducted on 01/11/13 at 3:05 PM with the DON and Corporate MDS Assessment Nurse regarding whether the side rails for Resident #1 met the FDA Recommendations. The DON and Corporate MDS indicated, " No, the bed rails did not meet the FDA Recommendations. " 2. Based on observations, staff interviews and medical records, the facility failed to apply a physician ordered personal alarm to the resident's bed and wheelchair after a fall resulting in injury for 1 of 3 residents investigated for falls (Resident #12). Findings include: According to the Minimum Data Set ((MDS) dated [DATE] Resident #12 was admitted to the facility with cumulative [DIAGNOSES REDACTED]. The MDS indicated Resident #12 was dependent on the staff for all activities of daily living and she had impaired cognition for decision making. Resident #12 had a history of [REDACTED]. According to the care plan dated 11/08/12 Resident #12 had a history of [REDACTED]. The resident required extensive assistance with all transfers from 1-2 staff members. During an observation of Resident #12 sitting in her wheelchair at the nurses' station on 01/11/13 at 1:28 PM, she was noted to have a laceration approximately 2 inches in length on her forehead with 4 sutures. Both of her eye lids were dark purple with the purple color extending below her eyes and onto her cheeks. She had redness and swelling noted to her face, nose and chin. There was no alarm noted attached to her wheelchair. A review of Nurses' Notes (NN) dated 01/06/13 at 2:40 PM revealed at 10:50 AM resident yelled and seconds later she was observed on the floor by her wheelchair by staff as they ran to her aid. The Nurse's Note revealed, " Lacerations noted to forehead and in the center of her head. Ice applied to forehead to slow bleeding and patient was placed on her side for comfort. Resident stated that she was trying to get the baby out of the bathroom. The (physician) was called and an order was given to send to hospital for further evaluation. The NP (nurse practitioner) also ordered upon return for a bed and chair alarm to be placed and the resident needs to be moved closer to the nurses' station." A review of a handwritten Nurses' Note (NN) dated 01/07/13 (no time indicated on the note) read in part: " ice wrap applied to decrease bleeding. Pt (patient) was sent to ER (emergency room ) for evaluation pt received 4 stitches to forehead on exam- redness around sutures-bruising around both eyes- pt in no distress " A review of a NN dated 01/07/13 at 5:14 AM read in part: " Late Entry. Ice applied for 15 minutes. Pt arrived back to facility 01/06/12 at 7:00 PM. (This note was signed by an agency nurse) " . The name was not provided. An interview with Nurse # 3 on 01/11/13 at 1:28 PM revealed Resident #12 fell the other night (Sunday 01/06/13) as she was trying to get her baby doll. Nurse # 3 continued, " the resident was in her room, we (the staff) heard her yell out and by the time we got to her room she had fallen landing on her face. She had a laceration on her forehead and the doctor who was in the building saw her and sent her to the emergency room for treatment. The PA (physician's assistant) ordered a bed alarm and chair alarm to be used for the resident when she returned from the emergency room " . She stated " I wrote the order that day, but it hasn't been done yet. I wrote the order but the central supply people have not put it (the alarms) on yet ". She also stated " I told the director of nursing (DON) and she said she would take care of it, but that was on Monday and it still was not done, so I have been keeping her at the nurses ' station so I can keep an eye on her " . Requests for a copy of the incident report and investigation and recommendation was made several times to the DON, she was unable to produce any documentation. A review of the physician's orders [REDACTED]. Bed alarm and chair alarm placed upon return " Resident returned to the facility on [DATE]. A review of a NN dated 01/07/13 at 5:38 PM revealed in part: " resident arrived back at facility alert and confused which is her baseline. Ecchymotic bruising noted to forehead along with sutures which is dressed with a band aid. Resident denies pain. Abrasion noted to the top of resident head. Resident appears neurologically intact. Resident placed in bed hob (head of bed) elevated. Ice applied for 150 (typographical error by transcriber) minutes to forehead covered in a towel. Per hospital orders suture removal in 3-5 days. Responsible party notified of resident's return back into facility. Bed in low position, call light in reach. Frequent checks made throughout shift will continue to monitor. (This Nurses note was signed by an agency nurse) " . The name was not provided. An observation on 01/11/13 at 4:55 PM of Resident #12 sitting in her wheelchair at the nurses' station revealed there was no alarm on the resident's wheelchair. There were no staff members at the nurses' station. An interview with the facility medical director on 01/11/13 at 5:49 PM revealed his expectation was that when an order was written, it would be carried out as soon as possible. He further stated the resident returned to the facility the same day she had fallen and he was concerned the alarms were not in place. An interview with the DON on 01/11/13 at 5:50 PM revealed she was aware the resident fell and was sent to the hospital. She stated " there was no incident report or investigation done because the state came in the building on Monday (01/06/13) morning and I have been busy helping the surveyors " . She further indicated she had spoken with Nurse #3 on Sunday and told her to put the alarms on the resident ' s chair and bed. She continued " I was not aware it (the alarm placement) had not been done; when I saw that she (Resident #12) did not have the alarm on her chair this morning (01/11/13) I again spoke with (Nurse #3) and told her to get it done " . She indicated it was her expectation that a physician's orders [REDACTED].

Based on observations, record review and staff and family interviews, the facility failed to prevent 1 of 3 sampled residents(resident #1) from being abused by a staff member. The resident accused a staff member of hitting her. Facility staff observed a red mark under the resident's eye and heard the resident say a particular staff member hit her and did not act upon it when it occurred. (Resident #1) Immediate jeopardy was identified on 11/04/2010 at 12:00PM. The immediate jeopardy began on 10/26/2010 and was removed on 11/05/2010 at 4:30PM when the facility demonstrated it had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that further in-services and training of direct care staff could be accomplished. Findings include: Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had short and long term memory deficits, was moderately impaired in making daily decisions, required limited assistance with transfers, extensive assistance with dressing, personal hygiene and toilet use and setup only for eating. The MDS indicated the resident had minimal hearing loss, highly impaired vision and periods of anger at self and others and sadness that was easily altered. Observation of Resident #1 in the resident's room on 11/02/2010 at 12:30 PM revealed a black bruise approximately 2 inches in length directly underneath the right eye surrounded by yellowing area. Upon being questioned about the bruise, the resident yelled and shook her finger toward the family member and asked the family member not to talk about it, at which point this writer ceased questions to the resident. At this point, the family member accompanied this writer to the conference room at her request. During an interview on 11/02/2010 at 12:40 PM in the facility conference room, the resident's family member reported that on 10/26/2010, she was in the facility with the resident until around 4:30 PM and the the resident was in no distress and had no signs of injury when the family member left. She revealed when she returned the next morning on 10/27/2010, the resident had a large bruise under the right eye. The resident informed the family member that a nursing assistant (NA) and she got into a fight the prior evening when the NA got her out of bed to attend an activity, and the NA hit her in the face. The resident's family member revealed she reported it immediately to the one of the facility's Social Worker (SW), SW #1. Review of the written statement dated 10/29/2010 by NA #2 indicated the NA entered the room of resident #1 on 10/26/2010 and told the resident it was time to get up and get ready for dinner. The statement indicated the NA notified the nurse for the first time about the eye after dealing with the resident in the hallway and revealed the NA discussed the resident's eye with LPN #1 and NA #3 in the dining room. During an interview with NA #2 on 11/02/2010 at 5:10PM, the NA reported she was one of a team of 2 NA's who provided care for resident #1 on the 3-11 shift on 10/26/2010. She indicated she got the resident out of bed and into her wheelchair. She reported the resident was calm and pleasant and did not resist care. She left the resident in her room, and stated she assumed NA #1 wheeled her or the resident wheeled herself to the dinner line in the hallway. NA #2 reported she noticed the resident in the dinner line and observed the resident's face was bright red on the right side. She reported she asked NA #1 what happened to the resident's face, and NA #1 said she did not know. She reported the resident thanked them for their care and then stated " you all are going to pay for what you did to me " . She reported the resident said it calmly and was not upset. She indicated she reported this to LPN #1. She stated she then wheeled the resident to the dining room for dinner. During an interview with NA #1 on 11/02/2010 at 4:20PM, the NA reported that she was one of 2 NA's assigned to resident #1 on the 3-11 shift on 10/26/2010. She revealed they worked in teams of 2, and she had not performed any care for resident #1 that shift and indicated NA #2 got the resident up for dinner. She reported she observed resident #1 in the tray line in her wheelchair waiting to be transferred to the dining room somewhere between 5:00PM to 6:00PM on 10/26/2010. She was not certain of the exact time but reported this is the time the residents are placed in the hall to be taken to the dining room. She reported NA #2 asked her what was wrong with resident #1's face, and she told her she did not know. She revealed the resident's face was red, and it looked like she had been crying. She stated NA #2 reported it to LPN #1. Review of the written statement signed by LPN #2 indicated that on the evening of 10/26/2010 at around 4:30PM, she noticed the resident in 220B (resident #1)had a red place under her right eye that was about 2 inches long and cylinder shaped. She indicated she was able to see her closely because she walked by every resident and said hello. She noticed a staff member pushing the resident to her room. She observed the resident telling the aide how good she was and then the resident started screamed and yelled " why you beat me, I hate what you do, so please leave me alone " . The LPN indicated she advised the staff member not to pay attention to 220B because she was very confused. During an interview with LPN #2 on 11/03/2010 at 3:05PM, the LPN reported she wrote the statement, and the resident mentioned as the resident in 220B was resident #1. She reported she worked on the 200 hall on the 3-11 shift on 10/26/2010. She reported two nurses are assigned to the hall and that she was not the nurse assigned to resident #1 on that day but she had visual access of all residents on the 200 hall. She revealed that at around 4:45Pm on 10/26/2010, she was doing her medication pass. She reported resident #1 took her hand as she was walked past her in the hall, and she saw a red area under her eye. She stated she observed NA #2 tell resident #1 that God loved her and all of a sudden, the resident yelled at the NA and said " why did you beat me " ? She revealed the resident was very upset. She reported the resident's nurse, LPN #1, approached the resident and the NA, and she thought the resident's nurse would handle it. LPN #2 reported she received abuse training at the facility. She stated if a resident reported abuse, it had to be reported immediately to the supervisor and the alleged abuser had to be removed from the resident. Review of the written statement dated 11/01/2010 by LPN #1 indicated that NA #4 reported on 10/27/2010 in the morning resident #1 had a bruise under her right eye. The LPN went to the resident's room and asked her what happened. The resident stated someone hit her in the eye trying to force her to get up and go downstairs. During an interview with LPN #1 on 11/03/2010 at 3:30PM, the LPN reported she received abuse training when hired. She stated she knew that at any time a resident alleged abuse, it had to be reported immediately to the supervisor, and the resident had to be protected from the alleged abuser. The LPN reported that she was the resident's nurse on 10/26/2010 on the 3-11 shift. She reported that at around 5:00PM on 10/26/2010, she observed resident #1 in the tray line in the hall pointing at NA #2 yelling, " you hit me, you punched me " . She indicated the resident appeared upset. She stated she did not assess the resident or report the incident at that time because she thought the resident was confused, and no one told her the resident had a mark on her face. Review of the written statement dated 10/28/2010 by NA #3 indicated the NA worked in the dining room on the evening of 10/26/2010. She indicated that at about 6:00PM, NA #2 brought resident #1 into the dining room. NA #3 reported the resident began accused her of beating her up. She indicated she ignored the resident and continued to pass out trays. The statement revealed she observed a mark under the resident's eye and asked NA #2 what happened to the resident's eye. She reported NA #2 told her she did not know but that the resident accused her of hitting her. During an interview with NA #3 on 11/03/2010 at 11:05AM, the NA reported she was in charge of the Diversional Activity Program (DAP) and assisted with the dinner meal in the dining room on Tuesday and Thursday evenings. She indicated she assisted with the evening meal in the dining room on 10/26/2010. She stated NA #2 wheeled resident #1 into the dining room around 6:00PM. She indicated when the resident saw her, she accused her of hitting her. She reported she saw a red mark with discoloration on the resident's face and asked LPN #1 and NA #2 what happened to her face and that neither of them knew. Review of the written statement dated 10/28/2010 by NA #4 indicated the NA entered resident #1's room at the beginning of the 7-3 shift on 10/27/2010 and noticed a red mark around her eye. The resident reported to her that an NA hit her in the eye on the prior evening. During an interview with NA #4 on 11/03/2010 at 11:30AM, the NA reported that on the morning of 10/27/2010 at the start of the shift, she noticed a bright red area under the resident #1's right eye. The resident told her an NA hit her in the eye the evening before when she tried to get the resident out of bed. The resident also reported she threw her water pitcher at the NA after she hit her. The NA stated the resident would not tell her the name of the NA because she didn ' t want to get anyone in trouble. The NA revealed she reported this information to LPN #1 immediately. NA #4 reported she regularly cared for resident #1 and had never seen her combative with staff and that she was always pleasant with her and never difficult. She indicated that at times the resident got confused, but most of the time, she was clear in her thinking. She further reported that when the resident described the event to her on 10/27/2010, her thinking was clear. She indicated the resident liked to be independent. During an interview on 11/03/2010 at 3:30PM, LPN #1 reported she worked the 7-3 shift on 10/27/2010 on resident #1's unit, station 2. She reported at the beginning of the shift, NA #4 informed her resident #1 had a bruise under her eye. She indicated she assessed the resident with a bruise under her right eye and reported it to SW #1. She stated she wrote the information in the doctor's book so the doctor could assess the resident. She gave no reason when asked why she did not call the doctor to report the injury. She reported she did not inform the unit supervisor because she was off that morning. Review of the nursing note on 10/27/2010 at 2:18 PM revealed: Resident alert and responsive. Respirations even and unlabored. Skin warm and dry. Resident with bruise noted to her right lower eye. No acute distress noted at this time. No complaints of pain offered. Will continue to monitor for status change. Vital signs 90/64, 68, 97.8, 16. Nursing note was signed off by Licensed Practical Nurse (LPN) #1. Review of statement written by SW #1 dated 10/27/2010 indicated SW #1 was approached by resident #1's family member on 10/27/2010 and informed that the resident had a black eye, and the resident reported a staff member hit her in the eye. The family member added that the eye was not like that when they left the prior evening. The statement further revealed SW #1 went to the resident's room and the resident revealed a staff member was tried take her somewhere she did not want to go, and the staff member punched her in the eye. The resident stated she did not know the staff's name but gave a physical description. The statement further indicated the resident did not want to say anything when other staff entered the room as she appeared to be afraid. SW #1 spoke with the resident's nurse, LPN #1, who reported the resident had a bruise, and she did not know what happened. The SW also spoke to station 2 unit secretary who reported NA #3 reported the resident had a bruise on the eye yesterday afternoon. The statement further revealed the SW spoke with NA #3 who reported she observed the bruise yesterday afternoon in the dining room during second feeding and further indicated the resident accused her of punching her in the face and she had not been with the resident and she did not know who hit the resident or what happened. During an interview with SW #1 on 11/03/2010 at 10:20 AM, the SW reported at around 9:30AM on 10/27/2010, a family member of resident #1 approached him and reported the resident had a bruise on her face and said a staff member hit her. The SW revealed he reported this information immediately to the facility administrator and the Director of Nursing. He indicated he then went to the resident and asked what happened. The resident reported that an NA was trying to get her out of bed the evening before to attend an activity and when she refused, the NA hit her in the face. He reported the resident would not give names although asked several times. He stated that the resident was calm and polite when she described the event and that her thinking was clear. He reported that as other staff entered the room, she appeared afraid and would not say anything. He indicated afterward he interviewed the resident's nurse, LPN #1, who knew only that the resident had a bruise under her eye but did not know how it occurred. The SW reported after interviewing several staff members and writing his report, he emailed the report to the facility administrator and the Director of Nursing the afternoon of 10/27/2010. Review of facility incident reports for October 2010 revealed resident #1 had a bruise to the right lower eye on 10/27/2010. The comments section of the incident reported: NA reported that resident had a bruise to the right lower eye. Resident with no complaints of pain or discomfort at this time. No acute distress noted. Will continue to monitor. Review of the written statement dated 10/28/2010 by LPN #3 indicated that on 10/28/2010 at 12:30AM, she was in resident #1's room, and the resident asked her if her eye looked bad. She asked the resident what happened to her eye, and the resident stated " That girl hit me in my eye " . When the nurse asked what girl, the resident answered, " That girl that came to take me to the birthday party in that big room up there. I told her I didn ' t want to go, but she said I had to go anyway. I tried to throw my water pitcher at her, which was wrong. I got both of us wet. I shouldn ' t have done that, but she hit me in the face. I didn ' t want to say anything. I don ' t want anyone to lose their job. I went anyway, because she made me go. I sat up there with those people, and it's ok. I know that our God is a forgiving God, and good will always be above evil. I don ' t want her to lose her job. It's just that she was not right. I just wanted to stay in my room " . (The statement indicated resident's remarks in quotations). During an interview with LPN #3 on 11/03/2010 at 6:15AM, the LPN reported on 10/28/2010 at 12:30AM, she gave medication to resident #1 and the resident asked her how her eye looked. She assessed the resident's eye and reported dark red bruise under the right eye and some discoloration under the left eye but not as bad as the right one. The resident told the nurse it was a little sore now. The nurse revealed when she asked the resident what happened to her eye, the resident explained a girl hit her while when she refused to go to a birthday party. The resident would not give a staff name because she didn ' t want the girl to lose her job. The nurse described the resident's mental status as alert and oriented, calm and thinking clearly as she told the story. She further reported that at times, resident #1 was confused, but on that night, she was not. The nurse stated she reported this information immediately to the night supervisor, RN #1. She also reported following an assessment of the resident, the doctor's group was called and notified. She indicated she wrote a detailed nursing note which included the resident's story, the condition of the eye, vital signs, and to whom she reported the information. She reported the note was missing from the record and could not be located. During an interview with RN #1 on 11/03/2010 at 6:30AM, the RN stated on 10/28/2010 LPN #3 reported to her that resident #1's eye was bruised looking, and the resident said she was socked in the eye. She further reported she assessed the resident and observed the area under her right eye was purple and an obvious bruise. She indicated there was also an area under the other eye with a purple area but much smaller than the right side. She reported the resident gave her the same story she gave to LPN #3. She indicated she advised LPN #3 to document everything. She reported she immediately called the Director of Nursing at around 1:00AM and reported the information. She stated she assisted LPN #3 with an assessment. She indicated the resident was alert, oriented, calm and coherent when she described what occurred. She indicated a note was written, but they could not locate it. Review of the written statement dated 10/28/2010 by the Assistant Director of Nursing, RN #3 indicated she interviewed resident #1 on 10/28/2010 at 8:05AM in the resident's room. According to the written statement, the resident reported she refused to go to an event, and a staff member told her she had to go. She reported she got punched in the eye because the staff person wanted things done her way. She went on to say she did not want the staff person to lose her job, the staff person wasn ' t a bad person and she believed she was sorry for hitting her. She did not give a name but described the staff member. The statement also indicated RN #3 reassured the resident that she had done the right thing when she reported the incident to the nurse. Review of facility record of complaint indicated an investigation of the resident's injury began on 10/28/2010 by the station 2 nurse manager, RN #2 and was completed on 11/01/2010. According to the findings on the complaint, RN #2 interviewed every staff member on 1st and 2nd shift who worked on 10/26/2010 and 10/27/2010 and was unable to pinpoint anyone who knew anything regarding the incident. The findings also indicated RN #2 reviewed abuse policies with the staff. During an interview with RN #2 on 11/02/2010 at 5:30PM, the RN reported she did an investigation and interviewed the resident as well as staff on 1st and 2nd shift who worked on 10/26/2010 and 10/27/2010 and got written statements from all of them. She indicated she was unable to pinpoint who the alleged staff might be. Review of the physician's progress note indicated resident #1 was assessed by the nurse practitioner on 10/28/2010 for bruising of the right eye. The note revealed that staff reported the resident had bruising to right eye yesterday and that the reported she was hit in the eye by a staff member. Per the report, resident refused to state who or why and stated, " I don ' t want to talk about it anymore " . The assessment revealed dark purple bruising noted below right eye, hematoma to right eye, continue to monitor closely, no vision changes or complaints of pain at this time. Record review of the 24 hour initial report indicated the facility filed the 24 hour report to the state on 10/28/2010 as injury of unknown origin. The report was prepared by RN #3. Review of the staffing schedule from indicated NA #1 and NA #2 provided resident care to resident #1 on 10/27/2010, 10/28/2010, 10/29/2010, 10/30/2010, 10/31/2010, and 11/02/2010 on the 3-11 shift on the days they worked. NA #1 and NA #2 were removed from care of resident #1 on 11/03/2010 indefinitely. During an interview with the Director of Nursing (D.O.N.) on 11/03/2010 at 9:30AM, she indicated all staff received abuse training when hired, and she expected all staff to report abuse or allegations of abuse immediately. She reported the allegation of abuse and the bruise was reported to her at around 1:30AM on 10/28/2010 by the night RN Supervisor. She revealed the investigation of the alleged abuse began on 10/28/2010, and the 24 hour report was sent to the North Carolina Health Care Registry that day. She indicated that the facility had not received enough information during their investigation that warranted removing the NA's from caring for the resident. She further reported that her investigation was ongoing when this writer entered the facility, and until yesterday, they had not narrowed down a particular shift or individual staff that may have been involved in the abuse allegation. The D.O.N. indicated the facility created a new mandatory training packet entitled " Abuse Prohibition Training " that included the 7 components of abuse prohibition, the definition of abuse with a mandatory post test. She reported the mandatory training began on 11/01/2010 and had to be completed by all employees by 11/07/2010. The administrator was notified of the immediate jeopardy on 11/04/2010 at 12:00 noon. The facility provided a credible allegation of compliance on 11/05/10 at 3:30PM. A. Address how corrective action will be accomplished for each resident found to be affected by the deficient practice. ? Care will not be delivered to the affected resident by the two 3-11 shift CNA's that were assigned on 10/26/10, effective 11/3/10 and indefinitely. Unit Manager has shared information with licensed staff related to assignment of staff. The two CNAs will not be allowed to deliver care or be assigned to the affected resident while residing in the facility. Completion Date: 11/3/10- ongoing ? This resident has a history of refusing care, though not prevalent over the past three months or greater. The Clinician will develop packet on methods to handle resistant residents and re-educate staff for those delivering care for affected resident. Those not trained will not be allowed to care for this resident until trained regarding resistant resident care for affected resident. The Clinician and Unit Manager will provide additional training for the staff caring for the affected resident. Completion Date: 11/5/2010 The facility submitted the 24 hour report to the state agency to report allegation of abuse of unknown origin on 10/28/10 per DON. The facility began its investigation on 10/28/10 that was conducted by Unit Manager. Five day report was submitted to the state agency on 11/3/10. ? Social Worker will give support to the affected resident by visiting twice per week for two weeks, then weekly for four weeks to evaluate for fear, concerns, depression, and additional behaviors. Evaluation will occur at the end of the six week visits. For additional support if indicated. Contact information will be provided to the resident during first visit. Completion Date: 11/05/10- 12/17/10 ? The affected resident's Careplan has been updated to reflect potential/actual episodes of fear. Completion Date: 11/05/10 ? Administrator, Director of Nursing revisited resident on 11/4/2010 to check on resident's status related to incident that occurred on 10/26/10 and to apologize. Administrator, DON, or ADON will visit resident twice per week for one week, then weekly for three weeks for support, identification of voiced concerns, and evaluation of resident's comfort in facility. Unit Manager to round on resident three times per week for one week to assess resident needs and voiced concerns, then weekly thereafter for three weeks. Completion Date: 11/4/10-11/25/10 B. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice. ? Clinician and Director of Nursing developed education packet to re-educate staff on abuse. The Abuse Prohibition education packet was developed to re-train staff on the facility's abuse policy which includes the seven components of abuse prohibition and how to deal with difficult residents. Staff will be re-educated in six months and annually thereafter; or more often as indicated. Completion Date: 11/ 1/ 10 ? The Clinician (Educator), Administrator and/ or Director of Nursing will re-educate all leadership staff (includes Managers and Supervisors) on the facility's abuse policy which includes the seven components; screening, training, prevention, identification, investigation, protection, and reporting/response per facility policy, and how to deal with difficult residents. Managers/ Supervisors will re-educate staff with the packet which includes discussion of handling difficult residents after they are trained (conducted on 11/1/10). Completion Date: 11/1/10 ? Mandatory housewide re- education for all staff to be conducted by Manager/Supervisor for assigned staff on facility policy, learning packet with post test, and signed acknowledgement form to validate that education has occurred which is included in the training packet . Those that have not received training will not provide any direct care to residents until training occurs. Completion Date: 11/5/10 ? Written warning for the 2 assigned CNA's that cared for affected resident for failure to exercise reasonable and responsible care during assigned shift. Completion Date: 11/5/10 ? The two CNA's will be closely monitored by the 3-11 Supervisor and licensed nursing staff after completion of training. Training occurred on 11/1/10 for Supervisor and 11/2/10 for assigned licensed nurses that will monitor the CNAs. Completion Date: 11/2/10 ? One of the assigned CNAs will be transferred to 7-3 shift, effective 11/8/10 for intense monitoring by Unit Manager, Supervisor, and assigned licensed nurses. Abuse Training occurred on 11/1/10 for CNA. Completion Date: 11/8/2010 ? The two assigned nurses that were apprised of the incident that occurred on 10/26/10 were re-educated on the facility's abuse policy which includes screening, training, prevention, identification, investigation, protection, and reporting/response. Documented disciplinary action taken for both nurses related to failure to provide protection based on an allegation of abuse, and not reporting the allegation in a timely manner. Completion Date: 11/5/10 Social Workers will interview a total of three residents and/or family members of residents who may not be able to speak for themselves; 12 audits per month per social worker to total 24 audits per month. Completion Date 12/14/2011 ? Unit Managers will discuss how to report suspected abuse and give business cards and or contact information to each affected resident. Completion Date 11/5/10 ? ? Unit Manager will conduct an individualized interview / audit with each resident residing on their units regarding issues of care and potential for abuse by caregivers. Completion Date 11/5/10 The following questions will be asked to each affected resident: 1. Do you know who you are to report concerns or complaints to? 2. Do you know how to make a complaint? 3. Do you feel comfortable expressing concerns / complaints to staff? 4. If you have complained or expressed concern, did the staff respond in an inappropriate manner? 5. Did the staff resolve the problem? ? All new admissions will be given information related to abuse prohibition to include how to report concerns by or per Admissions Coordinator. ? Completion Date 11/1/10 and ongoing ? The contact list is currently provided with Administrative Leader contact numbers to all new admissions / families. Completion Date 11/1/10 and ongoing C. Address what measures will be put into place or systemic changes made to ensure that deficient practice will not occur. ? Mandatory inservice re-education on abuse which includes screening, training, prevention, identification, investigation, protection, and reporting/response in progress for all staff. Those that have not received training will not provide any direct care to residents until training occurs. Completion Date: 11/5/2010 ? Licensed nursing staff will closely observe resident/ staff interactions for any evidence of abuse and report according to facility policy after training. Training conducted for Manager on 11/1/10 and licensed staff that will monitor on 11/2/10. Completion Date: 11/4/10- ongoing ? Monitoring tool will be developed from QIS Abuse Prohibition template for monitoring of residents/families and employees to ensure compliance in prevention, identification, protection, and reporting/response of abuse. Completion Date: 11/4/2010 D. The facility will monitor its performance to ensure that solutions are achieved and sustained. The facility will evaluate the plans effectiveness ? Unit Managers will conduct five random audits per month for all direct caregivers; to include all shifts; 20 audits per month for facility. Results will be reported and discussed in Interdisciplinary QA that is held monthly for identification of abuse concerns, educational training needs, tracking, and trending for staff. Retraining will occur as indicated and/or disciplinary action taken as indicated for violation of the facility's abuse policy. Monitoring will begin on 11/30/10 and results reported at the 12/14/10 Interdisciplinary QA meeting. Monitoring will be effective 12/14/10- 12/14/ 11. Completion Date: 12/14/10-12/14/11 ? Social Workers will interview three residents and/or family members who are unable to speak for themselves; 12 audits per month per social worker to total 24 audits per month. ? Results will be reported and discussed in Interdisciplinary QA that is held monthly for identification of abuse concerns, tracking, and trending for residents/family members. Education on reporting abuse will be provided to residents and /or families by the SW as indicated. Monitoring will begin on 11/30/10 and results reported at the 12/14/10 Interdisciplinary QA meeting. Monitoring will be effective 12/14/10- 12/14/ 11. Completion Date: 12 /14/2010-12-14-201 ? Managers/ Supervisors will monitor staff compliance per observation and conversation with residents (randomly) during daily rounding for compliance. Observed violation of facility's abuse policy will result in immediate retraining or disciplinary action if indicated ? . Completion Date: 11/5/10- ongoing Verification of the credible allegation was evidenced by interviews of direct care staff related

Based on observations, record review and staff and family interviews, the facility failed (Resident #1) to implement abuse policies and procedures related to protection for 1 of 3 sampled residents (Resident # 1). Immediate jeopardy was identified on 11/04/2010 at 12:00PM. The immediate jeopardy began on 10/26/2010 and was removed on 11/05/2010 at 4:30PM when the facility demonstrated it had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that further in-services and training of direct care staff could be accomplished. Findings include: Review of the undated facility's abuse policy indicated the resident has the right to be free from abuse, neglect or misappropriation of property. The " Training " section indicated staff was held responsible for reporting any suspected abuse to their supervisor and every effort made to protect the resident during an investigation. It was indicated in the " Identification " section if the resident had an unexplained injury and if there was a verbal report of hitting, the staff member immediately notified the immediate supervisor. Indicated under the " Protection " section was the staff member (when applicable) will be removed from the resident's care or suspended pending the completion of the investigation. Once a determination is made that abuse likely occurred, the staff member is suspended pending completion of the investigation. Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] indicated resident #1 had short and long term memory deficits, was moderately impaired in making daily decisions, required limited assistance with transfers, extensive assistance with dressing, personal hygiene and toilet use and setup only for eating. The MDS indicated the resident had minimal hearing loss, highly impaired vision and periods of anger at self and others and sadness that was easily altered. Observation of resident #1 in the resident's rooom on 11/02/2010 at 12:30 PM revealed a black bruise approximately 2 inches in length directly underneath the right eye surrounded by yellowing area. Upon asking questions related to the bruise, the resident yelled at her family member, shook her finger at the family member and asked her not to talk about it. At this point, the family member accompanied this writer to the conference room at her request. During an interview on 11/02/2010 at 12:40 PM, the resident's family member reported that on 10/26/2010, she was in the facility with the resident until around 4:30PM, and the resident was in no distress and had no signs of injury when the family member left. She revealed that when she returned the next morning on 10/27/2010, the resident had a large bruise under the right eye. The resident informed the family member a nursing assistant (NA) and she got into a fight the prior evening when the NA got her out of bed to attend an activity, and the NA hit her in the face. The resident's family member revealed she reported it immediately to the one of the facility's Social Worker (SW), SW #1. Review of the written statement dated 10/29/2010 by NA #2 indicated the NA entered the room of resident #1 on 10/26/2010 and told the resident it was time to get up and get ready for dinner. The statement indicated the NA notified the nurse for the first time about the eye after dealing with the resident in the hallway, and she indicated she discussed the resident's eye with LPN #1 and NA #3 in the dining room that evening. During an interview with NA #2 on 11/02/2010 at 5:10PM, the NA reported she was one of a team of 2 NA's who provided care for resident #1 on the 3-11 shift on 10/26/2010. She indicated she got the resident out of bed and into her wheelchair. She reported the resident was calm and pleasant and did not resist care. She left the resident in her room and stated she assumed NA #1 wheeled her or the resident wheeled herself to the dinner line in the hallway. NA #2 reported she noticed the resident in the dinner line and observed the resident's face was bright red on the right side. She reported she asked NA #1 what happened to the resident's face and NA #1 said she did not know. She reported the resident thanked them for their care and then stated " you all are going to pay for what you did to me " . She reported the resident said it calmly and was not upset. She indicated she reported this to LPN #1. She stated she then wheeled the resident to the dining room for dinner. Review of the written statement dated 11/01/2010 by NA #1 indicated she saw the resident with a red face when she was going to eat. No dates or other details were indicated on the statement. During an interview with NA #1 on 11/02/2010 at 4:20PM, the NA reported she was one of 2 NA's assigned to resident #1 on the 3-11 shift on 10/26/2010. She revealed they worked in teams of 2, and that she had not performed any care for resident #1 that shift and indicated NA #2 got the resident up for dinner. She reported she observed resident #1 in the tray line in her wheelchair waiting to be transferred to the dining room somewhere between 5:00PM to 6:00PM on 10/26/2010. She was not certain of the exact time but reported this is the time the residents are placed in the hall to be taken to the dining room. She reported NA #2 asked her what was wrong with resident #1's face, and she told her she did not know. She revealed the resident's face was red, and it looked like she had been crying. She stated NA #2 reported it to LPN #1. Review of the written statement signed by LPN #2 indicated that on the evening of 10/26/2010 at around 4:30PM, she noticed the resident had a red place under her right eye that was about 2 inches long and cylinder shaped. She indicated she was able to see her closely because she walked by every resident and said hello. She noticed a staff member pushing the resident to her room. She observed the resident telling the aide how good she was and then the resident started screaming and yelling " why you beat me, I hate what you do, so please leave me alone " . The LPN indicated she advised the staff member not to pay attention to the resident because she was very confused. During an interview with LPN #2 on 11/03/2010 at 3:05PM, the LPN reported she worked on the 200 hall on the 3-11 shift on 10/26/2010. She reported two nurses were assigned to the hall and that she was not the nurse assigned to resident #1 on that day, but she had visual access of all residents on the 200 hall. She revealed that at around 4:45Pm on 10/26/2010, she was doing her medication pass. She reported resident #1 took her hand as she was walked past her in the hall, and she saw a red area under her right eye. She stated she observed NA #2 tell resident #1 that God loved her and all of a sudden, the resident yelled at the NA and said " why did you beat me " ? She revealed the resident was upset. She reported the resident's nurse, LPN #1, approached the resident and the NA, and she thought the resident's nurse would handle it. LPN #2 reported she received abuse training at the facility. She stated if a resident reported abuse, it had to be reported immediately to the supervisor and the alleged abuser had to be removed from the resident. Review of the written statement dated 11/01/2010 by LPN #1 indicated NA #4 reported on 10/27/2010 resident #1 had a bruise under her right eye. The LPN went to the resident's room and asked her what happened. The resident stated someone hit her in the eye trying to force her to get up and go downstairs. During an interview with LPN #1 on 11/03/2010 at 3:30PM, the LPN reported she received abuse training when hired. She stated she knew if a resident alleged abuse, it had to be reported immediately to the supervisor, and the resident had to be protected from the alleged abuser. The LPN reported she was the resident's nurse on 10/26/2010 on the 3-11 shift. She reported that at around 5:00PM on 10/26/2010, she observed resident #1 in the hall, and the resident yelled at NA #2 " you hit me, you punched me " . She indicated the resident was upset. She stated she did not assess the resident or report the incident at that time because she thought the resident was confused, and no one told her the resident had a mark on her face. Review of the written statement dated 10/28/2010 by NA #3 indicated the NA worked in the dining room on the evening of 10/26/2010. She indicated that at about 6:00PM, NA #2 brought resident #1 into the dining room. NA #3 reported the resident began accusing her of beating her up. She indicated that she ignored the resident and continued to pass out trays. The statement revealed she observed a mark under the resident's eye and asked NA #2 what happened to the resident's eye. She reported NA #2 told her she did not know and that the resident accused her of hitting her. During an interview with NA #3 on 11/03/2010 at 11:05AM, the NA reported she was in charge of the Diversional Activity Program (DAP) and assisted with the dinner meal in the dining room on Tuesday and Thursday evenings. She indicated she assisted with the evening meal in the dining room on 10/26/2010. She stated NA #2 wheeled resident #1 into the dining room around 6:00PM. She indicated the resident saw her accused her of hitting her. She reported she saw a red mark with discoloration on the resident's face and asked LPN #1 and NA #2 what happened to the resident's face, and they told her they did not know. Review of the written statement dated 10/28/2010 by NA #4 indicated the NA entered resident #1's room at the beginning of the 7-3 shift on 10/27/2010 and noticed a red mark around her eye. The resident reported to her that an NA hit her in the eye on the prior evening. During an interview with NA #4 on 11/03/2010 at 11:30AM, the NA reported that on the morning of 10/27/2010 at the start of the shift, she noticed a bright red area under the resident #1's right eye. The resident told her an NA hit her in the eye the evening before when she tried to get the resident out of bed. The resident also reported that she threw her water pitcher at the NA after she hit her. The NA stated the resident would not tell her the name of the NA because she didn ' t want to get anyone in trouble. The NA revealed she reported this information to LPN #1 immediately. NA #4 reported she regularly cared for resident #1 and had never seen her combative with staff and that she was always pleasant with her and never difficult. She indicated that at times the resident got confused, but most of the time, she was clear in her thinking. She further reported that when the resident described the event to her on 10/27/2010, her thinking was clear. She indicated the resident liked to be independent. During an interview on 11/03/2010 at 3:30PM, LPN #1 reported she worked the 7-3 shift on 10/27/2010 on resident #1's unit, station 2. She reported at the beginning of the shift, NA #4 informed her resident #1 had a bruise under her eye. She indicated she assessed the resident with a bruise under her right eye and reported it to SW #1. She stated she wrote the information in the doctor's book so the doctor could assess the resident. She reported she did not inform the unit supervisor because she was off that morning. Review of the nursing note on 10/27/2010 at 2:18 PM revealed: Resident alert and responsive. Respirations even and unlabored. Skin warm and dry. Resident with bruise noted to her right lower eye. No acute distress noted at this time. No complaints of pain offered. Will continue to monitor for status change. Vital signs 90/64, 68, 97.8, 16The nursing note was signed off by Licensed Practical Nurse (LPN) #1. Review of statement written by SW #1 dated 10/27/2010 indicated SW #1 was approached by resident #1's family member on 10/27/2010 and informed the resident had a black eye, and the resident reported a staff member hit her in the eye. The family member added the eye was not like that when they left the prior evening. The statement further revealed SW #1 went to the resident's room and the resident revealed a staff member tried to take her somewhere she did not want to go, and the staff member punched her in the eye. The resident stated she did not know the staff's name but gave a physical description. The statement further indicated the resident did not want to say anything when other staff entered the room, as she appeared to be afraid. SW #1 spoke with the resident's nurse, LPN #1 who reported the resident had a bruise, and she did not know what happened. The SW also spoke to station 2 unit secretary who reported NA #3 reported the resident had a bruise on the eye yesterday afternoon. The statement further revealed the SW spoke with NA #3 who reported she observed the bruise yesterday afternoon in the dining room during second feeding and further indicated the resident accused her of punching her in the face, and she had not been with the resident and did not know who hit the resident or what happened. During an interview with SW #1 on 11/03/2010 at 10:20 AM, the SW reported at around 9:30AM on 10/27/2010, a family member of resident #1 approached him and reported the resident had a bruise on her face and said a staff member hit her. The SW revealed he reported this information immediately to the facility administrator and the Director of Nursing. He indicated he then went to the resident and asked what happened. The resident reported that an NA tried to get her out of bed the evening before to attend an activity, and when she refused, the NA hit her in the face. He reported the resident would not give names although asked several times. He stated the resident was calm and polite when she described the event and that her thinking was clear. He reported that as other staff entered the room, she appeared afraid and would not say anything. He indicated afterward he interviewed the resident's nurse, LPN #1, who knew only that the resident had a bruise under her eye but did not know how it occurred. The SW revealed after interviewing several staff members and writing his report, he emailed the report to the facility administrator and the Director of Nursing the afternoon of 10/27/2010. Review of facility incident reports for October 2010 revealed resident #1 had a bruise to the right lower eye on 10/27/2010. The comments section of the incident reported: NA reported that resident had a bruise to the right lower eye. Resident with no complaints of pain or discomfort at this time. No acute distress noted. Will continue to monitor. Review of the written statement dated 10/28/2010 by LPN #3 indicated that on 10/28/2010 at 12:30AM, she was in resident #1's room, and the resident asked her if her eye looked bad. She asked the resident what happened to her eye, and the resident stated " That girl hit me in my eye " . When the nurse asked what girl, the resident answered, " That girl that came to take me to the birthday party in that big room up there. I told her I didn ' t want to go, but she said I had to go anyway. I tried to throw my water pitcher at her, which was wrong. I got both of us wet. I shouldn ' t have done that, but she hit me in the face. I didn ' t want to say anything. I don ' t want anyone to lose their job. I went anyway, because she made me go. I sat up there with those people, and it's ok. I know that our God is a forgiving God, and good will always be above evil. I don ' t want her to lose her job. It's just that she was not right. I just wanted to stay in my room " . During an interview with LPN #3 on 11/03/2010 at 6:15AM, the LPN reported that on 10/28/2010 at 12:30AM, she was giving medication to resident #1 and the resident asked her how her eye looked. She assessed the resident's eye and reported dark red bruise under the right eye and some discoloration under the left eye but not as bad as the right one. The resident told the nurse it was a little sore. The nurse revealed when she asked the resident what happened to her eye, the resident explained a girl hit her while when she refused to go to a birthday party. The resident would not give a staff name because she didn ' t want the girl to lose her job. The nurse described the resident's mental status as alert and oriented, calm and thinking clearly as she told the story. She further reported that at times, resident #1 was confused, but on that night, she was not. The nurse stated she reported this information immediately to the night supervisor, RN #1. She also reported following an assessment of the resident, the doctor's group was called and notified. She indicated she wrote a detailed nursing note which included the resident's story, the condition of the eye, vital signs, and to whom she reported the information. She reported the note was missing from the record and could not be located. During an interview with RN #1 on 11/03/2010 at 6:30AM, the RN stated on 10/28/2010 LPN #3 reported to her that resident #1's eye was bruised looking and, the resident said she was socked in the eye. She further reported she assessed the resident and observed the area under her right eye was purple and an obvious bruise. She indicated there was also an area under the other eye with a purple area but much smaller than the right side. She reported the resident gave her the same story she gave to LPN #3. She indicated she advised LPN #3 to document everything. She reported she immediately called the Director of Nursing around 1:00AM and reported the information. She stated she assisted LPN #3 with an assessment. She indicated the resident was alert, oriented, calm and coherent when she described what occurred. She indicated a note was written, but they could not locate it. Review of the written statement dated 10/28/2010 by the Assistant Director of Nursing, RN #3, indicated she interviewed resident #1 on 10/28/2010 at 8:05AM in the resident's room. According to the written statement, the resident reported she refused to go to an event and that a staff member told her she had to go. She reported she got punched in the eye, because the staff person wanted things done her way. She went on to say she did not want the staff person to lose her job, the staff person wasn ' t a bad person, and she believed she was sorry for hitting her. She did not give a name but described the staff member. The statement also indicated RN #3 reassured the resident that she had done the right thing when she reported the incident to the nurse. Review of facility record of complaint indicated an investigation of the resident's injury began on 10/28/2010 by the station 2 nurse manager, RN #2 and was completed on 11/01/2010. According to the findings on the complaint, RN #2 interviewed every staff member on 1st and 2nd shift who worked on 10/26/2010 and 10/27/2010 and was unable to pinpoint anyone who knew anything regarding the incident. The findings also indicated RN #2 reviewed abuse policies with the staff. During an interview with RN #2 on 11/02/2010 at 5:30PM, the RN reported she did an investigation and interviewed the resident as well as staff on 1st and 2nd shift who worked on 10/26/2010 and 10/27/2010 and got written statements from all of them. She indicated she was unable to pinpoint who the alleged staff might be. Review of the physician's progress note indicated resident #1 was assessed by the nurse practitioner on 10/28/2010 for bruising of the right eye. The note revealed that staff reported the resident had bruising to right eye yesterday, and the resident reported she was hit in the eye by a staff member. Per the report, the resident refused to state who or why and stated, " I don ' t want to talk about it anymore " . The assessment revealed dark purple bruising noted below right eye, hematoma to right eye, continue to monitor closely, no vision changes or complaints of pain at this time. Record review of the 24 hour initial report indicated the facility filed the 24 hour report to the state on 10/28/2010 as injury of unknown origin. The report was prepared by RN #3. Review of the October and November 2010 staffing schedule indicated NA #1 and NA #2 provided care to resident #1 on 10/27/2010, 10/28/2010, 10/29/2010, 10/30/2010, 10/31/2010 and 11/02/2010 on the 3-11 shift. Per facility records, no facility staff were removed from care of resident #1 during the facility investigation. NA #1 and NA #2 were removed from care of resident #1 on 11/04/2010 per interview with RN # 2. During an interview with the Director of Nursing (DON) on 11/03/2010 at 9:30AM, she indicated all staff received abuse training when hired, and she expected all staff to report abuse or allegations of abuse immediately. She reported the allegation of abuse and the bruise was reported to her at around 1:30AM on 10/28/2010 by the night RN Supervisor. She revealed the investigation of the alleged abuse began on 10/28/2010, and the 24 hour report was sent to the North Carolina Health Care Registry that day. She indicated the facility had not received enough information during their investigation that warranted removing any particular staff from caring for the resident. She further reported that her investigation was ongoing when this writer entered the facility, and until yesterday, they had not narrowed down a particular shift and individual staff that may have been involved in the abuse allegation. The DON indicated the facility created a new mandatory training packet entitled " Abuse Prohibition Training " that included the 7 components of abuse prohibition, the definition of abuse with a mandatory post test. She reported the mandatory training began on 11/01/2010 and had to be completed by all employees by 11/07/2010. The DON clarified on 11/03/2010 at 12:00PM that SW #1 reported on 10/27/2010 that the resident's family member was upset but did not recall the SW said the resident alleged a staff person hit the resident. Review of records indicated the 5 day working report of the allegation investigation was sent to the N.C. Health Care Personnel Registry on 11/03/2010. A summary of the investigation dated and signed by the Director of Nursing indicated the incident occurred on 3-11 shift on 10/26/2010, and based on their investigation, they were unable to determine how the resident sustained [REDACTED]. A. Address how corrective action will be accomplished for each resident found to be affected by the deficient practice. ? Care will not be delivered to the affected resident by the two 3-11 shift CNA's that were assigned on 10/26/10, effective 11/3/10 and indefinitely. Unit Manager has shared information with licensed staff related to assignment of staff. The two CNAs will not be allowed to deliver care or be assigned to the affected resident while residing in the facility. Completion Date: 11/3/10- ongoing ? This resident has a history of refusing care, though not prevalent over the past three months or greater. The Clinician will develop packet on methods to handle resistant residents and re-educate staff for those delivering care for affected resident. Those not trained will not be allowed to care for this resident until trained regarding resistant resident care for affected resident. The Clinician and Unit Manager will provide additional training for the staff caring for the affected resident Completion Date: 11/5/2010 The facility submitted the 24 hour report to the state agency to report allegation of abuse of unknown origin on 10/28/10 per DON. The facility began its investigation on 10/28/10 that was conducted by Unit Manager. Five day report was submitted to the state agency on 11/3/10. ? Social Worker will give support to the affected resident by visiting twice per week for two weeks, then weekly for four weeks to evaluate for fear, concerns, depression, and additional behaviors. Evaluation will occur at the end of the six week visits. For additional support if indicated. Contact information will be provided to the resident during first visit. Completion Date: 11/05/10- 12/17/10 ? The affected resident's Careplan has been updated to reflect potential/actual episodes of fear. Completion Date: 11/05/10 ? Administrator, Director of Nursing revisited resident on 11/4/2010 to check on resident's status related to incident that occurred on 10/26/10 and to apologize. Administrator, DON, or ADON will visit resident twice per week for one week, then weekly for three weeks for support, identification of voiced concerns, and evaluation of resident's comfort in facility. Unit Manager to round on resident three times per week for one week to assess resident needs and voiced concerns, then weekly thereafter for three weeks. Completion Date: 11/4/10-11/25/10 B. Address how corrective action will be accomplished for those residents having potential to be affected by the same deficient practice. ? Clinician and Director of Nursing developed education packet to re-educate staff on abuse. The Abuse Prohibition education packet was developed to re-train staff on the facility's abuse policy which includes the seven components of abuse prohibition and how to deal with difficult residents. Staff will be re-educated in six months and annually thereafter; or more often as indicated. Completion Date: 11/ 1/ 10 ? The Clinician (Educator), Administrator and/ or Director of Nursing will re-educate all leadership staff (includes Managers and Supervisors) on the facility's abuse policy which includes the seven components; screening, training, prevention, identification, investigation, protection, and reporting/response per facility policy, and how to deal with difficult residents. Managers/ Supervisors will re-educate staff with the packet which includes discussion of handling difficult residents after they are trained (conducted on 11/1/10). Completion Date: 11/1/10 ? Mandatory housewide re- education for all staff to be conducted by Manager/Supervisor for assigned staff on facility policy, learning packet with post test, and signed acknowledgement form to validate that education has occurred which is included in the training packet Those that have not received training will not provide any direct care to residents until training occurs. Completion Date: 11/5/10 ? Written warning for the 2 assigned CNA's that cared for affected resident for failure to exercise reasonable and responsible care during assigned shift. Completion Date: 11/5/10 ? The two CNA's will be closely monitored by the 3-11 Supervisor and licensed nursing staff after completion of training. Training occurred on 11/1/10 for Supervisor and 11/2/10 for assigned licensed nurses that will monitor the CNAs. Completion Date: 11/2/10 ? One of the assigned CNAs will be transferred to 7-3 shift, effective 11/8/10 for intense monitoring by Unit Manager, Supervisor, and assigned licensed nurses. Abuse Training occurred on 11/1/10 for CNA. Completion Date: 11/8/2010 ? The two assigned nurses that were apprised of the incident that occurred on 10/26/10 were re-educated on the facility's abuse policy which includes screening, training, prevention, identification, investigation, protection, and reporting/response. Documented disciplinary action taken for both nurses related to failure to provide protection based on an allegation of abuse, and not reporting the allegation in a timely manner. Completion Date: 11/5/10 C. Address what measures will be put into place or systemic changes made to ensure that deficient practice will not occur. ? Mandatory inservice re-education on abuse which includes screening, training, prevention, identification, investigation, protection, and reporting/response in progress for all staff. Those that have not received training will not provide any direct care to residents until training occurs. Completion Date: 11/5/2010 ? Licensed nursing staff will closely observe resident/ staff interactions for any evidence of abuse and report according to facility policy after training. Training conducted for Manager on 11/1/10 and licensed staff that will monitor on 11/2/10. Completion Date: 11/4/10- ongoing ? Monitoring tool will be developed from QIS Abuse Prohibition template for monitoring of residents/families and employees to ensure compliance in prevention, identification, protection, and reporting/response of abuse. Completion Date: 11/4/2010 D. The facility will monitor its performance to ensure that solutions are achieved and sustained. The facility will evaluate the plans effectiveness ? Unit Managers will conduct five random audits per month for all direct caregivers; to include all shifts; 20 audits per month for facility. Results will be reported and discussed in Interdisciplinary QA that is held monthly for identification of abuse concerns, educational training needs, tracking, and trending for staff. Retraining will occur as indicated and/or disciplinary action taken as indicated for violation of the facility's abuse policy. Monitoring will begin on 11/30/10 and results reported at the 12/14/10 Interdisciplinary QA meeting. Monitoring will be effective 12/14/10- 12/14/ 11. Completion Date: 12/14/10-12/14/11 ? Social Workers will interview three residents and/or family members who are unable to speak for themselves; 12 audits per month per social worker to total 24 audits per month. ? Results will be reported and discussed in Interdisciplinary QA that is held monthly for identification of abuse concerns, tracking, and trending for residents/family members. Education on reporting abuse will be provided to residents and /or families by the SW as indicated. Monitoring will begin on 11/30/10 and results reported at the 12/14/10 Interdisciplinary QA meeting. Monitoring will be effective 12/14/10- 12/14/ 11. Completion Date: 12 /14/2010-12-14-2011 ? Managers/ Supervisors will monitor staff compliance per observation and conversation with residents (randomly) during daily rounding for compliance. Observed violation of facility's abuse policy will result in immediate retraining or disciplinary action if indicated. Completion Date: 11/5/10- ongoing Verification of the credible allegation was evidenced by interviews of direct care staff related to mandatory reeducation on abuse, review of the new " Abuse Prohibition Training " packet dated 11/01/2010, review of inservice rosters on reeducation of staff on abuse, review of disciplinary actions delivered to all staff involved in the incident on 10/26/2010, and review of the updated care plan for resident #1 that added the problem of fears and interventions that addressed the resident's fears. All direct care staff reported they received reeducation on abuse, the importance of reporting and protecting the resident and h