Every finding on record at Tarboro Health and Rehabilitation LLC

Based on observations, record review, and Resident, staff and Nurse Practitioner (NP) interviews the facility failed to ensure a physician's order for the administration of supplemental oxygen was in place for 1of 2 residents (Resident #2) reviewed for respiratory care. Findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic lung condition which can cause shortness of breath). A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She was not coded for receiving respiratory or oxygen therapy. A review of Resident #2's comprehensive care plan revealed a focus area last revised on 11/27/24 for risk of complications due to her asthma diagnosis. The goal was for Resident #2 not to exhibit signs of respiratory distress. An intervention was to administer oxygen as ordered. On 1/6/25 at 1:38 PM an observation of Resident #2 revealed she was receiving 2 liters of oxygen via nasal cannula. An interview with Resident #2 at that time indicated she used oxygen sometimes, especially at night if she had trouble breathing. On 1/6/25 a review of Resident #2's electronic medical record did not reveal any evidence of a physician's order for the administration of oxygen. On 1/6/25 at 1:54 PM an interview with Nurse #1 indicated she was caring for Resident #2 on the 7AM-3PM shift. She stated Resident #2 had been receiving 2 liters of oxygen via nasal cannula when she began her shift at 7:00 AM that day. Nurse #1 went on to say if oxygen was being administered to a resident, there should be a physician's order for this that would show up on the resident's medication administration record (MAR) letting the nurse know how much oxygen to administer. She stated she did not recall looking to see if Resident #2 had this order earlier, but she did not see a physician's order for oxygen now. On1/8/25 at 9:04 AM an interview with Nurse #3 indicated she cared for Resident #2 on 1/4/25 and 1/5/25 on the 3PM-11PM shift. She stated she did recall Resident #2 had been receiving oxygen at 2 liters via nasal cannula on her shifts on those days. She reported she did not check to see if Resident #2 had a physician's order for this oxygen. She went on to say if a resident experienced shortness of breath and needed supplemental oxygen, the facility had a standing order the nurse could activate. Nurse#3 stated once the nurse activated this order, it would appear on the resident's MAR. On1/8/24 at 9:08 AM an interview with Resident #2's Nurse Practitioner (NP) indicated he was familiar with Resident #2. He stated at times she experienced some anxiety that caused shortness of breath. He reported he would not want a nurse to wait to talk with him if a resident was experiencing a low oxygen saturation or shortness of breath. He stated there was some room for nursing judgement. He went on to say the facility had a standing order for oxygen therapy the nurse could initiate prior to speaking with a provider. The NP reported there should be an active physician's order in place if oxygen was being administered to a resident. On 1/9/25 at 8:39 AM an interview with the Director of Nursing (DON) indicated a resident should have an active physician's order in place if oxygen was being administered that included the amount of oxygen to be administered, and by what route. On 1/9/25 at 9:03 AM an interview with the Administrator indicated he would agree with the recommendation of Resident #2's NP and the DON regarding oxygen orders.

Based on resident and staff interviews the facility failed to provide access to resident funds after normal banking hours to include the weekends. This was for 2 of 2 residents (Resident #11, Resident #24) reviewed for personal funds and had the potential to affect all residents with personal funds accounts. Findings included: a. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #11's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact. An interview conducted with Resident #11 on 1/6/25 at 3:36 PM revealed she was unable to access her money the facility held for her after the business office closed for the day and on weekends. b. Resident #24 was admitted to the facility on [DATE]. Resident #24's quarterly Minimum Data Set assessment dated [DATE] indicated she was cognitively intact. An interview conducted with Resident #24 on 1/6/25 at 10:52 AM revealed she was unable to access her money the facility held for her after the business office closed for the day and on weekends. During an interview with the Business Office Manager (BOM) on 1/7/25 at 9:17 AM revealed she worked at the facility Monday through Friday, 9:00 AM to 5:00 PM and residents could not get money out of their account after she left the facility for the day and on the weekends. The BOM stated if residents wanted to withdraw money from their account, they needed to do so during business hours on working days. The interview further revealed the BOM was unaware that residents could request their funds after office hours during the week or on the weekend. During an interview with the facility's corporate Director of Reimbursement on 1/7/25 at 9:20 AM she stated resident funds should be available to residents 24 hours a day 7 days a week. During an interview with the Administrator on 1/7/25 at 9:27 AM he stated money used to be kept in an envelope in the locked medication room for the weekend cash access for residents. He stated he was not aware that this practice had been stopped. He stated residents did not have access to cash after business office hours (9:00 AM to 5:00 PM) during the week but concluded money should have been available to residents on weekends for residents who had accounts with the facility.

Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment and to ensure the Facility Assessment identified and addressed the care required for the population of residents with a tracheostomy and to address the staff training necessary to competently provide tracheostomy care. Findings included: Review of the Facility Assessment revealed the assessment was last updated in November 2022. The document indicated the facility had completed education/training/competencies with staff specific to resident care needs, however, the facility lacked training/competencies to care for residents who required a trach. The Facility Assessment also indicated the facility had an Emergency Preparedness Plan that was up to date, however the Emergency Preparedness Plan that was present was not complete. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator confirmed that the facility had 2 residents that were trach dependent and discussed that the Facility Assessment was a collaboration effort with management. He indicated he was unaware that tracheostomy care and training was not addressed in the Facility Assessment. The Administrator also stated he was not aware that some of the staff had not received education/competencies in providing trach care/suctioning. He also stated he believed the Emergency Preparedness Plan was complete and accurate.

Based on record review, observations, staff, and resident interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation surveys of 10-13-22. This was for 4 recited deficiencies in the areas of Emergency Preparedness (E001), Safe/Clean/Comfortable/Homelike Environment (F584), Respiratory/Tracheostomy care and Suctioning (F695), and Facility Assessment (F838). The continued failure during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag was cross referenced to: E001: Based on record review and staff interviews, the facility failed to establish and maintain a comprehensive Emergency Preparedness (EP) plan. The facility failed to establish policies and procedures, provide subsistence needed for staff and residents, list staff and their responsibilities, provide an alternate means of communication, review and update the communication plan, share information with residents or family members, complete a tabletop or full-scale exercise and EP education. During the recertification and complaint investigation survey of 10-13-22 the facility was cited for failing to include/document facility based and community-based risk assessment, address persons at risk, establish policies and procedures, develop a system to track residents' and staff, maintain/ update current contacts, review and update the communication plan, update names and contact information, share information with residents or family members and to complete a tabletop or full-scale exercise and EP education. F584: Based on observations and staff and resident interviews the facility failed to clean blood from a floor surface for 1 of 1 room reviewed for environment (room [ROOM NUMBER]). During the recertification and complaint investigation survey of 10-13-22 the facility was cited for not maintaining resident walls and heating/air units in good repair and maintaining a clean-living environment. F695: Based on record review, staff, and physician interviews, the facility failed to obtain a physician's order to suction a resident who was trach dependent. This occurred for 1 of 1 resident (Resident #73) reviewed for tracheostomy care. During the recertification and complaint investigation survey of 10-13-22 the facility was cited for failing to provide tracheostomy care following sterile technique and set oxygen as ordered. F838: Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment and to ensure the Facility Assessment identified and addressed the care required for the population of residents with a tracheostomy and to address the staff training necessary to competently provide tracheostomy care. During the recertification and complaint investigation survey of 10-13-22 the facility failed to review and annually update the Facility Assessment. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator discussed trying not to have repeat citations and stated, but it happens.

Based on observations and staff and resident interviews the facility failed to clean blood from a floor surface for 1 of 1 room reviewed for environment (room [ROOM NUMBER]). Findings included: During observation of room [ROOM NUMBER] on 11/13/23 at 10:24 AM an approximately 3.0 inch by 0.5 inch area of dried blood was observed on the floor between the window and bed. During observation on 11/13/23 at 3:05 PM the dried blood was observed still on the floor in room [ROOM NUMBER]. Resident #12 stated the blood on floor was from his toenail which had bled that morning. During observation on 11/14/23 at 8:13 AM, the same dried dried blood was again observed on the floor of room [ROOM NUMBER]. During an interview on 11/14/23 at 8:14 AM Nurse Aide #1 stated she did not notice the dried blood on the floor in room [ROOM NUMBER] and did not know how she had missed seeing it. During an interview on 11/14/23 at 8:17 AM Nurse #5 stated she saw him in the morning when giving his medicine and did not note the blood. During an interview on 11/14/23 at 8:23 AM the Director of Nursing stated around 8:30 AM she entered room [ROOM NUMBER] and Resident #12 informed the Director of Nursing of the blood on his toe but did not mention any blood on the floor. Where his wheelchair was at the time blocked her view of that area of the floor. She concluded blood should be cleaned from surfaces for infection control concerns. During an interview on 11/14/23 at 8:31 AM the Contracted Housekeeping Account Manager stated Housekeeper #1 should visualize the entirety of the floor while cleaning and Housekeeper #1 was the staff member responsible for room [ROOM NUMBER]. If housekeepers noted any blood, which they should have noted in room [ROOM NUMBER], they should have reported the area to nursing who would clean the blood and then come back and sanitized the area after. Housekeeper #1 was unavailable for interview.

Based on record review, resident, and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan related to tracheostomy care which included an intervention for suctioning for a resident who required suctioning daily and as needed. This occurred for 1 of 13 residents (Resident #73) reviewed for comprehensive care plans. Findings included: Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included encounter for tracheostomy and chronic respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was severely cognitively impaired. The MDS documented Resident #73's tracheostomy care but not suctioning. Resident #73's care plan dated 9-25-23 revealed goals and interventions for his tracheostomy but no goals and interventions related to as needed suctioning. Resident #73 was interviewed on 11-13-23 at 12:11pm. The resident used a communication board to state that he was suctioned at least once a day by nursing staff. Resident #73 communicated there were no issues with his suctioning. During an interview with Nurse #1 on 11-14-23 at 11:35am, Nurse #1 discussed Resident #73 having a tracheostomy. She explained the resident required to be suctioned at least once a shift but sometimes more. Nurse #1 stated she knew Resident #73 had a care plan for the care of his tracheostomy but said she did not recall ever seeing any goals or interventions for suctioning. The nurse explained when an order was written for trach care daily that it was understood by nursing staff that suctioning was part of daily trach care. Nurse #1 explained she would provide suctioning for Resident #73 when he had an increase in congestion. The MDS Nurse was interviewed on 11-14-23 at 11:41am. The MDS Nurse confirmed there were not any goals or interventions for Resident #73 to be suctioned. She explained the resident did not need a separate goal or intervention for suctioning because the task was part of his routine trach care. An interview with the Director of nursing (DON) occurred on 11-14-23 at 12:17pm. The DON discussed care plans for tracheostomy residents and stated she expected the residents to have goals and interventions for routine trach care and possibly suctioning. She explained not all their tracheostomy residents needed routine suctioning. The DON stated for Resident #73, she would expect to see interventions on his care plan for as needed suctioning. She said Resident #73 had not required routine suctioning but was aware he required suctioning at times. The DON stated she was not aware that there were not any goals or interventions for Resident #73's suctioning. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator discussed not knowing enough about tracheostomy care to say if Resident #73 should have goals and interventions on his care plan for suctioning.

Based on observations, record review, and staff and family interviews, the facility failed to place a splint on 1 of 1 resident reviewed for range of motion (Resident #88). Findings included: Resident #88 was admitted to the facility on [DATE]. Her active diagnoses included cancer, hypertension, cerebrovascular accident [(CVA), TIA, or stroke], depression, and secondary malignant neoplasm of bone. She received hospice services. Resident #88's minimum data set assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired. She had impairment to the upper and lower extremity of one side. She was dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, and chair/bed-to-chair transfer. She was always incontinent of bowel and bladder. Resident #88's care plan dated 10/9/23 revealed she was care planned for impaired mobility related to diagnoses of history of cerebrovascular accident, cancer with metastasis to bones and is on hospice services. The interventions included placing her left hand splint as ordered by Hospice 4 to 6 hours daily. During observation on 11/13/23 at 9:47 AM Resident #88 was observed in her room and had no splint applied to her left hand. During an interview on 11/13/23 at 11:02 AM Nurse Aide #2 stated at one time, Resident #88 had a splint for one of her hands. She had not put Resident #88's splint on because she did not know where it was or if she still needed it. During observation on 11/13/23 at 11:34 AM Resident #88 was observed in her room and had no splint applied to her left hand. During observation on 11/14/23 at 11:32 AM Resident #88 was observed in her room and had no splint applied to her left hand. During a follow-up interview on 11/14/23 at 12:14 AM Nurse Aide #2 stated she was not putting splints on Resident #88 because she did not know where it was, and splints were not on the care guide in the closet, so she did not know the resident was to get splints. During observation on 11/14/23 at 12:14 AM the care guide in the closet was observed to not have splint use documented on the closet door care guide. During an interview on 11/13/23 at 12:22 Nurse #5 stated the daughter had splints on the resident prior to coming to the facility and the splint was placed on Resident #88 by staff including herself at times. She stated she believed it was to be put on daily and she had put the hand splint on Resident #88 in the mornings. She stated if she put the splint on, she would document it in the chart. Since she did not put the splint on yesterday or today, the MAR was blank. She concluded she did not put the splints on Resident #88 yesterday or today as she was busy and had forgotten. During an interview on 11/14/23 at 12:29 the Medical Director, after reviewing the order, stated that the order was for the splint to be placed for 4 to 6 hours each day. He stated he did not remember any discussion with the family about the splint but would expect the orders to be followed. As the Medication Administration Record (MAR) was blank, either it was not documented, or the splint was not put on. During an interview on 11/14/23 at 1:22 PM the Director of Nursing stated most of the time hospice would bathe the resident in the morning and put the hand splint on the resident and if not, their staff should place the splint on Resident #88. She concluded, based on the MAR, the splint was not placed on the resident 11/1/23 through 11/13/23 and it should have been placed per physician's orders.

Based on record review, staff, and physician interviews, the facility failed to obtain a physician's order to suction a resident who was trach dependent. This occurred for 1 of 1 resident (Resident #73) reviewed for tracheostomy care. Findings included: Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included encounter for tracheostomy. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was severely cognitively impaired. Review of the Physician's standing orders dated 11-7-23 read trach care every shift. During an interview with Nurse #1 on 11-14-23 at 11:35am, Nurse #1 explained when a resident received tracheostomy care, the care was documented on the resident's Medication Administration Record (MAR). She further explained if the resident required suctioning, that would also be documented on the resident's MAR. Nurse #1 discussed Resident #73 not having suctioning on his MAR and stated, that is because there is not an order to suction the resident. The nurse explained that suctioning was part of Resident #73's routine trach care and she was not aware there needed to be an order. An interview with the Director of Nursing (DON) occurred on 11-14-23 at 12:17pm. The DON discussed if a resident required routine suctioning, there was a physician order for suctioning but if a resident required suctioning on an as needed basis, then the order for routine daily trach care would include suctioning. She explained that Resident #73 required suctioning on an as needed basis and stated she was not aware a separate order should be written. The Medical Director was interviewed on 11-14-23 at 1:59pm. The Medical Director explained he did not write orders for trach care because there were standing orders for trach care. He further explained it was understood by nursing that the standing order for trach care would include suctioning when needed. The Medical Director discussed Resident #73 and stated there should be a physician's order for as needed suctioning for the resident. He said he was not aware that there was not an order in place for Resident #73's suctioning. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator stated he was not familiar enough about tracheostomy care and would defer to what the DON and Medical Director discussed.

Based on record review, staff, and Physician interviews, the facility failed to educate 3 of 3 nurses (Nurse #2, Nurse #3, and Nurse #4) to ensure competency and demonstrate skills in providing care to 1 of 1 resident (Resident #73) reviewed for tracheostomy care. Findings included: Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included encounter for tracheostomy. A telephone interview occurred with Nurse #2 on 11-15-23 at 9:41am. Nurse #2 explained she began working at the facility in May 2023 and had been assigned to Resident #73 sometimes. She stated when she had worked with Resident #73, she remembered having to provide trach care and having to suction Resident #73 once during her shift. The nurse discussed not receiving trach training or having to show competency in providing trach care and/or suctioning to Resident #73. An interview with Nurse #3 occurred by telephone on 11-15-23 at 10:21am. Nurse #3 explained she had begun working at the facility in the middle of October 2023 and stated she had provided trach care and suctioning to Resident #73. She discussed not receiving training or skills competency on trach care and/or suctioning since she was hired. During an interview with Nurse #4 on 11-15-23 at 4:11pm, Nurse #4 discussed working for an agency and often being assigned to Resident #73 where she stated she had performed trach care and suctioning. She said she had not been provided training and/or skills competency on trach care and/or suctioning to Resident #73. The Medical Director was interviewed on 11-14-23 at 1:59pm. The Medical Director discussed not being aware the nurses had not received competency education or demonstrated their competency to provide trach care to Resident #73. He stated all nursing staff should have competency training and be able to demonstrate their competency in providing trach care. The Staff Development Coordinator (SDC) was interviewed on 11-15-23 at 12:24pm. The SDC explained when there was a new nurse hired, the new nurse would be paired with a seasoned nurse who would be responsible for completing the competency skills check list with the new hire. He stated trach care and suctioning was part of the new hire competency check list, however when reviewing the document, the SDC realized trach care and suctioning was not part of the new hire competency check list. The SDC discussed not being aware that trach care and suctioning was not part of the new hire competency check list but stated all new nursing staff should be trained and show competency prior to performing trach care and/or suctioning. The Director of Nursing (DON) was interviewed on 11-14-23 at 12:17pm. The DON discussed not being aware that all the new nurses hired had not had trach care and/or suctioning training and competencies completed. She stated all nurses should be trained and show competency in trach care and/or suctioning prior to working with trach residents.

Based on record review and staff and Responsible Party (RP) interviews the facility failed to provide the resident or their RP quarterly statements for their personal trust fund account managed by the facility for 1 of 1 resident (Resident #85) reviewed for personal funds. Findings included: Resident #85 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of the quarterly Minimum Data Set (MDS) assessment for Resident #85 dated 10/23/23 revealed she was severely cognitively impaired. On 11/13/23 at 11:39 AM a telephone interview with Resident #85's RP indicated Resident #85 had a personal trust fund account with the facility. The RP stated Resident#85 used this account to pay for things like beauty shop appointments at the facility. The RP went on to say she was not receiving quarterly statements from the facility for Resident #85's personal trust fund account. On 11/16/23 at 10:06 AM an interview with the Business Office Manager confirmed Resident #85 had a personal trust fund account with the facility. She stated she had been in her position as the Business Office Manager since February 2023. She went on to say she had not been sending quarterly statements for resident trust fund accounts to residents or their RPs. The Business Office manager stated she would provide one if a resident or RP asked, but she was not aware she was supposed to be providing them quarterly. On 11/16/23 at 11:16 AM an interview with the Administrator indicated the facility resident trust fund account policy specified that quarterly statements for resident trust fund accounts would be given to the resident or their responsible party. He stated the Business Office Manager should be providing these in accordance with the facility's policy.

Based on observations, record review and interviews with the resident, facility staff, and physician the facility failed to provide a safe transfer of a resident using a mechanical lift which caused a resident (Resident #72) to fall and fracture her right upper leg. This was for 1 of 3 residents reviewed for accidents. The findings included: Resident #72 was admitted to the facility on [DATE]. Her diagnoses included diabetes, [CONDITION(S)], bilateral lower extremity amputations and a fracture of the right femur. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was cognitively intact. She required extensive assistance with bed mobility, dressing, toilet use ad personal hygiene. She was totally dependent with the assistance of 2 staff for transfers. She required supervision for locomotion off the unit and used a wheelchair for locomotion. She had range of motion impairment of both lower extremities. A nursing note dated 7/29/22 documented at 8:45 AM Nurse #4 was called to Resident #72's room by the Nursing Aide (NA) who stated she was transferring Resident #72 by mechanical lift to her wheelchair when the lift pad snapped/broke. Nurse #4 observed Resident #72 sitting upright on the floor in front of her wheelchair. The note documented Nurse #4 asked Resident #72 what was different, and the resident's response was pad. Nurse #4 documented the resident's right below knee amputation (BKA) was leaning on the foot of the mechanical lift. A review of the hospital discharge summary dated 8/2/22 documented Resident #72 was admitted on [DATE] for a fracture of the right femoral shaft (straight part of the long bone from the hip to the knee). The resident had surgical repair of the right leg fracture on 7/31/22 with intramedullary nailing of the right femur (a metal rod is inserted inside the bone and across the fracture to provide a solid support for the fractured bone). She was discharged back to the facility on [DATE] A review of the physician's progress note dated 8/2/22 revealed Resident #72 was admitted to a medical center on 7/30/22 and was discharged back to the facility on [DATE] for management of a right femoral shaft fracture after a fall. His note documented the resident was being transferred in a mechanical lift, which resulted in her sustaining a fracture. She was sent to the local hospital emergency department and was transferred to the medical center. She had surgical repair of the right femur with nailing on 7/31/22. The admission and significant change MDS dated [DATE] indicated Resident #72 was readmitted to the facility on [DATE] from an acute care hospital. Resident #72 was cognitively intact. She required extensive assistance with bed mobility, dressing, and personal hygiene. She was totally dependent for transfers and locomotion off the unit in a wheelchair which required 2 or more staff. She was totally dependent with assistance of 1 staff for toilet use. She had range of motion impairment of both lower extremities. The care plan last updated 8/9/22 revealed Resident #72 was at risk for falls related to impaired mobility due to left AKA (above knee amputation) and right BKA (below knee amputation). The approaches included name brand mechanical lift +2 for transfers was documented below the approach of s/p fall 7/29/22. ED (Emergency Department) visit for right hip pain. On 10/10/22 at 12:10 PM Resident # 72 stated she broke her right hip when she fell while being transferred from the bed to her wheelchair using a mechanical lift. She said she tried to tell the NA that something was not right, and she was leaning too far over. She was not able to state which NA it was. On 10/11/22 at 9:00 AM Nurse #4 stated she remembered Resident #72 fell from the mechanical lift when the lift pad broke. Nurse #4 said she was not present in the room when it happened there was 1 NA present when that happened. She said she did not remember which NA was present. Nurse #4 said she saw Resident #72 on the floor and the NA told her she was had the resident up in the lift. Nurse #4 assessed Resident #72 and called the physician to have her sent to the hospital due to severe pain in her right hip. She said the lift pad was not the correct pad for the resident's weight. The fall investigation report was reviewed. This report documented on 7/29/22 at 8:45 AM the NA was transferring the resident via mechanical lift to the wheelchair when the lift pad snapped and broke. The nursing assistant was documented as NA #5. The report documented the fall huddle (team meeting to review the fall) revealed the resident had leg pain of 8-9 (on a pain scale of 1-10), hit leg on lift, and the resident was sent to the hospital. Attempts to contact NA #5 were unsuccessful. On 10/11/22 at 10:50 AM Physician #1 stated he was aware of the fall and broken right femur of Resident #72. He stated she had surgery to repair the fracture and she currently self-propels in her wheelchair daily. On 10/12/22 at 11:45 AM Resident #72 was observed out in the hall propelling her wheelchair. An interview with the Director of Nursing (DON) on 10/11/22 at 4:00 PM revealed the facility conducted a complete investigation with a root cause analysis and implemented a plan of correction. She said NA #5 used the wrong lift pad. The DON explained the lift pads have weight requirements and NA #5 used the wrong pad for Resident #72's weight so the strap on the pad broke which caused Resident #72 to fall from the lift onto the floor. The DON said NA #5 did not use 2 staff which was the protocol for all mechanical lifts. The DON provided the documentation of the plan of correction. The facility provided the following corrective action plan with a completion date of 7/30/22. Allegation of Compliance for mechanical lift Incident F689 On 7/29/22 at 8:50 am resident #72, who has a diagnosis of End Stage Renal Disease, Type 2 Diabetes, and [CONDITION(S)] fell from the mechanical lift about 3 feet onto the floor as NA #5 was moving her from the bed to a wheelchair. Emergency care was provided, and the resident was transferred to the emergency room . Resident #72 has a BIMS score or 15 and is her own responsible party. Physician was notified of fall at 9:00am by charge nurse on the hall. EMS (Emergency Medical Services) was called, and resident was transferred to the local hospital at 9:15am. Resident's husband, who is her only family, was in facility for respite care. He was notified at 2:00pm once facility was able to get more information about resident #72's status. Upon investigation, the following was determined: a. Aide (NA#5) did not follow facility protocol of having 2 people involved on every mechanical lift. b. Aide (NA#5) did not use the correct pad. c. NA's who were working at the time were interviewed and NA #5 had not asked anyone to assist her with lift use. d. Staffing levels were appropriate and another NA was available to assist but was not asked. Root cause analysis revealed the cause of the fall to be a combination of the aide not following facility protocol and using the incorrect pad. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. a. NA#5 was terminated on 7/29/2022 at 10 am for failure to follow facility protocols. 2. Use of mechanical lifts was suspended for all residents until all investigations complete. a. All residents using a mechanical lift have the potential to be affected. b. 100% of NAs and Nurses were in-serviced on facility policy regarding mandatory use of two people for all mechanical lifts, what correct lift pads look like, where to locate the pads and how to use them. Staff then showed understanding through return skills demonstration. Any staff member that was not able to be in-serviced on this date will not be allowed to return to work until they have received their education. Completed 7/29/22 c. All lift pads were inspected and found to be appropriate in size/fit for the Facility's mechanical lifts. Completed 7/30/22 d. Maintenance Director inspected all lifts for proper function and found that all mechanical lifts are in proper working order and have been routinely inspected and found to be in working order per Facility policy and/or manufacturer's recommendations. Completed 7/29/22 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. a. 100% of NAs and Nurses were in-serviced on facility policy regarding mandatory use of two people for all mechanical lifts, what correct pads look like, where to locate them and how to use them. Any staff member that was not able to be in-serviced on this date will not be allowed to return to work until they have received their education. Completed 7/29/22 b. All lift pads were inspected and found to be appropriate in size/fit for the Facility's mechanical lifts. Completed 7/30/22 c. Maintenance Director inspected all lifts for proper function and found that all mechanical lifts are in proper working order and have been routinely inspected and found to be in working order per Facility policy and/or manufacturer's recommendations. Completed 7/29/22 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. a. Nursing Administration staff will conduct random skills checks on 10% of NAs for proper use of lifts and pads weekly x4 weeks, monthly x 2 months, and quarterly x3 or until such time as no incidents of failure to comply with Facility policy are noted. b. Mechanical lifts will be checked monthly by Maintenance Director and lift pads will be checked monthly by Central Supply. c. The QA committee will review all results monthly and implement or modify actions as need. This corrective action plan was in place on 7/30/22 by the Administrator. The corrective action plan was verified through record review of the education and monitoring of mechanical lift transfers, interviews with facility staff, observation of a mechanical lift transfer and observations of Resident #72. Based on observations, interviews, and record reviews the facility's compliance date of 7/30/22 was verified.

Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment. Findings included: Review of the Facility Assessment revealed the assessment was last updated in September 2022. The document indicated the facility had a facility based and community-based risk assessment utilizing an all-hazards approach however there was not a risk assessment completed in the document. The Facility Assessment also indicated the facility had an Emergency Preparedness Plan that was up to date however the Emergency Preparedness Plan that was present was not complete. The Administrator was interviewed on 10-13-22 at 5:07pm. The Administrator stated he was not able to produce a facility based and community-based risk assessment. He explained he thought it was completed but said he was unable to locate the assessment. The Administrator also discussed not being aware the Emergency Preparedness plan was not complete at the time the Facility Assessment was updated.

Based on observation, record review, resident and staff interviews, the facility failed to (1) honor resident choice to receive a shower for 2 of 2 residents (Resident #82 and Resident #77), (2) honor resident choice when to receive [CONDITION(S)] care and enteral feedings for 1 of 1 resident (Resident #16) and the facility failed to (3) honor resident choice to receive double portions as ordered by the Physician for 1 of 1 resident (Resident #25) reviewed for choices. Findings included: 1 Resident #82 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was mildly cognitively impaired with no documentation of refusal of care. The MDS documented Resident #82 required extensive assistance with one person for bed mobility, dressing, personal hygiene, total assistance with 2 people for transfers and total assistance with one person for toileting and bathing. The MDS also documented Resident #28 choosing a tub or bed bath or shower was very important to him. Resident #82's care plan dated 9-2-22 revealed a goal of Activities of Daily Living (ADL) constant. The interventions for the goal were provide a shower on scheduled shower days. An attempt was made to locate the facility's shower schedule for Resident #82 however there was not a shower schedule available. Review of Resident #28's bathing documentation from August 2022 through October 2022 revealed the resident had not received a shower but had consistently received a bed bath. Resident #82 was interviewed on 10-10-22 at 11:20am. The resident discussed receiving a bed bath daily but stated he would like to have a shower at least once a week. Resident #82 commented he had not received a shower in a very long time. Nursing Assistant (NA) #13 was interviewed on 10-12-22 at 7:13am. The NA stated he had been working at the facility for a month and had never seen a shower schedule. He discussed never providing a shower to a resident nor being informed that he needed to be providing showers to residents. NA #13 stated he had been assigned to Resident #82 and that the resident had requested a shower, but he did not provide a shower to him because he was not aware he needed to provide showers. An interview with NA #14 occurred on 10-12-22 at 7:20am. NA #14 stated the facility did not have care guides for the residents, but the NAs could look in the computer for the residents required care. She stated she was familiar with Resident #82 and said she was not aware of the resident's shower days because they no longer had a shower schedule. NA #14 stated she could not remember if the resident ever requested a shower and she had never provided a shower to Resident #82. During an interview with NA #11 on 10-12-22 at 7:24am, the NA stated she had not seen a shower schedule but would provide a shower if the resident requested. NA #11 stated she was familiar with Resident #82 and said he had requested a shower in the past, but she did not give him one because she did not feel comfortable showering the resident. Nurse #7 was interviewed on 10-12-22 at 7:28am. The nurse discussed the facility stopping all showers when COVID19 started 2 years ago. She stated since then she had not been provided a shower schedule for the residents and had not seen any of the residents including Resident #82 receive a shower. The Assistant Director of Nursing (ADON) was interviewed on 10-12-22 at 7:55am. The ADON stated showers had stopped when COVID19 started but said she did not know why. She explained the staff were educated 2 months ago on resident showers restarting. The ADON explained the showers were supposed to start back on hall 200 west first and then the facility would gradually start showers back on the other halls. She explained since Resident #82 resided on hall 200 east there would not be a shower schedule for him yet since the new schedule started on hall 200 west. The Director of Nursing (DON) was interviewed on 10-12-22 at 8:05am. The DON stated the facility had not been providing showers to the residents since the start of COVID. She explained the facility had to work on preparing the shower rooms by disinfecting before showers could resume. The DON discussed hall 200 west was supposed to start back showering the residents on their assigned days but said the facility had struggled in reimplementing showers into the NAs schedule. 2. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact with no documentation of refusing care. The MDS documented the resident required extensive assistance with one person for bed mobility, dressing, personal hygiene, extensive assistance with 2 people for transfers and total assistance with one person for toileting and bathing. Resident #77's care plan dated 8-31-22 revealed a goal of Activities of Daily Living (ADL) constant. The interventions for the goal were record personal hygiene and record bathing. An attempt was made to locate the facility's shower schedule for Resident #77 however there was not a shower schedule available. Review of Resident #77's bathing documentation from August 2022 through October 2022 revealed the resident had not received a shower but had consistently received a bed bath. Resident #77 was interviewed on 10-10-22 at 11:28am. The resident discussed receiving a bed bath but stated she had never received a shower. Resident #77 stated she would like to have a shower 1-2 times a week. She stated she had asked several times for a shower but was told the NAs were not able to provide a shower. Nursing Assistant (NA) #13 was interviewed on 10-12-22 at 7:13am. The NA stated he had been working at the facility for a month and had never seen a shower schedule. He discussed never providing a shower to a resident nor being informed that he needed to be providing showers to residents. NA #13 stated he had been assigned to Resident #77 and that the resident had requested a shower, but he did not provide a shower to him because he was not aware he needed to provide showers. An interview with NA #14 occurred on 10-12-22 at 7:20am. NA #14 stated the facility did not have care guides for the residents, but the NAs could look in the computer for the residents required care. She stated she was familiar with Resident #77 and said she was not aware of the resident's shower days because they no longer had a shower schedule. NA #14 stated she could not remember if the resident ever requested a shower and she had never provided a shower to Resident #77. During an interview with NA #11 on 10-12-22 at 7:24am, the NA stated she had not seen a shower schedule but would provide a shower if the resident requested. NA #11 stated she was familiar with Resident #77 and said she can not remember if the resident ever requested a shower but stated she had not ever provided a shower to Resident #77. Nurse #7 was interviewed on 10-12-22 at 7:28am. The nurse discussed the facility stopping all showers when COVID19 started 2 years ago. She stated since then she had not been provided a shower schedule for the residents and had not seen any of the residents including Resident #77 receive a shower. The Assistant Director of Nursing (ADON) was interviewed on 10-12-22 at 7:55am. The ADON stated showers had stopped when COVID19 started but said she did not know why. She explained the staff were educated 2 months ago on resident showers restarting. The ADON explained the showers were supposed to start back on hall 200 west first and then the facility would gradually start showers back on the other halls. She explained since Resident #77 resided on hall 200 east there would not be a shower schedule for her yet since the new schedule started on hall 200 west. The Director of Nursing (DON) was interviewed on 10-12-22 at 8:05am. The DON stated the facility had not been providing showers to the residents since the start of COVID. She explained the facility had to work on preparing the shower rooms by disinfecting before showers could resume. The DON discussed hall 200 west was supposed to start back showering the residents on their assigned days but said the facility had struggled in reimplementing showers into the NAs schedule. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated he expected staff to be providing showers to residents when the resident had asked. 3. Resident #16 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired. He received tube feedings and [CONDITION(S)] care. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM and 7:00 AM. The orders also included a water flush of 100 ml before and after each bolus which was scheduled for 10:00 AM, 2:00 PM, 6:00 PM 10:00 PM and 02:00 AM. The order for the [CONDITION(S)] care was scheduled as every shift without a specific designated time. The change of the inner cannula was ordered daily on the 7:00 AM to 3:00 PM shift and as needed. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It was signed as being given at 02:00 AM from 10/05/22 through 10/12/22. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/10/22 at 10:09 AM during an interview with Resident #16 he communicated he did not like that he received [CONDITION(S)] care and tube feedings between 1:00 AM and 2:00 AM. He did not like to be awakened at that time to receive this care and felt it could be scheduled at a different time, so he was not awakened in the middle of the night. On 10/13/22 at 3:21 PM during a follow-up interview Resident #16 communicated he was frustrated by being awakened during the night for changing out his [CONDITION(S)] tube and getting tube feedings. On 10/12/22 at 3:55 PM Nurse #8 who worked on the 3:00 PM to 11:00 PM shift stated Resident #16 received tube feedings 2 times on her shift and also received [CONDITION(S)] care once on her shift. Nurse #8 said Resident #16 also received a feeding on the 11:00 PM to 7:00 AM shift. A telephone interview was attempted with the 3rd shift nurse, Nurse #8. She was unable to be reached. On 10/13/22 at 3:30 PM the Director of Nursing stated she was not aware Resident #16 had expressed concerns for being awakened during the night to have his [CONDITION(S)] changed and to receive a bolus tube feeding. She said he should not have to be awakened during regular sleeping hours to have this type of care provided and it should be scheduled differently to provide the resident quality sleep. 4. Resident #25 was readmitted to the facility on [DATE]. A review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Weight loss of 5 percent (%) or more in the last month or 10% or more in the last 6 months was no. A review of Resident #25's October 2022 active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/2022 at 1:36 PM a telephone interview with the facility Registered Dietician (RD) indicated she was familiar with Resident #25. She stated when Resident #25 was first admitted to the facility, he shared with staff that he was not getting enough food on his meal trays. She went on to say this was addressed with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She went on to say Resident #25's weight was currently stable. On 10/10/2022 at 12:36 PM an interview with Resident #25 indicated he was not getting enough food on his meal trays. He stated he spoke with someone from dietary about this and was told he would be getting large portions but he had not been. He went on to say he wasn't still hungry because his family brought him snacks. Resident #25 stated did not think he had lost weight but he felt he should be getting more food during his meals. On 10/13/2022 at 12:37 PM an observation of Resident #25's lunch meal tray ticket present on his lunch meal tray with the District Dietary Manager (DDM) revealed his serving sizes for the meal were listed as a #8 scoop (4 ounces) of ground baked chicken breast, 2/3 cup of buttered macaroni noodles, 2/3 cup of roasted green beans, a roll and a #16 scoop (2 ounces) of pureed sugar cookie. The lunch meal ticket indicated Resident #25 was to receive large portions. An interview with the DDM at that time indicated Resident #25 did not have large or double portions of food on this lunch meal tray. She stated the portion sizes of food present on Resident #25's lunch meal tray were standard size portions. On 10/13/2022 at 1:10 PM an interview with Cook #1 indicated he plated the food present on Resident #25's lunch meal tray that day. He stated a dietary aide read each meal ticket out loud in the kitchen to him and would have read out the large portion instruction which was present at the bottom of Resident #25's lunch meal ticket. He stated when this was read, he should have added additional portions of food to Resident #25's meal. Cook #1 stated he must have either misheard or not heard the dietary aide that day because he had not added additional portions of food for Resident #25. On 10/13/2022 at 4:15 PM an interview with the Director of Nursing (DON) indicated Resident #25 should be receiving what was listed on his meal ticket and what he requested

Based on observation and staff interviews the facility failed to ensure (1) 16 of 22 dishware were dry before being stacked and ready for use and (2) 2 of 10 dented cans were removed from the cart ready for use. The facility also failed to ensure 6 of 20 plates and bowels were clean prior to placing them on the tray line ready to use. These practices had the potential to affect food served to the residents. Findings included: 1.The initial tour of the kitchen was conducted on 10-10-22 at 10:05am with the Dietary Manager. The tour revealed the following: a. One 3-inch steam table pan was stacked wet on the rack labeled ready for use. b. one large flat metal pan was stacked wet and placed on a rack labeled ready for use. c. One 6 pound can of tropical fruit salad and one 6 pound can of pineapple tidbits were dented around the rim of the cans and placed on the rack ready for use. The Dietary Manager was interviewed on 10-10-22 at 10:20am. The Dietary Manager stated the pans, and the cans were ready to be used. She explained she was unaware of the pans being stacked wet or the cans being dented. The Dietary Manager explained the pans were to be left separated during the drying process on the shelf and the cans should have been removed from the rack and placed on the shelf marked dented cans. 2. A second observation of the kitchen occurred on 10-12-22 at 11:30am with the Dietary District Manager. The second tour revealed the following: a.14 of 30 plastic dome plate lids on the tray line ready for use were observed to be stacked wet. b. 3 of 15 meal plates on the tray line ready for use were observed to have dried food particles. c. 3 of 10 small bowls on the tray line ready for use were observed to have dried food particles. The Dietary District Manager was interviewed on 10-12-22 at 11:45am. The Dietary District Manager stated she was unaware of the issues with the plate lids, plates and bowls. She explained staff were to inspect the dishes for cleanliness prior to placing them on the tray line and stated the kitchen did not have enough rack space for the plate lids to be separated so they could dry and so staff were stacking the plate lids wet and placing them on the tray line. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated the dirty bowls and plates should not have been placed on the tray line and that he had already spoken with the Dietary District Manager.

Based on observation, record review, staff and Physician interviews the facility failed to follow infection control practices when 2 of 2 nursing assistants (NA) (NA #11 and NA #12) failed to perform hand hygiene between resident contact while passing meal trays. Findings included: Review of the facility's Hand Washing policy and procedure dated October 2014 revealed in part all personnel shall follow established hand washing procedures to prevent the spread of infection and disease. Alcohol based sanitizers may be used instead of soap and water if hands are not visibly dirty. Hand washing is performed before and after resident contact. Review of the Hand Hygiene: Why, How and When education revealed all staff received education on hand washing 9-14-22. The education included when to use alcohol-based sanitizer and when to use soap and water. a.A continuous observation of lunch trays being passed occurred on 10-10-22 from 12:17pm through 12:20pm. NA #11 was observed in resident room [ROOM NUMBER] touching the resident's silverware, the drinking glasses and holding the resident's hand. NA #11 walked out of room [ROOM NUMBER] without performing hand hygiene, opened the meal cart, retrieved another lunch tray off the meal cart and entered resident room [ROOM NUMBER], approaching the resident in bed A. NA #11 was observed touching the resident's silverware and drinking glasses then holding the resident's hand. She exited room [ROOM NUMBER] without performing hand hygiene, walked to the meal cart, obtained a meal tray and walked into resident room [ROOM NUMBER]. She approached the resident in bed A touching the resident's tray table and removing the lid off the resident's meal. NA #11 exited room [ROOM NUMBER] without performing hand hygiene. NA #11 was interviewed on 10-10-22 at 12:20pm. The NA stated she had received education on hand hygiene last month but stated she thought she only had to perform hand hygiene when her hands were visibly dirty. NA #11 commented she did not think she had to perform hand hygiene between resident interactions if her hands were not dirty. NA #11 was observed to perform hand hygiene before continuing to provide lunch trays to the residents. On 10-10-22 at 12:35pm, Nurse #7 was interviewed who stated she was responsible for supervising the NAs but said she cannot monitor them closely when she was trying to pass medications. The nurse discussed NA #11 needing to perform hand hygiene between each resident encounter and stated she would discuss hand hygiene with the NA. b. On 10-11-22 from 9:16am to 9:18am, a continuous observation of delivery of breakfast trays occurred. NA #12 was observed entering resident room [ROOM NUMBER] and approaching the resident in bed B with the breakfast tray. She was observed touching the resident's tray table, silverware and drinking glasses. NA #12 exited room [ROOM NUMBER] without performing hand hygiene and walked to the meal cart to retrieve another breakfast tray. She entered room [ROOM NUMBER] and approached the resident in bed A, touching the residents tray table, silverware and drinking glasses. NA #12 exited room [ROOM NUMBER] without performing hand hygiene, walked to the meal cart and retrieved another breakfast tray. The NA entered resident room [ROOM NUMBER] and approached the resident in bed A. She was observed touching the resident's tray table and the lid to the resident's meal. NA #12 exited room [ROOM NUMBER] without performing hand hygiene. NA #12 was interviewed on 10-11-22 at 9:19am. The NA stated she had received education on hand hygiene yesterday (10-10-22). The NA retrieved a bottle of hand sanitizer from her pocket and stated I am supposed to be sanitizing my hands between each resident encounter. I just forgot. NA #12 was observed to perform hand hygiene before continuing to provide breakfast trays to the residents. The Assistant Director of Nursing (ADON) was interviewed on 10-10-22 at 1:15pm. The ADON stated staff had received education on hand hygiene but could not remember when the education occurred. She stated she expected staff to perform hand hygiene between each resident encounter. During an interview with the Infection Preventionist (IP) Nurse on 10-10-22 at 1:47pm, the IP nurse discussed the staff had received education on hand hygiene last month. She stated the education included washing hands between each resident encounter and that she expected staff to perform hand hygiene between each resident encounter. The IP nurse stated she did not know why staff was not performing hand hygiene but planned on providing further education. The Director of Nursing (DON) was interviewed on 10-11-22 at 9:20am. The DON discussed staff receiving education on hand hygiene last month and stated management had started re-educating staff on hand hygiene yesterday (10-10-22). The DON said she thought NA #12 had not performed hand hygiene between each resident contact because she was nervous but expected staff to perform hand hygiene between each resident encounter. A telephone interviewed with the facility Physician occurred on 10-13-22 at 3:15pm. The Physician discussed the recommendation for hand hygiene was to be completed between each resident contact and stated staff should be performing hand hygiene between residents. The Physician also stated there could be a possibility of infections to be spread from one resident to another when hand hygiene was not performed. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator discussed hand hygiene education was provided to staff almost monthly and did not know why staff were not completing hand hygiene between each resident contact.

Based on observations, record review and staff interviews, the facility failed to keep 2 of 2 residents (Resident #78 and Resident #77) covered while providing care and the facility failed to provide incontinent care for 1 of 7 residents (Resident #16) who stated he felt mad and ignored. Findings included: 1.Resident #78 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set (MDS) revealed Resident #78 was severely cognitively impaired. An observation of Activities of Daily Living (ADL) care occurred on 10-13-22 at 10:48am with Nursing Assistant (NA) #13. The NA was observed providing Resident #78 a full bed bath. He was observed removing the resident's gown, not covering Resident #78's lower half, leaving the resident laying in the bed with a brief. NA #13 washed the upper half of the resident's body then removed the resident's brief without covering the upper half of the resident's body. The NA was observed to continue completing Resident #78's bath leaving the resident fully exposed with no cover or brief. Once the bath was completed, the NA left Resident #78 on his back fully exposed as the NA cleaned up the dirty linen. NA #13 was then observed to place a brief and gown on the resident. NA #13 was interviewed on 10-13-22 at 11:10am. The NA discussed his usual practice was to keep the resident covered during a bath but stated he did not think about covering Resident #78 because he was hurrying, and he was nervous. NA #13 said since the resident did not have a privacy curtain it would have been better to cover the resident in case someone walked into the room. The DON was interviewed on 10-13-22 at 1:00pm. The DON discussed being pleased NA #13 provided good care, but she expected staff to maintain resident dignity and privacy during care. 2. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact. An observation of wound care occurred on 10-12-22 at 10:21am with the Treatment Nurse and Nurse Practitioner (NP) #1. Resident #77's window blind was open, and the window was observed to be facing the driveway and walkway. The Treatment Nurse was observed to turn the resident on her side and remove Resident #77's brief allowing the resident's buttocks to be exposed to the open window blind. The Treatment Nurse was interviewed on 10-12-22 at 10:33am. The Treatment Nurse stated she should have closed the blind because anyone walking by could have seen Resident #77's buttocks. She commented she did not think about closing the blind or the window being a breech of dignity and privacy. During an interview with the Director of Nursing (DON) on 10-12-22 at 3:08pm, the DON stated the Treatment Nurse should have closed the blind in Resident #77's room so the resident would not have been exposed to anyone walking by. She also said she expected staff to provide respect and dignity to all residents when providing care. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated all staff needed to provide privacy and dignity to all residents when receiving care. 3) Resident #16 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired. He required extensive assistance with all activities of daily living including toileting, bathing, and personal hygiene. He was always incontinent of bowel and bladder. The care plan for Resident #16 indicated he had impaired mobility related to right sided [CONDITION(S)]. The approaches included assist with ADLs to completion and assist resident with toileting needs PRN (as needed). On 10/10/22 at 2:22 PM Resident #16 reported the last time he had received incontinent care was on the 11:00 PM to 7:00 AM shift. He acknowledged he was soiled and had been wet for a long time. On 10/10/22 at 2:55 PM an observation of incontinent care was completed with Nurse Aide (NA) #8 and revealed Resident #16's adult brief was saturated with a dark dry ring on the inside. The Resident's under pad was noted to be wet with a dark dry ring around the edges. The Resident's gown was noted to be wet. On 10/10/22 at 3:18 PM NA #8 said she and NA #9 worked together to meet the residents' needs but she was assigned to Resident #16. She said she provided incontinent care to Resident #16 between 8:00 and 9:00 AM that morning. She said the resident's pad was dirty when she provided care, but there were no clean pads available, so she used a folded sheet instead of a pad. When asked about the resident having a soiled pad, she stated there were no pads in the clean utility room. She said she was told by the 11:00 PM - 7:00 AM shift that Resident #16 received a partial bath that morning so she did not provide a bath for Resident #16. On 10/11/22 at 3:00 PM NA #10 reported she worked on the 11:00 PM to 7:00 AM shift on 10/10/22 and was assigned to Resident #16. She reported she provided incontinent care to him between 12:30 AM and 1:00 AM then again at 4:00 AM and around 6:00 AM. She said she did not provide a full bath. On 10/13/22 at 3:30 PM the Director of Nursing (DON) stated the NA should be checking the residents more frequently as least every 2-3 hours and a resident should not remain in wet briefs for an entire shift. On 10/13/22 at 4:00 PM Resident #16 stated being left wet during the 7:00 AM - 3:00 PM shift on 10/10/22 made him feel mad and ignored because he did not have a voice. He felt the staff did not provide care to him because he could only communicate with his communication board.

Based on record review and staff and family interviews the facility failed to notify the resident's representative (RP) of a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for one of one resident (Resident #89) reviewed for notification of change. Findings included: Resident #89 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. A review of Resident #89's medical record revealed a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was signed as being reviewed by Nurse #1. A further review of Resident #89's medical record revealed no documentation that her RP was notified of this new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/11/22 at 2:08 PM a telephone interview with Resident #89's RP indicated she was not notified of the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she found out at a visit after the medication was already started. She went on to say she expected the facility to notify her of any change in her family members condition or new medication order. She further indicated the facility was aware of her desire to be notified. On 10/13/22 at 8:21 AM an interview with Nurse #1 indicated she was the nurse who reviewed and signed off the new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #89 on 9/27/2021. She stated which ever nurse reviewed and signed off a new order for a resident would be responsible for notifying the RP. She went on to say if there was no documentation in the progress notes she could not recall if she notified Resident #89's RP of this new order or not. She further indicated if she had notified Resident #89's RP, she would have documented this notification in Resident #89's progress notes. A further review of Resident #89's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility physician's progress note dated 1/25/22 revealed Resident #89's RP was not present when Resident #89 saw the orthopedist. On 10/11/22 at 2:08 PM a telephone interview with Resident #89's RP indicated she was not made aware that Resident #89 had an orthopedic consult appointment on 1/14/2022 in Rocky Mount and so she had not been present at this appointment. She stated she would have gone if she had been notified of the appointment date and time. She stated Resident #89 had dementia and was not capable of making her needs known, understanding information given to her, or consenting to any treatments. The RP stated the facility was aware that she wanted to be notified of any outside consult appointments so she could be present with her family member. On 10/12/22 at 11:16 AM an interview with the Schedular indicated she scheduled the 1/14/22 orthopedic consult for Resident #89 to see the physician in Rocky Mount who originally did Resident #89's left knee surgery in response to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would have been responsible for notifying Resident #89's RP of the appointment location, date, and time. She went on to say after Resident #89 went to this appointment, her RP called the facility upset because she had not been made aware of the appointment and had not been present. The Schedular stated she apologized to Resident #89's RP. She went on to say while she would have been responsible for notifying Resident #89's RP of the appointment when she arranged it, she thought Nurse #4 notified Resident #89's RP. On 10/12/22 at 12:37 PM an interview with Nurse #4 indicated Resident #89's RP had been upset that she was not notified of Resident #89's 1/14/22 orthopedic consult. She stated she had apologized to Resident #89's RP. Nurse #4 went on to say she did not think it had been her responsibility to make Resident #89's RP aware as she had not scheduled the appointment. She stated it was usually the person scheduling the appointment who made the RP aware. In a follow-up interview on 10/13/22 at 12:10 PM Nurse #4 indicated she did receive information about the location, date, and time of Resident #89's orthopedic consult from the Schedular via a text message prior to the 1/14/22 appointment when Resident #89's RP was in the facility, however, had not passed the information on to Resident #89's RP because she had gotten busy with an emergency. On 10/13/22 at 4:15 PM an interview with the Director of Nursing (DON) indicated while there may have been some miscommunication between Nurse #4 and the Schedular, Resident #89's RP should have been immediately made aware of any change in her condition, her new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review and staff interview the facility failed to protect resident medical information for 1 of 1 resident (Resident #250) when a Nursing Assistant (NA) #11 left Resident #250's medical information up on a computer screen located on hall 200 east. Findings included: Resident #250 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) revealed Resident #250 was severely cognitively impaired. Observation of the computer on hall 200 east occurred on 10-10-22 at 12:23pm. The computer monitor was observed to have Resident #250's medical information on the screen. During an interview with NA #11 on 10-10-22 at 12:25pm, the NA said she had Resident #250 pulled up on the screen charting on him when the lunch trays arrived on the unit, and she did not log off. NA #11 stated I don't understand what the problem is. The NA logged off the computer and walked away. Nurse #7 was interviewed on 10-10-22 at 12:35pm. The nurse stated it was a privacy violation to leave resident information visible to the public. She said if she would have seen Resident #250's medical information on the computer screen when she would have logged NA #11 out of the system, so the resident information was no longer visible. An interview with the Director of Nursing (DON) occurred on 10-10-22 at 9:20am. The DON stated all staff had training on keeping resident information private on 5-4-22 and expected all staff to keep resident information private. She also stated she thought NA #1 was charting and when the lunch trays arrived, the NA forgot to log out. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated the computers had been set to power down after one minute but said somehow the computer NA #11 was using became programmed to never time out or power down. The Administrator stated he expected all resident information to remain confidential and for staff to log out of the system if they are leaving the area.

Based on resident and facility staff interviews and record review the facility failed to have a cognitively intact resident participate in the care plan meetings. This was for 1 of 2 residents reviewed for care plans (Resident #72). The findings included: Resident #72 was admitted to the facility on [DATE]. She had reentries on 8/2/22 and 8/30/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was cognitively intact. The admission and significant change MDS dated [DATE] indicated Resident #72 was readmitted to the facility on [DATE] from an acute care hospital. Resident #72 was cognitively intact. Her quarterly MDS dated [DATE] indicated Resident #72 was cognitively intact. On 10/10/22 at 12:04 PM Resident #72 stated she was not aware of being invited and had not attended a meeting about her care. She said she had not participated in the development or review of her plan of care. On 10/12/22 at 1:15 PM Social Worker (SW) #1 said the residents who are capable of understanding are invited to the care plan meeting. SW #1 said she had spoken to Resident #72 in the past about attending the care plan meeting. She said Resident #72 told her in the past that she did not need to come to the meeting. She said she had verbally communicated with Resident #72 but had not provided written information to the resident about the care plan meetings. SW #1 said she did not remember when she had last spoken to Resident #72 about the care plan meetings. A review of the Care Plan Participation Record provided by SW #1 for Resident #72 revealed the interdisciplinary team members participated in the care plan development on 3/9/22, 6/8/22,7/6/22, 8/24/22 and 9/21/22. The area of these forms for documentation of resident/representative included 1) participated by telephone, 2) participated by videotelephony or 3) declined to participate. On each of the forms this area was not completed. On 10/13/22 at 2:15 PM SW #1 said she was not aware of the need to document if Resident #72 attended the meeting or chose not to attend the meeting. She said she had developed a new form since the previous conversation with the surveyor on 10/12/22 to make the cognitively intact residents a sign to remind the residents of their meetings. On 10/13/22 at 3:40 PM the Director of Nursing reported she was not aware Resident #72 was not participating in the care plan development meetings and that there should be documentation of her invitation and declination to participate.

Based on observations, record review, and resident, and facility staff interviews the facility failed to provide incontinent care for 1 of 7 residents (Resident #16) reviewed for activities of daily living (ADLs). The findings included: Resident #16 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired. He required extensive assistance with all activities of daily living including toileting, bathing, and personal hygiene. He was always incontinent of bowel and bladder. The care plan for Resident #16 indicated he had impaired mobility related to right sided [CONDITION(S)]. The approaches included assist with ADLs to completion and assist resident with toileting needs PRN (as needed). On 10/10/22 at 2:22 PM Resident #16 reported the last time he had received incontinent care was on the 11:00 PM to 7:00 AM shift. He acknowledged he was soiled and had been wet for a long time. On 10/10/22 at 2:55 PM an observation of incontinent care was completed with Nurse Aide (NA) #8 and revealed his adult brief was saturated with a dark dry ring on the inside. The Resident's under pad was noted to be wet with a dark dry ring around the edges. The Resident's gown was noted to be wet. On 10/10/22 at 3:18 PM NA #8 said she and NA #9 worked together to meet the residents' needs but she was assigned to Resident #16. She said she provided incontinent care to Resident #16 between 8:00 and 9:00 AM that morning. She said the resident's pad was dirty when she provided care, but there were no clean pads available, so she used a folded sheet instead of a pad. When asked about the resident having a soiled pad, she stated there were no pads in the clean utility room. She said she was told by the 11:00 PM - 7:00 AM shift that Resident #16 received a partial bath that morning so she did not provide a bath for Resident #16. On 10/11/22 at 3:00 PM NA #10 reported she worked on the 11:00 PM to 7:00 AM shift on 10/10/22 and was assigned to Resident #16. She reported she provided incontinent care to him between 12:30 AM and 1:00 AM then again at 4:00 AM and around 6:00 AM. She said she did not provide a full bath. On 10/13/22 at 3:30 PM the Director of Nursing (DON) stated the NA should be checking the residents more frequently as least every 2-3 hours and a resident should not remain in wet briefs for an entire shift.

Based on observations, facility staff and physician's clinic staff interviews and record review the facility failed to follow correct loading procedures by not securing a resident's wheelchair while loading the resident (Resident #96) into the transport van which resulted in the wheelchair rolling backwards off of the lift while the lift was in the raised position resulting in a subdural hematoma and multiple fractures for 1 of 6 residents reviewed for accidents. The findings included: Resident #96 was admitted to the facility 7/5/13. He had [DIAGNOSES REDACTED]. A review the annual Minimum Data Set (MDS) for Resident #96 dated 7/16/18 revealed he was cognitively intact and had no behaviors. He required extensive assistance for most of his activities of daily living (ADLs) except he needed supervision for locomotion and eating and was total dependence for bathing. He had no range of motion limitation of his upper or lower extremities. A review of the hospital history and physical dated 8/23/18 revealed presenting with falls: Was being loaded onto a wheelchair van in his wheelchair when it tipped back and he fell to the ground (approximately 3 feet in the air). On 8/22/19 at 12:41 PM the Director of Nursing (DON) reported Resident #96 was transported to a local physician's clinic to have lab work completed. She stated when the contracted van company was loading Resident #96 back into the transport van, after the appointment, Resident #96 fell backwards off of the van lift gate. The DON stated the physician's clinic office staff responded immediately and assisted Resident #96 until the ambulance arrived to transport him to the local hospital. The DON stated she was notified of the fall and that he was going to the emergency room (ER). A record review of the contracted transportation company Incident Report revealed Van Driver #1 was driving vehicle # on 8/22/18. The report also stated the passenger was Resident #96. The description of the incident was written as; VD #1 was loading Resident #95 when VD #1 walked down to the side door to pull passenger into the van and he flipped backwards off of the lift. Back flap on lift was not connecting to the lift a lot. It was closed but not locked and that was how (Resident #96) fell off. The report was completed and signed by VD #1. Attempts to contact the contracted transportation van driver #1 were unsuccessful. On 8/22/19 at 3:00 PM the contracted van transportation company with van driver (VD) #2 provided a demonstration of the van lift using the same van as identified in the incident report. The observation revealed as the lift gate was electronically lowered a set of hand grab handles automatically lowered into place. As the lift gate touched the ground a 7.5 inch high kick plate automatically lowered to the ground which provided a ramp for the wheelchair to roll onto the lift. The wheelchair was pushed forward onto the lift gate. VD #2 instructed the wheelchair occupant, who was facing toward the van, to hold onto the grab handles located on each side of the lift. VD #2 then checked the wheelchair brakes to make sure they were locked. VD #2 then reached for the strap which was anchored to the grab handles. The strap was pulled and extended around the rear of the wheelchair just under the wheelchair hand grips. The strap was clipped onto the opposite side grab bar similar to a seat belt strap and attachment. Next the lift was raised and as it began to come off of the ground the rear kick plate automatically popped up perpendicular (at a right angle) to the lift gate floor. VD #2 was observed to check the kick plate to be sure it was locked into place. VD #2 continued to raise the lift until it stopped at the level of the van entrance. When the lift gate was at this upper stopped position it was measured at 2.5 feet off of the ground. On 8/22/19 at 3:10 PM VD #2 stated the strap which went around the rear of the wheelchair was present on the van when it was purchased. He stated some of the older model vans did not have this strap. VD #2 also stated the wheelchair's wheels had to be in a locked position in addition to the strap being put into place. On 8/22/19 at 4:22 PM clinic lab worker #1 stated the clinic had a rapid response team that responded to any emergencies on the clinic's property. On 8/23/19 at 10:12 AM clinic nurse #1was interviewed. Clinic nurse #1 stated she was the first person from the rapid response team to arrive at the scene of the fall. The nurse stated Resident #96 was laying o his back on the concrete walkway. She stated he was responding but not completely coherent. She said the lift was still up in the air and it was about waist high on her. Clinic nurse #1 said there was a moderate amount of blood on the back of the resident ' s head. She added it was enough blood that it required a dressing. On 8/223/19 at 10:23 AM clinic nurse #2 stated she saw Resident #96 when he fell off of the van lift because she was already at the main entrance area but did she did not remember why she was there. She said Resident #96 came partially out of the wheelchair while he was still in the air. She said he fell on his back and was bleeding from the back of his head. She added Resident #96's arms were scratched and bleeding. She initially said the little panel (kick plate) had not or did not securely engage but upon additional questioning she stated she did not see if the kick plate was up or if the grip handles or a safety belt were present. She stated she responded as a member of the rapid response team. On 8/23/19 AT 10:42 AM clinic nurse #3 reported she was part of the rapid response team. Resident #96 was outside the main clinic entrance. He was on his back. She stated his vital signs were obtained and he was conscious. He complained of back pain and head pain. He could not state what happened. Clinic nurse #3 said 911 was called immediately and the response team tried to keep Resident #96 as comfortable as possible. She added Resident #96 could tell us about the pain but he could not tell us his name. He was not in respiratory distress or any distress and he was a bit diaphoretic (increased sweating). We tried not to move him but needed to see the back of his head. She said the physician's assistant (PA) was doing the assessment. On 8/23/19 at 10:57 AM clinic PA was interviewed. He stated the van driver and a staff member from the facility were present at the scene of the fall. He referred to a progress note he had written which stated Resident #96 had his eyes open but he not verbally responsive initially. His initial vital signs were stable including his blood sugar and pulse ox. The PA stated he put a cervical collar on him. Resident #96 wanted to sit up but he could not do so on his own. The PA added there was an occipital (back of the head) abrasion on his head and his C-spine felt normal. His pelvis was stable and his level of consciousness improved. On 8/23/19 at 11:53 AM Clinic receptionist #1 stated she looked out the front window area and saw as Resident #96 was pushed onto the ramp. She said he was lifted up and she saw him fall backwards off of the ramp. She said she called the rapid response team. She stated Resident #96 fell backwards in his wheelchair and his head hit the cement first. She said the response team responded and 911 were called. She said she stayed inside the building. She stated she remembered the name of the van and identified it as the contracted transportation company van. On 8/23/19 at 12:43 PM the facility scheduler stated she went to the appointment to escort Resident #96 on 8/22/18. She stated after his appointment she was walking back to her vehicle on the side of the physician's clinic with her back towards the van when she heard a scream. The scheduler said she turned around and saw the contracted transport van was still in the same place so she went back to the van to see a large number of people around Resident #96. She stated Resident #96 was on the ground. She said she remembered saying out loud that she needed to call the facility. The facility scheduler reported she talked to the DON. A review of the rescue squad report revealed on 8/22/18 at 11:43 AM a call was received in reference to a fall. Upon arrival Resident #96 was laying on his back on the sidewalk in front of the entrance and was surrounded by staff members. The report stated Resident #96 fell backwards and landed on his back and hit his head on the cement sidewalk. Resident #96 was alert but confused. There were no remarkable injuries upon assessment. He was complaining of neck and back pain. Staff had already placed a c-collar on patient. He was placed into the ambulance and he was stable. Additional record review revealed a history and physical report from the trauma center dated 8/23/18 at 7:47 AM which revealed the local hospital completed a workup which showed bilateral frontal subarachnoid hemorrhages, closed burst fracture of [MEDICATION NAME] vertebra, fractures of the right ribs 7, 8, 10, 11 and left rib fracture of 8. He also had a right [MEDICATION NAME] process [MEDICAL CONDITION] lumbar vertebra. Resident #96 remained hospitalized for [REDACTED]. The discharge summary from the trauma center dated 9/26/18 revealed Resident #96 was non-ambulatory at baseline and fell on his back when being loaded on the van. Resident #96 did not remember the event due to a history of dementia. Additional problems listed as dysphagia, urinary tract infection, subarachnoid hemorrhage medial, bilateral frontal lobes, closed burst fracture of 8th [MEDICATION NAME] vertebra and on 8/23/18 had a T6-T10 percutaneous fusion with no brace needed. He had closed fracture of right ribs 5-7, 10 & 11 and left 4-8. He also had closed [MEDICAL CONDITION] lumbar vertebra a closed [MEDICAL CONDITION] end of the right ulna which did not have surgery and a splint/sling was used for management. He had a right hemothorax (blood collected in the space between the chest wall and the lung) for which a chest tube was placed and was removed on 8/27/18. Resident #96's facility medical doctor (MD) was interviewed on 8/23/19 at 9:30 AM. The MD stated he had known Resident #96 for many years. The MD said when Resident #96 was admitted to the facility years ago he had no motivation and just wanted to lie in bed. Resident #96 had early dementia and some confusion before the accident. After the accident he was less vocal when he first returned to the facility. He was initially more passive. The MD said Resident #96 does not remember and has short term memory deficit but that was present before the accident too. The MD stated he monitored Resident #96 while he was in the hospital and when he returned to the facility he was not different. The MD also discussed the brain bleed. He stated a brain bleed could be immediately catastrophic and cause death but without a lot of swelling the blood gets reabsorbed and there are no other problems. Resident #96 did not require any surgical treatment for [REDACTED].#96 had a bleed and got through it with no additional problems. On 8/22/19 at 2:20 PM the facility Administrator stated immediate action was taken by the facility with the contracted van company. On 8/23/19 at 1:46 PM the Administrator provided the following Plan of Correction: Allegation of Compliance for Van Incident F689 1. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited. · On 8/22/18 Resident #96 was taken out for appointment at a local Physician's Clinic via Transport Company 1. · At approximately 11 am, the resident was placed on the van lift by the Transport Driver to return to the facility. The driver did not lock the wheels allowing the wheelchair to roll backwards as the lift was raised. This caused it to tip off and the resident fell to the ground. · Resident received treatment at the scene from the Physician's Clinic staff until EMS (Emergency Medical Services) arrived to transport him to the local hospital. · Admin/DON made aware at approximately 11:30 am. · Medical Director notified on 8/22/18 · All transportation with Transport Company 1 was suspended immediately. · At 11:47am DON notified resident's Responsible Party. · Root Cause analysis on 8/22/18 revealed the cause of the accident to be the failure of the transportation company van driver to follow proper protocol for safe loading/unloading of patients on to transportation vehicles by not engaging the wheelchair brakes. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. · 8/22/18 The administrator spoke with the owner of Transport Company 1 and suspended all further transports. · The administrator also requested proof of an inspection by a third party stating the vans general condition and all safety measures are in good working order. · The administrator also made the owner of the Transport Company 1 aware that they must provide proof of retraining of all employees on safe loading/unloading procedures, safety protocols, and secure positioning of residents in the van before services will resume. · All further transports were moved to EMS. · Interviews and due diligence began with other transport companies to replace Transport Company 1. Another local transport company was selected as facilities Transport Company. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements. · The administrator will observe the loading and unloading of a resident by the transport company weekly x 8, monthly x 2, and quarterly x 3. · The administrator will interview a transport driver for their knowledge of retraining regarding safe loading/unloading procedures, safety protocols, and secure positioning of residents weekly x 8, monthly x 2, and quarterly x 3. · The administrator will complete a van inspection checklist weekly x 8, monthly x 2 and quarterly x 3. · The QAA Committee will discuss all results monthly. This allegation of compliance was in place on 8/22/18 by the Administrator. The Plan of Correction was verified through interviews with the facility staff, observations of Resident #96 and record review of the education and monitoring of the current contracted van company. Based on the interviews and record reviews the facility did not use the original contracted van company for any other transports since the fall on 8/22/18. The facility's compliance date of 8/22/18 was verified.

Based on record review, resident and staff interviews, and observations the facility failed to provide supervision to prevent a severely cognitively impaired resident (Resident #274) who displayed wandering behaviors from exiting the facility unsupervised for 1 of 3 residents reviewed for accidents. The resident was returned to the facility on ly after a staff member was alerted by an alert and oriented resident that Resident #274 was observed in an adjoining parking lot. No injuries were reported. Immediate Jeopardy began on 7/22/18 when Resident #274 was observed outside the facility without supervision in her wheelchair in the facility parking lot. The resident was retrieved by Nurse #1 and returned to the facility with no physical injuries. Immediate jeopardy was removed on 8/8/18 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings Included: Resident #274 was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #274's minimum data set (MDS) assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She was assessed to have behaviors not directed towards others 1 to 3 days of the previous 7 days. She required extensive assistance by one staff member for bed mobility, transfers, and locomotion off unit. She had no impairment to the range of motion of her upper and lower extremities and used a wheelchair as a mobility device. She received antipsychotic, antidepressant, and antianxiety medications 7 of the previous 7 days. No restraints, including wandering/elopement alarms were in use at that time. Review of Resident #274's care plan dated 7/12/18 revealed she was care planned for memory problems and impaired decision making as she was unable to decide what clothes to wear, when to go to meals, what time to eat, or when to go to bed and sleep for the night related to impaired decision making ability secondary to dementia with behavioral disturbances. The interventions included to monitor for any changes or decline in cognitive status. There were no care plans present for supervision to prevent wandering. Review of an undated and unsigned Elopement Risk Assessment, for Resident #274 revealed the form instructions read Complete upon admission or per facility policy. For each question under Resident Evaluation Factors, check yes/no as appropriate. Check all interventions used then summarize findings, conclusions and recommendations in the space provided. Resident #274 was assessed, and the intervention put in place was identification bracelets. The interventions to be on the care plan were left blank. There was no documentation in the summarization/conclusions/recommendations section of the assessment. The Elopement Risk Assessment did not specify if the resident was at risk for elopement or not. Review of Resident #274's nurse's notes revealed no nurse's notes were written with regards to an attempted unsupervised exit from the facility by Resident #274 around 2 PM on 7/22/18. This attempted exit was made known to the surveyor per interviews with Nurse #1, Nurse Aide #1, and Resident #110. Review of a nurse's note dated 7/22/18 at 7:11 PM, signed by the House Supervisor, revealed Resident #274 made one unassisted exit from the facility. Resident #274 was assisted back in to the facility and was documented to be unharmed. A wander guard was put in place and the family was notified. No further information was documented. Review of an undated and unsigned Elopement Risk Assessment revealed the form instructions read Complete upon admission or per facility policy. For each question under Resident Evaluation Factors, check yes/no as appropriate. Check all interventions used then summarize findings, conclusions and recommendations in the space provided. Resident #274 was assessed, and the intervention put in place was personal safety alarm devise. The interventions to be on the care plan were left blank. There was no documentation in the summarization/conclusions/recommendations section again. The Elopement Risk Assessment did not specify if the resident was at risk for elopement or not. Review of a facility report completed by the Director of Nursing revealed on 7/22/18 the Director of Nursing was notified by staff that Resident #274 had gone out through the front door in her wheelchair. Resident #274 was brought back into the facility by Nurse #1. Resident #274 was assessed and found to have no injuries. Resident #274 had a wander guard applied following the occurrence. The Resident Representative (RP) was called and made aware. On 7/23/18 Resident #274 was interviewed by the Director of Nursing regarding her desire to sit outside and informed Resident #274 she could continue to go outside only with staff or family at her request and the resident verbalized understanding and the wander guard was left in place. This report was signed by the Director of Nursing and not dated or timed. Review of a care plan intervention dated 7/22/18 revealed the resident had a wander guard in place related to risk for elopement/exit seeking behaviors. Review of www.wunderground.com for Tarboro weather history revealed the temperatures on 7/22/18 at 5:01 PM was 85 degrees Fahrenheit. The humidity was 69%, there was variable 6 mile per hour winds, no precipitation, and it was mostly cloudy. The House Supervisor no longer worked at the facility and was unavailable for interview. During an interview on 8/7/18 at 3:22 PM Nurse Aide #2 stated Resident #274 would easily get lost and ask where her room or the dining room was. She further stated Resident #274 would usually be in the bathroom or go to the dining room and was very forgetful and would not remember things that were told to her during conversation. She further stated she did not consider Resident #274's behavior to be wandering because she would simply be lost, so she did not feel she needed to report the behavior. She further stated the resident had a wander guard, so she must be a wandering resident. Nurse Aide #2 was not working when the resident eloped. During an interview on 8/7/18 at 3:39 PM Nurse #2 stated she was the nurse supervisor for the 200 hall. She further stated she was familiar with Resident #274's care. She stated that Resident #274 was very forgetful and would not be compliant with reeducation especially when she first arrived in the facility. She further stated Resident #274 would also get lost very easily and every evening she came to the nurse's station to ask where the dining room was. She further stated Resident #274 had behaved in this manner since she arrived in (MONTH) but no staff had ever reported to her that she had made statements that she was leaving the facility. During an interview on 8/7/18 at 4:18 PM Nurse Aide #1 stated she was familiar with Resident #274 and was assigned to care for her during the 3:00 PM to 11:00 PM Shift on 7/22/18. She stated Resident #274 had very bad memory problems and would ask the same questions over and over and would get confused a lot. She further stated she would forget things said to her five minutes later. She stated it was not very effective to reeducate Resident #274. The Nurse Aide stated Resident #274 once said she was having a baby and needed to go out of the facility to have the baby. Resident #274 had also stated to the Nurse Aide that family was coming to get her when no one was coming to get her. The Nurse Aide stated she would go to the front lobby occasionally and get confused about where she was going and state she was being picked up by family. She further stated this had been going on during her entire stay since her admission in June. Nurse Aide #1 stated this was her normal behavior and she did not report it to anyone because everyone knew she was forgetful and would say strange things. She then stated one time Resident #274 was so convincing saying her brother was coming to get her that the Nurse Aide pushed Resident #274 away from the lobby to the 200 hall nurse's station to check with the House Supervisor if Resident #274's brother really was coming to get the resident. She stated it was around 2:30 PM or 3:00 PM on the same day she exited the building unassisted but she was unsure of the exact time or date. She further stated the brother was not coming to get her and the House Supervisor explained to Resident #274 she could not leave the facility without supervision. She further stated she believed that was all that was done by the House Supervisor in response to the behaviors. The Nurse Aide then stated later that day the resident was supposed to be in the dining room eating. Nurse Aide #1 last saw the resident sometime around 4 or 4:30 PM that day at the 200 hall nurse's station as the resident was going to dinner. Nurse Aide #1 remained on the hall assisting other residents with dinner. She stated Resident #274 either left the dining room or never stopped at the dining room and went out the front door. She further stated the resident left the facility and was headed towards the eye center. The Nurse Aide stated she did not know how far she made it and only found out about the incident after Resident #274 had been brought back inside the facility. Nurse Aide #1 concluded that Resident #274 was wearing clothing and appropriate footwear that evening as she was on her way to the dining room. During an interview on 8/7/18 at 4:34 PM Nurse #1 stated she usually worked on 100 east hall and was not assigned to Resident #274. She further stated she was not familiar with Resident #274's care. She stated a visitor came in to the facility on [DATE] way before Resident #274's unsupervised exit and was opening the door for Resident #274 not knowing the residents could not go outside unsupervised. She stated she told the visitor please do not let the residents outside before asking a nurse. She further stated had she not intervened Resident #274 was going to exit the facility but had not made it out of the door. She then stated she called the 200 hall and spoke to the House Supervisor, who was the floor supervisor for Resident #274, and the House Supervisor informed Nurse #1 that Resident #274 was not allowed to go outside without supervision. A Nurse Aide from the 200 hall then came and took the resident back to the 200 hall. The nurse stated later that day on 7/22/18 one of her alert and oriented residents (Resident #110) alerted her to the fact that the resident was outside. She was unable to recall the time this occurred, but it was well after the first incident. She stated she asked Resident #110 who the resident was and she told her that Resident #274 was outside in the far parking lot. She further stated she looked and could see out the 100 hall exit door at the end of the hall and could see the resident. She stated there were two sections directly across from the rehab hall and she was in the parking sections furthest away from the facility. She immediately retrieved Resident #274 and assessed her to have no injuries. She reported what had just occurred to the House Supervisor and a 200 hall Nurse Aide came and got Resident #274 and took her back to the 200 hall. She was unable to recall which nurse aid it was who retrieved the resident both times. During an interview on 8/8/18 at 8:07 AM Resident #110 stated he was at the front lobby one Saturday or Sunday (7/21 or 7/22) at about 2 PM and saw a resident that he did not know at that time attempt to leave the facility and Nurse #1 stopped the resident who was halfway out the door and told the resident she could not go outside without supervision. He further stated Nurse #1 then brought the resident back inside. He stated his wife was visiting him around 5 PM on that same day and the blinds were open in his room. He saw the same resident pass by his window and was concerned. He was already in his wheelchair, so he went to the hall and found Nurse #1 and asked her if that same resident was supposed to be outside. Nurse #1 told him no so he informed her she was outside and then looked out the 100 hall back door and said, in fact, there she goes. He stated at that point she was outside in the parking lot of the rehab area about in the middle to further side of the parking lot. He further stated he could not tell how far it was. During an interview on 8/8/18 at 8:35 AM Nurse Aide #3 stated Resident #274 had dementia and would not always remember reeducation. She further stated she could sometimes get lost and would talk about being a teacher and needing her classroom. She further stated she had seen Resident #274 wander daily in the facility. The nurse aide stated if wandering was identified the nurse would document it. She further stated Resident #274 had wandered during her entire stay in the facility since (MONTH) and it was her baseline behavior so because staff were aware she wandered, she did not report the behavior to her nurse. During an interview on 8/8/18 at 9:05 AM Nurse #3 who was the 200 hall team leader stated stated if a resident was observed attempting to exit the facility who required supervision outside the facility, it was the facility's protocol to place a wander guard on the resident and assess them. She further stated that if she was told Resident #274 had attempted to leave the facility that would be abnormal behavior for her and she would have placed a wander guard on the resident and notified the Director of Nursing as soon as she was aware. She further stated no staff had shared any concerns with her about Resident #274's confusion or wandering prior to 7/22/18. During an interview on 8/8/18 at 9:57 AM the Director of Nursing RN stated the Elopement Risk Assessment form was having a glitch in their computer system and could not be signed and dated by some staff. She further stated it would not prevent the staff from completing the summarization/conclusions/recommendations section. She stated if she performed the evaluation she would complete the summarization/conclusions/recommendations sections, however, since all the questions in the form were answered she did not believe it was necessary to complete the Elopement Risk Assessment form. The Director of Nursing stated the first Elopement Risk Assessment was done on 6/29/18 because in the computer program the Elopement Risk Assessment had been opened on 6/29/18. She stated she was unable to know who performed the assessment due to the computer glitch. The Director of Nursing stated the resident was not at risk because only three of the fifteen questions were answered yes. She further stated the second Elopement Risk Assessment was done 7/22/18, because of the date it was opened in the computer, after Resident #274 exited the facility unsupervised and was at risk for elopement and a wander guard was put in place. During observation on 8/8/18 at 2:00 PM, the parking lot where Resident #274 was found was observed. The approximate location Resident #274 was found was about 175 feet from the entrance to the facility. The location was approximately 50 feet away from a heavily traveled two-lane road with a 45 mile per hour speed limit. The edge of the parking lot, where Resident #110 had said Resident #274 was going, had a five-foot jagged edge in the cement. The edge dropped approximately three inches to the grass. The nearby road had a ditch along the road about 45 feet away from where the resident was approximately found. During an interview on 8/8/18 at 4:16 PM the Director of Nursing stated if Resident #274 had stated she was being taken out of the facility by a family member and had even almost convinced a nurse aide of this fact she would have expected the concern to be documented and at least a new wandering assessment performed. She further stated no nurses or nurse aides had brought that concern to her attention and if it had happened she would have expected the staff to bring these issues to her attention and they did not. She further stated she had not been made aware that Resident #274 had attempted to leave the facility earlier in the day on 7/22/18 around 2 PM until 8/8/18. During an interview on 8/9/18 at 8:25 AM the Administrator stated on 7/22/18 at around 7 PM the Director of Nursing called him and informed him of Resident #274's unsupervised exit from the facility. He further stated the Director of Nursing informed him of the actions that had been taken. A wander guard was put in place after the resident had exited the facility and an elopement risk assessment was done. He further stated he was not familiar at that time with Resident #274's care and behaviors. The Administrator stated no staff had shared concerns with him that Resident #274 indicated she was leaving because family was picking her up. He further stated until 8/8/18 no staff had informed him that she had attempted to exit the facility earlier on 7/22/18 at about 2 PM. He further stated he did interview Resident #110 on 7/23/18 and he only shared with him the actual elopement and did not mention she had tried to leave the facility unsupervised earlier on 7/22/18. The Administrator concluded he let his Director of Nursing handle clinical concerns, however he felt a reasonable person would have placed a wander guard on Resident #274 following her first attempt to leave the facility and did not know why the House Supervisor did not. During an interview on 8/9/18 at 9:30 AM Resident #274's Physician stated Resident #274 was very challenging behaviorally. He further stated Resident #274 was combative and resistive to care and had a history of [REDACTED]. He further stated she was alert with a degree of confusion. The Physician continued to state Resident #274 did not have good executive decision making abilities for certain decisions about her best interest. He further stated he had only had one visit with the resident and was not able to give further information about elopement risk because his other observations of the resident were when she was on the hall in passing. The Administrator and DON were notified of the immediate jeopardy on 8/8/18 at 12:35 PM. On 8/9/18 at 11:34 AM the facility provided the following credible allegation of compliance for immediate jeopardy removal: Allegation of Compliance 1. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited. · Resident #274 was admitted to the facility on [DATE] and an Elopement Risk Assessment was completed. At that time, the resident was determined not to be an elopement risk because she never expressed a desire to leave the facility, she did not wander, and she had no exit-seeking behavior. FL-2 ' s from her previous facility indicated she was not a wanderer. · Nurse aide #1 reports that on an earlier date that she could not recall, the resident had previously indicated that she was planning to leave the facility and was redirected to her room. This was not reported to administration. It was reported to the surveyor. · Nurse #1 indicates that the resident was removed from being near the door at approximately 2:00 p.m. On 7/22/18 when an unrelated family member was leaving, the nurse cautioned the family not to let the resident out as they were holding the door open as if to let someone through. The nurse pulled the resident away from the door. The nurse did not report this to administration. She reported this to the surveyor. · At approximately 5:00 p.m., the charge nurse was notified by resident #1 that resident #274 was outside his window. Nurse #1 went outside and immediately returned her to the facility. · The resident was assessed for injury by charge nurse #1 and there was none. · A Wanderguard was placed on the resident on 7/22/18 by nurse #1 · The House Supervisor was immediately notified on 7/22/18 · The House Supervisor notified the DON and administrator on 7/22/18 · The resident ' s son was notified and he reported that she was just admitted to us from an ALF where she was permitted to and enjoyed sitting on the front porch outside. · A root cause analysis conducted on 7/23/18, revealed that the resident went out the front door after the receptionist left. The door had no staff member to monitor from 4:30-8:00 p.m. The root cause analysis to determine why administration was not notified of exit-seeking behavior found that staff indicated they did not notify administration because they did not see the resident try to exit the facility, she was known to make nonsensical statements, and staff felt as if they were monitoring the resident ' s activities. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. · Resident #274 had a new Elopement Risk Assessment completed on 7/23/18, a Wanderguard added on 7/22/18, and care plan updated 7/23/18. · On 7/24/18, a 100% audit was completed on all residents regarding the risk for elopement by the DON and ADON. There were no additional residents that were determined to be elopement risks. · An audit was conducted for all doors and Wanderguard bracelets and units on 7/23/18 to assess proper function by the Administrator. · On 7/24/18, an audit was completed on all care plans for those who wander on by the MDS Nurse. · On 7/23/18, a staff member was assigned to monitor the door after the receptionist leaves (from 4:30 pm-8:00 pm.) The door automatically locks from 8:00 pm to 8:00 a.m. · On 7/23/18, an order was placed for a remote buzzer/camera apparatus to allow the door to be visualized and unlocked from the nurse's station and/or lobby. The device will be installed as soon as available but the door will continue to be monitored by assigned staff when unlocked from 4:30 p.m.-8:00 a.m. · On 8/8/18 staff members (nurses, nurse aides, physical therapist, occupational therapist, speech language therapists, therapy assistants, department managers, dietary, housekeeping and laundry) were in-serviced on appropriate response to exit seeking behavior, notification of administration, and assignment of staff monitoring of door from 4:30-8:00 p.m. All nurses were in-serviced on proper completion of the Elopement Risk Assessment. No staff member will be permitted to return to work until they have been in-serviced. · The QAA Committee and Medical Director met on 7/24/18 and 8/8/18 and approved this Allegation of Compliance. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements. · The DON or ADON will review all new admission's Elopement Risk Assessments for accuracy weekly x 8, monthly x 2, and quarterly x3. · The DON or ADON will review all significant change Elopement Risk Assessments for accuracy weekly x8, monthly x2 and quarterly x3. · The Elopement Audit Tool will be completed monthly x4 and then quarterly x 3. · The QAA Committee will discuss all results monthly. The Administrator, is responsible for this A[NAME] and the credible allegation of compliance date is 8/8/18. The credible allegation for Immediate Jeopardy removal was validated on 8/9/18 at 12:30 PM, which removed the Immediate Jeopardy on 8/8/18, as evidenced by staff interviews, in-service record reviews, and observation. The in services included information on Resident #274's elopement risk, elopement risk assessments and how to complete them, and identification of residents who are at risk for elopement and what actions to take if a resident appears to be at risk for elopement. The in service also included information about having a door monitor during the times of the day the front door was unlocked.