Every finding on record at The Graybrier Nursing and Retirement Center

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of accidents (Resident #37) and urinary catheter (Resident #25) for 2 of 19 residents whose MDS assessments were reviewed (Resident #37 and Resident #25). The findings included: 1) Resident #37 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, history of a left hip fracture and mild cognitive impairment. A review of Resident #37's medical record showed that she experienced three falls since the last quarterly MDS assessment dated [DATE]: a fall with major injury on 8/1/25, a fall with no injury on 8/9/25, and a fall with minor injury on 10/19/25. The quarterly MDS assessment dated [DATE] indicated that Resident #37 was cognitively intact and was coded as having had one fall with minor injury since the previous assessment of 7/24/25. On 1/22/26 at 12:31 PM, an interview occurred with the MDS Coordinator who reviewed Resident #37's 10/23/25 MDS assessment and medical record. She confirmed the resident had experienced three falls since the previous assessment dated [DATE]. She acknowledged that the 10/23/25 MDS should have been coded to reflect one fall with no injury and one fall with major injury, in addition to the fall that was already coded with a minor injury. She stated an as needed MDS nurse completed that portion of the MDS assessment and felt the omission was an oversight. An interview with the Director of Nursing on 1/22/26 at 1:25 PM indicated that it was her expectation that MDS assessments be coded accurately for accidents. 2) Resident #25 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder and neurogenic bladder. Resident #25's physician orders included an order dated 4/21/25 to flush the suprapubic catheter with 60 cubic centimeters (cc) of normal saline (NS) every shift and an order dated 4/21/25 to provide urinary catheter care every shift. The care plan initiated 4/30/25 revealed Resident #25 had an indwelling suprapubic catheter. A review of Resident #25's December 2025 and January 2026 Medication Administration Records (MARs) revealed that nurses documented Resident #25's suprapubic catheter was flushed every shift with 60cc of NS from 12/27/25 through 1/2/26. A review of Resident #25's December 2025 and January 2026 Treatment Administration Records (TARs) revealed nurses documented Resident #25 received urinary catheter care every shift from 12/27/25 through 1/2/26. Resident #25's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact and did not have an indwelling urinary catheter. An interview was conducted on 1/22/26 at 3:50 PM with MDS Coordinator. She reviewed Resident #25's quarterly MDS assessment dated [DATE] and verified Resident #25 was coded as not having an indwelling urinary catheter. The MDS Coordinator indicated an as needed MDS Nurse coded the Bladder and Bowel Section of Resident #25's MDS and felt it was coded incorrectly in error. The MDS Coordinator revealed Resident #25 had a suprapubic catheter present when the assessment was completed and should have been coded as such. During an interview on 1/22/26 at 3:57 PM with the Director of Nursing (DON), she stated she expected the MDS assessments to be coded accurately for each resident.

Based on record review and staff interviews, the facility failed to update the Do Not Resuscitate (DNR) status for 1 of 32 residents reviewed for Advanced Directives (Resident #10). The findings included: Resident #10 had been admitted on [DATE]. Resident #10's admission Minimum Data Set assessment dated [DATE] indicated she had severe cognitive impairment. A Care Plan with an initiation date of [DATE] and a review date of [DATE] indicated Resident #10 had a Full Code status. The care plan goal was to honor the Full Code status. Interventions included staff will follow the Advanced Directives as written. On [DATE] Resident #10's electronic medical record (EMR) was observed to have Full Code status indicated on the resident dashboard (information banner). In the Advanced Directive section, a scanned copy of a goldenrod Do Not Resuscitate (DNR) form was observed, signed by the physician dated [DATE]. An Advance Directives form was also included noting allow natural death (Do Not Resuscitate [DNR]; no CPR (cardiopulmonary resuscitation) will be given in the event of cardiopulmonary arrest [when the heart stops beating and there is no breathing]) This form was signed by Resident #10's Responsible Party on [DATE] and by her physician on [DATE]. The hard copies of both forms, the goldenrod DNR and the Advance Directives, both of which documented Resident #10 was a DNR, were filed in the Code Status notebook for Resident #10's hallway located at the nurses' station. This notebook contained each resident's face sheet (demographic information), goldenrod form (code status form signed by the physician), and their Advance Directives form. An interview with Nurse #1 was conducted on [DATE] at 10:05 AM. The Nurse stated each resident's code status was noted in the EMR and also in the Code Status notebook located at each nursing station. An interview with the Medical Records Clerk was conducted on [DATE] at 10:28 AM. She stated that after the physician signed the forms (goldenrod DNR and Advance Directives forms), she scans them into the EMR and then places the hard copies into the Code Status notebook at the nurses' station. She explained that each nurses' station had a book with each resident's face sheet, goldenrod and advance directives forms. An interview with Nurse Aide #1 was conducted on [DATE] at 11:08 AM. She stated she regularly cared for Resident #10. She explained the residents' code status could be found in the Code Status notebook at the nurses' station. An interview with the Social Work Assistant was conducted on [DATE] at 3:23 PM. She explained the DNR status and care plans were reviewed quarterly and updated as needed. After reviewing the EMR information for Resident #10, the goldenrod DNR form, the Advance Directives form, and the care plans, she stated the information should match but didn't. During an interview on [DATE] at 9:54 AM the Social Worker (SW) stated she was unsure how the resident's EMR being updated to reflect Resident #10's DNR status had been missed. She explained Resident #10's dashboard had indicated Full Code status, and she used that information to develop and update the Code Status care plan. She also explained that during care plan meetings with Resident #10's family, she would ask if there was any change in the code status but did not clarify what the status was. She stated she was unsure who updated the resident dashboard. During an interview with the Administrator on [DATE] at 10:12 AM he stated upon entry, residents were considered Full Code until the Code Status was determined. He explained he thought the paperwork for Resident #10's Code Status had been completed and scanned into the EMR but the administrative nurse who updated the dashboard didn't see the paperwork. The Administrator also explained the SW developed the care plan with the information on the resident's dashboard. During an interview with Nurse #4 on [DATE] at 10:35 AM she stated any nurse could update the Code Status information. She explained that upon admission Resident #10 had a Full Code status and several days after admission her family signed paperwork for the DNR status. She explained that updating the EMR Code Status update had been missed.

Based on observation, record review, and interviews with the Medical Director and staff, the facility failed to obtain an order to delay the removal of sutures until the wound was healed for 1 of 2 residents reviewed for professional standards (Resident #62). The findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #62 was severely cognitively impaired without mood or behavioral concerns. Review of the nurses' notes revealed an entry dated [DATE] that Resident #62 had a witnessed fall on [DATE]. Resident #62 was taken to the local emergency room for evaluation where she received sutures for a wound to the right side of her forehead. Review of the emergency room discharge paperwork dated [DATE] revealed Resident #62 was supposed to be scheduled for a follow up appointment to have her sutures removed in seven days. Review of the physician's orders transcribed in the chart for Resident #62 uncovered an expired order for suture removal on [DATE]. There was no documentation in the nurse's notes that explained why the order had expired without being completed. There were no further orders or physicians follow up notes regarding suture removal noted in the chart. Review of Resident #62's [DATE] Treatment Administration Record (TAR) revealed the expired order for suture removal but no further orders for removal were documented. The order to remove the sutures was not signed off as completed and left blank. The nurses' notes reviewed for [DATE] contained a note from the night shift nurse who documented Resident #62 had a clean dry dressing over the right brow area with light greenish-yellow bruising. There were no other nurses' notes or documentation about the sutures discovered in the record. A note written by the Wound Care nurse dated [DATE] at 4:40 PM documented Resident #62 had sutures present on her forehead with improved bruising. There was no mention of obtaining an order to remove the sutures. An interview was conducted with Nurse #2 on [DATE] at 12:15 PM. She stated there was an order for suture removal for Resident #62 on [DATE]. She stated she was not working that day, and she was unaware why the sutures had not been removed. The Wound Care Nurse was interviewed on [DATE] at 2:56 PM. She stated on [DATE] the provider noted Resident #62's wound looked wet and soft so the order to remove sutures was extended due to the wound's appearance. The Wound Care Nurse did not write a new order for suture removal. Nurse #5 was interviewed on [DATE] at 9:32 AM. Nurse #5 stated she had worked the morning shift on [DATE]. She verbalized on [DATE] the hospice agency nurse had visited Resident #62, and they jointly assessed her sutures that day. Nurse #5 stated the hospice nurse told her she didn't think the wound looked good enough to remove the sutures and she agreed with her. Nurse #5 indicated she had decided not to remove the sutures, but she did not notify the NP or Medical Director of the wound's condition to obtain a new order because she thought the hospice nurse was going to contact the provider instead. An observation on [DATE] at 12:10 PM revealed Resident #62 had sutures on the right side of her forehead. The laceration's edges were clean, dry and approximated. Minimal pale pink discoloration was noted around the site. The Nurse Practitioner (NP) was interviewed on [DATE] at 3:34 PM. She stated that she had not assessed Resident #62 previously because residents who received hospice care were followed by the facility's Medical Director. She stated that the resident was added to her list to be seen on[DATE] for evaluation for suture removal. The Medical Director was interviewed on [DATE] at 10:50 AM. He stated that Resident #62 had fallen and suffered a laceration on [DATE]. He stated he had told the Wound Care nurse to leave the sutures in place for at least ten days during one of his daily phone calls with her, but he was unsure of the exact date. He stated that he was unsure why the order was not changed for Resident #62.

Based on observations, record reviews, resident and staff interviews, the facility failed to secure Resident #1 in a mechanical lift per manufacturer's instructions and failed to provide a safe transfer which resulted in a fall. This deficient practice was for 1 of 3 residents reviewed for supervision to prevent accidents. The findings included: Manufactures guidelines for the U-Sling or Divided Leg Sling indicated this sling has full coverage along the patient ' s back, with two divided straps that crisscross under the patient ' s legs. The crisscrossed legs ensure that the patient doesn ' t slide out of the sling during transport. Resident #1 was admitted to the facility on [DATE] with the following diagnoses, Dementia, Alzheimer ' s Disease, anxiety, and history of cerebrovascular event (CVA). Resident #1 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. She was dependent on staff for all transfers and had a range of motion (ROM) limitation to both lower extremities. She also had 1 fall with minor injury. Resident #1 ' s care plan, revised on 05/01/24, had a focus that indicated she had impaired physical mobility, and required a mechanical lift for transfers. She was unable to stand or ambulate, causing her to be at risk of injury. She also had decreased ROM to bilateral lower extremities. The interventions included for staff to provide the appropriate level of assistance to promote safety. Another focus read she had the potential for fall related injuries. Resident #1 required assistance with bed mobility and transfers due to diagnoses of Alzheimer ' s Disease, Dementia, CVA, and she was unable to stand. The care plan also indicated she had an assisted fall from the mechanical lift during a transfer. The interventions included that she required staff assistance with transfers by a mechanical lift, and for staff to use appropriate size sling for mechanical lift. Incident report dated 03/27/24 revealed Resident #1 was being transferred from the bed to her chair with the mechanical lift when she slipped through the opening at the bottom of the harness and guided onto the floor by 2 NAs. She did not hit her head. Neuro checks were initiated. The resident ' s cognition was at baseline, she was verbally responsive, and able to make needs known. An abrasion was noted to the right side/under breast/upper abdominal area with no bleeding or bruising observed at that time. Resident #1 complained of pain in her right leg. An X-ray was ordered of her right femur (thigh bone), right knee, right tibia/fibula (2 bones of the lower leg), or right and left foot. The X-ray was completed, awaiting results. Resident #1 had an active order for tramadol 25mg to be given as needed every 8 hours for complaints of pain. Resident #1 received tramadol for complaints of right leg pain with effective results. Review of X-ray results, dated 03/27/24, revealed no fractures and no soft tissue swelling identified for the right femur, right knee, right tibia/fibula, or right and left foot. An interview was conducted on 06/04/24 at 11:20 AM with Resident #1. She stated she had a fall from the mechanical lift in her room. She stated during the transfer there were 2 Nursing Assistants (NAs) present during the transfer. She further stated she started sliding out of the pad and the NAs guided her to the floor while protecting her head. She also stated she thought the pad had 3 hooks and only 2 were hooked but was not sure how she fell out. She indicated she had a bruised bottom and leg but no other injuries. An interview was conducted on 06/04/24 at 2:15 PM with the Unit Coordinator. She stated she was the first to respond to the fall with Resident #1 on 03/27/24. Upon entering the room, the mechanical lift pad was disconnected from the lift. She stated the Nursing Assistants (NAs) reported that all 6 hooks were fastened and locked in place prior to the transfer. The resident was on the floor with the NAs. There were 2 NAs that were in the residents ' room during the transfer. She indicated Resident #1complained of some discomfort to her right leg and she had a small abrasion under her right breast area. The Unit Coordinator assessed the range of motion to extremities and assisted with getting Resident #1 to bed. The Unit Coordinator verified NA #2 had received training during the hiring process and was given check offs for mechanical lift transfers and bed mobility and repositioning. Review of training and education revealed Nursing Assistant #2 received training for mechanical lift transfers and bed mobility and repositioning. An interview was conducted on 06/04/24 at 2:30 PM with Nursing Assistant (NA) #1. She verified she was one of the NAs in the room when Resident #1 fell from the sling during a transfer with the mechanical lift. She stated all 6 hooks were connected properly prior to lifting the resident. She also stated she does not know how the resident slid out; it was a freak accident. She further stated she and the other NA assisted the resident to the floor. The sling was the correct size. Review of a statement written by Nursing Assistant (NA) #2 dated 03/27/24 revealed when preparing Resident #1 for a transfer using the mechanical lift, she hooked all 6 hooks securely in place, however, she forgot to cross the bottom portion of the pad before hooking those straps. When using a half body lift pad, you should cross the bottom of straps of the lift pad. A phone interview was conducted on 06/04/24 at 4:10 PM with Nursing Assistant (NA) #2 she verified she wrote the statement dated 03/27/24. She stated when preparing Resident #1 for the transfer using the mechanical lift, she forgot to cross the bottom portion of the pad straps before hooking those straps which caused her to slide out the bottom of the lift pad. In a follow up interview on 06/04/24 at 3:55 PM with the Unit Coordinator she stated she agreed with the statement written by Nursing Assistant (NA) #2. She further stated the reason Resident #1 fell was because the NA forgot to cross the bottom portion of the pad before hooking those straps. Education was done with all nurses and NAs following the incident. An interview was conducted with the Director of Nursing (DON) on 06/04/24 at 4:16 PM. She was not aware of the incident involving the transfer of Resident #1 as she started her employment on 04/29/24 with the facility. She indicated she expected nursing staff to apply and transfer residents with mechanical lifts per manufactures guidelines.

Based on observation, record review, and interviews of resident, staff, and physician, the facility failed to provide care in a safe manner that prevented Resident #1 from rolling out of her bed during the provision of personal care. Resident #1 fell from her bed onto the floor and sustained a hematoma to her right temple and laceration to her lower right leg. Resident #1 was sent to the Emergency Department and was diagnosed with a closed hip fracture next to her hardware from a previous hip fracgture, laceration of the right lower leg that was too wide to suture, pain, and right temple hematoma head injury. This deficient practice affected one of two sampled residents (Resident#1). Findings included: Resident #1 was admitted to the facility on [DATE] with the diagnoses of venous insufficiency of the extremities, acute kidney failure, chronic pain, deep vein thrombosis with anticoagulant administration, diabetes, polyneuropathy, and osteoarthritis. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] documented she had an intact cognition, a minimal hearing deficit, wore a hearing aide, had clear speech, and understands/understood. The resident was coded dependent for bathing and transfers and required substantial/maximal assist for bed mobility. Active diagnoses were diabetes, venous insufficiency of the extremities, kidney failure, osteoarthritis, and polyneuropathy. The resident had scheduled, and as needed pain medication provided. The worst pain over the past 5 days was a score of a 2 (score rating 0 to 10 with 10 being the worst). The resident had one fall since admission with minor injury. The resident was receiving an anticoagulant and opioid pain medication. Resident #1's care plan dated 11/15/23 documented she was at risk for alteration in skin integrity related to incontinence and cellulitis, chronic pain from arthritis, and falls. A review of the Facility Incident Accident Report dated 12/21/23 at 11:22 am written by Nurse #1 documented Resident #1 had a witnessed fall, reported by Nursing Assistant (NA) #1. A head-to-toe assessment was completed by Nurse #1: skin tear right lower leg with bruise/discoloration and laceration noted. NA #1 observed Resident #1's fall with injury. NA #1 informed Nurse #1 she was changing the resident's brief and bedding. The NA rolled the resident towards her when she took her hands off the resident, the resident kept rolling and fell off the bed. The resident was dependent on staff for transfers. The resident was alert and oriented to person, place, and situation. The resident had impaired hearing. The resident's blood pressure was 142/79, pulse 80 and regular, respirations 18, temperature 98.2, and oxygen saturation was 94%. A pain assessment revealed a pain score was 8 on a scale of 0 to 10 with 10 being the worst. First aid was provided to the resident' lower right leg wound with sterile dressing to cover. Emergency Medical Services were called via 911 telephone call and the resident was sent to the Emergency Department. Follow up interventions per the Supervisor investigating added side rails on both sides of the bed and a two-person assist for care. The description of the incident: Resident #1 was yelling out help me upon walking into the room (Nurse #1). The resident was on the floor on her back undressed from the waist down. There was a large bleeding laceration to the right lower leg, bruising above the right eye and skin tear to the left elbow was evident upon assessment. The resident complained of left side and right leg pain. On 1/18/24 at 2:40 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 12/21/23 day shift. In the morning the nurse heard the resident yelling help me. Nurse #1 entered the resident's room and NA #1 was coming around the bed to assist Resident #1 who had fallen off the bed onto the floor. Nurse #1 stated the resident was on the floor next to her bed and had a large injury to the lower right leg that was bleeding, a small skin tear to the left elbow, and a hematoma on the right side of her temple. Nurse #1 stated she immediately dressed the wound with a dressing, notified the physician, and called 911 for immediate transfer to the Emergency Department. The resident was complaining of pain to the right lower leg wound. Once the resident was cared for, Nurse #1 asked NA #1 what happened when Resident #1 fell . Nurse #1 stated NA #1 informed her that during incontinence care and linen change, when the resident was rolled to her left side, the resident rolled forward and off the bed. The resident had not rolled on her own before and was able to remain side lying for care. Nurse #1 had not observed NA #1 use her phone during the shift. On 1/19/24 at 4:45 pm an interview was conducted with NA #1. NA #1 stated she was assigned to Resident #1 on 12/21/23 day shift. The resident received incontinence care in the morning. The resident had a large, loose stool that went onto the linen. The resident was rolled to her right side (window side), cleaned and linen changed. The resident was able to remain on her right side for care. The resident was then rolled to her left side (door side) to continue cleaning her of incontinence when the resident reached over the side of the bed towards the tray table and then continued rolling out of the bed onto the floor. The resident had been cared for and able to side lie on the right and left side before. The bed was elevated to waist height for care when the resident fell . Nurse #1 came into the room to assist the resident. NA #1 stated the resident was hard of hearing and the NA had to lean over the resident to be heard. NA #1 stated she was not on her phone during care provided to the resident or any other care. NA #1 was trying to communicate with the resident and talked with the resident during care. The resident was looking the other way and could not see you to know you were talking to them. The Administrator wrote a timeline documented on 12/21/23 at 11:30 am: Resident #1 had a fall from her bed during care. NA #1 was providing incontinence care, the resident reached towards the side of the bed and rolled towards her stomach and off the bed. The resident informed her assigned nurse, and another NA that NA #1 was on her phone when the resident fell off the bed. Following the incident, NA #1 was interviewed, and documentation completed by the Director of Nursing (DON). NA #1 informed the DON she was not on her phone. Nurse #1 had not observed NA #1 use her phone during the shift. NA #1 was reapproached on 12/21/23 to clarify about earbud use and she stated no, NA #1 was not using her phone or ear buds. Review of investigation documents: The day of the accident, 12/21/23, the family member called the Administrator. The family member requested NA #1 no longer care for Resident #1 and that the resident was larger and care would have been physically impossible for one staff member. On 12/22/23 the resident stated she had not seen NA #1 on the phone but heard her talking to someone. The resident was hard of hearing. NA #1 was removed from work since a resident injury had occurred. The resident returned from the hospital on 12/22/23. Orders were obtained for 2-person assistance for care and bilateral (both sides) bed rails for bed mobility. A hand-written statement dated 12/21/23 documented by NA #1: NA #1 went into Resident #1's room to perform incontinence care. The resident's brief and bedding was soiled with stool. Resident #1's bed was raised to NA #1's waist height for changing. NA #1 rolled the patient (Resident #1) to the left side. The resident was rolled and stopped on her side. The resident was nervous and went to reach towards that side and rolled further towards her stomach and onto the floor. Resident #1's hospital Emergency Department record and discharge summary visit dated 12/22/23 documented the Resident fell off the bed during care at the facility. She sustained multiple closed right hip fractures next to her hardware from a previous hip fracture, a hematoma to the right temple area, and a large laceration/evulsion that was 18 centimeters long by 15 centimeters wide. The physician was unable to approximate the wound edges to close/suture because the skin was so fragile, and the wound was too wide. The resident complained of acute pain of the right lower leg wound. There was [NAME] bleeding that stopped. A non-adherent dressing was applied, and care was to be followed up at the facility. The hip fracture was non-surgical and had minimal pain. The head scan revealed there was no bleeding inside. Resident #1's physician progress note dated 12/22/23 documented a right lower extremity wound and for Resident #1 to follow up at the wound clinic. Antibiotics were ordered at the Emergency Department for cellulitis. The resident had severe pain and Tramadol 50 milligrams was ordered and ineffective. The Tramadol was increased to 100 milligrams and Oxycodone 5 milligrams every 6 hours as needed was ordered. The Pregabalin was increased to 50 milligrams twice a day (for neuropathy pain). On 1/17/24 at 6:12 pm an interview was conducted with the Physician. He stated the facility had informed him of Resident #1's fall and the Emergency Department (ED) visit. The Physician stated he was not informed of the particulars of how the resident fell and the NA's role. The Quality Assurance members had not discussed this accident/incident yet. He stated he was following the resident's right lower leg wound. The physician stated he saw the wound on 12/21/23 and it was very bad, large, and bleeding. The Emergency Department physician could not close the wound, it was too wide. The Physician stated the wound was getting better but because the resident was bedbound, had diabetes, heart disease, very fragile skin, and was on chronic blood thinner, the wound would take a long time to heal. Since the resident had been bedbound for some time, she was at a high risk of fracture with falls. On 1/17/24 at 3:55 pm an observation and interview was done of Resident #1. She was in her bed in a hospital gown. The resident no longer had the bruise to the right forehead. She was lying on a large, air mattress bed with bilateral side rails. The bed had an air mattress and was the same bed/mattress the resident fell out of. The side rails were added after the fall and fit the bed with no gap. The resident had a dressing to the right lower leg that covered most of her calf in place. The resident was interviewed and able to state that she fell out of bed. The NA rolled her off the bed during care and she fell to the floor (before side rails were placed). The resident stated she was in a lot of pain after falling and her lower right leg had a bad injury that was currently open, not healing, and very painful with the dressing change. The resident had not remembered reaching while being rolled for care. The resident stated she was concerned about the size of the wound and what would happen to her leg. The resident commented she was receiving her pain medication. The resident also commented at present, the resident had no pain from the wound just her usual arthritis. On 1/18/23 at 12:30 pm an observation of Resident #1's wound assessment and care by the Wound Nurse was done. The dressing was removed, and yellow and serous drainage was present on the dressing. The wound appeared large and took up more than half of the calf in length and three quarters of the calf in width on the outer side of the leg. The outer edges of the wound were granulating, and the center appeared to be approximately 2 to 3 centimeters deep with uneven tissue and 3 areas of black tissue. The area around the wound was light pink. The Wound Care Nurse commented that the black tissue was bruising from a hematoma that developed in the wound, not necrotic tissue. On 1/18/24 at 2:05 pm an interview was conducted with the Medication Aide. The Medication Aide stated she was not aware of nursing staff being informed of the accident, how it happened, or education/in-service provided. The interventions added were bed rails at the resident's request to hold on for bed mobility and two staff for bed mobility and care.

Based on record reviews, observations, and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #46 and #32) and failed to provide showers as scheduled (Resident #42). This was for 3 of 3 residents reviewed for Activities of Daily Living (ADLs). The findings included: 1. Resident #46 was initially admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, macular degeneration, and hypertension. A quarterly Minimum Data Set (MDS) assessment dated ,d+[DATE] indicated Resident #46's cognition was moderately impaired and displayed no behaviors or rejection of care. She required limited assistance from staff for personal hygiene and total dependence on staff for bathing. Resident #46's active care plan, last reviewed 04/04/23, indicated she required assistance with all ADL care related to functional decline. The interventions, in part, included provide assistance with bathing as needed and ensure her preferred way of bathing is honored. A review of Resident #46's nursing progress notes from 05/22/23 to 06/01/23 revealed no refusals of nail care documented. On 05/30/23 at 10:21 AM, an observation of Resident #46 occurred while she was in her room, sitting in her wheelchair. Underneath her fingernails on her right hand contained a thick dark substance. Resident #46 was observed on 05/31/23 at 3:10 PM, in the dining room with other residents and eating a cookie. Her nails were unchanged from prior observation. On 06/01/23 at 9:01 AM, Resident #46 was observed sitting in her wheelchair in her room. Her fingernails remained with dark substance under the nails to the right hand. An observation and interview occurred with Nurse Aide (NA) #5 on 06/01/23 at 9:48 AM. She indicated she was familiar with Resident #46 and her care needs. She stated she was the NA assigned to care for Resident #46 on 05/30/23. 05/31/23, and 06/01/23. She stated Resident #46 did not refuse care and was receptive to assistance by the staff. She stated she gave Resident #46 a bed bath every morning. She stated nail care should be completed when there was a need during a shower or personal care. An observation occurred with NA #5 of Resident #46's nails. NA #5 confirmed a dark substance was under the nails to the right hand and stated she had not noticed the need for nail care during her morning care. The Director of Nursing was interviewed on 06/01/23 at 10:03 AM and stated she would expect fingernails to be observed on shower days and during personal care with nail care rendered as needed. 46095 2. Resident #32 was admitted to the facility on [DATE] with diagnosis that included dementia with behavioral disturbances, paranoid schizophrenia, and heart failure. A quarterly Minimum Data Set (MDS) assessment dated ,d+[DATE] indicated Resident #32's cognition was moderately impaired. She exhibited verbal behavioral symptoms directed toward others 1 to 3 days, other behavioral symptoms not directed toward others occurred daily, and rejection of care on 1 to 3 days during the observation period. She was totally dependent on staff x 2 for personal hygiene and totally dependent on staff x 1 for bed mobility, dressing, eating, toilet use, and bathing. She had range of motion (ROM) impairment on both sides of upper and lower extremities. Resident #32's active care plan, last reviewed 04/05/23, revealed a focus that read Resident #32 had an ADL self-care performance deficit and required assistance with bed mobility, transfers, toileting and hygiene related to Dementia with behavioral disturbances and decreased range of motion (ROM) to bilateral upper extremities (BUE). Interventions included she required extensive to total assistance. A review of Resident #32's nursing progress notes from 05/15/23 to 06/01/23 revealed no refusals of nail care documented. A review of Resident #32's personal hygiene and showers/baths under Activities of Daily Living (ADL) documentation revealed no refusals documented. An observation was conducted with Resident #32 on 05/30/23 at 1:09 PM. She was observed in bed in her room resting. Fingernails on left hand were long, extending out 1/8th to 1/2 of an inch past the tip of fingers. Left hand contracted, pointer finger and pinky fingernail resting on palm of left hand with slight indentions to areas where the nails were resting. Middle fingernail 1/2 inch long extended out with no contact with skin. Middle fingernail and pinky on left hand also jagged on the ends. Fingernails on her right hand were long and jagged, extending out 1/8th to 1/4th of an inch past the tip of fingers. A continuous observation was conducted with Resident #32 on 05/31/23 at 9:27 AM through 10:32 AM. Resident #32 yelling out hey. Nurse #4 went into her room and asked Resident #32 what was wrong and if she needed anything. Resident #32 stated my hands are hurting, take these things off. (Splint and carrot to hands). Nurse removed splints from hands and Resident #32 stated that was better. When nurse left room, she started yelling again. An interview with Nurse #4 was conducted on 05/31/23 at 9:28 AM. Nurse #4 stated she had worked at the facility for 20+ years. She stated Resident #4 had just received a shower and that normally after requesting a shower she will yell out afterwards. She also stated this was her normal behavior. She yells out often and she had several medication adjustments, but nothing seems to help it. Staff go in and redirect and talk with her when she yells out. An interview with Resident #32 was conducted on 05/31/23 at 9:33 AM. She stated she just had a shower as she was yelling out at times during interview. She denied pain or discomfort. Stated she didn't know why she was yelling. She then stated staff needed to cut her nails because they were too long and were hurting. She further stated staff had not cut her nails in a long time. Review of shower sheets which were located at the nurses ' station in a binder revealed Resident #32 ' s shower days are every Wednesday and Saturday. No documented refusal of showers or nail care on the written and signed sheets. An interview with Nurse Aide (NA) #7 was conducted on 05/31/23 at 2:14 PM. She stated she normally provided nail care when she gave a resident their shower/bath. She was the direct care NA for Resident #32 for first shift from 05/30/23 through 06/01/23. She also stated she normally cared for Resident #32, and she gave her a bed bath on non-shower days. She then stated Resident #32 received a shower this AM, but she did not cut her nails because she was yelling out. She also stated her nails are very long and jagged and need to be cut because they are digging into her palm. She further stated she had not tried to go back and cut them this shift but she would reattempt at this time. If the resident refused, she would notify the nurse and would then document under comments on the Activities of Daily Living (ADL) flow sheet. An interview was conducted on 05/31/23 at 2:22 PM with Nurse #4. She stated she would document shower/bath and/or nail care refusals in the residents nursing notes when the NAs notified her. A continuous observation was conducted on 05/31/23 at 2:25 PM of NA #7 and NA #8 cutting & filing Resident #32 ' s nails. Resident was tolerating well, no yelling out observed. NA #8 stated they are long. The Director of Nursing was interviewed on 06/01/23 at 10:03 AM and stated she would expect fingernails to be observed on shower days and during personal care with nail care rendered as needed. She also stated the NA should also inform the nurse and document the refusal on the shower record. 40197 3. Resident #42 was admitted to the facility on [DATE] with diagnoses that included difficulty in walking, lymphedema, and venous insufficiency. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #42 was cognitively intact and displayed no behaviors or rejection of care. She required extensive assistance for bathing. Resident #42's active care plan, dated 4/13/23, included a care area for self-care deficit related to resident requires assistance in all Activities of Daily Living (ADLs) related to functional decline and diagnosis of arthritis. The interventions included assistance of one person for ADLs (bathing, toileting, transfers, personal hygiene). A review of the nursing progress notes from 4/11/23 until 5/30/23 revealed Resident #42 required limited to extensive assistance for ADLs and had one refusal specific to scheduled showers on 4/21/23. A review of the medical records indicated Resident #42 was to receive a shower every Tuesday and Friday on the 3:00 PM to 11:00 PM shift. A review of Resident #42's shower/bathing records for April 2023 and May 2023 indicated she had not received any showers on her scheduled shower days. An interview occurred with Resident #42 on 5/30/23 at 12:30 PM, and stated she was to receive showers on Tuesday and Friday evenings. She recalled being offered a shower once on those days but had refused as she was already in bed and felt it was too late in the evening. She stated she had only received sponge baths on those scheduled days. Resident #42 stated there was a nurse aide (NA) on Saturday that offered her showers sometimes. On 5/31/23 at 3:15 PM, an interview occurred with NA #1 who stated he was familiar with Resident #42 and scheduled to care for her at times on the 3:00 PM to 11:00 PM shift. He stated he normally offered a bed bath/sponge bath to Resident #42 on her scheduled shower days but was unable to state why. He could not confirm or deny attempts to provide the scheduled showers on the Tuesday and Fridays that were not documented as refused or given in the personal care records. A phone interview occurred with NA #3 on 6/1/23 at 9:37 AM who was familiar with Resident #42. She explained she worked the weekend day shift and would offer a shower to Resident #42 when time allowed or if Resident #42 asked for one. A phone interview was completed with NA #4 on 6/1/23 at 11:36 AM, who worked the 3:00 PM to 11:00 PM shift and was assigned to care for Resident #42 at times. She was unable to confirm or deny attempts to provide the scheduled showers on Tuesdays and Fridays that were not documented as refused or given in the personal care records. The Director of Nursing (DON) was interviewed on 6/1/23 at 10:00 AM. She reviewed the shower sheets for Resident #42 and confirmed she was to receive a shower on the 3:00 PM to 11:00 PM shift on Tuesday and Friday. The DON stated she was unaware Resident #42 was not being provided her showers as scheduled but stated if a resident refused, the NA should alert the nurse so a progress note could be written, and an alternate means of bathing provided. The DON added the NA should also document the refusal on the shower record.

Based on observations, staff interviews and record review, the facility failed to implement the standing order for changing an oxygen (O2) nasal cannula tubing and failed to initiate the order to change the water container used to humidify the O2 for Resident #134. This was for 1 of 2 residents reviewed for respiratory care. The findings included: Resident #134 was admitted on [DATE] with Acute Renal Failure, Cerebral Vascular Accident (CVA) and Chronic Obstructive Pulmonary Disease (COPD). Review of a nursing note dated 5/19/23 at 6: 02 PM read Resident #134's blood pressure dropped to 76/44 while on the therapy bike with a O2 saturation of 79% on room air. Resident #134 was taken back to his room where his blood pressure was 102/62 and his oxygen saturation was 76 % on room air. The standing order for O2 at 2 liters per minute (L/M) via nasal cannula tubing was initiated and his O2 saturation percent increased to 99%. The Medical Director (MD) was notified and he ordered the continuation of his oxygen, a stat (immediate) chest x-ray, stat bloodwork and the administration of Rocephin (antibiotic) intramuscularly on 5/20/23 and 5/21/23. The chest x-ray results dated 5/19/23 were positive for pulmonary infiltrates present in his right lung based compatible with pneumonia. Review of Resident #134's May 2023 orders included an order dated 5/19/23 for O2 at 2L/M using a nasal canula tubing continuously to maintain a O2 saturation of 90% or above. The order also read for the nurse to check placement of oxygen, settings, concentrator function and O2 saturation percent every shift. There were no orders to change his nasal cannula tubing and humidification water container weekly. Review of Resident #134's electronic standing orders included an order to change the O2 tubing and the container of humidifying water every Tuesday night shift (7:00 PM-7:00 AM). This order was not marked as initiated. The admission Minimum Data Set, dated dated dated [DATE] indicated Resident #134 had severe cognitive impairment, no behaviors and coded for the use of O2 while at the facility. Resident #134 was care planned on 5/26/23 for the use of supplemental O2 due to his COPD and recent diagnosis of pneumonia. Interventions included O2 per nasal cannula as ordered by the MD. Resident #134 was observed on 5/30/23 at 11:45 AM. He was lying in bed with his unlabeled nasal cannula tubing and a container of humidifying water in use with his O2 concentrator running at the ordered rate. Review of Resident #134's May 2023 medication administration record (MAR) and his treatment administration record (TAR) did not include anything about changing his O2 tubing and the container of humidifying water. Resident #134 was observed on 5/30/23 at 4:02 PM. His O2 tubing and container of humidifying water were unchanged from previous observation. An observation was completed on 5/31/23 at 11:00 AM with the Treatment Nurse. She stated the facility did not routinely label oxygen tubing or containers of humidifying water when changed but rather it was charted on the electronic medical record on the MAR or TAR and would pop up when it was due again. She stated the tubing and the container of humidifying water were changed weekly on the night shift. Resident #134 was observed on 6/1/23 at 10:15 AM. His O2 tubing and container of humidifying water were unchanged from previous observation. An interview was completed on 6/1/23 at 10:20 AM with Nurse #2. She stated there were standing orders to change the oxygen tubing and the container of humidifying water weekly on the night shift. Nurse #2 reviewed the electronic medical record, but she stated she found no documented evidence that the standing order was ever initiated on 5/19/23. An observation was completed on 6/1/23 at 10:30 AM with Nurse #1. He stated the nurses were supposed to put a label with the date on the oxygen tubing and date the container of humidifying water were replaced. Nurse #1 stated if the standing order to change his oxygen tubing and container of humidifying water were initiated in the electronic medical order, it would appear on the TAR for the night shift nurse to do. Nurse #1 verified that the standing order to change oxygen tubing and the container of humidifying water weekly was not initiated when the original order was put in on 5/19/23. An interview was completed on 6/1/23 at 10:55 AM with Nurse #3. She recalled the evening Resident #134 experienced a drop in his blood pressure and oxygen saturation level. She initiated the standing order for supplemental oxygen but it appeared she did not initiate the standing order to change his oxygen tubing and his container of humidifying water weekly. An interview was completed on 6/1/23 at 11:55 AM with the Director of Nursing (DON). She stated when Nurse #3 initiated the standing order for supplemental oxygen on 5/19/23, she forgot to also initiate the standing order to change his oxygen tubing and the container of humidifying water weekly on Tuesday nights. The DON stated it appeared that Resident #134 had been using the same oxygen tubing and container of humidifying water since 5/19/23.

Based on observations and staff interviews the facility failed to date multi-dose medications upon opening on 2 of 3 medication carts reviewed (Upper [NAME] River, and Lower [NAME] River medication carts). The findings included: A. An observation was conducted on 05/31/23 at 11:05 AM of the medication cart on Upper [NAME] River Hall in the presence of Medication aide (MA) #1 and Nurse #1. The observation revealed no opened date on the following multi-dose medications: 1. One multi-dose package of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation vials. 2. One multi-dose package of Albuterol Sulfate 0.63mg/3ml inhalation vials. 3. One Tresiba (insulin degludec) FlexTouch(R) insulin pen (150units left in pen). Medication Aide (MA) #1 removed the undated medications from the medication cart. Nurse #1 stated he did not notice the insulin was not dated. He stated insulin should be labeled and dated when opened. An interview was conducted with MA #1 on 05/31/23 at 2:01 PM. She stated she was aware the nebulizer treatments were to be dated when opened and she removed them from the medication cart. B. An observation was conducted on 05/31/23 at 2:06 PM of the medication cart on the Lower [NAME] River Hall in the presence of Medication aide (MA) #2. The observation revealed 1 multi-dose opened pack of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation package with 1 individual vial left in package with no opened date. MA #2 verified the multi-dose pack of Ipratropium Bromide and Albuterol Sulfate 0.5mg/3ml inhalation package was not dated. MA #2 stated she was aware it was to be dated when opened and she removed them from the medication cart. An interview was conducted on 05/31/23 at 2:11 PM with Nurse #1. He confirmed he did administer the Tresiba (insulin degludec) FlexTouch this AM. He stated he did not realize the pen was not dated. He was aware the pen should have been dated when opened. An interview was conducted on 05 06/01/23 at 12:24 PM with the Director of Nursing (DON). She stated nurses were to date all nebulizer packages and insulin vials and pens upon opening and they should be checking dates daily prior to administration.

Based on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to hold blood pressure medications as ordered for 2 of 13 residents whose medications were reviewed (Residents #50 and #83). The findings included: 1) Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #50's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure less than or equal to 110 or diastolic blood pressure less than or equal to 60. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 was alert and oriented. The November 2021 and December 2021 Medication Administration Records (MARs) were reviewed and revealed Resident #50 had received [MEDICATION(S)], despite the systolic blood pressure (SBP) below 110 or diastolic blood pressure (DBP) below 60 on the following dates: - 11/13/21- DBP was 55 - 11/14/21- SBP was 101 and DBP was 59 - 11/22/21- DBP was 59 - 12/7/21- DBP was 58 - 12/11/21- SBP was 106 and DBP was 53 - 12/16/21- SBP was 103 - 12/30/21- DBP was 58 An interview occurred with Nurse #2 on 1/6/22 at 9:25 AM, who was assigned to Resident #50 on 12/7/21. Nurse #2 indicated she was aware the resident had parameters to hold the [MEDICATION(S)]. She reported the blood pressure was taken by the nursing assistants (NAs) and recorded on the MAR. Nurse #2 reviewed the December 2021 MAR, verified the [MEDICATION(S)] was administered despite the DBP being below 60 when it should have been withheld and responded it was an oversight. On 1/6/22 at 10:22 AM, a phone interview occurred with Nurse #3 who was assigned to Resident #50 on 11/13/21 and 11/14/21. The November 2021 MAR was reviewed with her and she stated even though the NA's obtained vital signs to include blood pressure, she manually checked Resident #50's blood pressure before administering [MEDICATION(S)] due to the hold parameters ordered. She was unable to recall why the [MEDICATION(S)] was administered outside the parameters other than to say it was an error on her part and the medication should have been withheld. A phone interview occurred with the Nurse Practitioner (NP) on 1/6/22 at 10:30 AM and stated if the resident had received a few dosages of [MEDICATION(S)] outside of the parameters it would not have caused any serious harm. The NP added she would have expected the nurses to follow the orders for [MEDICATION(S)] parameters as written though. The Director of Nursing (DON) was interviewed on 1/6/22 at 12:19 PM and stated she expected the nurses to follow doctor's orders including blood pressure medications with parameters to hold. The DON further stated she expected the nurses to check the blood pressure right before administering the medication. 2) Resident #83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #83's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure (SBP) less than 100, diastolic blood pressure (DBP) less than 60 or heart rate (HR) less than 60. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 was alert and oriented. The November 2021, December 2021, and January 2022 Medication Administration Records (MARs) were reviewed and revealed Resident #83 had received [MEDICATION(S)], despite the SBP below 100 or DBP below 60 on the following dates: - 11/1/21 DBP was 55 - 11/7/21 DBP was 55 - 11/8/21 DBP was 58 - 11/11/21 DBP was 55 - 11/19/21 DBP was 59 - 11/30/21 DBP was 54 - 12/1/21 DBP was 54 - 12/10/21 DBP was 57 - 12/19/21 DBP was 58 - 12/20/20 SBP was 97 and DBP was 53 - 12/22/21 DBP was 57 - 12/26/21 DBP was 55 - 12/28/21 DBP was 58 - 1/3/22 SBP was 96 and DBP was 60 An interview occurred with Medication Aide (MA) #1 on 1/5/22 at 12:38 PM. She was assigned to Resident #83 on 11/8/21, 11/11/21, 11/30/21, 12/1/21, 12/20/21, 12/22/21, 12/26/21, 12/28/21 and 1/3/22. MA #1 indicated she was aware the resident had parameters to hold the [MEDICATION(S)]. She reported she rechecked Resident #83's blood pressure prior to administering the medication but put in the values provided by the nursing assistants (NAs) and didn't document what she obtained. MA #1 reviewed the November 2021, December 2021 and January 2022 MARs and verified the [MEDICATION(S)] appears to have been administered despite the SBP below 100 and DBP below 60. She added the medication should have been withheld and stated it was an oversight. On 1/6/22 at 8:40 AM, a phone call was placed to Nurse #4 who had been assigned to Resident #83 on 12/10/21, 12/19/21 and 12/26/21. A message was left for a return call that was not received during the course of the survey. Nurse #5 was interviewed on 1/6/22 at 9:24 AM, who was assigned to Resident #83 on 11/19/21. She was aware the resident had parameters to hold the blood pressure medications. After reviewing the November 2021 MAR, she verified the resident's DBP was documented as 59, should have withheld the [MEDICATION(S)] and felt like it was an oversight. An interview occurred with Nurse #2 on 1/6/22 at 9:25 AM, who was assigned to Resident #83 on 11/7/21. After reviewing the November 2021 MAR, she verified the resident had parameters to hold the blood pressure medication, the documented DBP was 55 requiring the medication to be held and felt it was an error on her part. A phone interview occurred with the Medical Director on 1/6/22 at 10:33 AM and stated he would have expected the nursing staff to have followed the orders regarding [MEDICATION(S)] blood pressure parameters, however he felt there was no serious harm caused as he monitored her lab work very closely. The Director of Nursing (DON) was interviewed on 1/6/22 at 12:19 PM and stated she expected the nurses to follow doctor's orders including blood pressure medications with parameters to hold. The DON further stated she expected the nurses to check the blood pressure right before administering the medication.

Based on record review, observations, and staff interviews, the facility failed to provide a privacy cover for 1 of 3 resident reviewed for urinary catheters (Resident # 15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) dated [DATE] indicated Resident #15 was cognitively intact, had functional hearing and vision, could understand others and could be understood by others. The resident required extensive assistance with all activities of daily living, personal hygiene and toileting. Resident #15 was coded for indwelling urinary catheter during the assessment period. Resident #15's comprehensive care plan updated 10/24/2021 had a focus for indwelling urinary catheter related to neuromuscular dysfunction of the bladder. The resident's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/03/2022 at 11:34 AM the urinary drainage bag, containing urine, was observed from the hall. The drainage bag was positioned on the door side of the bed, off the floor, with no privacy cover on the drainage bag. On 1/03/2022 at 11:51 AM an interview was conducted with Resident #15. She stated she does usually have a cover over her urinary drainage bag. She was not sure why there wasn't one on the bag at that time. She stated she keeps her door closed most of the day but she does go out of the facility frequently and she would not want others to see her urinary drainage bag without a cover. During a wound care observation on 1/04/2022 at 1:51 PM, the urinary drainage bag was observed without a privacy cover. Unit manager #1 who was also the treatment nurse provided the wound care. On 1/05/22 at 3:33 PM an interview was conducted with Nurse # 9 who was assigned to Resident #15. She stated all residents should have a privacy cover on their urinary drainage bag. She was not aware Resident #15 did not have a privacy cover and she was not sure why Resident #15 did not have a privacy cover on her bag. She stated the resident was a very private person. On 1/05/22 at 3:34 PM an interview was conducted with Unit Manager #1. She stated all residents with urinary catheters should have a privacy cover on their urinary drainage bag. She was not certain why Resident #15 did not have one, but they did have privacy covers in the facility and they would get her one.

Based on record review and staff interview, the facility failed to refer a resident with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #89 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #89 was not evaluated for PASARR Level 11. Review of the PASARR screening form revealed that a Level 1 PASARR screen was performed prior to admission to the facility. The screening form was sent by the hospital on 1/30/2017. The facility's Social Worker (SW) was interviewed on 1/6/22 at 9:10 AM. The SW stated that she just started working at the facility as a social worker. She indicated that when a resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She reported that the last PASARR screening for Resident #89 was on 1/30/2017 and she was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she didn't know why the reevaluation was not performed for the resident. The Administrator was interviewed on 1/6/22 at 11:44 AM. The Administrator stated that the previous SW might have missed to send the information to the state for a Level 11 PASARR evaluation when the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record reviews, resident and staff interviews, the facility failed to provide an air mattress overlay as ordered by a physician (Resident #291) and failed to have accurate setting for air mattress (Resident #79) for 2 of 6 residents reviewed for pressure ulcers. The findings included: 1.Resident #291 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #291's admission Minimum Data Set (MDS) was not available. The resident's baseline care plan dated 12/31/2021 had a focus for impaired skin integrity. Resident #291's active order history revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was restarted on the same date 1/3/2022. On 1/03/2022 at 11:12 AM an interview was conducted with Resident #291. She stated she had a wound on her bottom that was painful. She stated she was told by facility staff she would be placed on an air mattress, but she had been there several days and still was not on an air mattress. Observed resident was on a regular mattress. On 1/04/2022 at 10:07 AM an interview was conducted with Nurse #9. She stated she was assigned to Resident #291 and confirmed the resident had a pressure injury to her sacral area. When asked about the order for the air mattress she stated the resident did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #9 confirmed the order was from 12/31/2022 (4 days prior). An interview was conducted with unit manager #1 who also served as the treatment nurse, on 1/4/2022 at 10:10 AM. She stated she was aware Resident #291 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged the order was from 12/31/2021. 01/04/22 01:53 PM during a wound care observation, the resident was observed to have a stage four pressure ulcer to the sacrum. The resident was not on an air mattress. A second interview was conducted with Unit Manager #1 who was also the treatment nurse on 1/05/2022 at 3:30 PM. She stated she would not speculate as to why Resident #291 did not get an air mattress on admission 12/31/2021. A phone interview was conducted with the medical director on 1/06/2022 at 10:44 AM. He stated he would have expected the resident to have been placed on an air mattress on her admitted , 12/31/2022 or shortly after due to her stage four pressure ulcer. He was not sure why that would not have been done. 2.Resident # 79 was admitted to the facility on [DATE]. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's significant change Minimum Data Set (MDS) dated [DATE] indicated the resident was mildly cognitively impaired and total dependent for bed mobility and all activities of daily living. She had a stage four pressure injury during the assessment period. Resident #79's comprehensive care plan, update on 12/17/2021 had a focus for alteration in skin integrity. Active orders for Resident #79 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #79's medical record revealed she was evaluated by a wound care physician every 4-6 weeks. The wound care physician's most recent assessment dated [DATE] indicated the wound was much larger, most likely due to protein malnutrition and pressure. On 1/04/2022 at 10:05 AM observed Resident #79's air mattress was set on 550 pounds (lbs). The residents most recent documented weight was 241 lbs. on 12/2/2022. A wound care observation was conducted on 1/04/2022 at 11:03 AM. Resident #79 had a large stage four sacral wound. On 1/04/2022 at 11:10 AM immediately following wound care, an interview was conducted with the treatment nurse. She stated the air mattress should be set according to the resident's weight. She acknowledged the mattress was set on 550lbs. She further stated she was not sure of the resident's most recent weight, but she was certain the resident was not 550lbs. When asked who sets up the air mattresses, she stated the nursing staff were responsible for placing the mattress on the bed and ensure proper settings and function. An interview was conducted with Nurse #11 on 1/04/2022 at 4:11 PM. She stated she checked the mattress to make sure it was inflating but she had not looked at the settings.

Based on record review and interview with the resident or responsible party (RP) and staff, the facility failed to notify the resident or the RP in writing of the reason for the discharge to the hospital for 3 of 3 sampled residents reviewed for hospitalization s (Residents #140, #1 & # 90). Findings included: 1. Resident #140 was admitted to the facility on [DATE]. Review of the nurse's note dated 12/11/21 at 6:49 PM revealed that Resident #140's hemoglobin level was low, and she was sent to the emergency room (ER) for evaluation. Resident #140 was readmitted back to the facility on [DATE]. Nurse Unit Manager #1 was interviewed on 1/06/22 at 9:48 AM. The Unit Manager stated that when a resident was transferred/discharged to the hospital, the RP was called to notify her/him that the resident was discharged to the hospital. She added that she didn't know that the RP should be notified in writing of the reason for the discharge. The RP of Resident #140 was interviewed on 1/06/22 at 10:01 AM. The RP stated that when the resident was discharged to the hospital, she had not received a letter notifying her of the reason for hospitalization . Nurse # 7 was interviewed on 1/6/22 at 11:10 AM. The Nurse reported that she normally notified the RP by phone when a resident was discharged to the hospital. She added that she didn't know that she had to notify the RP in writing of the reason for the discharge to the hospital. The Administrator was interviewed on 1/6/22 at 11:40 AM. The Administrator stated that a notice of transfer/discharge was sent to the RP when a resident was discharged . When asked for a copy of the notice, the Administrator was unable to provide a proof that the RP was notified in writing of the reason for the hospitalization . 2. Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessments revealed that Resident #1 was discharged to the acute hospital on 2/17/21 and 3/5/21. The quarterly MDS assessment dated [DATE] indicated that the resident had moderate cognitive impairment. The nurse's notes did not have information regarding the resident's discharge/transfer to the hospital on 2/17/21 and 3/5/21. The hospital discharge summary revealed that Resident #1 was admitted to the hospital on 2/17/21 due to gastrointestinal (GI) bleed and on 3/5/21 due to infection to the hip joint. Resident #1 was readmitted back to the facility on [DATE] and 3/11/21. Nurse Unit Manager #1 was interviewed on 1/06/22 at 9:48 AM. The Unit Manager stated that when a resident was transferred/discharged to the hospital, the RP was called to notify her/him that the resident was discharged to the hospital. She added that she didn't know that the RP or the resident should be notified in writing of the reason for the discharge. Resident #1 was interviewed on 1/06/22 at 10:56 AM. The resident stated that she was admitted to the hospital twice months ago, and she had not received any letter from the facility notifying her of the reason for her hospitalization . Nurse # 7 was interviewed on 1/6/22 at 11:10 AM. The Nurse reported that she normally notified the RP by phone when a resident was discharged to the hospital. She added that she didn't know that she had to notify the RP or the resident in writing of the reason for the discharge to the hospital. The Administrator was interviewed on 1/6/22 at 11:40 AM. The Administrator stated that a notice of transfer/discharge was sent to the RP when a resident was discharged . When asked for a copy of the notice, the Administrator provided a notice of discharge/transfer with date of transfer 2/17/21 and the reason for the transfer it is necessary for your welfare and your needs can not be met in this facility. There was no specific reason for the transfer/discharge documented on the notice. The Administrator was unable to provide a copy of the discharge notice for the discharge date of [DATE]. 3. Resident # 90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired cognition, required extensive assistance for activities of daily living, and received oxygen. Review of MDS assessments revealed Resident #90 was admitted to the acute hospital on 11/27/2020 through 12/3/2020 and again on 12/8/2020. The hospital discharge summary dated 12/3/2020 revealed Resident #90 was admitted to the hospital on 11/27/2020 due to acute on chronic hypoxic respiratory failure (low oxygen saturation) and COVID-19 infection and was discharge back to the facility on [DATE]. Hospital discharge summary dated 12/29/2020 revealed the resident was admitted for acute on chronic hypoxic respiratory failure due to COVID-19 pneumonia on 12/8/2020 and discharged home on 12/29/2020. Nurse Unit Manager #1 was interviewed on 1/06/22 at 9:48 AM. The Unit Manager stated that when a resident was transferred/discharged to the hospital, the RP was called to notify her/him that the resident was discharged to the hospital. She added that she didn't know that the RP or the resident should be notified in writing of the reason for the discharge. Resident #90's RP was interviewed via phone on 1/06/2022 at 10:57 AM. She stated she got a phone call from the facility notifying her of the resident's change in status, but she did not receive anything in writing from the facility regarding reason for discharge to the hospital. On 1/06/2022 at 9:51 AM an interview was conducted with the admission and discharge coordinator. She stated she does not send out a written notice of reason for discharge when a resident goes to the hospital. The Administrator was interviewed on 1/6/22 at 11:40 AM. The Administrator stated that a notice of transfer/discharge was sent to the RP when a resident was discharged . When asked for a copy of the notice, the Administrator provided a notice of discharge/transfer with date of transfer 11/27/2020 and the reason for the transfer it is necessary for your welfare and your needs can not be met in this facility. There was no specific reason for the transfer/discharge documented on the notice. The Administrator was unable to provide a copy of the discharge notice for the discharge date of [DATE].

Based on record reviews and staff interviews, the facility failed to maintain accurate medical records in the area of medication management for 2 of 13 residents' whose medications were reviewed (Residents #50 and #83). The findings included: 1) Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #50's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure less than or equal to 110 or diastolic blood pressure less than or equal to 60. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 was alert and oriented. The November 2021, December 2021, and January 2022 Medication Administration Records (MARs) were reviewed and revealed there was no documented blood pressure to indicate the reason why [MEDICATION(S)] was withheld on the following: 11/1/21 at 2:00 PM 11/27/21 at 8:00 PM 12/12/21 at 2:00 PM 12/15/21 at 8:00 PM 12/20/21 at 8:00 PM 12/21/21 at 8:00 PM 12/22/21 at 8:00 PM 12/27/21 at 8:00 PM 12/28/21 at 8:00 PM 1/2/22 at 8:00 PM 1/3/22 at 8:00 PM 1/4/22 at 8:00 PM A phone call was placed to Nurse #10 on 1/6/22 at 8:42 AM, who was assigned to Resident #50 on 11/27/21 and 1/2/22. A message was left for a return call which was not received during the survey. A phone interview occurred with Nurse #1 on 1/6/22 at 3:00 PM. She was assigned to Resident #50 on 12/15/21, 12/20/21, 12/21/21, 12/22/21, 12/27/21, 12/28/21, 1/3/22 and 1/4/22. She reported she most likely held the blood pressure medication due to the parameters to withhold. She was unable to state why she didn't document the blood pressure value on the MARs. The Director of Nursing (DON) was interviewed on 1/6/22 at 12:19 PM and stated she expected the nurses to obtain and document blood pressure values on the MARs when indicated and per physician orders. 2) Resident #83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #83's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for systolic blood pressure (SBP) less than 100, diastolic blood pressure (DBP) less than 60 or heart rate (HR) less than 60. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 was alert and oriented. The November 2021 and December 2021 Medication Administration Records (MARs) were reviewed and revealed there was no documented blood pressure or heart rate to indicate the reason why [MEDICATION(S)] was withheld on 11/26/21, 12/6/21, 12/8/21, 12/15/21 and 12/16/21. An interview occurred with Medication Aide (MA) #1 on 1/5/22 at 12:38 PM, who was assigned to Resident #83 on 12/6/21. MA #1 reviewed the December 2021 and verified there was no blood pressure or heart rate documented to indicate the reason why [MEDICATION(S)] was withheld and stated it was an oversight. A phone interview was conducted with Nurse #6 on 1/6/22 at 9:55 AM. She was assigned to Resident #83 on 12/8/21, 12/15/21 and 12/16/21. After reviewing the December 2021 MAR with her she stated she had recently started at the facility within the last few months and was still trying to learn the Electronic Medical Record (EMR) system. Nurse #6 added she obtained Resident #83's blood pressure and heart rate before administering the medication and felt the medication was withheld due to the parameters. She acknowledged the incomplete documentation on the MAR and stated it was an error on her part. The Director of Nursing (DON) was interviewed on 1/6/22 at 12:19 PM and stated she expected the nurses to obtain and document blood pressure values on the MARs when indicated and per physician orders

Based on record review, observation, review of facility's infection control policy and procedure, and interviews with the staff and Health Department Nurse, the facility failed to ensure that 3 of 3 COVID positive residents (Residents #1, #2 & #3) did not share rooms with COVID negative residents (Residents #13, #14 & #5) which resulted in 1 of the 3 COVID negative residents (Resident #14) tested positive for COVID. The facility also failed to separate COVID positive residents from COVID negative residents on the unit by placing 3 of 26 COVID negative residents (Residents #5, #6 & #7) on the COVID positive unit and 7 of 32 COVID positive residents (Residents #1, #2, #8, #9, #10, #11, #12) on the COVID negative unit which resulted in 2 of 3 COVID negative residents (Residents #6 & #7) tested positive for COVID. Additionally, the facility failed to implement the guidelines regarding the use of Personal Protective Equipment (PPE) when 1 of 1 maintenance staff failed to wear a gown, to remove gloves and to perform hand hygiene when entering and exiting the room of a resident on enhanced droplet/contact precautions. These failures occurred during the COVID 19 pandemic. As of 12/1/20, there were 61 residents and 63 staff members who tested positive for COVID 19 and on 12/9/20, 20 more residents, a total of 81 residents, and 5 more staff, a total of 68 staff, tested positive for COVID. Immediate jeopardy began on 11/28/20 when the facility failed to ensure that COVID positive residents did not share rooms and units with COVID negative residents. Resident #14 tested positive while sharing a room with Resident #2 and Residents #6 & #7 tested positive while placed on the COVID positive unit. Immediate jeopardy was removed on 12/4/20 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the action plan put into place in cohorting COVID positive and COVID negative residents are effective. Findings included: The facility's policy and procedure (updated on 11/23/20) indicated identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit if possible. Roommates of residents with COVID-19 should be considered exposed and potentially infected and if all possible should not share rooms with other residents unless they remain asymptomatic and or have tested negative for COVID 14 days after their last exposure (such as date the roommate was moved to the COVID unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Residents with known or suspected COVID-19 should be cared for using all recommended PPE which includes use of N95 or higher level of respirator (or face mask if respirator is not available), eye protection, gloves and gown. The facility's door signage for suspected or known COVID positive was enhanced droplet/contact precautions which include gown, eye protection, surgical mask, gloves when entering room, hand hygiene, private room and to keep door closed. 1a. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #14 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The alphabetical resident list provided on 12/1/20 revealed that Resident #2, who tested positive for COVID on 11/28/20 shared a room with Resident #14, who tested negative for COVID on 11/26/20. On 12/1/20 at 11:16 AM, Resident #2 and Resident #14 were observed sharing the same room on the COVID negative unit and their door has a signage enhanced droplet/contact precaution. They were not wearing a mask and their privacy curtain was not pulled between their beds. Resident #14 was retested and became positive for COVID on 12/1/20. b. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The alphabetical resident list provided on 12/1/20 revealed that Resident #2 who tested positive for COVID on 11/28/20, resided on the COVID negative unit. The resident in the room next door was COVID negative. On 12/1/20 at 11:16 AM, Resident #2 was observed in bed on the COVID negative unit with her door wide open. Her door has a signage enhanced droplet/contact precaution with the instruction to keep the door closed. c. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #13 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The alphabetical resident list provided on 12/1/20 revealed that Resident #1, who tested positive for COVID on 11/28/20 and Resident #13, who tested negative for COVID on 11/26/20 shared a room on the COVID negative unit. Resident #1 was observed in bed on 12/1/20 at 11:15 AM. He was not wearing a mask. The staff was in the process of moving Resident #13 to a different room. Their room has a door signage enhanced droplet/contact precautions. Nurse #1 was interviewed on 12/1/20 at 11:30 AM. She reported that Residents #1 who tested positive for COVID shared a room with Resident #13 who tested negative and Residents # 2 who tested positive for COVID shared a room with Resident #14 who tested negative. She indicated that she was assigned to rooms 35 through 60 and had 20 residents. The unit has COVID positive and COVID negative residents. d. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan also revealed that rooms 35-60 were designated as COVID negative unit. Review of Resident #1's COVID test result revealed that he tested positive on 11/28/20 and he resided on the COVID negative unit. The resident in the room next door was COVID negative. Resident #1 was observed in bed on 12/1/20 at 11:15 AM on the COVID negative unit with his door wide open. His room has a door signage enhanced droplet/contact precautions with instruction to keep the door closed. e. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the alphabetical resident list provided on 12/1/20 revealed that Resident #3, who tested positive for COVID on 11/30/20 shared a room with Resident #5, who tested negative for COVID on 11/30/20. On 12/1/20 at 11:20 AM, Resident #3 and Resident #5 were observed sharing the same room on the COVID positive unit. They were not wearing a mask and their privacy curtain was not pulled between their beds. f. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 61-71 were designated as COVID positive unit. On 12/1/20 at 11:23 AM, Resident #6, who tested negative for COVID on 11/30/20, was observed residing on the COVID positive unit with her door wide open. Her room has a door signage enhanced droplet/contact precautions with the instruction to keep the door closed. On 12/3/20, Resident #6 was retested and became positive for COVID. g. Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 61-71 were designated as COVID positive unit. Review of the alphabetical resident list provided on 12/1/20 revealed that Resident #7 resided on the COVID positive unit. Review of Resident #7's COVID test result revealed that she tested negative for COVID on 11/30/20. On 12/1/20 at 11:25 AM, Resident #7, who tested negative for COVID, was observed residing on the COVID positive unit with her door wide open. Her room has a door signage enhanced droplet/contact precautions with the instruction to keep the door closed. On 12/8/20, Resident #7 was retested and became positive for COVID. h. Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility ' s floor plan revealed that rooms 61-71 were designated as COVID positive unit. Review of Resident #5's COVID test result revealed that she tested negative for COVID on 11/30/20. On 12/1/20 at 11:20 AM, Resident #5, who tested negative for COVID, was observed residing on the COVID positive unit with her door wide open. Her room has a door signage enhanced droplet/contact precautions with the instruction to keep the door closed. i. Resident #8 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 35-60 were designated as COVID negative unit. Review of the alphabetical resident list provided on 12/1/20 revealed that Resident #8 resided on COVID negative unit. Review of Resident #8's COVID test result revealed that she tested positive for COVID on 11/28/20. On 12/1/20 at 11:35 AM, Resident #8, who tested positive for COVID, was observed residing on the COVID negative unit with her door wide open. Her door has a signage enhanced droplet/contact precautions with the instruction to keep the door closed. j. Resident #9 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 35-60 were designated as COVID negative unit. Review of Resident #9's COVID test result revealed that she tested positive for COVID on 11/28/20. On 12/1/20 at 11:37 AM, Resident #9, who tested positive for COVID, was observed residing on the COVID negative unit. The resident in the room next door was COVID negative. Her door was observed wide open and she has a door signage enhanced droplet/contact precautions with the instruction to keep the door closed. k. Resident #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 35-60 were designated as COVID negative unit. Review of Resident #10's COVID test result revealed that she tested positive for COVID on 11/30/20. On 12/1/20 at 11:38 AM, Resident #10, who tested positive for COVID, was observed residing on the COVID negative unit. The resident in the room next door was COVID negative. Her door was open and has a signage enhanced droplet/contact precautions with the instruction to keep the door closed. l. Resident #11 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 35-60 were designated as COVID negative unit. Review of Resident #11's COVID test result revealed that she tested positive for COVID on 11/28/20. On 12/1/20 at 11:39 AM, Resident #11, who tested positive for COVID, was observed residing on the COVID negative unit. The residents in the room across the hall were COVID negative. Her door was open and has a signage enhanced droplet/contact precautions with the instruction to keep the door closed. m. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's floor plan revealed that rooms 35-60 were designated as COVID negative unit. Review of Resident #12's COVID test result revealed that she tested positive for COVID on 11/30/20. On 12/1/20 at 11:40 AM, Resident #12, who tested positive for COVID, was observed residing on the COVID negative unit with her door open. The residdnt in the room next door was COVID negative. She has a door signage enhanced droplet/contact precautions with the instruction to keep the door closed. In an interview with the Administrator on 12/2/20 at 1:15 PM, he confirmed that Residents #1, #2, #3, #8, #9, #10, #11, #12 & #14 tested positive for COVID and Residents # 5, #6, #7, & #13 remained negative for COVID. He indicated that he was aware that these residents were either sharing rooms or units. He reported that residents had already been exposed and moving the resident would cause an increase spread and would make the outbreak worse, so the facility decided to leave the exposed residents in place. The Administrator also stated that the facility had rooms available but had to be deep cleaned and due to staffing shortages in the housekeeping department, the rooms were not available. He further reported that he had been in contact with the Health Department (HD) who had given him direction to isolate residents in place. The Administrator reported that on 11/27/20, he started leaving COVID positive and COVID negative residents in place. On 12/16/20 at 4:20 PM, a follow up interview was conducted with the Administrator. He reported that he had informed the Health Department about their staffing shortages (didn't remember the date) and he had reached out to the local emergency healthcare coalition for staffing needs. His last contact with the local emergency healthcare coalition was on 11/27/20 and he was told that they did not have housekeeping staff, only nurses and nurse's aides. He indicated that the emergency coalition had provided him some nurses and a paramedic who worked as nurse's aide. The Administrator also reported that he had called their contracted housekeeping agency and they were unable to provide him with housekeeping staff. In an interview with the HD Nurse on 12/2/20 at 1:52 PM, she stated that she was aware that the facility has COVID outbreak and she had advised the Administrator to lock down the facility and to separate COVID positive from COVID negative residents. On 12/16/20 at 4:30 PM, a follow up interview with the HD Nurse was conducted. She stated that the Administrator had informed her about their staffing needs for nurses and nurse's aides but not for housekeeping staff. He was advised to call the local emergency staffing management and she had sent a request for them. In an interview with the Director of Nursing/Infection Control Preventionist on 12/2/20 at 2:29 PM, she stated that she was aware that COVID positive and COVID negative residents shared rooms and units. The DON reported that the Health Department had instructed the facility to stop moving the residents and to leave the residents in place since the residents had already been exposed. She confirmed that Residents #1, 2, 3, 8, 9, 10, 11. 12 & 14 tested positive for COVID and Residents # 5, 6, 7, & 13 remained negative for COVID. She indicated that Resident #14 who tested negative on 11/26/20, became positive on 12/1/20. On 12/9/20 at 1:20 PM, the DON reported that Resident #6 became positive on 12/3/20 and Resident #7 became positive on 12/8/20. 2. Resident #1 was observed on 12/1/20 at 11:15 AM with a door signage enhanced droplet/contact precautions. The instruction on the sign revealed to wear surgical mask, eye protection, gown, gloves when entering the room, perform hand hygiene, private room and to keep the door closed. Review of Resident #1's COVID test result revealed that he tested positive on 11/28/20. On 12/1/20 at 11:25 AM, the Maintenance staff member was observed entering Resident #1's room without wearing a gown and he was wearing a non- disposable pair of gloves. He was observed to enter and to exit the resident's room three times without wearing a gown, without removing/changing his gloves and not performing hand hygiene. At 11:55 AM, the Maintenance staff member was observed to leave the unit without removing his gloves and without performing hand hygiene. On 12/1/20 at 11:57 AM, the Maintenance staff member was interviewed. He stated that he was moving the personal belongings of Resident #13. He stated that he was aware that Resident #13 was COVID negative, but he didn ' t know that Resident #1 was COVID positive. He also reported that he didn ' t notice the sign on the door to wear a gown, gloves and to perform hand hygiene. A follow up interview was conducted with the Maintenance staff member on 12/2/20 at 2:50 PM and he revealed that he was not responsible for room changes including transfer of resident's personal belongings, but he was just helping. He indicated that the housekeeping department was responsible for the room changes but most of their staff were out due to COVID. The Maintenance staff member verified that he did not wear a gown, nor changed his gloves and performed hand hygiene when entering and exiting the room and he did not remove his gloves and performed hand hygiene when leaving the unit. He reported that he had attended an in-service on the use PPE in the past but could not remember the date. On 12/2/20 at 2:29 PM, the Director of Nursing/Infection Control Preventionist was interviewed. She stated that she expected the staff to implement the guidelines on the use of PPE and the door signage when entering the room of resident on enhanced droplet/contact precautions. The Administrator was interviewed on 12/3/20 at 2:48 PM. He stated that he could not find documentation that the Maintenance staff member had attended training/in-service on the use of PPE and door signage. The Administrator was notified of the immediate jeopardy on 12/4/20 at 12:27 PM. The facility provided the following credible allegation for immediate jeopardy removal: Allegation of Compliance F880 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Previous and on-going communication had been made with the Health Department (HD) nurse regarding the facility COVID-19 status. The facility had 2 positive staff and one positive resident as of 11/19/2020, which caused the facility to be in COVID outbreak status. By 11/27/2020, the facility had 37 residents and 46 staff testing positive for COVID. On 11/27/2020, the Nursing Home Administrator (NHA) called the local HD contact, to inform the HD of new positive cases and to discuss steps of action for increasing positive cases. On 11/28/2020, twelve new residents became positive. The facility did not have space to isolate new positive residents, due to limited rooms (seven were available on the COVID-hall at that time) and due to limited staff, both housekeeping and total staff. The facility was only able to safely conduct a portion of required room changes to the COVID-hall. All residents could not be relocated due to limited space, limited staff, and limited staff to disinfect rooms of previously identified positive residents. The remaining room changes were not conducted based on the limited staff and access to clean rooms to relocate residents. The housekeeping department had no COVID-negative housekeeping staff available to work on 11/28/2020. Additionally, due to numerous new nursing and administrative staff, there were no alternative staff available to complete room changes. Prior to 11/28/2020 numerous room changes were conducted by the remaining non-COVID Administrative staff, due to housekeeping staff shortages as housekeeping staff tested positive for COVID. On 11/26/2020, two Administrative staff members conducting room changes tested positive for COVID, they were required to leave and isolate. On 11/27/2020, the last remaining Administrative team leader available for room changes tested positive for COVID, he was required to leave and isolate. All other Administrative and support staff had previously tested positive and were not safe to conduct room changes for negative residents. · Resident #1 resided on a non-COVID unit with resident #13. On 11/28/2020 resident #1 tested positive for COVID. Resident #13 was tested negative for COVID on 12/1/2020 and was relocated to a private room on a non-COVID unit. Resident #1 was moved to the COVID unit on 12/4/2020. · Resident #2 resided on a non-COVID unit with resident #14. On 11/28/2020 resident #2 tested positive for COVID. Resident #14 tested positive for COVID on 12/1/2020. Resident remained in current room. On 12/4/2020, residents were moved to the COVID unit. · Resident #3 resided on a COVID unit with resident #5. Resident number #3 tested positive for COVID on 11/30/2020. Resident #5 tested negative for COVID and was moved to the non-COVID unit on 12/4/2020. · Resident #4 became COVID positive on 11/30/2020. Resident is appropriately placed on COVID-positive unit as of 11/30/2020. · Resident #6 resided on a COVID unit with resident #7. Resident #6 was tested positive for COVID on 12/3/2020. Resident is appropriately placed on COVID-unit. Resident #7 was tested for COVID on 12/4/2020 and remains negative, resident was moved to the non-COVID unit on 12/4/2020. · Resident #8 was in a private room on the non-COVID unit. On 11/28/2020 resident became COVID positive. Resident was moved to the COVID-unit on 12/4/2020. · Resident #9 was in a private room on the non-COVID unit. On 11/28/2020 resident became COVID positive. Resident was moved to the COVID-unit on 12/4/2020. · Resident #10 was in a private room on the non-COVID unit. On 11/30/2020 resident became COVID positive. Resident was moved to the COVID-unit on 12/4/2020. · Resident #11 was in a private room on the non-COVID unit. On 11/28/2020 resident became COVID positive. Resident was moved to the COVID-unit on 12/4/2020. · Resident #12 was in a private room on the non-COVID unit. On 11/30/2020 resident became COVID positive. Resident was moved to the COVID-unit on 12/4/2020. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. On 12/1/2020, some negative staff were available to conduct room changes. An audit was conducted of residents that were negative and roomed with residents that were positive. Results of the audit concluded there were three room changes to occur. The facility focused on residents sharing rooms versus, specific negative and positive hallways. Based on an audit of all residents in the facility on 12/4/2020, all residents had been appropriately separated based on COVID status by room. On 12/4/2020, the facility implemented room changes and developed clearly defined units: COVID-positive, COVID-negative, and COVID-recovered (for those removed from quarantine), which aligns with the facility Infection Control Policy. As of 12/4/2020 all residents that remain COVID-negative have been relocated to a COVID-negative unit. All residents that are positive for COVID are relocated to a COVID unit. · Residents #1, #2, #3, #4, #6, #8, #9, #10, #11, #12, and #14 have tested positive for COVID and are appropriately placed on a COVID unit as of 12/4/2020. · Residents #5, #7, and #13 remain negative for COVID and are appropriately placed on the non-COVID unit as of 12/4/2020. To prevent future deficient practice, a corporate team representative met with the NHA and Director of Nursing (DON) on 12/1/2020 and has re-enforced that the facility cannot rely on guidance that is not consistent with CDC, CMS, and NC DHHS guidelines. The facility is expected to follow all current guidelines from the above listed entities and no changes are allowed at the facility level, even during an outbreak, without approval from the corporate team. This clarification will reduce the potential for miscommunication, misunderstanding or other future deficient practice that occurred during the cited outbreak. To clarify, the facility will follow testing, monitoring, and surveillance guidance for residents and staff as defined by CMS, state, and local regulations. The facility will continue twice weekly testing of staff and residents for COVID, during the outbreak status and will follow the appropriate CMS guidelines following the outbreak based on county positivity rates. The facility will follow the Infection Control Policy, including appropriate cohorting of residents based on COVID status. The facility will explore additional options for staffing, in addition to staffing plans already included in the Staffing Contingency Plan. The Facility alleges the removal of the immediate jeopardy on 12/4/2020. On 12/9/20, the facility's credible allegation for immediate jeopardy removal was validated by the following: -review of the alphabetical resident list and the list of residents tested positive for COVID - observation of residents on the COVID positive unit and COVID negative unit to verify proper placement of residents according to their COVID test results - observation of staff on the COVID unit to verify use of PPE according to the CDC guidelines and facility's policy - interview with staff on COVID positive and COVID negative units to verify proper placement of residents according to their COVID test results - review of in-service record and interview with the Maintenance staff member regarding the use pf PPE The facility's date of immediate jeopardy removal of 12/4/20 was validated.

Based on record reviews, family interview and physician and staff interviews, the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 3 residents reviewed for facility-initiated transfer (Resident #1). The findings included: Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her payor status was listed as Medicare and Medicaid. Review of the medical record from (MONTH) 2019 to present revealed Resident #1 had frequent episodes of yelling out for staff members to stay in her room, increased anxiety when left alone in her room, fixating on whether her oxygen was working or not being in the center of the bed as well as nonsensical questions to the staff and fear of dying. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment, was able to make her needs known and understood others. She had displayed verbal behaviors directed towards other and other behavioral symptoms daily during the 7 day look back period. She required setup supervision for eating; extensive assistance from staff for bed mobility, dressing, toileting, hygiene and total assistance from staff for transfers and bathing. Review of the care plan dated 8/21/19 included problem areas of delusions and hallucinations at times, believing in occurrence of false events and seeing people in her room, requiring assistance from staff for all ADL's with frequent demanding attitude, threatening to throw self on the floor if staff left her alone, periods of difficulty sleeping, frequent yelling out for staff to come sit with her. She was also care planned for falls risk and the use of antianxiety, antidepressant and antipsychotic medications. The most recent MDS was coded as a discharge assessment with return anticipated and was dated 8/26/19. A review of the nurse's notes completed by Nurse #1, dated 8/26/19 and timed 6:44 AM, revealed Resident #1 had been transferred to the hospital via Emergency Medical Services (EMS) on 8/26/19. The resident was documented as having a fall with a hematoma and abrasion to her forehead and when the physician was made aware an order was obtained to send the resident to the emergency room (ER). Further review of the documentation revealed the resident's responsible party had been notified via phone about the resident being sent to the ER. A Hospital Discharge Summary dated 9/7/19 revealed Resident #1 presented to the ER from the facility on 8/26/19 following a fall. She was admitted for further treatment of [REDACTED]. She was discharged to a Long-Term Acute Care Hospital for continued Intravenous (IV) [MEDICATION NAME] twice a day. A Long-Term Acute Care (LTAC) Hospital Discharge Summary dated 9/26/19 revealed Resident #1 was transferred from the hospital on [DATE] for continuation of respiratory support, IV [MEDICATION NAME], nutritional support and physical therapy. During her stay at the LTAC, Resident #1 had increased confusion and [MEDICAL CONDITION] requiring medication adjustments to correct ammonia levels. Once the levels returned to normal her mental status improved. She was followed by a psychiatrist as well as therapy and a dietician. She had completed her course of IV [MEDICATION NAME] and was on an oral tablet at the time of discharge. Resident #1 was diagnosed with [REDACTED]. She would need 3 more days of the IV medication after discharge from the LTAC. The SNF had provided her with IV antibiotics in the past. Her condition at the time of discharge was described as stable with disposition to a SNF. Discharge instructions read in part: to be followed by the facility physician, Oxygen at 2 liters via nasal cannula, [MEDICATION NAME] 40 milligrams (mg) by mouth twice a day, Meropenem (an antibiotic) 1 gram IV twice a day for 3 days for treatment of [REDACTED]. A narrative note by the Case Manager dated 9/13/19 at 12:43pm indicated the discharge disposition would be back to prior Skilled Nursing Facility (SNF) with an anticipated transition date of 9/24/19. Review of a narrative note by the Case Manager dated 9/16/19 at 3:00pm revealed a clinical update was faxed to the facility and per the facility's admissions coordinator, they could no longer meet the patient's needs. The family was informed and provided a list of Skilled Nursing Facilities. The resident was subsequently discharged to another SNF on 9/26/19. On 10/23/19 at 12:50pm an interview occurred with Nurse #2. She indicated the facility was able to provide care and services to Resident #1, but the resident had daily episodes of anxiety and yelling out when she was alone in her room as well as the resident's family had been noncompliant with medication aspects of the resident's care. An interview was conducted on 10/23/19 at 1:07pm with Resident #1's responsible party (RP). He stated he had called the facility about two weeks after the resident had gone to the hospital and spoke with the Social Worker to inquire about a bed hold since he knew it could be a few more weeks until Resident #1 was ready to come back and was told No. That's not an option and just expected the resident would have been readmitted to the facility as before. The RP further stated he had met with the Administrator on 9/16/19 and was told the facility was not readmitting the resident due to her continued behaviors and the family's resistance to medication management. He added he had not received any written documentation from the facility. On 10/23/19 at 2:45pm an interview was held with the Administrator. He stated typically when a resident was discharged to the hospital, the physician and family are made aware, a packet of information about the resident with bed hold information was sent out with the resident, a staff member followed up with the hospital to clarify if the resident was going to be admitted and the resident's family is contacted the following day to discuss bed hold. He further stated the RP called the facility about 2 weeks after the resident was hospitalized inquiring about a bed hold, but felt it was unethical to take the bed hold money when we felt we could no longer manage her. He added that due to her continued behaviors, the danger of her self-inflicted fall, disrupting other residents and staff when she was anxious and family resistance to medication management the facility could no longer meet her needs. An interview occurred with the Social Worker on 10/23/19 at 3:33pm. She was able to recall speaking with the responsible party when he called about two weeks after the resident was transferred to the hospital and his inquiry regarding a bed hold. She stated she discussed it with the Administrator and relayed that a bed hold was not possible. On 10/23/19 at 3:50pm an interview was conducted with the Director of Admissions. She explained that she had started working at the facility at the beginning of (MONTH) 2019 and did not have any conversations related to Resident #1. She stated typically information about bed hold was sent out with the resident when they were transferred to the ER and she followed up with the responsible party to discuss bed hold the next business day. She further stated no documentation occurred or paperwork obtained when she discussed bed holds. An interview occurred with the Clinical Specialist from the nursing home on 10/23/19 at 4:01pm. She recalled looking at the clinical information from the LTAC Hospital and the resident was refusing to wear the Bilevel Positive Airway Pressure Machine ([MEDICAL CONDITION]-a non-invasive therapy for people suffering from sleep apnea) but she had refused to wear one at the facility as well, but her behaviors continued and was being followed by psychiatry at the LTAC. She confirmed the resident was seen by a Psychiatric Nurse Practitioner while a resident in the facility. She stated the facility was able to provide care and services to Resident #1, but since she was still exhibiting behavioral issues and due to the family noncompliance with medication management the facility felt they could no longer meet her needs. She was able to acknowledge the resident had not been placed in a nursing home with special features to provide care to the resident. On 10/24/19 at 8:20am an interview was conducted with the Administrator and Chief Operations Officer. The Administrator stated Resident #1 did not receive a 30-day discharge notice. They both stated the facility felt Resident #1 was not stable enough for readmission due to her multiple behavioral issues and the family's resistance to medication management. They further stated, Resident #1 was disruptive to the other residents when they were trying to sleep, and the staff endured constant outbursts from the family. A phone interview occurred with the Facility Psych Nurse Practitioner on 10/24/19 at 11:12am. She recalled working with Resident #1 on several occasions regarding her anxiety as well as talking with the Resident's RP. She added the RP was receptive to the medication management changes they were pursuing to help with the severe anxiety and verbal outbursts but was aware of her liver disease and the caution that had to be taken regarding medications. A phone interview occurred with the Medical Director on 10/24/19 at 12:35pm. He was familiar with Resident #1 and stated she had lots of medical issues but felt the facility was managing her behaviors appropriately as she needed lots of attention as well as the family issues.

Based on record reviews, family interview and physician and staff interviews, the facility failed to permit a resident to return to the facility from the hospital for 1 of 3 residents reviewed for discharge (Resident #1). The findings included: Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her payor status was listed as Medicare and Medicaid. Review of the medical record from (MONTH) 2019 to present revealed Resident #1 had frequent episodes of yelling out for staff members to stay in her room, increased anxiety when left alone in her room, fixating on whether her oxygen was working or not being in the center of the bed as well as nonsensical questions to the staff and fear of dying. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment, was able to make her needs known and understood others. She had displayed verbal behaviors directed towards other and other behavioral symptoms daily during the 7 day look back period. She required setup supervision for eating; extensive assistance from staff for bed mobility, dressing, toileting, hygiene and total assistance from staff for transfers and bathing. The most recent MDS was coded as a discharge assessment with return anticipated and was dated 8/26/19. A review of the nurse's notes completed by Nurse #1, dated 8/26/19 and timed 6:44 AM, revealed Resident #1 had been transferred to the hospital via Emergency Medical Services (EMS) on 8/26/19. The resident was documented as having a fall with a hematoma and abrasion to her forehead and when the physician was made aware an order was obtained to send the resident to the emergency room (ER). Further review of the documentation revealed the resident's responsible party had been notified via phone about the resident being sent to the ER. A Hospital Discharge Summary dated 9/7/19 revealed Resident #1 presented to the ER from the facility on 8/26/19 following a fall. She was admitted for further treatment of [REDACTED]. She was discharged to a Long-Term Acute Care Hospital for continued Intravenous (IV) [MEDICATION NAME] twice a day. A Long-Term Acute Care (LTAC) Hospital Discharge Summary dated 9/26/19 revealed Resident #1 was transferred from the hospital on [DATE] for continuation of respiratory support, IV [MEDICATION NAME], nutritional support and physical therapy. During her stay at the LTAC, Resident #1 had increased confusion and [MEDICAL CONDITION] requiring medication adjustments to correct the ammonia levels. Once the levels returned to normal her mental status improved. She was followed by a psychiatrist as well as therapy and dietician. She had completed her course of IV [MEDICATION NAME] and was on an oral tablet at the time of discharge. Resident #1 was diagnosed with [REDACTED]. She would need 3 more days of the IV medication after discharge from the LTAC. The SNF had provided her with IV antibiotics in the past. Her condition at the time of discharge was described as stable with disposition to a SNF. Discharge instructions read in part: to be followed by the facility physician, Oxygen at 2 liters via nasal cannula, [MEDICATION NAME] 40 milligrams (mg) by mouth twice a day, Meropenem (an antibiotic) 1 gram IV twice a day for 3 days for treatment of [REDACTED]. A narrative note by the Case Manager dated 9/13/19 at 12:43pm indicated the discharge disposition would be back to prior Skilled Nursing Facility (SNF) with an anticipated transition date of 9/24/19. Review of a narrative note by the Case Manager dated 9/16/19 at 3:00pm revealed a clinical update was faxed to the facility and per the facility's admissions coordinator, they could no longer meet the patients needs. The family was informed and provided a list of Skilled Nursing Facilities. A Case Manager note dated 9/18/19 at 11:27am indicated the resident was alert and verbal with behaviors of constantly calling out. The goals of care were to complete antibiotic for infection, exhibit optimal respiratory function within the limits of her disease and maintain nutrition. The discharge disposition was SNF with anticipated transition date of 9/25/19. On 9/25/19 at 12:29pm a Case Manager narrative read the discharge was cancelled due to the need for a PASRR evaluation (a Preadmission Screening and Resident Review is a federal requirement to help ensure individuals are not inappropriately placed) and would be discharged to another SNF on 9/26/19. On 10/23/19 at 12:50pm an interview occurred with Nurse #2. She indicated the facility was able to provide care and services to Resident #1, but the resident had daily episodes of anxiety and yelling out when she was alone in her room as well as the resident's family had been noncompliant with medication aspects of the resident's care. An interview was conducted on 10/23/19 at 1:07pm with Resident #1's responsible party (RP). He stated he had called the facility about two weeks after the resident had gone to the hospital and spoke with the Social Worker to inquire about a bed hold since he knew it could be a few more weeks until Resident #1 was ready to come back and was told No. That's not an option and just expected the resident would have been readmitted to the facility as before. The RP further stated he had met with the Administrator on 9/16/19 and was told the facility was not readmitting the resident due to her continued behaviors and the family's resistance to medication management. He admitted the family was cautious about medications since Resident #1 had liver disease and had tried many when she was still living at home with negative side effects. The RP further stated he felt the facility psych Nurse Practitioner (NP) was working towards finding a good balance for Resident #1's anxiety and his was receptive to her recommendations. On 10/23/19 at 2:45pm an interview was held with the Administrator. He stated typically when a resident was discharged to the hospital, the physician and family are made aware, a packet of information about the resident with bed hold information was sent out with the resident, a staff member followed up with the hospital to clarify if the resident was going to be admitted and the resident's family is contacted the following day to discuss bed hold. He further stated the RP called the facility about 2 weeks after the resident was hospitalized inquiring about a bed hold, but felt it was unethical to take the bed hold money when we felt we could not longer manage her. He added that due to her continued behaviors, the danger of her self-inflicted fall, disrupting other residents and staff when she was anxious and family resistance to medication management the facility could no longer meet her needs. An interview occurred with the Social Worker on 10/23/19 at 3:33pm. She was able to recall speaking with the responsible party when he called about two weeks after the resident was transferred to the hospital and his inquiry regarding a bed hold. She stated she discussed it with the Administrator and relayed that a bed hold was not possible. On 10/23/19 at 3:50pm an interview was conducted with the Director of Admissions. She explained that she had started working at the facility at the beginning of (MONTH) 2019 and did not have any conversations related to Resident #1. She stated typically information about bed hold was sent out with the resident when they were transferred to the ER and she followed up with the responsible party to discuss bed hold the next business day. She further stated no documentation occurred or paperwork obtained when she discussed bed holds. An interview occurred with the Clinical Specialist from the nursing home on 10/23/19 at 4:01pm. She recalled looking at the clinical information from the LTAC Hospital and the resident was refusing to wear the Bilevel Positive Airway Pressure Machine ([MEDICAL CONDITION]-a non-invasive therapy for people suffering from sleep apnea) but she had refused to wear one at the facility as well, but her behaviors continued and was being followed by psychiatry at the LTAC. She confirmed the resident was seen by a Psychiatric Nurse Practitioner while a resident in the facility. She stated the facility was able to provide care and services to Resident #1, but since she was still exhibiting behavioral issues and due to the family noncompliance with medication management the facility felt they could no longer meet her needs. She was able to acknowledge the resident had not been placed in a nursing home with special features to provide care to the resident. On 10/24/19 at 8:20am an interview was conducted with the Administrator and Chief Operations Officer. The Administrator stated Resident #1 did not receive a 30-day discharge notice. They both stated the facility felt Resident #1 was not stable enough for readmission due to her multiple behavioral issues and the family's resistance to medication management. They further stated, Resident #1 was disruptive to the other residents when they were trying to sleep, and the staff endured constant outbursts from the family. A phone interview occurred with the Facility Psych NP on 10/24/19 at 11:12am. She recalled working with Resident #1 on several occasions regarding her anxiety as well as talking with the Resident's RP. She added the RP was receptive to the medication management changes they were pursuing to help with the severe anxiety and verbal outbursts but was aware of her liver disease and the caution that had to be taken regarding medications. A phone interview occurred with the Medical Director on 10/24/19 at 12:35pm. He was familiar with Resident #1 and stated she had lots of medical issues but felt the facility was managing her behaviors appropriately as she needed lots of attention as well as the family issues.

Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 1 of 5 sampled residents reviewed for unnecessary medications (Resident # 26). Findings included: Resident #26 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#26 had severe cognitive impairment and she had received an antipsychotic medication for 7 days during the assessment period. The assessment further indicated that a gradual dose reduction (GDR) for the antipsychotic medication had not been attempted. Resident #26 was admitted (1/18/17) with a doctor's order for [MEDICATION NAME] (antipsychotic medication) 2 milligrams (mgs.) by mouth at bedtime for [MEDICAL CONDITION] disorder. On 7/6/17, the [MEDICATION NAME] was increased to 2 mgs every 12 hours and on 7/11/19, the [MEDICATION NAME] was increased to 5 mgs every 12 hours. On 4/8/18, there was a doctor's order to decrease the [MEDICATION NAME] to 5 mgs at bedtime and on 10/3/18, there was an order to decrease the [MEDICATION NAME] to 2.5 mgs daily. On 9/5/19 at 9:03 AM., the MDS Nurse was interviewed. She reviewed Resident #26's medical records and verified that Resident #26 had received a GDR on [MEDICATION NAME] on 4/8/18 and 10/3/18. She stated that the quarterly MDS assessment dated [DATE] was coded wrong, a GDR had been attempted. On 9/5/19 at 2:36 PM, the Director of Nursing (DON) was interviewed. The DON stated that she expected the MDS assessments to be coded accurately.

Based on record review and staff interview, the facility failed to prevent a resident from falling out of bed during incontinent care for 1 of 8 sampled residents reviewed for accidents (Resident #55). Findings included: Resident #55 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#55 had severe cognitive impairment and she needed two plus persons physical assist with personal hygiene and toileting. Resident #55's care plan dated 4/12/19 was reviewed. One of the care plan problems was potential for fall related injury. The goal was for Resident #55 to have no fall with significant injury. The approaches included to encourage the resident to notify staff with need of assistance for transfer and to keep bed in low position. The care plan also revealed that on 6/9/19, Resident #55 had a witnessed fall. An Aide was providing incontinent care and the resident rolled out of bed. A hematoma and small abrasion were noted to the left side of the forehead. Resident #55's nurse's notes were reviewed. A note dated 6/9/19 at 1:53 PM written by Nurse #2 revealed that a nurse aide (NA #1) reported to writer that resident had rolled out of bed while the NA was providing care. The resident was noted on the floor between the wall and the bed. Head to toe assessment was performed and the resident was noted to have a hematoma with abrasion to the left forehead and redness to the left shoulder. Resident #55 had complained of pain to her left forehead. The physician and the responsible party (RP) were notified. The RP requested not to send the resident to the hospital and just to monitor changes at the facility. The incident report dated 6/9/19 was reviewed. The report revealed that on 6/9/19 at 11:15 AM, NA #1 reported to Nurse #2 that Resident #55 had rolled out of bed during care. The resident was observed on the floor on her back between the wall and the bed. Hematoma with abrasion was noted to her left forehead and redness to her left shoulder. On 9/5/19 at 9:05 AM, a telephone interview was conducted with NA #1. She stated that she no longer worked at the facility. She stated that she was assigned to Resident #55 on 6/9/19 when the resident had a fall. She indicated that Resident #55 was stiff and was hard to turn to her sides. The resident needed two persons assist with any care since she could not hold herself when turned. NA #1 further reported that it was about lunch time and Resident #55 had to go to the dining room for lunch. She indicated that there were two NAs assigned on the hall, but one NA was assigned to assist in the dining room during lunch. She could not find anybody to help with the incontinent care, so she did the care by herself. She turned the resident to her side, and then she turned around to reach for the wash towel. When she turned around, the resident rolled out of bed. On 9/5/19 at 10:35 AM, the Quality Assurance (QA) Nurse was interviewed. She stated that she was responsible for investigating all the incidents/accidents including the falls. She reported that she investigated the fall on Resident #55 dated 6/9/19. She interviewed the NA and the Nurse. She didn't obtain written statements from the witnesses and she didn't observe how the fall had happened. The QA Nurse was unable to explain the root cause of the fall. She also stated that after the fall a bolster mattress was placed in resident's bed. On 9/5/19 at 11:15 AM, Nurse #2 was interviewed. She stated that she was assigned to Resident #55 on 6/9/19 when the resident had a fall. Nurse #2 stated that Resident #55 was stiff, and she could not move. She reported that NA #1 had reported that the resident rolled out of bed during incontinent care. On 9/5/19 at 2:36 PM, the Director of Nursing (DON) was interviewed. The DON stated that she expected the staff to prevent resident from falling during care.

Based on observations, staff and resident interviews and record review, the facility failed to store a nebulizer mask in a sealed bag when not in use for Resident #72. This was for 1 of 3 residents reviewed for respiratory care. The findings included: Resident #72 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #72's significant change Minimum Data Set ((MDS) dated [DATE] indicated she was cognitively intact and exhibited no behaviors. Review of Resident #72's care plan revised 8/21/19 read she had alteration in respiratory status. Interventions included changing her nebulizer mask weekly and storing the nebulizer mask in a storage bag per facility policy. Review of Resident #72's (MONTH) 2019 Physician orders [REDACTED]. Review of Resident #72's Medication Administration Record [REDACTED]. Review of Resident #72's Treatment Administration Record (TAR) for (MONTH) 2019 indicated staff last changed her nebulizer mask on 9/2/19 and the nebulizer mask was to be stored in a storage bag (Ziplock) per facility policy. In an observation on 9/3/19 at 10:45 AM, Resident #72's nebulizer mask was lying on top of the nebulizer machine that was sitting on top of her over the bed table. The nebulizer mask was not sealed in a storage bag. Resident #72 stated she received breathing treatments daily using the nebulizer mask. In an observation on 9/4/19 at 2:20 PM, Resident #72's nebulizer mask was partially lying on top of the nebulizer machine on her over the bed table. Also observed was an unopened Ziplock bag lying on the over the bed table. In an observation on 9/5/19 at 8:45 AM, Resident #72's nebulizer mask was partially lying on top of the nebulizer machine on her over the bed table. Also observed was an unopened Ziplock bag lying on the over the bed table. Nurse #1 reached for the nebulizer mask in preparation to administer Resident #72's breathing treatment. Nurse #1 was stopped and asked where the nebulizer mask was to be stored when not in use. He stated the mask should be stored inside the provided Ziplock bag lying on the over the bed table when it was not in use. Nurse #1 stated it must have been an oversight and stated the rationale for storing the nebulizer mask in a sealed bag was to prevent contamination and control infections. In an interview on 9/5/19 at 11:45 AM, the Administrator stated the facility did not have a policy regarding the storage of nebulizer mask when not in use and only recently instituted the storing of the nebulizer mask in Ziplock bag. He stated it was his expectation Resident #72's nebulizer mask be stored in a sealed bag when not in use.

Based on observation, record review, family and staff interviews, the facility failed to prevent injury for one of three residents, Resident #6, who was at risk for injury related to a history of falls. Resident #6's last fall at the facility resulted in the resident being hospitalized for [REDACTED]. The findings included: Resident #6 was admitted to the facility from the resident's home on 10/19/17 and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #6's care plan had been initiated on 10/19/17 and had two care areas. The resident was care planned for being at risk for adverse effects from psychotropic medications such as low blood pressure, mood disorders, further falls, and gait disturbances. Interventions included, in part, assist resident to common area for increased visualization, bed/chair alarm at all times to alert staff at attempt with independent mobility, monitor resident's gait for steadiness, and provide activities to entertain resident during periods of restlessness. The second care area was in regards to addressing the resident's pain and discomfort. A review of the Admission Data for Resident #6 dated 10/19/17 revealed the resident had the following: Problems with balance, a [DIAGNOSES REDACTED].e. from the bed to a wheelchair), incontinence, his cognitive status varied through the day, he was admitted with skin tears to the left shoulder, right and left arm, and right and left leg, and under the comment section it was documented the family reported to the facility the resident would try to get up unassisted. A review of the Fall Risk assessment for Resident #6 dated 10/19/17 revealed the resident was at a high risk for falls related to cognitive impairment, requiring assistance for balance for mobility, requiring extensive assistance for transfers (i.e. from the bed to a wheelchair), he utilized a wheelchair for mobility, incontinence, and receiving a psychotropic medication. A nursing note dated 10/20/17 stated Resident #6 had a fall in the sunroom and experienced a skin tear to the left arm. The injury was treated at the facility. Another nursing note dated 10/20/17 stated at 8:25 PM Resident #6 had gotten up out of his wheelchair and was attempting to ambulate without assistance at the nurses' station. A nurse who witnessed the fall was unsuccessful to intervene and prevent the resident from falling. The resident suffered a cut to the forehead and was sent via ambulance to the emergency room (ER) at the local hospital at 8:35 PM. A nursing note dated 10/21/17 stated at 1:10 AM stated Resident #6 returned from the ER via ambulance. A computerized tomography (CT) scan completed at the hospital was reported as having been negative. The resident had sutures to the forehead. It was documented the resident was assisted to bed, a pad alarm was in place, and frequent checks for safety were in progress. A nursing note dated 10/21/17 stated at 1:15 AM Resident #6's bed pad alarm had been heard to sound several times within a few minutes. The resident was noted to be attempting to get out of bed without assistance. The resident was assisted out of bed to the wheelchair, assisted to the bathroom, and brought into the day room. The note further stated, Constant one to one (1:1) in progress. A nursing note dated 10/21/17 stated at 3:40 AM Nursing Assistants (NAs) were providing constant 1:1 for Resident #6 in the day room. The resident was noted to be dozing off to sleep. The NAs left the resident unsupervised to answer call lights. The nurse had gone to another nurses' station in the building. When NA #2 came out of a resident's room she observed Resident #6 had stood up from his wheelchair and was walking near the nurses' station. NA #2 observed the resident fall before she could reach him to intervene. Resident #6 fell backwards and hit the back of his head. The resident suffered a cut to the back of his head and a hematoma, a localized collection of blood under the skin. The resident had a noted decrease in level of consciousness. A dressing was applied to the wound to the back of the resident's head. The resident was sent to the ER at the local hospital via ambulance. A review of Resident #6's hospital record with an admission date of [DATE] revealed a CT exam which read in part, the CT scan of the head was compared to the CT scan of the head dated 10/20/17. The findings of the CT of the head from 10/21/17 included acute bleeding of the brain and skull fracture, hematoma, and a cut with staples to the back of his head. The CT scan of the head dated 10/20/17 did not show a skull fracture or hematoma and was documented by the ER physician as being unremarkable. The resident was documented as having been unresponsive or poorly responsive for his admission and stay from 10/21/17. The hospital social worker was consulted for a hospice referral as well as an inpatient consult for palliative care. The resident was evaluated by the speech therapist at the hospital. The recommendation from the speech therapist was due to brain injury the resident was at very high risk for aspiration pneumonia. The speech therapist recommended the resident only receive very limited ice chips while under nursing supervision, no food and no liquids. The resident was discharged to a local hospice facility with comfort measures only on 10/23/17 including [DIAGNOSES REDACTED]. The resident was documented as having been lethargic and unable to respond to pain stimulus at the time of discharge. An interview conducted with NA #1 on 10/24/17 at 4:05 PM revealed she was familiar with Resident #6. She stated he would not sit still, she remembered having to tell him to sit down quite a few times on 10/20/17 during the 3-11 shift. She stated she had assisted him to the bathroom and he needed assistance due to being unsteady on his feet. An interview conducted with NA #3 on 10/25/17 at 10:33 AM revealed she had worked with Resident #6 on 10/19/17 and 10/20/17. The NA stated she was working on 10/19/17 when Resident #6 was admitted . The NA had talked with the resident's family and a caregiver who had been assisting the resident at home prior to admission to the facility. The NA stated the resident had bruises on his arms and legs. The caregiver told the NA the resident had fallen at home and was being admitted to the facility because he had many falls at home and the resident's family could no longer take care of him at home. She further added the resident was unsteady when he would stand and walk and he had a pad alarm for his wheelchair and bed. An interview conducted with the unit manager on 10/25/17 at 10:47 AM revealed she had completed the admission assessment for Resident #6 on 10/29/17. She stated the resident had several skin tears, to his shoulder, his legs, and arms. The Unit Manager stated the resident's family told her the resident fell a lot. The unit manager added the resident was fine initially with sitting in the wheelchair and then he started standing. The intervention put into place for the resident was a padded chair alarm for the resident to notify staff when the resident stood up. The Unit Manager stated the resident was unable to safely stand or ambulate on his own without assistance. The Unit Manager stated she made sure the NAs were aware the resident was a high fall risk. The Unit Manager recalled the resident was attempting to stand every 2-3 minutes and his chair alarm would signal he was attempting to stand. The Unit Manager further added she was aware the resident had fallen three times at the facility with the last fall having occurred at approximately 3 AM the morning of Saturday, 10/21/17, and he was sent to the hospital after the last fall. A phone interview conducted with Nurse #1 on 10/25/17 at 12:30 PM revealed she was the nurse who was working from 7 PM on 10/19/17 through 7AM on 10/20/17 and Resident #6 was on her assignment. Nurse #1 stated Resident #6 became more anxious in the evening he exhibited sundowning behaviors, such as anxiety and wanting to go. The nurse stated in order to keep the resident safe she and the other two nursing assistants maintained the resident under direct supervision for his safety. She stated when she arrived on 10/19/17 Resident #6 was at the nurses' station and had fallen earlier in the day. The nurse said she tried to keep the resident with her and had tried to keep him near her medication cart. The nurse stated when she was completing her 8:00 PM medication pass the resident was sitting in his wheelchair at the nurses' station. The day shift nurse, who had worked 7 AM to 7 PM was finishing her charting at the nurses' station. Nurse #1 stated at about 8:40 PM Resident #6 had stood up and fallen at the nurses' station when the day shift nurse was present. She stated the day shift nurse was unable to reach the resident in time to keep him from falling and injuring himself. The resident sustained [REDACTED]. The resident was sent via ambulance to the hospital. Nurse #1 then recalled Resident #6 returned to the facility via ambulance from the hospital at about 1:40 AM. The cut the resident had sustained to the forehead had been closed with sutures. The nurses added the resident seemed calm when he returned. The NAs assisted the resident to bed. The nurse then added about 15 minutes after the resident was assisted to bed, staff heard his bed alarm and the resident was standing at the doorway of his room. The resident continued to appear to be unsteady on his feet while standing or ambulating. The NAs assisted the resident to sit in his wheelchair. Nurse #1 stated she returned to her duties and told the NAs, NA #2 and NA #4, they would all have to take turns watching Resident #6. She added she told the NAs if a call light had to be answered, one NA was to stay with the resident. At approximately 3:15 AM, Nurse #1 went to another nurses' station. While at the other nurses' station, Nurse #1 stated she heard a scream. Upon returning to her nurses' station she stated she observed NA #2 and NA#4 on the floor by Resident #6 who was on the floor on his back and the back of his head was bleeding. The nurse stated Resident #6 was unconscious, he became alert momentarily, then returned to being unconscious. The nurse stated the approximate time of the fall was 3:40 AM. Nurse #1 further added the ambulance was called and the resident went out to the ER of the local hospital. Nurse #1 further added when she discussed what had happened with NA #2 and NA #4 she discovered NA #2 and NA #4 were both in the day room with Resident #6. She then stated NA #4 left the day room to answer a bed alarm shortly thereafter NA #2 then left Resident #6 unsupervised to answer a call light. She further added when NA #2 returned to check on Resident #6 he was walking and she witnessed him falling but was unable to reach him in time and she had screamed. An interview conducted with NA #4 on 10/25/17 at 3:59 PM revealed she was working the night Resident #6 experienced his third fall. NA #4 recalled she, NA #2, and the resident were in the TV room. She stated they had tried several interventions with Resident #6 including watching TV, snacks, and walking with the resident. She stated she and NA #2 were staying with the resident due to his history of falls and it was agreed upon that Resident #6 needed to be supervised. She added the nurse informed her and the other NA she was going to the other nurses' station. NA #4 stated she heard a bed alarm and left NA #2 supervising Resident #6 so she could answer the alarm. NA #4 stated while she was in the bathroom with another resident she heard a chair alarm sound and thought it may have been Resident #6's chair alarm but she was unable to safely leave the resident she was with, she then heard NA #2 yelling. NA #4 added when she had finished assisting the resident she was working with she went to check on Resident #6. NA #4 further added she discovered Resident 36 to be on the ground, on his back, with a cut to the back of his head, he was unresponsive and NA #2 was with him. A phone interview conducted with Resident #6's physician on 10/25/17 at 4:16 PM revealed Resident #6's family was having a very difficult times taking care of him because of his confusion. The resident's family admitted him to the nursing home because of his decline and falls; the resident needed 24 hour a day care. The doctor stated the resident had suffered a skull fracture with an intracranial bleed after his fall. The doctor further added the intracranial bleed caused by the fall led to the resident's hospitalization and his admission to a local hospice facility. A phone interview conducted with NA #2 on 10/25/17 at 4:42 PM revealed she was working from 11 PM to 7 AM the night Resident #6 experienced his third fall. NA #2 stated she remembered Resident #6 being up in the wheelchair and she and NA #4 were supervising him and another resident who was also trying to stand. NA #2 stated, she, NA #4, and the two residents were all in the TV room. NA #2 stated it was a mutually agreed upon decision to maintain direct supervision of Resident #6 due to his falls and he kept trying to stand up, according to NA #2 every couple of seconds. NA #2 stated she remembered NA #4 went to answer a call light. NA #2 stated Resident #6 was drowsy and started to go to sleep while he was sitting in the wheelchair in the TV room. NA #2 stated she had to answer a call light and left Resident #6 unsupervised. NA #2 then stated when she was assisting another resident she heard a pad alarm sounding and after she finished assisting the other resident she returned to the nurses' station and discovered Resident #6 had stood up from his wheelchair and was walking unassisted. NA #2 further added she observed Resident #6 start to fall and she screamed. NA #2 stated she saw Resident #6 fall backwards and hit his head. NA #2 finally added there was no individual who was assigned to supervise Resident #6 and she did not think he would get up in the short time it took her to answer the call light. On 10/25/17 at 5:05 PM, an interview was conducted with the Administrator and the Chief Operating Officer. They stated they had initiated an in-service for nursing staff and put a Plan Of Correction (P(NAME)) in place. He stated the facility had put an audit system into place as to interventions which have been put into place to decrease fall risk. The Administrator stated there were no residents at the facility who were receiving one to one supervision in the facility at that time. The corrective action for past non-compliance dated 10/23/17 was as follows: 1. The resident fell while in the facility Sunroom after getting up unassisted on 10/20/17 at approximately 3:00 PM. Interventions put into place at that time include a medication review by the pharmacy consultant who was onsite for a QA meeting. Nursing staff, including the RN Clinical Specialist and pharmacy consultant, ambulated the resident at that time as part of their post fall interventions. Thereafter, the nursing staff also started increased monitoring for the resident in common areas of the facility. Resident fell again at 8:25 PM while at the Nurse's station (a common area). This second fall occurred while the resident was standing unassisted from his wheelchair. A nurse was directly across from the resident at the Nurse's station at the time of this fall; however, the resident stood up and fell forward suddenly. After an assessment by the nurse, the resident was sent to the ED for evaluation and treatment. The resident returned to the facility at approximately 1:50 AM on 10/21/17. Upon returning to the facility, the resident's nurse and nursing assistant started 1:1 and diversional activities including engaged conversation, snacks, toileting, ambulation and watching TV with the resident beside the nurse's station. The 3rd fall occurred on 10/21/17 when nursing staff members (nurse and certified nursing assistants) temporarily stepped away from 1:1 monitoring with the resident for a period of time believed to be up to approximately 2 minutes (resident was still watching TV in the open room beside the nurse's station at this time). This time estimation is derived from interviews by the administrative team of relevant nursing staff who were providing care for the resident at that time. Nursing staff members each verbalized during the interviews that they believed the resident was safe while they briefly stepped away to provide care for another resident on the hallway. The resident was transported to the hospital and never returned to the facility. Were the resident to return, the facility would initiate 1:1 monitoring as a baseline intervention until it could be determined and documented that the resident did or did not require 1:1 monitoring. The facility believes the nurse in charge of the resident at the time of the event in question could have better elaborated and communicated to the nursing assistants her expectations that resident should not be left alone (as a part of the 1:1 monitoring which was put into place to promote resident safety). The nursing staff had been conducting 1:1 monitoring for this resident (in addition to other and previous fall prevention interventions already in place that are listed above); if the nurse had specified that the resident in question could not be left unattended, even briefly with a pad alarm in place, the fall likely would not have occurred. To clarify, the facility does not believe the event in question is a failure to implement fall prevention interventions. 2. The facility created a new QI team, referred to here as the 1:1 Monitoring QI Team, to direct and implement this plan of correction. The team was formed and met for the first time on 10/23/17. Team members include the Nursing Home Administrator, Director of Nursing (on medical leave at this time), a Unit Coordinator, Corporate Representative and facility Clinical Specialist. Additional members can be added at the discretion of the facility administrator as/if needed. This QI team collaborated to create the in-service, the schedule for in-servicing nurses, the QA tool (the 1:1 QA Monitoring Tool) for monitoring and the review of current residents for possible 1:1 monitoring needs or a change in fall prevention interventions. To address this issue and to prevent future similar issues: The facility initiated a 100% nursing staff in-service meant to elaborate and clarify that it is the responsibility of the nurse to ensure fall prevention interventions, including 1:1 monitoring expectations, are clearly communicated to nursing assistants and other nursing staff members (nurses for example). The facility also created a QI team to continuously review and monitor the interventions put into place specific to a plan of correction. The facility QI team initiated work to create an improved system of implementation and follow up on fall prevention interventions. This substantial document will be implemented with nursing staff as soon as it can be finalized. It is in addition and to meant to supplement previous interventions already in place as part of a continuous quality improvement project document. The facility (1:1 Monitoring QI team members) reviewed all current residents on 10/23/17, looking to determine if any other residents were in need of or receiving 1:1 monitoring. As of 10/23/17, no other residents are receiving or are in need of 1:1 monitoring for fall prevention intervention (or other purposes). This determination was made using a team approach to discuss and review each resident currently in the facility. Tools/resources utilized in this determination discussion include resident observations, staff interviews, chart reviews and Incident/Accident report review(s). The purpose or goal of the review/audit was to determine if any other residents would be in need of 1:1 monitoring OR any new/ different fall prevention intervention. The Clinical Specialist (RN nurse in charge of Incident/Accident reviews at this time) led this discussion amongst the 1:1 Monitoring QI team members on 10/23/17 including any follow up areas. The facility also checked to make sure that fall prevention interventions were being followed for all other residents and found them to be in compliance. The facility (1:1 Monitoring QI team members) reviewed all current residents on 10/23/17, looking to determine if any other residents were in need of or receiving 1:1 monitoring. As of 10/23/17, no other residents are receiving or are in need of 1:1 monitoring for fall prevention intervention (or other purposes). This determination was made using a team approach to discuss and review each resident currently in the facility. Tools/resources utilized in this determination discussion include resident observations, staff interviews, chart reviews and Incident/Accident report review(s). The purpose or goal of the review/audit was to determine if any other residents would be in need of 1:1 monitoring OR any new/ different fall prevention intervention. The Clinical Specialist (RN nurse in charge of Incident/Accident reviews at this time) led this discussion amongst the 1:1 Monitoring QI team members on 10/23/17 including any follow up areas. The facility also checked to make sure that fall prevention interventions were being followed for all other residents and found them to be in compliance. 3. The facility created and initiated an in-service on 10/23/17 for all nurses, medication aides and nursing assistants who are currently on the active payroll. The in-service was created during a QI team meeting discussion on 10/23/17 that was prompted and led by the facility administrator. The in-service was provided to the nursing staff and directed by the facility Clinical RN Specialist and the Nurse Unit Coordinators. Starting on 10/23/17 and moving forward, any nursing staff employee who has not been in-serviced will be in-serviced upon their return to the facility for their next scheduled shift. This will be continued until 100% of nursing staff members are in-serviced. Future new hires will be in-serviced as part of their general orientation process prior to being released from orientation/probation. The facility administrator will direct and monitor this area for compliance until the D.O.N. returns from medical leave. The in-service to the nursing staff was specific to the event in question on 10/21/17. The information provided to the nursing staff is meant to help prevent any future deficient practice in this area of fall intervention prevention. Specifically, the nurses were instructed to clearly communicate any changes in fall prevention interventions, including the need for 1:1 monitoring. The nurses were re-educated that, if an intervention is changed (modified up or down depending on what is needed and necessary to promote safety), to then make sure they have communicated that information to staff members they are working with and to document that information accordingly so the rationale or logic can be followed by others. Nurses were also educated to pick the fall prevention intervention(s) which they believe are most appropriate based on the resident's specific needs, including 1:1 monitoring. As an overview of the actions by the facility when a resident falls, a charge nurse assesses and documents the fall in the nurse's notes and on an incident accident QI report. This documentation triggers activity within the Electronic Medical Record (EMR) system, including fall prevention intervention communication and resident care planning. This course of action occurs for any resident fall as a standard part of the facility post fall process. Additional interventions are assessed/re-assessed on an ongoing basis as determined by the resident's needs. For QA purposes, the facility monitors and analyzes all resident falls utilizing the aforementioned incident accident form/QI tool. This tool, which is populated from information by the charge nurse(s), is the starting point for enabling the facility to analyze and determine root cause(s) on a resident by resident basis. The QA Fall Intervention Monitoring Tool, is maintained and managed by the Administrative Nurses and reviewed daily. The Administrative Nurses continue to use the tool to assess and ensure compliance with fall prevention interventions such as 1:1 monitoring, bed alarms, bolster mattress covers, bolster pillows, high winged mattresses, low beds, etc. The QI team meets weekly to review and discuss these processes. 4. The QI team met on 10/23/17 and will meet again prior to 10/27/17 and again on 10/30/17. The purpose of these QI meetings being to gauge the plan of correction progress and to ensure ongoing compliance. The QI team will meet at least weekly for the next 12 months, most likely during the weekly administrative nurse's meeting where care issues are reviewed. The Administrator will be responsible for chairing this QI team in addition to assigning new members, changes or updates to the plan of correction and the responsibility of ensuring monitoring of fall prevention interventions including 1:1 interventions. Note: the facility will continue to assess this internal plan of correction and reserves the ability to add or adjust to this plan of correction. For example, expanded nurse staff training and systematic approaches for staff to implement and follow that may be needed to ensure continued compliance. These documents and facility interventions will be added and reflected in the QI meeting minutes. As part of the validation process on 10/24/17 through 10/26/17, the plan of correction was reviewed including the re-education of staff and observations of interventions put into place to minimize the risk of falls. Resident #6 did not reside in the facility at the time of the investigation. Observations of interventions for other residents were conducted on 10/26/17 and all were appropriately in place. Interviews with licensed staff and nursing assistants revealed they were retrained in the areas of 1:1 supervision and nurse directives for interventions put into place. A review of the monitoring tools revealed that the facility completed the audit of falls as noted in their P(NAME). Due to the brief period of time between the incident, the intervention of the P(NAME), and the complaint investigation in-servicing of remaining nursing staff remained ongoing as of 10/26/17. The facility showed additional documentation that provided information that included in addition to in-servicing staff prior to their shift starting they had started in-servicing staff not at the facility over the phone. In-service documentation review included NA #2, NA #4, and Nurse #1 who were involved with Resident #6 from 10/19/17 and 10/20/17. A review of the audit tools revealed audits for one to one monitoring had been not been conducted due to there being no residents with one to one monitoring. The administrator reviewed the one to one tool and how it would be put into place and be utilized in the event one to one supervision was necessary for a resident. The facility alleges full compliance with this plan of correction effective 10/23/17.

Based on medical record reviews, administrative staff interviews, family interview and staff interviews the facility failed to provide supervision to prevent resident to resident altercations for one (1) of one (1) residents with aggressive behaviors (Resident #1) exhibited towards four (4) other residents. (Residents #2, #5, # 6 and # 7). The immediate jeopardy (IJ) for Resident #1 began on June 28, 2012 when Resident #2 and #5 were in a physical altercation and were hit by Resident #1. The Assistant Administrator and Director of Nursing were notified of Immediate Jeopardy on 8/9/12 at 1:55 PM. The IJ was removed on 8/10/12, at 5:20 PM after Credible Allegation of Compliance was validated through staff interviews and record reviews. The facility was left out of compliance at no actual harm, with potential for more than minimal harm that is not immediate jeopardy, to allow for completion of employee training. The findings were: Review of the "Resident Abuse Policy & Procedure" with revised date of 2/07 revealed "6. ....If Resident-to-Resident Abuse occurs, the residents will be separated and removed from the area until the investigation is complete. " Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the North Carolina Medicaid FL2 dated 6/14/12 revealed an assessment of Mood Indicators - Behavioral Symptoms. Resident #1 was assessed as being " Dangerous to Self, Others, or Property: Yes " . Further review of this document revealed under " Additional Information or Comments " Resident #1 " does have a hx (history) of agitation and behaviors when agitated per family. " Review of the medications ordered upon admission revealed an antipsychotic medication, Seroquel 25 milligrams to be taken twice a day for possible dementia. There were no other medications for mood or behaviors ordered on admission. Review of the Minimum Data Set, 5 day Assessment, dated 6/22/12 revealed Resident #1 had poor short term memory recall and was combative with care. Resident #1 was assessed as being ambulatory on and off the unit. Review of the Care Area Assessments dated 6/22/12, completed by Social Worker #1 revealed Resident #1 was confused to time and situation, unable to make safe, consistent decisions independently and wandered throughout the secure unit. Resident #1 was easily redirected, and could become agitated with care and redirection. Review of the care plan dated 6/22/12 revealed problems of short term memory recall, combative towards staff at times, wanders daily going in and out of other ' s rooms and will get easily agitated during redirection, and dementia with use of antipsychotic medication. The approaches for these problems included the following: - Redirect inappropriate behaviors with use of diversional activities such as offering snack, toileting. - Involve social worker as needed. - Consult with MD related to behaviors as needed. - Redirect resident to an activity when restless and anxious - Remove resident from a situation that causes increased anxiety. - Reorient resident as necessary - Monitor and document behaviors. Review of the nurse's notes signed by licensed nurse #1, dated 6/28/12 at 6:15 PM the nurse documented she was informed by a family member Resident #1 had hit two residents ( Residents #2 and #5) and attempted to hit a third resident (Resident #7). The three residents were seated in the dining room. Resident #1 walked up to the two residents and hit them. The nurse responded, separated the residents, and removed Resident #1 from the dining room. This incident was not reported to administrative personnel, an incident report was not completed, the physician was not notified and the social worker was not notified. Review of the social work progress note dated 6/27/12 revealed Resident #1 " gets easily agitated with redirection and assistance. " Resident #1 had been " combative towards staff. " He would " kick staff when they attempted to redirect him and assist him. " Resident #1 was assessed as " Res (resident) physical behaviors can be harmful to others. " Review of the nurse's notes dated 7/1/12 at 2:00 PM, signed by licensed nurse #2, revealed the nurse took a shoe away from Resident #1. The nurse observed Resident #1 with a shoe in his hand and " rared back to hit " resident # 7. This is the second incident with a physical threat displayed to Resident #7 by Resident #1. This incident was not reported to administrative personnel, the physician was not notified and the social worker was not notified. Review of the nurses notes dated 7/4/12 at 11:00 PM, signed by licensed nurse #3, revealed Resident #1 was angry with staff at the nurse ' s station. The door was locked and he could not get behind the nurse ' s station. The licensed nurse documented Resident #1 threw the tray of snacks and papers on top of the station to the floor. Resident #1 was assisted to bed. The physician nor the social worker were notified of this incident. Review of the behavior documentation flowsheet for July 2012 revealed Resident #1 exhibited behaviors of "Yelling and screaming (#4) and Clear threats of violence towards others and/or staff (#5) on 7/9/12 at two different times. Review of this document for the dates of 7/10/12 revealed Resident #1 "Swings at others/staff" and "grabs others hair. " Review of the social work progress note dated 7/11/12 revealed Resident #1 " gets easily annoyed c (with) other residents more recently & (and) gets agitated c (with) staff. " Resident #1 was assessed as " wander in/out others rooms & plunders in their things ... gets angry when staff redirect him. " Resident #1 was assessed as " resistive of care & redirection. " Review of the nurse's notes dated 7/12/12 at 6:00 PM, signed by licensed nurse #1, revealed Resident #1 had an altercation with a resident in her room (Resident #6). The nurse was called to the room by an aide. The nurse documented the female resident #6 was found on the floor, Resident #1 was behind her wheelchair, with his hands on the handles. Resident #6 complained Resident #1 " hit me hard, in my head and jerked my chair out from under me. " The Director of Nursing was notified on the morning of 7/13/12 of the incident. An incident report was completed by licensed nurse #1, who worked on 7/12/12. Review of the Resident Incident Report that was completed on 7/12/12 revealed Resident #6 was noted to have a red area on the left side of her head. There were no other injuries documented on the incident report. Review of this incident report revealed the Director of Nursing signed the incident report was reviewed by her on 7/13/12. Review of the physician's orders [REDACTED]. Review of the nurse's notes dated 7/13/12 at 6:45 PM, signed by licensed nurse #2, revealed Resident #1 had an altercation with a female resident (Resident #2). This was the second altercation with Resident #2. Resident #1 hit the Resident #2 in the face twice, with a closed fist. He then took her glasses off, and put them on his face. An incident report was completed by licensed nurse #2 for Resident #2, the family was notified, a note was left in the physician ' s book. An incident report was not completed for Resident #1. Review of the Medication Administration Record revealed the first dose of Ativan was administered on 7/13/12. Review of this documentation did not reveal the time of administration, or if it was effective. Resident #2 that was hit in the face had a bruise on the lower lip. Review of the nurse's notes dated 7/14/12 at 9:00 AM, signed by licensed nurse #2, revealed Resident #1 was hitting staff, tried to pull the blankets off the roommate and yelling at residents. The licensed nurse notified the Director of Nursing and physician. Ativan was administered on 7/14/12 at 9:00 AM and was documented as being " no effective 10A. " An order was obtained to send Resident #1 to the emergency room for evaluation due to behaviors. Interview on 8/9/12 at 11:50 AM with the Director of Nursing revealed she was not informed by the nursing staff Resident #1 was difficult to redirect. The first incident that occurred on 6/28/12 was not reported to her and an incident report was not completed. The incidents on 7/1/12 and 7/4/12 were not reported to her. She was first informed of the aggressive behaviors on the morning of 7/13/12. The incident of 7/12/12 was shared with the other department heads and assistant administrator in the " stand up meeting " on 7/13/12. After the incident on 7/13/12, the Director of Nursing requested the Quality Assurance nurse to investigate the incident on 7/14/12. On the morning of 7/14/12 the Quality Assurance nurse assisted the licensed nurse with sending Resident #1 out to the hospital. Interview on 8/9/12 at 10:59 AM was conducted with licensed nurse #1. This staff member was the nurse working on 6/28/12. Licensed nurse #1 recalled being informed by someone, could not remember who, that she was needed in the dining room. When she entered the dining room, she was informed Resident #1 had hit two other residents. There was nothing that provoked the incident. She checked the two residents for injuries and had staff take Resident #1 down the hall. Continued interview with licensed nurse #1 revealed she was working on 7/12/12. She remembered a staff member calling for her to come to a resident's room. The female resident was on the floor, and Resident #1 was holding onto her wheelchair. The female resident was removed first, then Resident #1. When questioned when would she call the physician about aggressive physical behaviors, she responded " probably after the second incident. " Further interview confirmed the physician had not been notified on 7/12/12. Interview on 8/9/12 at 12:00 PM with the Director of Nursing regarding interventions the staff would be expected to take for aggressive behaviors would include redirection, offering snacks, removal from the situation, toileting, activities or medication if ordered. Further interview revealed she would expect staff to obtain assistance from other staff members in the building when needed. One to one supervision could be provided, but on a temporary basis. During this interview, it was asked how the staff monitored Resident #1. The response was during rounds, while providing care and at activities. One to one supervision or assistance from other staff members was not obtained for Resident #1 to her knowledge. Interview on 8/9/12 at 12:15 PM with MDS nurse #1 revealed she was aware Resident #1 was aggressive towards residents and staff. This staff member was not a personal witness to his physical aggressiveness. . During interview, this staff member did remember discussing Resident #1 during the care plan meetings. The care plan interventions were to redirect the resident, do diversional activities, toileting, snacks or activities. Redirection was effective at times, and other times it was not effective. Further interview revealed she did not have an answer for what staff were to do if redirection did not work. Interview conducted on 8/9/12 at 12:30 PM with a family member who has a relative on the Alzheimer's unit. Interview with the family member revealed she was aware of who Resident #1 was, and she visits daily on the unit. During this interview, it was revealed she had witnessed Resident #1 push a resident in a wheelchair and the wheelchair rolled several feet, and just missed another resident standing in the hallway. Further interview revealed staff had been informed they needed to keep Resident #1 away from her relatives. Interview conducted on 8/9/12 at 2:30 PM with licensed nurse #2 revealed she could not remember the events of 7/1/12. Resident #1 did not like to be approached by other residents. On 7/13/12, licensed nurse #2 was off the unit. Upon return, an aide told her Resident #1 had come up to Resident #2, took her glasses and said the glasses were his. Further interview revealed Resident #2 had not done anything to provoke Resident #1. Both residents were in the dining room, and Resident #1 punched Resident #2 in the face. Licensed nurse #2 explained she separated the two residents, checked Resident #2 for injuries and Resident #1 was easily redirected. Interview conducted on 8/9/12 at 2:30 PM with licensed nurse #2 revealed she worked on 7/14/12 on the unit. Resident #1 was agitated, tried to hit an aide, or did hit an aide in the back due to refusing care. The medication Ativan was administered with no effect. Licensed nurse #2 spoke with an administrative nurse about the behaviors. Resident #1 was sent to the hospital for evaluation. Further interview revealed this nurse did what she thought was in her best nursing judgment on 7/13/12. After the inservice conducted by the Director of Nursing, she would have called the physician and the Director of Nursing. The Assistant Administrator and Director of Nursing were notified of Immediate Jeopardy on 8/9/12 at 1:55 PM. The Allegation of Compliance was received on 8/10/12 at 11:30 AM. The Allegation of Compliance was accepted on 8/10/12 at 4:09 PM. The Corrective Plan of Action: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: - Regarding the incident on 6/28/12, the attending nurse #1 removed the aggressive resident (Resident #1) from the scene of the incident, separating the two residents. The two residents in between two residents were physically assessed by the attending nurse, and no injuries or harm were found. No other aggressive behaviors were noted for the rest of the day. Seroquel was administered to the resident with aggressive behaviors and was effective due to no further behaviors. - Regarding the incident that occurred on 7/12/12, the attending nurse #1 separated the two residents involved in the incident. (Resident # 1 and Resident #6) The attending nurse physically assessed both residents and found no injuries or harm. Seroquel was administered to the resident with aggressive behaviors and was effective due to no further behaviors. - On the evening of 7/13/12 the nurse in the secure unit (nurse #2), immediately separated two residents involved in a physical altercation. Resident #2 was brought out of the dining room and taken to her room; her glasses were replaced on her face. Resident #1 was given Ativan PRN, for which he had a physician's orders [REDACTED]. The nurse, and C N A continued to visually monitor resident #1 through the evening by circulating the halls to ensure resident #1 and resident #2 separated, and checked on those residents during rounds. The nurse completed physical assessments on both residents involved to evaluate residents for physical injury and/or harm. On 7/13/2012 the primary physician was notified, and responsible parties were notified. Family members of resident #2 came to the facility following notification of the incident. The resident did not show any other behaviors on the evening of 7/13/12. Incident report were completed on 7/14/12 by the Quality Assurance nurse. On 7/14/12 resident #1 became angry when staff redirected the resident. PRN Ativan was administered at 9:00 am, with no effective results at 10:00 am. The DON was made aware on 7/14/12 at 10:00 am from the Quality Assurance nurse; after being made aware, the DON had the resident sent out to the hospital immediately - The Quality Assurance nurse, and administrative nurse, began investigating on the incident on 7/14/12 after being made aware of the incident that occurred on 7/13/12. The QA nurse arrived to the facility at 6:20 am. The medical director was notified at 10:00 am, an order was written to send the resident to the hospital. QA nurse also initiated one on one monitoring until the EMS arrived to the facility. She notified EMS to transport the male resident to (name of local hospital) Emergency Department at 10:00 am, with instructions not to send the resident back until a mental evaluation could be completed in the hospital. The local police are notified when there is a report of abusive behaviors; police were utilized to give assistance to EMS to get the resident in the ambulance. Resident #1 left the facility via EMS at 10:30 am. The QA nurse interviewed the staff members that were on duty, the nurse on duty in the secure unit and the nurse aides on the secure unit; she reviewed the charts of resident #2 and #1; and contacted responsible party of residents involved. - Incidents that occurred on 7/12/12 and 7/13/12 involving the male resident were reported to NCDHSR Complaint Intake Unit via fax on 8/9/12. 2. Address how corrective action will be accomplished for those residents having potential to be affected by the same efficient practice;\ - When the DON arrived to the facility on [DATE] at 9:30 am, she observed all units for resident behaviors; all primary nurses on duty reported to her no residents having current behaviors on this day to the DON, to ensure there were no other potential or actual behaviors currently that needed further interventions. DON assessed resident #2 and no mental anguish was observed. Through investigation, the DON realized a previous incident occurred between resident #2 and resident #1 that was not reported to anyone in the facility, this incident occurred 6/28/12. The incident was discovered in the nurses' notes for the female resident involved. -The DON created and initiated an internal Plan of Correction (PoC) on 7/15/12 to prevent any reoccurrence of the incident and maintain regulatory compliance. This internal PoC/Allegation of Compliance included the development of the " Resident Altercations/Potential Altercations Follow-Up " tool, which is used to document and monitor any actual or potential altercations. The QA nurse, DON, or ADON will document on the tool. Documentation included on the tool includes interventions (offer toileting, fluids/food, activities, supervision, monitor for discomfort, and/or one-on-one monitoring), medication changes, lab discrepancies, intervention effectiveness, and notifications of responsible party and physician. The tool will be stored in the QA office. See attached " Resident Altercations/Potential Altercations Follow-Up " tool. -Beginning on 8/9/12, a team of staff members, consisting of administrative nurses and other administrative staff members were assembled to audit each resident chart throughout the facility. Nurses' notes and mood and behavior sheets were used to determine any further behaviors. Interventions and effectiveness recorded on the " Resident Altercations/Potential Altercations Follow-Up " tool. Some residents were found with behaviors, in each case where behaviors were noted, interventions were in place and effective. Each chart was audited from 7/1/2012 to present for any behavior changes that could result in future combative behaviors or resident altercations. Care plans will be updated for residents displaying aggressive behaviors to address behaviors. 3. Address what measures will be put into place or systematic changes made to ensure that the deficient practice will not occur: -All nursing staff scheduled on 7/15/12 were educated on resident-to-resident altercations/interventions. All other available licensed and unlicensed staff were inserviced by 7/18/12. In-servicing instructs staff on immediately reporting incidents including resident to resident altercations and abuse, after interventions are put into place. Incidents should be reported to the resident responsible party, physician, and one of the following: DON, ADON or Administrator. Interventions include immediate resident separation (staff members should request additional staff assistance as needed), offering re-direction, toileting, food, fluids, quiet time, and/or one-on-one supervision; DON explained factors that can lead to escalating aggressive behaviors including the need for toileting, food, fluids, pain, or other wants/needs. All new hires will be ins-serviced on " Resident Abuse Policy & Procedure and Reporting Reasonable Suspicion of a Crime in a LTC Facility. " Staff will report occurrence to the primary nurse. The primary nurse will assess residents involved for injury and/or harm and treat as necessary. Further attempts of altercations will result in PRN medication administration (with order) additional medication orders, one-on-one monitoring, and family may be requested to monitor and/or intervene as needed. Once interventions are successful, altercations must be reported to the responsible party and physician; altercations will also be reported to the DON, ADON, or Administrator. The nurse will complete incident reports on each resident involved in the occurrence. Covered individuals that have a reasonable suspicion of crime committed against a resident of the facility will report the incident according to the guidelines of statute 1150B. The DON, ADON, or QA nurse will investigate cases of abuse or alleged abuse. - All licensed and unlicensed staff will be in-serviced on " Resident Abuse Policy & Procedure and Reporting Reasonable Suspicion of a Crime in a LTC Facility " by 8/10/12. Any unavailable staff members will be required to complete in-service on " Resident Abuse Policy & Procedure and Reporting Reasonable Suspicion of a Crime in a LTC Facility " before returning to work. - Residents who are showing a pattern of behaviors that could escalate to an incident will be discussed in weekly QI meetings. Incident reports involving resident-to-resident altercations and aggressive incidents will be reported from the QA nurse during weekly QI meetings. The Social Worker will report on behaviors that escalate in between MDS assessments. The QA nurse, DON, or ADON will use the " Resident Altercations/Potential Altercations Follow-Up " tool at the weekly QI meetings to monitor altercation and potential altercations. During weekly QI meetings the MDS Coordinator and the Social Worker will review and discuss residents ' current care plan to evaluate the need to make adjustments regarding aggressive behaviors. The QI team members will evaluate on residents with multiple behaviors, effectiveness of interventions, current interventions and discuss the need for further interventions and preventive measures on residents with behaviors and/or residents involved in resident-to-resident altercations. Incidents involving resident-to-resident altercations, cases of abuse, and cases of alleged abuse will be reported in daily stand up meetings. - The " Resident Abuse Policy & Procedure was edited on 8/9/2012 to include resident-to-resident cases of abuse or alleged abuse; reporting of cases of abuse and alleged cases of abuse not pertaining to staff members were also addressed with the policy change. - Nursing staff will observe and document in the residents nurses note any abusive and aggressive behaviors on new admissions to the facility. Nursing staff should request additional information from the family and contact the MD within 24 hours of admission for any resident displaying abusive or aggressive behaviors. Any aggressive and abusive behaviors noted should be reported to the DON and/or Administrator to review. Residents that display aggressive behaviors that were not present on admission will be evaluated through the " Resident Altercations/Potential Altercations Follow-Up " tool. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. The PoC is integrated into the quality assurance system of the facility. - Chart audits will be conducted for residents having aggressive behaviors with each occurrence. Residents displaying aggressive behaviors will be collected from the 24-hour reports, which are completed by all floor nurses documenting resident conditions during a 24-hour period, and reviewed daily by the DON, Administrator, Assistant Administrator, ADON or QA nurse. All residents having aggressive behaviors will be monitored daily for 7 days, at least weekly for 4 weeks, and then random chart audits will be performed on two residents per unit (East, West and SEA) on a monthly basis for a period of six months. - In-servicing regarding revised " Resident Abuse Policy & Procedure and Reporting Reasonable Suspicion of a Crime in a LTC Facility " will be provided by the Administrator, Assistant Administrator, and DON on an annual basis. - Continuous Quality Assurance reporting will be completed by the QA nurse or DON at Quality Assurance meetings. The QA nurse or DON will report on results of the audits, any reportable incidents, and any changes needed based on events that occurred during the quarter. Beginning at 4:55 PM on 8/10/12, interviews were conducted with staff members in various departments, and in nursing to determine compliance. Interviews revealed staff had been provided the inservices, were able to repeat the reporting procedures, and steps to take if aggressive behaviors did re-occur. Interviews were conducted with the social worker and MDS nurse for their role in follow with residents who have aggressive and/or abusive behaviors. These staff members knew their role and what action to take for these altercations. Information was reviewed that was used in the inservice training, the signature lists of all staff, chart audits completed by administrative nursing staff members on 8/9/12, and careplans for residents identified as having behaviors which required interventions. The revised " Resident Abuse Policy & Procedure " was reviewed. Attachment A of this policy directs staff to follow in a numbered sequence for resident-to-resident abuse guidelines. Other information reviewed consisted of the QI tool " Resident Altercations/Potential Altercations Follow-Up for two residents. These were completed and reviewed by the Director of Nursing with no resident to resident altercations occurring. As of 8/10/12 at 5:20 PM Immediate Jeopardy was lifted. The severity of the citation was lowered to no actual harm with potential for more than minimal harm that is not immediate jeopardy