Every finding on record at The Greens at Maple Leaf

Based on observation and staff interviews, the facility failed to maintain sanitary conditions in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, and 1 of 1 dry storage area. These practices had the potential to affect food served to residents. The findings Included:a. During the initial tour of the kitchen with the Dietary Manager on 07/28/2026 at 10:50AM, the following was observed in the walk in cooler:-Six (6) single serve ice cream cups observed on the floor underneath the shelving unit,-Several pieces of used plastic cling wrap observed underneath the shelving unit,-Other unidentified debris was scattered throughout the walk-in cooler floor and underneath the shelving unit,-A dark brownish/ grayish/ blackish substance was observed scattered across an extended area of the left wall of the walk-in cooler,-A dark brownish/ grayish/ blackish substance was observed across several areas of the shelving unit (this shelving unit was positioned directly in front of the wall at the entrance door of the walk-in cooler),-A plastic container was observed with dark brownish/ grayish/ blackish substance scattered across the container and rim of the container located on the top shelf of the shelving unit. The plastic container contained the following items: (2) ketchup bottles, (2) mustard bottles, (3) strawberry syrup bottles, (1) chocolate syrup bottle, and (1) liquid creamer container; all of which were observed with dark brownish/ grayish/ blackish substance on the bottles/ containers.-Water was observed leaking from the ceiling fan from condensation that had accumulated along the rim of the ceiling fan vent.On 07/28/2026 at 10:55AM an interview with the Dietary Manager was completed. She explained the ceiling fan ventilation seals had been leaking for 2-3 months and Maintenance was aware. The Dietary Manager stated Maintenance had repaired the ceiling fan ventilation seals in the past (March 2026), but it began to leak again. Further interview with the Dietary Manager stated the leaking walk-in cooler ceiling fan was an ongoing issue that worsened during heavy rains. The Dietary Manager explained she had verbally informed the Maintenance Director for several months about the presence of a dark brownish/ grayish/ blackish substance on the left wall of the walk-in cooler during the morning department head meeting. The Dietary Manager also stated she had reported the issues to her Director of Operations for dietary services. The Dietary Manager could not recall the exact time she had reported the issue to her Director of Operations for dietary services. b. On observation of the walk-in freezer was completed on 07/28/2026 at 11:00AM which revealed the following:-Fallen food debris and unidentified debris scattered beneath the bottom shelving units,-An accumulation of ice on the walk-in freezer floor beneath the bottom of the shelving unit,-Ice accumulation along the walk-in freezer door threshold and the lower edges of the walk-in freezer door,An interview was completed with the Dietary Manager on 07/28/2026 at 11:06AM who stated there was no definitive cleaning schedule for the walk-in freezer. The Dietary Manager stated she was not certain as to why there was ice build up on the floor or underneath the shelving unit. c. On observation of the dry storage was completed on 07/28/2026 at 11:10AM which revealed the following: -(1) Fallen package of crackers, crumbs, and unidentified debris scattered throughout the floor beneath the bottom shelving units,-(1) Fallen condiment package observed underneath the shelving unit.An interview with the Dietary Manager on 07/28/2026 at 11:15AM. The Dietary Manager further stated there was no definitive cleaning schedule for the dry storage area.An interview with the Maintenance Director on 07/30/2026 at 3:23PM confirmed that staff identified daily repair needs by completing the facility's maintenance clipboard located at the nursing station. He stated a second clipboard was located in the kitchen. The Maintenance Director stated he seldom reviewed it unless someone informed him of an important issue. He preferred the Dietary Manager notify him directly of needed kitchen concerns. The Maintenance Director explained that when he became aware of a repair need, he consulted with the Dietary Manager and the Administrator to begin the process of submitting the requests to the corporate office. The Maintenance Director stated that there had not been an issue with the walk-in cooler ceiling fan leaking or producing condensation because there has been very little rain. Due to recent heavy rain this caused a backup of standing water on the rooftop. He explained that water had gotten in the condenser and produced moisture inside the walk-in cooler. The Maintenance Director stated he was not aware of the dark brownish/ grayish/ blackish substance on the left wall and shelving unit in the walk in cooler until yesterday (07/29/2026), when the Director of Operations for dietary services instructed the dietary staff to remove the walk-in cooler equipment and clean. He confirmed that the dark brownish/ grayish/ blackish substance had resulted from moisture and from staff opening the cooler door, which allowed warm air to enter. The Maintenance Director stated he was not aware there was ice buildup on the floor at the threshold of the walk-in freezer door opening. He stated the kitchen staff had not reported the issue to maintenance. He stated the current process of communicating needed repairs worked well for the facility and did not believe changes were necessary. However, he preferred that staff communicated more consistently, provided clearer information, and take greater responsibility for cleaning.An Interview with the Director of Operations for dietary services was completed on 07/30/2026 at 11:50AM revealed she was aware of the dark brownish/ grayish/ blackish substance in the walk-in cooler. She was also aware of the walk-in cooler leaking ceiling fan. She stated she expected the Dietary Manager to submit a maintenance request using the facility's maintenance clipboard located in the kitchen hanging on the wall outside the Dietary Manager's office to initiate the repair process for the leaking ceiling fan and other necessities. She further stated she expected the identified repairs to be completed promptly by the facility to maintain a safe and sanitary work environment.During a follow up interview with the Dietary Manager on 07/31/2026 at 7:50AM she stated she had not entered additional requests on the maintenance log for the dark brownish/ grayish/ blackish substance because she had already informed Maintenance several times during the department head morning meeting. The Dietary Manager reported that Maintenance had not come to the kitchen to assess the dark brownish/ grayish/ blackish substance, although administration was aware of the concern. In an interview with the Administrator on 07/31/2026 at 11:18AM she stated she expected improved communication between the Dietary Manager and the Maintenance Director. The Administrator stated the facility leadership and staff have shared a long-standing good work environment, and they share strong relationships with one another. She stated that once she became aware of the dark brownish/ grayish/ blackish substance, she instructed the Dietary Manager to discard the contents of the cooler and disinfect the area. The Administrator explained that she believed because the reach in refrigerator had been out of service, its contents were moved to the walk in cooler, which increased the traffic in and out of the cooler and caused irregular temperature fluctuations, which created conditions favorable to the dark brownish/ grayish/ blackish substance growth. The Administrator stated if she had known sooner, the matter would have been addressed. The Administrator further stated it was the Dietary Manager's responsibility to clean the dark brownish/ grayish/ blackish substance in the walk-in cooler. The Administrator expressed she was unaware of the dark brownish/ grayish/ blackish substance in the walk-in cooler until 07/28/2026.

Based on record review, observation and staff interviews, the facility failed to remove expired medications from 1 of 4 medication carts reviewed for medication storage (100 Hall Medication Cart).The findings included:An observation of the medication cart for the 100 Hall was conducted on 7/30/2026 at 3:50 PM in the presence of Nurse #1. The observation revealed the following expired medications:-Nine (9) benzonatate 100 milligrams (mg) capsules (medication used to treat cough) with an expiration date of 6/8/2026. Nurse #1 confirmed the expiration date by reading aloud the date printed on the medication card.-Six (6) metoclopramide 5 mg tablets (medication used to treat nausea, vomiting, and delayed stomach emptying) with an expiration date of 5/18/2026. Nurse #1 confirmed the expiration date by reading aloud the date printed on the medication card.-Sixteen (16) ondansetron 4 mg tablets (medication used to prevent and treat nausea and vomiting) with an expiration date of 6/13/2026. Nurse #1 confirmed the expiration date by reading aloud the date printed on the medication card.An interview with Nurse #1 was conducted on 7/30/2026 at 3:58 PM. Nurse #1 stated she was a as needed (PRN) employee and was working her second shift at the facility. Nurse #1 stated she did not check the medication cart for expired medications that day and only verified expiration dates on medications she administered. She indicated medication carts should be checked weekly and all medications on the cart, including PRN medications, should be within their expiration dates. An interview with Unit Coordinator #1 was conducted on 7/31/2026 at 10:54 AM. The Unit Coordinator stated every nurse and medication aide were instructed to inspect their medication cart at the beginning of each shift and again at the end of the shift. Unit Coordinator #1 stated nurses and medication aides were educated to routinely check their medication carts for expired medications.During an interview on 7/31/2026 at 12:16 PM, the Director of Nursing (DON) stated nurses and medication aides were educated and instructed to inspect medication carts for expired medications daily and again prior to medication administration. The DON stated Unit Coordinators conducted weekly medication cart inspections and reported the medication cart was inspected the previous week. She further stated pharmacy conducted monthly medication cart inspections and the most recent inspection, completed on 6/26/2026, documented no expired medications on the cart. The DON indicated she was unsure how the expired medications were subsequently found on the medication cart. She stated expired medications should not be administered and should be removed from the medication cart, returned to the pharmacy, and reordered if needed.

Based on record review, observations, and staff interviews, the facility failed to keep essential equipment clean and in safe operating order for 2 of 2 dryers (dryer #1 and dryer #2) observed for safe operating conditions.The findings included: On 07/31/2026 a continuous observation beginning at 9:02 AM, was made of the laundry rooms with the Housekeeping Manager and he was asked to open the dryer lint trap access panel to be able to observe the dryer lint traps. The observation yielded dryer #1 and dryer #2 with copious amounts of lint observed in both lint traps of the two dryers and each had a visible sheet of lint hanging from the lint traps. When the Housekeeping Manager obtained a broom and removed the lint, it looked to be approximately one quarter inch thick, all one piece, and the lint covered the entire lint trap, which was approximately 16 inches wide by 20 inches long. The Housekeeping Manager removed the Dryer Lint Trap sign-off form for the month of July 2026 from a bulletin board above the trashcan in the laundry room and provided it to the surveyor and continued the interview. A review of the Dryer Lint Trap revealed the form was last signed off on 7/30/2026 at 4:00 PM. There were no initials or names in the check boxes of the Dryer Lint Trap form after 7/30/2026 at 4:00 PM. The Housekeeping Manager stated he was unaware the Dryer Lint Trap form was missing staff initials for the evening of 7/30/2026 beginning at 4:00 PM and stated the second shift laundry aide (Laundry Aide #2) worked from 4:00 PM to 9:00 PM on 7/30/26 and explained Laundry Aide #2 may have forgotten to sign the form during her shift on the evening prior. The Housekeeping Manager explained the process for checking and removing the lint from the lint traps for both dryers, dryer #1 and dryer #2, was for the laundry aides to sign the Dryer Lint Trap form using their initials in the appropriate boxes every two hours indicating they had checked and removed the lint from the lint trap. An interview was then conducted with Laundry Aide #1, who had entered the laundry room during the observation and interview with the Housekeeping Manager. Laundry Aide #1 revealed she understood the process of removing lint from the lint traps of the dryers every two hours and then sign the Dryer Lint Trap form with her initials in the appropriate box on the form indicating she had checked and removed the lint from both dryers. Laundry Aide #1 stated she started her shift at 7:00 AM on the morning of 7/31/2026 and had not yet signed off on the Dryer Lint Trap form because she had been busy. Laundry Aide #1 stated she removed the lint from the lint traps on the morning of 7/31/2026 but could not remember the exact time. She continued by saying, usually there was only a tiny amount of lint after a two-hour span and used her fingers to make a small round circle about the size of a dime to show how much lint accumulated during a two-hour span. Laundry Aide #1 stated she had washed and dried two loads of sheets and blankets that morning. The dryers were running during the interview. A phone interview was conducted with Laundry Aide #2 on 7/31/2026 at 9:32 AM. Laundry Aide #2 stated she worked on 7/30/2026 from 4:00 PM to 9:00 PM and stated no other staff would have worked in laundry until Laundry Aide #1 arrived for work on 07/31/2026 at 7:00 AM. Laundry Aide #2 stated she had forgotten to sign Dryer Lint Trap form indicating the lint was removed from both lint traps which meant there would have been blank boxes on the Lint Trap Dryer form between the hours of 4:00 PM - 9:00 PM. She stated the facility's process was to check the dryer lint traps for buildup of lint and remove all buildup of lint the lint traps every two hours and sign the Dryer Lint Form to show the task has been done. Laundry Aide #2 explained she removed the lint from the lint traps before she left at 11:00 PM on 7/30/2026. Laundry Aide #2 stated when she removed the lint from the lint trap after a two-hour period there was normally a little bit of lint to remove, but not too much, stating not enough for the lint to hang down. Laundry Aide #2 stated if the lint traps were not checked and the lint was not removed every two hours or the lint was hanging down, from what she has experienced, that meant the lint traps had not been checked much that day.A second interview was conducted with the Housekeeping Manager and Laundry Aide #1 on 7/31/2026 at 11:10 AM. The Housekeeping Manager stated he did not think the lint buildup, like what was found, was a safety concern even if lint was hanging down from the lint traps. Laundry Aide #1 stated she removed the lint from lint traps on the morning of 7/31/2026, but could not remember at what time, and felt like the lint could have built up in a two-hour period due to drying sheets and blankets the dryer. Laundry Aide #1 could not explain the buildup of lint that was found. The Housekeeping Manager indicated he agreed the buildup of lint like what was found could possibly have been from drying sheets and blankets and stated if the lint traps were to produce a buildup of lint remaining like what was found, the lint traps would need to be checked more than every two hours. The Housekeeping Manager stated he did not think the amount of lint discovered was a fire safety concern.An interview with the Administrator on 7/31/2026 at 12:05 PM revealed the lint traps should be checked for buildup of lint and with instruction from the Housekeeping Manager.

Based on observations, record reviews and interviews with staff, Nurse Practitioner (NP) and Medical Director, the facility failed to provide care in a safe manner when Resident #1 rolled out of her bed and hit the floor during incontinence care. Resident #1 was sent to the Emergency Department (ED) and diagnosed with an occult (subtle hip bone break often in older adults that often does not show up on imagining but causes pain, tenderness, and difficulty walking) nondisplaced (the bone breaks but maintains it proper alignment) left hip fracture, distal left femur fracture (fracture of the lower portion of the thighbone near the knee joint) and a left side scalp hematoma (bruise that occurs when blood pools outside blood vessels). The deficient practice occurred for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and dementia with agitation.Review of Resident #1's physician orders revealed an order dated 08/28/24 for clopidogrel bisulfate (antiplatelet) 75 milligrams (mg) one tablet by mouth one time a day. Antiplatelet medications can increase the risk of bleeding.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, required substantial assistance from staff for bed mobility and positioning and had no functional limitations on either side. The MDS also indicated that the Resident had no falls since the previous review and was not on an anticoagulant.The care plan last reviewed on 11/10/25 revealed Resident #1 had a self-care performance deficit in her activities of daily living (ADL) related to disease processes and was at risk for a decline in physical function related to limited mobility and dementia. The goal that Resident #1 would improve her current level of function would be attained by utilizing interventions such as encouraging the Resident to fully participate with each interaction, allowing for increased support as necessary and encouraging participation in skilled therapies when provided.Review of an Incident Report dated 11/24/25 at 10:30 AM and written by Nurse #2 revealed Nurse Aide (NA) #1 was in the process of cleaning Resident #1 up for the day when the Resident was asked to roll over. Resident #1 was asked to roll back over to NA #1 after the NA placed a pad onto the bed. The Resident was on her side facing the opposite direction. The Resident then rolled out of the bed and onto the floor instead of back towards the NA. Resident #1 stated, I rolled over like she asked me to. The Report continued to explain that Resident #1 was assessed by the Nurse Practitioner (NP) who determined that due to a head injury the Resident needed to be evaluated at the hospital. Resident #1's left leg appeared to be shorter than her right leg. Resident #1 remained on the floor until the emergency medical services (EMS) arrived.An interview was conducted with NA #1 on 12/18/25 at 10:10 AM. The NA explained that she was providing incontinent care for Resident #1 on 11/24/25 and after she put the brief and incontinent pad under the Resident, she asked Resident #1 to roll back over towards her, but the Resident rolled away from her instead and rolled off the bed onto the floor. The NA continued to explain that she had both of her hands under Resident #1 to hold the brief and pad down, but the Resident rolled over so fast that she did not have enough time to grab her before she fell off the bed. She reported that she went to Resident #1 who had landed halfway on her front and her left side between the two beds and asked her if she was hurt and the Resident stated her left arm hurt. The NA stated she immediately went and found Nurse #1 and asked him to come to Resident #1's room because she had fallen off the bed. She explained that when they returned to the Resident's room the Resident had blood coming from her head. The NA reported that the NP entered Resident #1's room within seconds after she and Nurse #1 arrived and started assessing the Resident for injuries. She stated Resident #1 was sent to the hospital for evaluation of her injuries. The NA explained that Resident #1 was a one person assist because she was able to roll herself over and hold onto the bed while incontinence care was being provided and she did not know why the Resident decided to roll in the opposite direction.An interview conducted with Nurse #1 on 12/18/25 at 10:40 AM. The Nurse explained that he was at the nurses' station when he was called to Resident #1's room by NA #1 who reported that the Resident rolled out of bed. He continued to explain that when he entered the Resident's room, he observed her lying between her left side and her front side on the floor between the beds with her left leg and right arm underneath her. The Nurse reported that the NP was seconds behind him and entered the room and immediately started to assess the Resident after which the NP and Nurse #1 rolled Resident #1 over onto her back. Nurse #1 stated that there was blood coming from the left side of the Resident's forehead, so they obtained some gauze while the NP rendered first aid and continued to assess Resident #1 for further injuries while Nurse #1 called 911.Review of a Progress Note written by Nurse #2 dated 11/24/25 at 10:33 AM revealed Resident #1 was in the middle of being cleaned up for the day when she was asked to roll over by NA #1. The Resident rolled over and continued to roll out of bed onto the floor. Resident #1 does not have bed rails on her bed. The NP was onsite and assessed Resident #1. The Resident presented with a large hematoma to the left scalp. The Resident's left leg appeared to be shorter than the right leg. Resident #1 was being sent out to the hospital to be evaluated per NP.Review of a Progress Noted written by Nurse #2 dated 11/24/25 at 10:30 AM revealed Resident #1 was being sent to the hospital for evaluation for post fall and possible fracture per the NP.Review of Resident #1's Emergency Department report dated 11/24/25 revealed a Computed Tomography (CT) of the pelvis that showed severe bone demineralization and a non-displaced left hip fracture and a distal left femur fracture. The CT scan of the skull showed no midline shifts of structures, no subarachnoid hemorrhage and no fractures. The scan showed hemorrhage (bleeding) in the frontoparietal scalp. The report indicated that orthopedics was consulted and Resident #1's family opted for no surgical intervention, so a knee immobilizer was placed. There was no orthopedic follow-up ordered for the Resident. Resident #1 was discharged back to the facility on [DATE] with orders for acetaminophen 500 mg by mouth four times a day for pain and tramadol 50 mg by mouth every six hours as needed for pain.Review of Resident #1's physician orders dated 12/04/25 revealed: wear immobilizer as Resident allowed.Review of Resident #1's Medication Administration Record for from 12/03/25 through 12/18/25 revealed the Resident received acetaminophen 500 mg by mouth four times a day routinely for pain. There was also an order for tramadol 50 mg by mouth every six hours as needed for pain dated 12/05/25. The tramadol had been given 4 times for extra coverage for pain.An observation and interview were conducted with Resident #1 on 12/18/25 at 9:30 AM. The Resident was lying on her back in bed with the head of her bed slightly raised. The bed had a concaved mattress (a mattress with raised sides) and no side rails. She had green and yellow bruising on her left forehead and face that appeared to be fading, and she wore an immobilizer on her left leg. Both legs were resting on a pillow. When Resident #1 was asked if she remembered falling, she replied in a low voice, No and when she was asked if she was in pain she pointed to her left leg. A sitter who stayed with Resident #1 reported that the Resident had recently received her pain medication.An interview was conducted with the Nurse Practitioner on 12/18/25 at 10:55 AM. The NP explained that she was summonsed to Resident #1's room by Nurse #1 when NA #1 informed Nurse #1 that the Resident had fallen off the bed. The NP went to the room to find Resident #1 lying on her abdomen and her left side and the Resident had a large hematoma on the left side of her forehead that was bleeding. The NP reported that she and Nurse #1 log rolled Resident #1 onto her back, and she asked the Resident if she had pain and Resident #1 stated her left leg was hurting but denied head pain. The NP continued to report that she assessed the Resident and found her left leg was shorter and internally rotated. She stated she advised Nurse #1 to call 911 while she applied a pressure bandage to stop the hematoma from bleeding. The EMS arrived shortly afterwards, and Resident #1 was transported to the hospital. The NP reported that Resident #1 returned to the facility with a left side forehead hematoma with no cranial bleed or fracture and a left mid-distal femoral fracture. She stated the Resident's bones were severely demineralized. The NP reported Resident #1's pain was controlled with routine and as needed pain medication and a long leg immobilizer that stayed in place except for bathing.An interview was conducted with Nurse #2 on 12/18/25 at 9:55 AM. The Nurse explained that she was assigned to Resident #1 on 11/24/25 but was not on the hall when the Resident fell off the bed. The Nurse reported that all the nurses received a message on their phone application from the NP to go to Resident #1's room stat (immediately), and when the Nurse entered the Resident's room, the NP and Nurse #1 were already in the room and working with Resident #1. Nurse #2 continued to explain that she observed Resident #1 lying on the floor on her back between both beds with her head pointed toward the roommate's bed. The left side of her forehead was bleeding. The Nurse reported that by that time, the NP was treating the Resident's bleeding, and the EMS had already been called. She stated Resident #1 was repeating, get me out of the floor and when Nurse #2 asked her what happened, the Resident stated, I rolled out of bed. Nurse #2 stated Resident #1 remained on the floor until the EMS came to transport her to the hospital which was within minutes.Review of a physician progress note dated 12/04/25 at 11:34 AM written by the Medical Director revealed Resident #1 had a fall with a head injury on 11/24/25 and was sent to the hospital and was noted to have a left mid/distal femoral shaft fracture. The Resident was seen by orthopedics, but she was non-ambulatory and family did not wish for surgery at this time.An interview was conducted with the Medical Director on 12/18/25 at 12:40 PM. The Medical Director explained that Resident #1 had a fall at the facility and was transported to the hospital where she was found to have a head injury, but the CT scan ruled out a subdural hematoma. She also sustained a fracture of the femur, but her family refused surgery. When the Medical Director was asked if he considered the Resident's injuries to be significant, he explained that he did not consider her injuries to be significant because she was not ambulatory before the fall and she was not ambulatory after the fall so he did not feel that the fracture hindered her quality of life. Multiple attempts were made to interview the ED Physician, but the attempts were unsuccessful.Interviews were conducted simultaneously with the Administrator and Director of Nursing (DON) on 12/18/25 at 2:55 PM. The DON explained that she felt like the fall was an unfortunate accident because Resident #1 was assessed to be a one person assist with incontinence care and bed mobility and she was able to roll over with little assistance and hold onto the bed frame by herself. She stated she felt that the Resident was confused when she was asked to roll back towards the NA and rolled in the opposite direction instead. The DON continued to explain that Resident #1's pain was being managed with routine acetaminophen and as needed tramadol when she would take it. She stated Resident #1 did not want to take other pain medications except for acetaminophen. The DON added that the Resident always wore the immobilizer. She continued to explain that skilled therapy orders were initiated to evaluate and treat Resident #1 when she returned to the facility. The DON added the NP will monitor Resident #1 for the healing fractures and obtain x-rays as necessary. The Administrator added that the facility has provided a sitter 24/7 for the time being until it was determined not to be necessary.The facility provided the following corrective action plan:The decision to monitor and QA incident was made on 11/25/25 at an AD HOC meeting.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:On 11/24/2025, Resident #1 was assessed immediately following the fall out of bed during incontinent care by the Nurse Practitioner. The Nurse Practitioner placed an order on 11/24/2025 to transfer the resident to the local hospital Emergency Department for further evaluation and treatment of a possible fracture. The resident's care plan was updated on 11/24/2025 by the nursing staff to require two-person assistance for all bed mobility tasks. On 11/24/2025, the Director of Nursing completed one-on-one education and a competency review with the Nurse Aide #1 involved in the incident regarding safe turning and positioning techniques. The resident's family and facility Nurse Practitioner were notified of the incident and the transfer to the hospital on [DATE]. The family was notified of the incident by Nurse #2. The Facility NP was notified of incident by Nurse #1. Completion Date: 11/25/20252. Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On 11/24/2025, the Assistant Director of Nursing reviewed all resident falls that occurred within the past 30 days to identify any incidents related to staff assistance with bed mobility. No additional concerns were identified during this review of falls. On 11/24/2025, the Minimum Data Set (MDS) Coordinator and Therapy Program Manager audited each resident's GG assessment Section (GG0170), care plan and resident care summaries for bed mobility to ensure accuracy and presence on the resident care summary for nursing staff reference. No additional negative findings were identified during the GG assessment, care plan and resident care summary audit.Completion Date: 11/25/20253. Address what measures will be put into place or systemic changes were made to ensure that the deficient practice will not recur:Beginning on 11/24/2025, the Director of Nursing provided in-service education to the nursing staff regarding the facility policy and procedure for turning and repositioning residents in bed. The education completed on 11/25/2025 included instruction to ensure staff are aware of the residents' bed mobility status listed on the resident care summary and to use the correct assistance level, such as one or two-person assistance. Staff were educated to be cautious when asking confused residents to follow commands during turning and positioning. Staff were instructed that it is acceptable to use more assistance if needed, but never less than what is documented on the resident care summary. On 11/24/25 Nurse Managers were educated by the Director of Nursing that newly hired and/or absent nursing staff will be educated by a Nurse Manager on these policies prior to accepting patient assignments. Care summaries are located on the inside of the door of the resident's closet. The care summary is updated daily by the MDS Nurse if any new changes are made. Staff are instructed to check the care summary every day/shift that they care for a resident since sheets may have been updated. On 11/25/25 the MDS Nurse was notified by the Director of Nursing of their responsibility to update the residents' care summary every day if changes have been made to their care summaries. Completion Date: 11/25/20254. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing or Designee will audit all falls out of bed to ensure no falls occurred because of improper turning and repositioning staff. These audits will be conducted five days a week for four weeks, then three days a week for four weeks as determined at the Ad HOC QAPI meeting on 11/25/25. The Director of Nursing or Designee will conduct the Skills Checklist for Bed Mobility/Positioning on Side with nursing staff across all shifts to ensure proper technique is utilized. The Nursing Assistant Clinical Skills Checklist and Competency Evaluation will be completed with five Certified Nursing Assistants per week for eight weeks across all shifts. Nurse Manager will observe all Certified Nursing Assistants to ensure they are turning and repositioning the resident correctly by utilizing the Nursing Assistant Clinical Skills Checklist and Competency Evaluation. The Nurse Managers were notified by the Director of Nursing on 11/25/25 to complete competency evaluations with staff and to review the amount of assistance that was needed prior to allowing staff to perform tasks. The Nurse Manager reviewed the amount of assistance that was needed prior to allowing staff to perform tasks. The Administrator or Designee will review the results of these audits and the plan during the monthly Quality Assurance and Performance Improvement (QAPI) meeting. The audits will continue at the discretion of the Quality Assurance and Performance Improvement committee based on compliance results. Date of Compliance: 11/26/2025 The facility's plan of correction was validated on 12/18/25 that included reviews of Resident #1's care plan to require a two person assist with bed mobility and turning, audits of falls within the past 30 days that occurred with staff assistance to ensure there were no issues and reviewed audits to ensure residents mobility assessments and care plans matched to the amount of assistance required. The review also included how education was provided with nursing staff through verbal instruction and return demonstration of the education. Interviews were obtained to verify the Nurse Managers were conducting the observations during their daily rounds of staff utilizing proper bed mobility and turning techniques and making sure the correct bed mobility assistance reflected the residents' care summary. The facility's compliance date of 11/26/25 was validated.

Based on manufacturer guidelines, observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors from 2 of 6 medication carts (100 and 200 Hall) and failed to label DuoNeb solution (inhalation breathing solution) with a open date and store DuoNeb solution according to the manufacturer's guidelines for 1 of 6 medication carts (200 Hall) reviewed for medication storage. The findings included: 1a. An observation was made of the 100 hall medication cart on 07/02/25 at 10:45 AM accompanied by Medication Aide (MA) #1. The cart yielded 20 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers. An interview conducted with MA #1 on 07/02/25 at 10:45 AM. The MA explained that it was every MA's responsibility to keep the carts clean, but he did not know if it was a rule or not. b. An observation was made of the 200 hall medication cart on 07/02/25 at 10:55 AM accompanied by MA #2. The cart yielded 41 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers. An interview was conducted with MA #2 on 07/02/25 at 10:55 AM. The MA explained that it was the MA's responsibility to keep the medication carts clean and orderly, but she did it most of the time. On 07/02/25 at 12:00 PM an interview was conducted with the Unit Manager who explained that it was each MA's responsibility to keep the carts clean and orderly and at one time they had vacuums to use to clean the carts, but she did not know if they had them anymore. An interview was conducted with the Director of Nursing (DON) on 07/03/25 at 11:00 AM. The DON explained that it was the MA's responsibility to keep the medication carts clean and she had an extra nurse to work third shift on 07/01/25 with the only responsibility to clean the medication carts. The DON stated it was her expectation that the medication carts be neat, clean and orderly. 2. Review of the manufacturer's guidelines for DuoNeb solution revealed the solution should be stored in the foil pouch to protect from light. After opening the foil pouch: Individual vials of DuoNeb should be used within 7 days once removed from the foil pack. Unused vials removed from the pouch should be protected from light and used within one week. On 07/02/25 at 11:40 AM an observation was made of the 200 Nurse medication cart accompanied by Nurse #1. The cart yielded 5 DuoNeb inhalation vials loosely stored in a plastic cup. The vials were not in a foil package or dated when they were removed from the foil pack. An interview was conducted with Nurse #1 on 07/02/25 at 11:40 AM. The Nurse explained that she did not know who the DuoNeb solution belonged to, nor did she know how the solution should be stored. The Nurse stated that the solution should be dated when opened. On 07/02/25 at 12:00 PM an interview was conducted with the Unit Manager who explained that it was each nurse's responsibility to keep the carts clean and orderly. The Unit Manager stated the DuoNeb solution should be kept in the foil pouch and dated when opened. An interview was conducted with the Director of Nursing (DON) on 07/03/25 at 11:00 AM. The DON explained that it was the MA's responsibility to keep the medication carts clean and she had an extra nurse to work third shift on 07/01/25 with the only responsibility to clean the medication carts. The DON stated it was her expectation that the medication carts be neat, clean and orderly and the DuoNeb solution should be dated when open and stored in the foil pouch.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with mental health disorders for 1 of 2 residents reviewed for PASRR (Resident #33). Findings included: A PASRR Determination Notification letter dated 09/23/20 revealed Resident #33 had a Level I PASRR with no expiration date. Resident #33 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder and dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident 33's electronic medical record revealed the following active physician orders: *04/28/25: Quetiapine fumarate (antipsychotic) 100 milligrams (mg) in the evening for bipolar disorder. *04/28/25: Sertraline (antidepressant) 100 mg at bedtime for bipolar/depression. *04/28/25: Trazodone (antidepressant) 100 mg at bedtime for restlessness. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #33 received antipsychotic and antidepressant medications during the MDS assessment period. A North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 07/02/25 revealed Resident #33 had a Level I PASRR effective 09/30/20. There were no requests for a PASRR reevaluation submitted or completed since 09/30/20. During an interview on 07/02/25 at 3:02 PM, the Social Worker (SW) revealed Resident #33's request for a PASRR reevaluation was overlooked. The SW explained she was not always informed when a resident admitted with mental health diagnoses and had she been aware, she would have submitted a request for a Level II PASRR reevaluation for Resident #33. During an interview on 07/03/25 at 8:07 AM, the Administrator revealed the SW was responsible for submitting PASRR reevaluation requests when needed. The Administrator stated she had completed a PASRR audit on 04/16/25 that was reviewed with the SW to determine if there were any PASRR reevaluation requests that needed to be submitted. The Administrator explained that a request for a Level II PASRR reevaluation should have been submitted for Resident #33 but hers was overlooked due to her admitting to the facility after the PASRR audit had been completed.

Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #1) and 1 of 1 resident (Resident #22) reviewed for anticoagulant medication. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of Resident #1's physician orders revealed orders dated 05/15/23 for gabapentin (an anticonvulsant) 100 milligrams (mg) by mouth twice a day for diabetic neuropathy (nerve damage) and metformin (a hypoglycemic) 500 mg by mouth once a day for diabetes mellitus dated 05/09/23. Review of Resident #1's Medication Administration Record for 04/01/25 through 04/30/25 revealed the Resident received gabapentin 100 mg by mouth twice a day and metformin 500 mg by mouth once a day as ordered. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the MDS was not coded as receiving an anticonvulsant or a hypoglycemic medication. On 07/03/25 at 10:08 AM an interview was conducted with MDS Nurse #1 who reviewed Resident #1's quarterly MDS dated [DATE] and acknowledged the MDS was coded as not receiving an anticonvulsant or a hypoglycemic medication and stated she did not know why she miscoded the MDS but agreed the MDS was coded in error. On 07/03/25 at 11:00 AM an interview was conducted with the Administrator who stated she expected the MDS assessments to be completed accurately. 2. Resident #22 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation. Review of Resident #22's physician orders for 06/10/25 revealed the Resident was not prescribed an anticoagulant (blood thinner) medication. Review of Resident #22's Medication Administration Record for 06/01/25 through 06/30/25 revealed the Resident did not receive an anticoagulant medication. Review of Resident #22's quarterly MDS assessment dated [DATE] revealed the MDS was coded as receiving an anticoagulant medication. On 07/03/25 at 10:08 AM an interview was conducted with MDS Nurse #2 who reviewed Resident #22's 06/15/25 quarterly MDS and acknowledged the MDS was miscoded as receiving an anticoagulant medication and stated she coded the MDS in error. On 07/03/25 at 11:00 AM an interview was conducted with the Administrator who stated she expected the MDS assessments to be completed accurately.

Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #17 asked Nurse Aide (NA) #1 multiple times to let go of his right arm during incontinent care and when she did not Resident #17 pulled his right arm away from NA #1 and during the interaction received a small skin tear with a red/purple bruise that was approximately the size of a half dollar on his right forearm for 1 of 3 residents reviewed for accidents. Resident #17 stated that NA #1 ignored his request to let go of his arm and then laughed at him. The skin tear required a treatment with calcium alginate (dressing used for management of draining wounds) three times weekly and as needed. The findings included: Resident #17 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, cognitive communication deficit, hypertension, diabetes, heart failure, and chronic obstructive pulmonary disease. Review of a physician order dated 11/06/23 read, Aspirin 81 milligram (mg) by mouth every day. Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact for daily decision making and had verbal behaviors 1 to 3 days, was frequently incontinent of bladder and required extensive assistance of two staff members for bed mobility. A care plan revised on 04/03/24 read, Resident #17 has a behavior problem. At increased risk for falls/injury related to overt behaviors, noncompliant with medication and treatments frequently. The goal read; Resident #17 will have no evidence of behavior problems by the review date. The interventions included: administer medications as ordered, caregivers to provide opportunities for positive interactions and attention, monitor behavior episodes and attempt to determine underlying cause (consider location, time of day, persons involved, and situation), and praise any indication of the resident's progress/improvement in behavior. An observation and interview were conducted with Resident #17 on 05/12/24 at 11:00 AM, Resident #1 was resting in bed with his head of bed elevated and had a long sleeve flannel shirt on and was covered with a sheet. Resident #17 reported that at approximately 3:00 AM he was awakened by the Nurse Aide (later identified as NA #1) who stated she was going to change him. Resident #17 stated she grabbed my right arm while standing on the left side of the bed and was trying to turn him towards her but because of her girth he could not turn over and I kept telling her that she was hurting my arm, and she would not let go so I had to pull my arm away from her. Resident #17 pulled up the right sleeve of his flannel shirt to reveal a dime size red/purple bruise that had a small 2 x 2 bordered gauze over it. He reported that the nurse (Nurse #1) had put the dressing on this morning. Resident #17 stated that NA #1 was in his room alone that night with no other staff present. Nurse #1 was interviewed on 05/12/24 at 11:30 AM who stated that Resident #17 reported when NA #1 was changing him through the night she held his arm too tight, and he had a discolored area and a small skin tear. Nurse #1 stated she had cleaned the area and put a gauze over the area. NA #1 was interviewed via phone on 05/13/24 at 12:09 PM, she confirmed that she had worked on Saturday night (05/11/24) to Sunday (05/12/24) morning and was caring for Resident #17. She explained that she was not very familiar with Resident #17 and had only cared for him while in training with NA #2 for one shift. NA #1 stated that he gave me a hard time that night and NA #2 told Resident #17 to be nice referring to the first time she cared for Resident #17 while in training. She added, Resident #17 did not like me from day 1. NA #1 stated that she went into Resident #17's room on 05/12/24 but could not recall the time and asked to check him and see if he was soiled and he agreed. She stated his blanket was on the floor, so she picked it up and placed it at the foot of the bed because she was getting ready to change Resident #17. NA #1 stated I grabbed his elbow and turned him towards me, and he said why are turning me so fast? NA #2 replied in a jovial manner I am not turning you fast, but I am sorry. When NA #1 was asked which elbow she grabbed she replied, I did not grab his elbow, I had one hand on his shoulder and one hand on his hip and when asked to explain why she stated previously she stated she had grabbed his elbow she replied, I never grabbed his elbow, and he had a place on his wrist already. NA #1 stated that Resident #17 was insistent that she put cream on his bottom but the only cream he had was for arthritis and she told him she would finish caring for him and ask the nurse about the cream. NA #1 stated that she closed Resident #17's brief, put the sheet and blanket on him, and lowered his bed and went and told Nurse #3 that Resident #17 was fussing a me and she stated, he does that to everyone. NA #1 again stated, I never had my hand on his right arm, his skin looks like it tears easily, and he had something on his wrist already. He had on long sleeves, and he called the nurse, and she inspected his wrist, but I did not touch his arm. An observation and interview were conducted with Resident #17 on 05/13/24 at 1:10 PM. Resident #17 was resting in bed with his head of bed elevated and was alert and verbal. Resident #17's right forearm continued to have a red/purple bruise that extended to the size of a quarter and continued to have a small, bordered gauze covering the skin tear. Resident #17 was asked to repeat how the skin tear and bruise occurred. Resident #17 stated, that girl was about 300 pounds which isn't her fault, and she grabbed my right arm and tired to turn me into her but because of her stomach I could not turn over anymore and I told her she was hurting my arm and to let go and she just ignored me and laughed at me. I reached over and removed her hand and pulled my arm away and there was red place where she had ahold of my arm. Resident #17 confirmed that NA #1 was alone in the room providing care to him that night. He explained the first night NA #1 had taken care of him she was training and was with NA #2 but this night 05/12/24 she was by herself. A review of Resident #17's medical record on 05/13/24 revealed no documentation of the incident, or red/purple bruise or skin tear. The medical record contained no order for treatment of the skin tear. The Administrator was interviewed on 05/13/24 at 5:45 PM. She stated that she was unaware of the incident with Resident #17 and NA #1 but stated that there should be documentation of the skin tear in his medial record. The Administrator was made aware that there was no documentation of the skin tear or incident in Resident #17's medical record. Review of a progress note written by the Administrator on 05/13/24 at 7:15 PM read, spoke with Resident #17 about skin tear on right forearm. Resident stated that when NA was changing him, she began to roll him to his left side, he stated he pulled his arm loose from her and grabbed her arm to make her turn loose. He said he did it because she was not allowing him to assist with rolling. Unit Manager (UM) #2 was interviewed on 05/14/24 at 9:42 AM, she stated that she was instructed by the Administrator to go and talk to Resident #17 late in the evening on 05/13/24. She stated that Resident #17 stated the aide got ahold of his arm and pulled him over, and I pulled away from her and that is what probably caused the skin tear. UM #2 stated to Resident #17 that NA #1 was trying to help and when UM #2 was asked why Resident #17 would have to pull away from NA #1, she replied that is just Resident #17. An observation and interview were conducted with Resident #17 on 05/14/24 at 3:36 PM. He was observed to have a small dressing on his right forearm with a red/purple bruise that was now the size of half dollar. Resident #17 stated, I forgot to tell you that I have a pulled muscle in that arm and that was why it hurts when they grab it. Resident #17 stated three ladies have been down here to talk to me about the incident and I told them the same thing I told you. Resident #17 was asked to explain what happened again, he stated she had me by my arm pulling me toward her and I kept telling her to let me go and she ignored me and laughed at me and finally it got to hurting and I had to make her turn me loose. He again confirmed that NA #1 provided care to him that night by herself. The Director of Nursing (DON) was interviewed on 05/14/24 at 5:03 PM. She stated that UM #2 went down and talked to Resident #17 and the story she got was it occurred during turning and repositioning and Resident #17 reached out and grabbed NA #1's her arm to remove her hand from his arm and that was what caused the skin tear/bruise. The DON stated she called Nurse #1 and asked her why she did not do the incident report or the change in condition and made her come back to the facility to complete them. She also stated that she spoke to NA #1 who stated she had her hand on Resident #1's shoulder and hip and that was how she rolled him and when he complained of pain, she (NA #1) reported to Nurse #3 who looked at Resident #17's arm and stated that there was nothing there except two scabbed area. The DON added she had UM #1 go and talk to Resident #17 as well and she got the same story. The DON stated she did not feel the incident was abuse and she believed that Resident #17 caused the area when he jerked his arm away from NA #1. Nurse #3 was interviewed via phone on 05/15/24 at 6:28 AM who confirmed that she worked Saturday night (05/11/24) into Sunday Morning (05/12/24). She stated that the only thing NA #1 reported to her was that Resident #17 was being rude to her and was being non complaint with incontinent care and she told NA #1 to not take it personal. Nurse #3 stated that Resident #17 was do a blood sugar check on Sunday morning so around 6:30 AM she went in to check his blood sugar. Resident #17 stated to Nurse #3, when these aides roll me from my arms they hurt me. She stated he unbuttoned his right sleeve and showed me 2 spots near his elbow that were scabbed over, and I asked him if those happened with NA #1, and he said no. Nurse #3 stated Resident #17 usually required two staff members so that they always had a witness, but this night NA #1 was in there by herself. A follow up interview was conducted with the Administrator and DON on 05/15/24 at 10:42 AM. The Administrator stated they completed a grievance on the issues, talked to Resident #17, talked to his family, and at his request they added grab bars to Resident #17's bed to aide in turning and repositioning. The Administrator stated that she had spoken with Resident #17 as did the DON and explained that Resident #17 had a history of telling different stories to different people. They spoke to NA #1 and Nurse #3 and the incident report was completed as was the change in condition. The Administrator stated that NA #1 told her that she did nothing with his arm and she rolled him with his shoulder and hip and he was fighting against her and he jerked his arm away from her. Nurse #3 saw 2 scabbed areas. The Administrator stated did not identify this as abuse but that she would start their investigative process. The DON stated that Nurse #1 did not report the issue and had not completed the incident report which was where she would have caught the potential abuse situation. A follow up interview with Nurse #1 was completed on 05/15/24 at 11:46 AM via phone. She stated she had not completed the incident report because the incident occurred on third shift, and she thought Nurse #3 had completed the required information. She confirmed that Resident #17 reported to her on Sunday 05/12/24 that the aide had held his arm too tight during incontinent care and he needed a dressing put on his forearm. She further explained that Resident #17 stated that he may have caused the area when he pulled his arm from her. Nurse #1 stated she did not think that was abuse or she would have immediately reported it to the DON. UM #1 was interviewed via phone on 05/15/24 at 12:41 PM. She stated she had spoken to Resident #17 about the skin tear and bruise on his right forearm. He reported that the girl was rolling me over towards the window and she grabbed my arm and he pulled his arm away from her stating that he wanted to do it on his own. UM #2 stated that was the only conversation she had with Resident #17 regarding the incident. The Wound Nurse (WN) was interviewed on 05/15/24 at 1:08 PM. She stated Resident #17's skin tear to his right forearm was draining serosanguinous (clear) drainage and she was using a calcium alginate product that was gentle on the skin and less likes to tear the skin when removed. The Nurse Practitioner was interviewed on 05/15/24 at 2:32 PM. She stated she had evaluated and spoke to Resident #17 who reported that the aide tried to roll him over and he told her to let him go so he could show her how to roll him and he pulled his arm away. The NP stated that calcium alginate was very appropriate for treatment of the skin tear.

Based on observations, record reviews and staff interviews, the facility failed to remove expired medications available for use from a medication refrigerator in 1 of 1 medication room reviewed for medication storage. The findings included: A review of the manufacturer's recommendation for Purified Protein Derivative (PPD) storage, PPD vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 05/14/24 at 11:25 AM during an observation of the medication room refrigerator with Nurse #2 and Unit Manager (UM) #1 the observation yielded 2 open vials of PPD solutions. One vial was in a box with an open date of 04/01/24 printed on the box and one vial was in a box in a plastic pouch with an open date of 04/03/24 printed on the box. During interviews with both the Unit Manager and Nurse #2 on 05/14/24 at 11:25 AM neither nurse knew how long the PPD solution could be used after opening. The UM explained that she inspected the refrigerator the previous evening and there was one PPD vial in the refrigerator, but the solution was not out-of-date. The UM stated she could not remember the date on the vial or if the vial was in a box or plastic pouch. The UM left the medication room and returned at 11:28 AM and reported the PPD solution was good for 30 days after opening. An interview was conducted with the Director of Nursing (DON) on 05/14/24 at 11:31 AM. The DON was informed of the findings in the medication room refrigerator and the DON stated the Unit Manager had looked in the refrigerator the prior evening and did not find any out-of-date PPD solution.

Based on observations, record reviews and staff interviews, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without knowledge of the staff. On 04/23/24 between the hours of 6:00 PM and 7:00 PM Resident #325 was observed by Nurse Aide (NA) #2 in the back parking lot walking away from the building approximately 30 yards away from the exit door. The findings include: Resident #325 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, hypertension, atrial fibrillation and cerebral vascular accident (CVA). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #325's cognition was severely impaired, and she ambulated independently with a walker. No wandering behaviors were noted during the observation period. On 05/12/24 at 6:30 AM during an interview with Nurse Aide (NA) #2 the NA explained that one evening of 04/23/24 he was working second shift instead of his normal third shift and was assigned to the hall that Resident #325 resided on which was the first time he had worked with the Resident. The NA described Resident #325's behavior that day as having to be redirected multiple times back to her room. He continued to explain that after he collected the supper trays, he took the meal cart back to the kitchen and on his way, he stopped at the nursing desk to inform Nurse #4 who was the Nurse on the hall that he was going to take his break. The NA reported when he came back from the store and was sitting in his car in the back parking lot, he saw Resident #325 walking away from the building toward his car approximately 30 yards from an exit door holding a plastic bag with her clothes in it with no staff following her. NA #2 stated he did not know which exit door the Resident went out of to leave the facility. The NA stated he redirected Resident #325 to the entrance door to the service hall and as they approached the door Nurse #4 and Nurse #5 were running up to them to bring the Resident back inside the facility. NA #2 reported he did not know which exit door Resident #325 left out of, but he heard that it was determined to be the exit door at the end of 400 hall which was the hall the Resident resided on. The NA stated he did not notice any cuts or bruises on Resident #325 that would indicate she had fallen while outside the facility. An observation of the back parking lot was made on 05/12/24 at 6:47 AM. The back parking lot contained a flat black top surface that was surrounded by a wooded lot. The parking lot contained several parking spaces that staff used but no other obstacles, structures, or hazards were noted. An interview was conducted with Nurse Aide #3 on 05/12/24 at 12:19 PM. The NA explained that she did not remember the day, but she was on 100 hall and looked out the exit door at the end of the hall and noticed a resident bending over to pick up something from the ground behind a truck. When the Resident stood up, she realized that she was one of the residents and went toward the nursing desk to alert the nurses when as she passed the service hall she noticed NA #2 bringing the Resident back into the building. By that time the NA stated the nurses were at the service hall and met NA #2 with the Resident. An interview was conducted with Nurse #4 on 05/12/24 at 9:51AM who confirmed she was the Nurse on the hall when Resident #325 left the building unsupervised on 04/23/24. The Nurse explained that the Resident was acting like her usual self that evening in that she was pleasantly confused and would piddle around in her room and mess in her drawers which was what she always did. The Resident ate her supper meal sitting in her chair in her room. Nurse #4 continued to explain that she and Nurse #5 were sitting at the nursing desk when NA #2 stopped by to let her know that he would be taking his break after he delivered the meal cart back to the kitchen. Approximately 10-15 minutes later Nurse Aide #3 was down on 100 hall hollered up to the desk and asked if we had a resident walking around outside. At that time Nurse #4 and Nurse #5 ran to the service hall and out the door to find Nurse Aide #2 had already gotten to Resident #325 and was bringing her back into the building. Nurse #4 reported the Resident was carrying a water pitcher and a bag of clothes and she was wearing a sweat outfit of a pink top and gray pants and shoes. The Nurse explained that they got a wheelchair and took her back to her room where she conducted a full body skin assessment to determine if she had fallen when she was outside and there were no areas like cuts or bruises noted on her skin assessment. The Nurse stated after the skin assessment Resident #325 sat in her chair in her room for a while then went to bed where she stayed for the rest of the shift (11:00 PM). Nurse #4 reported that as she assessed the Resident, Nurse #5 called the facility management to inform them of Resident #325 exiting the building. She stated the management came to the facility and a resident head count was conducted to ensure every resident was accounted for. The Nurse continued to explain that the management team investigated the incident and determined Resident #325 exited the building from the exit door at the end of 400 hall because they found the door had been left unlocked. A review of Resident #325's progress note dated 04/23/24 at 9:56 PM written by Nurse #5 read wander guard placed to left ankle at this time. Checked the device to make sure it was working properly. On 05/13/24 at 11:45 AM during an interview with Nurse #5, the Nurse explained that he was at the nursing desk with Nurse #4 when NA #3 called to the desk that a resident was outside in the parking lot. When he and Nurse #4 got to the service hall NA #2 was bringing Resident #325 back into the building. They put her in a wheelchair and took her to her room where Nurse #4 did a head-to-toe assessment to determine if there were any injuries on her and there were no injuries on the Resident. Nurse #5 continued to explain that the management team was notified of the Resident exiting the facility and soon after the management team arrived at the facility. The Nurse stated he applied a wander guard bracelet on Resident #325's left ankle and made sure the device was working properly. He reported they conducted a resident head count to make sure all the residents were accounted for, then they started an investigation to determine how Resident #325 got out of the facility. When they checked all the exit doors to ensure they were locked they found that the exit door at the end of 400 hall was unlocked therefore they determined Resident #325 left out of that door. Nurse #5 described Resident #325 as being pleasantly confused and liked to piddle around in her room or near her room but that he had not known of her having exit seeking behaviors. On 05/13/24 at 1:29 PM during an interview with the Maintenance Supervisor (MS) the Supervisor stated that on the evening of 04/23/24 he was called back to the facility because Resident #325 was discovered outside the building. He explained that he completed an investigation of all the exit doors and found that the exit door at the end of 400 hall where the Resident resided was unlocked. He continued to explain that the power to the exit door was turned off and the switch was in the off position. He continued to explain that you must have a key to unlock the door and the key was in the unlocked position as well. The MS reported that the only time the door was unlocked was for deliveries and the oxygen company delivered oxygen supplies earlier that same day and he was the one who unlocked the door for the delivery. The MS stated he stayed at the door during the delivery and made sure he locked the door after the delivery was complete. The MS continued that the door had a screamer alarm and when the cover was raised it should have made a loud sounding alarm, but no staff admitted to hearing an alarm during the evening shift. The MS explained in response to the incident he made two rounds every day on all the exit doors to ensure the doors were locked and when he was not at the facility the weekend office staff made the rounds in his place. He also added the facility was in the process of installing cameras throughout the facility as well. An interview was conducted with the Wound Nurse on 05/13/24 at 1:05 PM. She explained that the management team was called back to the facility on the evening of 04/23/34 because Resident #325 had gotten out of the facility unsupervised. It was determined that she exited the facility from the exit door at the end of 400 hall because the door was not locked. The Nurse stated she conducted a head-to-toe assessment on Resident #325 when she returned to the facility and found no indication of injuries that she could have attained through a fall or injury. Interviews were conducted with the Nurse Practitioner (NP) on 05/13/24 at 12:23 PM and 3:26 PM. The NP explained that Resident #325 had a history of a brain bleed (CVA) that left her cognition impaired, but she was physically getting stronger with her ambulation. She continued that she was notified by the facility the evening of 04/23/24 that Resident #325 exited from the building, and she visited the Resident the next day. The NP performed a thorough assessment on the Resident and found no skin tears or injuries. The facility conducted a complete resident count and checked the exit doors and wander guards. They moved Resident #325 to the locked unit shortly after that. The NP stated that because of her history and poor safety awareness Resident #325 was not cognitively safe to be outside on her own. An interview was conducted with the Medical Director (MD) on 05/14/24 at 12:23 PM. The MD explained that Resident #325 had a history of spontaneous brain hemorrhage which left her cognition compromised but she was progressing slowly physically with skilled therapies. He continued that he saw the Resident during his rounds on the Tuesday (04/23/24) and Thursday (04/18/24) prior to the incident and found her to be as her normal behavior of walking from chair to chair. The MD reported that he was notified the evening of the incident and was informed that they would be moving Resident #325 to the locked unit on 300 hall which he stated was more appropriate for her. A review of Resident #325's progress note dated 04/26/24 at 4:23 PM written by the Director of Nursing read interdisciplinary team (IDT) meeting held to discuss Resident ambulating outside. The Resident was moved to 300 hall locked unit and a wander guard bracelet was applied. The Resident has adjusted well and seems to like her new room. No further concerns at this time. An interview was conducted with the Director of Nursing (DON) on 05/13/24 at 2:18 PM. The DON explained that Resident #325 was alert but confused and mainly piddled around in her room which was nothing out of the ordinary. She was not on their radar of wandering. The DON continued that on the evening of 04/23/24 she was notified by Nurse #5 that Resident #325 was found outside of the facility in the back parking lot and was brought back inside the building. She explained that she instructed them to do a head-to-toe assessment on the Resident and do a resident head count to ensure all the residents were accounted for. The DON stated that by the time she arrived at the facility Nurse #4 or Nurse #5 had discovered that the exit door at the end of 400 hall was unlocked and locked it back. She reported that by that time most of the management team was at the facility, and she instructed the Wound Nurse to conduct another head-to-toe skin assessment on Resident #325 and found nothing. The DON explained at that time they conducted a reenactment of the situation and had NA #2 and both Nurses #4 and #5 walk them through the entire situation and it was determined that Resident #325 left the facility out of the unlocked exit door at the end of 400 hall since that was the only exit door found unlocked. The DON reported the last time the 400 hall exit door was known to be used was earlier in the day when the Maintenance Supervisor unlocked it for the oxygen company to deliver the oxygen. She stated the Maintenance Supervisor insisted that he locked the door back but there was no other explanation as to why the door was unlocked since the door required a key and a code to unlock the door. The DON stated she had Nurse #5 place a wander guard bracelet on Resident #325, and she called the Resident's family member and explained the situation to them. She informed the family member of the situation and that they had placed a wander guard bracelet on the Resident and that they wanted to move her to the locked unit for her protection which they did move the Resident to the unlocked unit. The DON reported that she notified the Nurse Practitioner that evening. The DON added that the facility was in the process of installing cameras facility wide for surveillance. During an interview with the Administrator on 05/13/24 at 2:50 PM. The Administrator explained that she was notified of Resident #325's elopement by the DON on the evening of 04/23/24 and had the management team return to the facility for the investigation. She continued to explain that through a reenactment with the staff involved they determined the Resident left the building through the exit door at the end of 400 hall which was found unlocked at the time of the incident. She reported at that time the only time the exit door was used was when the oxygen company delivered oxygen once a week and they happened to deliver oxygen earlier that same day as the elopement. She stated the only explanation was that the door had mistakenly been left unlocked. The Administrator reported to ensure Resident #325's safety they placed a wander guard bracelet on her and moved her to the locked unit. The Administrator continued to explain that the facility developed a plan of correction that included the exit door at the end of 400 hall was not used for anything including the oxygen company delivery and that all deliveries had to go through the front main entrance. The facility provided the following corrective action plan with the completion date of 04/25/24. All items listed on this self-imposed action plan were complete and implemented on 04/23/24 with ongoing monitoring to ensure compliance. This includes the action plan and any potential citation associated with this action plan should be considered past noncompliance as of 04/25/24. The facility identified concerns regarding Resident #325 exited side door and observed in the parking lot by staff and returned to the facility without issue on 04/23/24. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: On 04/23/24 Resident #325 was assisted into the facility by CNA and assessed by licensed nurse with no injury noted. On 04/23/24 licensed nurse notified responsible party and medical provider of incident. On 04/23/24 Resident #325's elopement assessment was updated by licensed nurse to reflect current wandering behaviors. On 04/23/24 an order for wander guard device obtained from provider by licensed nurse and applied to the Resident. On 04/23/24 the Resident's photograph was placed in the Elopement risk book at the front desk and nurses' station. On 04/23/24 the Resident's care plan was updated by licensed nurse to reflect new orders and new behaviors. On 04/23/24 all exit doors were checked by the Maintenance Director to validate that doors were functioning/locked/alarming properly with any unlocked / non alarmed door reset to ensure proper locking and alarming. On 04/23/24 Administrator educated the Maintenance Director on assurance of locking/alarming doors after any vendor enters the facility. IDENTIFICATION OF OTHER RESIDENTS: On 04/23/24 licensed nurses conducted a 100% audit of current residents to validate all residents were accounted for. All residents were present and accounted for. On 04/23/24 licensed nurses reviewed wandering assessments for all current residents to ensure appropriate interventions are in place for those residents identified as a wandering risk. No one was out of compliance, but we did identify a resident who had a change of status, and we placed a wander guard bracelet on her. On 04/23/24 the licensed nurses conducted an audit of residents identified with wander guard bracelets to validate that the bracelets were in place and functioning. MEASURES FOR SYSTEMIC CHANGE: The process to address residents identified with new behavior of wandering or exit seeking was updated to include Educated all staff to notify management if a resident begins to have new behaviors of wandering or exit seeking. When management is notified, a new assessment will be completed to determine if a wander guard needed to be initiated. Process to address all doors checked whenever vendor enters/exits to ensure locked, and alarm activated: Maintenance Director was educated by the Nursing Home Administrator on 04/23/24 regarding validation of exit door lock and alarm after use and routine checks twice daily on all exit door locks and alarms. The Administrator will appoint another Department Head if the Maintenance Director is absent/vacation and the weekend receptionist responsible for doing checks on weekends. Director and/or Administrator completed education for all staff on or before 04/24/24 regarding identification of and response to residents with exit seeking behaviors, missing residents and process to check that doors are properly secured. Education will be provided for all new hires in orientation. HOW CORRECTIVE ACTION WILL BE MONITORED: The decision to formulate how the corrective action will be monitored was made on 04/23/24. The Director of Nursing and or the Administrator will review progress, wandering assessments and 24-hour reports 5 days a week times 4 then 3 times a week for 2 months to identify residents with wandering or exit seeking behaviors and validate that appropriate interventions are initiated. The Administrator will audit the exit door securement logs five days a week for four weeks and then weekly for eight weeks to ensure twice daily checks completed. The Administrator and or Director of Nursing will review the audit to identify patterns and trends and will adjust the plan to maintain compliance. The Administrator and or Director of Nursing and interdisciplinary team inclusive of Medial Director and or the Nurse Practitioner held an ad hoc QAPI to review incident and root cause analysis in its entirety with proposed plan of correction interventions. The Administrator or Director of Nursing will review the plan during the monthly QAPI meeting, and the audits will continue at the direction of the QAPI committee. Validation Statement: During the recertification and complaint survey investigation the facility provided information through observations and interviews from staff to support the facility conducted a 100 % audit of resident census on 04/23/24 after Resident #325 was discovered outside the building in the back parking lot. The facility also provided information such as exit door audits twice a day, 100% facility wide education to current employees and new hires on the new process, the elopement risk assessments and the updated elopement notebook and the clinical morning meeting of discussion of the information and audits conducted. The completion date of 04/25/24 was validated.

Based on observation, record review, resident, and staff interview this facility failed to identify abuse and then failed to implement and follow their abuse policy and procedures in in the areas of reporting and protection for 1 of 3 residents reviewed for accidents (Resident #17). The findings included: Review of the facility's Abuse and Neglect Protocol revised on 06/13/21 read in part, any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. A complete copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator immediately after the occurrence. If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours after forming the suspicion if the event that caused the suspicion resulted in serious bodily injury, or not later than 24 hours if the events that caused the suspicion do not result in serious bodily injury to designated state agency. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the state agency within 5 working days or as designated by state law. Employees of this facility who have been accused of resident abuse shall be suspended from duty until the results of the investigation have been reviewed by the Director of Nursing/Designee or Administrator. Resident #17 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, cognitive communication deficit, hypertension, diabetes, heart failure, and chronic obstructive pulmonary disease. Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact for daily decision making and had verbal behaviors 1 to 3 days, was frequently incontinent of bladder and required extensive assistance of two staff members for bed mobility. An observation and interview were conducted with Resident #17 on 05/12/24 at 11:00 AM, Resident #1 was resting in bed with his head of bed elevated and had a long sleeve flannel shirt on and was covered with a sheet. Resident #17 reported that at approximately 3:00 AM he was awakened by the Nurse Aide (later identified as NA #1) who stated she was going to change him. Resident #17 stated she grabbed my right arm while standing on the left side of the bed and was trying to turn him towards her but because of her girth he could not turn over and I kept telling her that she was hurting my arm, and she would not let go so I had to pull my arm away from her. Resident #17 pulled up the right sleeve of his flannel shirt to reveal a dime size red/purple bruise that had a small 2 x 2 bordered gauze over it. He reported that the nurse (Nurse #1) had put the dressing on this morning. Resident #17 stated that NA #1 was in his room alone that night with no other staff present. Nurse #1 was interviewed on 05/12/24 at 11:30 AM who stated that Resident #17 reported when NA #1 was changing him through the night she held his arm too tight, and he had a discolored area and a small skin tear. Nurse #1 stated she had cleaned the area and put a gauze over the area. The Administrator was interviewed on 05/13/24 at 5:45 PM. She stated that she was unaware of the incident with Resident #17 and NA #1 but stated that there should be documentation of the skin tear in his medial record. The Administrator was made aware that there was no documentation of the skin tear or incident in Resident #17's medical record. The Director of Nursing (DON) was interviewed on 05/14/24 at 5:03 PM. She stated that Unit Manager (UM) #2 went down and talked to Resident #17 and the story she got was it occurred during turning and repositioning and Resident #17 reached out and grabbed NA #1's her arm to remove her hand from his arm and that was what caused the skin tear/bruise. The DON stated she called Nurse #1 and asked her why she did not do the incident report or the change in condition and made her come back to the facility to complete them. She also stated that she spoke to NA #1 who stated she had her hand on Resident #1's shoulder and hip and that was how she rolled him and when he complained of pain, she (NA #1) reported to Nurse #3 who looked at Resident #17's arm and stated that there was nothing there except two scabbed area. The DON stated she did not feel the incident was abuse and she believed that Resident #17 caused the area when he jerked his arm away from NA #1. A follow up interview was conducted with the Administrator and DON on 05/15/24 at 10:42 AM. The Administrator stated they completed a grievance on the issues, talked to Resident #17, talked to his family, and at his request they added grab bars to Resident #17's bed to aide in turning and repositioning. The Administrator stated that she had spoken with Resident #17 as did the DON and explained that Resident #17 had a history of telling different stories to different people. They spoke to NA #1 and Nurse #3 and the incident report was completed as was the change in condition. The Administrator stated that NA #1 told her that she did nothing with his arm and she rolled him with his shoulder and hip, and he was fighting against her, and he jerked his arm away from her. Nurse #3 saw 2 scabbed areas. The Administrator stated she did not identify this as abuse but that she would start their investigative process which included interviewing the resident, staff, suspending NA #1, and reporting to the appropriate agencies. The DON stated that Nurse #1 did not report the issue and had not completed the incident report which was where she would have caught the potential abuse situation. A follow up interview with Nurse #1 was completed on 05/15/24 at 11:46 AM via phone. She stated she had not completed the incident report because the incident occurred on third shift, and she thought Nurse #3 had completed the required information. She confirmed that Resident #17 reported to her on Sunday 05/12/24 that the aide had held his arm too tight during incontinent care and he needed a dressing put on his forearm. She further explained that Resident #17 stated that he may have caused the area when he pulled his arm from her. Nurse #1 stated she did not think that was abuse or she would have immediately reported it to the DON.

Based on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the Recerfification and Compliant Survey on 03/01/23. This failure was for 2 deficiencies that were originally cited in the areas of (F600) Free from Abuse and Neglect and (F880) Infection Control that were subsequently recited on the current Recertification and Complaint Survey on 05/15/24. The repeat deficiencies during the 2 surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. The findings include: This tag is cross referenced to: F-600: Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #17 asked Nurse Aide (NA) #1 multiple times to let go of his right arm during incontinent care and when she did not Resident #17 pulled his right arm away from NA #1 and during the interaction received a small skin tear with a red/purple bruise that was approximately the size of a half dollar on his right forearm. The deficient practice occurred for 1 of 3 residents reviewed for accidents. During the recertification and compliant survey on 03/01/23 the facility failed to provide supervision to prevent a cognitively impaired resident from attacking another cognitively impaired resident in their shared bathroom which resulted in a resident having a bloody right lower lip, left nostril and left cheek. Her wrist was swollen, bruised and painful and required evaluation and treatment at the emergency room . F-880: Based on observations, record reviews and interviews the facility failed to follow their infection control policy when the Wound Nurse failed to change her gloves after removing a soiled dressing, that contained a moderate amount of brown drainage, and before cleansing a sacral wound on 1 of 4 residents (Resident #18) reviewed for pressure ulcers. The facility also failed to follow their hand hygiene policy when the Unit Manager failed to change her gloves and preform hand washing hygiene after she provided incontinent care and before she applied a moisture barrier cream and touched other environmental surfaces for 1 of 3 residents (Resident #54) reviewed for incontinence care. During the recertification and compliant survey on 03/01/23 the Nurse failed to perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound, and before applying a clean dressing to a wound. An interview was conducted with the Administrator on 05/15/24 at 3:30 PM who explained she was not the Administrator at the time of the last recertification when the previous citations were given but she felt as if the current citations were isolated issues and not a result of facility failures. The Administrator indicated that through the plan of corrections for the citations the staff will be educated, audits will be conducted and monitored through the quality assurance committee. Hopefully the citations will not be repeated.

Based on observations, record reviews and interviews the facility failed to follow their infection control policy when the Wound Nurse failed to change her gloves after removing a soiled dressing that contained a moderate amount of brown drainage and before cleansing a sacral wound on 1 of 4 residents (Resident #18) reviewed for pressure ulcers. The facility also failed to follow their hand hygiene policy when the Unit Manager failed to change her gloves and preform hand washing hygiene after she provided incontinent care of stool and before she applied a moisture barrier cream and touched other environmental surfaces for 1 of 3 residents (Resident #54) reviewed for incontinence care. The findings include: 1. A review of the facility's policy on Dry Clean Dressing dated 09/2013 revealed steps in the procedure, 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull gloves over dressing and discard them into plastic or biohazard bag. 8. Wash and dry hands thoroughly. On 05/14/24 at 2:02 PM an observation of wound care was made by the Wound Nurse. The Nurse washed her hands and donned clean gloves to remove the old, soiled dressing which was saturated with brown drainage from Resident #18's sacrum. With the same gloved hands, the Wound Nurse proceeded to cleanse the stage 3 sacral wound with a gauze saturated with wound cleanser then removed the gloves and washed her hands before she donned a clean pair of gloves to apply the ordered treatment to the sacral wound and secured the wound with a border dressing. An interview was conducted with the Wound Nurse on 05/14/24 at 5:08 PM who explained she did not realize that she did not remove her gloves and wash her hands after she removed the soiled dressing from Resident #18's stage 3 pressure ulcer. She stated that it was her normal routine to remove her gloves and wash her hands after she removed the old dressing but that she was nervous being watched during the procedure. An interview was conducted with the Wound Nurse Practitioner on 05/15/24 at 10:50 AM. The Nurse Practitioner explained that Resident #18's stage 3 sacral pressure ulcer was being closely monitored for signs and symptoms of osteomyelitis because of the near bone exposure. She continued to explain that she had not observed the Wound Nurse's dressing change technique as being bad but stated she normally documented her wound assessments while the Wound Nurse redressed the wounds on rounds. During an interview with the Director of Nursing on 05/15/24 at 12:15 PM she explained that the Wound Nurse had already informed her of the wound treatment and stated that she would have to be more careful being sure to remove her gloves when she removed the old dressings. 35789 2. A review of the facility's hand washing/hand hygiene policy revised on October 2023 read; Hand hygiene is indicated: immediately before touching a resident, before performing a aspect task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the residents environment, before moving from work on a soiled body site to a clean body site. A continuous observation was made on 05/12/24 from 9:14 AM to 9:47 AM. Resident #54 was resting in his bed and was covered with a sheet. He reported he was wet with urine and needed to be changed. He explained that the last time the staff had provided care to him was around 3:00 AM to 3:15 AM and he was pretty wet. Resident #54 was able to turn himself onto his right side using the grab bar. When he turned himself over it was noted that his brief was saturated to the very edge of the absorbent part of the incontinent product, the draw sheet under him was not wet. At 9:29 AM Resident #54 turned on his call light and stated, they should have done been in here. At 9:31 AM a staff member entered the room and Resident #54 stated that he needed to be changed, the staff member stated she would let his Nurse Aide (NA) know and left the room. At 9:35 AM Unit Manager (UM) #2 entered Resident #54's room and Resident #54 told her he needed to be changed. UM #2 turned off the call light and stated she was going to get some gloves and would be right back. UM #2 returned to Resident #54's room with supplies and with NA #4 to assist. UM #2 obtained a rag with warm water and placed soap on the rag and proceeded to wash Resident #54's peri area, once she had rinsed and dried his peri area, Resident #54 grabbed his right grab bar and turned himself to his right side. Once Resident #54 was on his right side, using a different rag that was wet with soap and water UM #2 was observed to wash Resident #54's buttock that were noted to be soiled with stool. It took several attempts from UM #2 wiping and cleaning Resident #54's buttock to get all the stool off of his buttocks. Once clean and without changing her gloves UM #2 was observed to grab her name tag and put inside her scrub top, then grab a tube of cream from Resident #54's table and open the tube and apply a generous amount to both buttocks. Once she had applied the cream without changing her gloves, UM #2 and NA #4 applied a new brief and covered him with a sheet before removing their gloves using hand sanitizer and exiting Resident #54's room at 9:47 AM. UM #2 was interviewed on 05/14/24 at 9:29 AM, she explained that Resident #54 had been incontinent since he was admitted to the facility and at times, he would ring his call bell for assistance. UM #2 confirmed that she had provided incontinent care to Resident #54 on 05/12/24 and stated, to be honest I forgot to change my gloves between clean and dirty and I knew immediately when I came out of the room I had messed up. She added that she should have removed her gloves used hand sanitizer and applied new gloves before applying the cream to Resident #54's buttocks and again before applying his clean brief. The Infection Preventionist (IP) was interviewed on 05/14/24 at 3:47 PM who stated that during incontinent care staff were expected to perform hand hygiene before starting the procedure and again after cleaning the resident up and removing the soiled brief or incontinent product but before applying a clean incontinent product. The IP explained this was to ensure that the staff did not contaminate the environment with dirty gloves. The Director of Nursing (DON) was interviewed on 05/14/24 at 5:24 PM. The DON stated that UM #2 was nervous during the incontinence change that was observed on 05/12/24. She stated that as soon as UM #2 came out of Resident #54's room she came and stated that she had messed up and had not taken her gloves off nor completed hand hygiene like she was supposed to. The DON stated she immediately reeducated UM #2 on the hand hygiene policy and also started a reeducation for all staff as well.

Based on record review and staff interviews the facility failed to provide supervision to prevent a cognitively impaired resident (Resident #129) from attacking another cognitively impaired resident (Resident #130) in their shared bathroom which result in Resident #130 having a bloody right lower lip, left nare and left cheek. Her right wrist was swollen, bruised, and painful and required evaluation at the emergency room (ER). The Findings included: Resident #129 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #129's diagnoses included schizoaffective disorder, dementia, and bipolar disorder. A care plan created on [DATE] read, Resident #129 is/has the potential to be verbally aggressive, yelling, threatening staff, lying to staff about things related to ineffective coping skill, mental/emotional illness, and poor impulse control. The interventions included: administer medications as ordered, analyze key times, places, triggers and what de-escalates the behavior, assess, and anticipate resident needs, and give the resident as many choices as possible, Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #129 was moderately cognitively impaired for daily decision making, had no behaviors, and required limited assistance with walking in room and on corridor during the assessment reference period. An incident report dated [DATE] read in part, staff heard yelling down hallway, nurse ran down hallway with Nurse Aide (NA). Found another resident (Resident #130) sitting on toilet. Resident #129 was standing beside Resident #130 yelling and had a hold of Resident #130's right upper arm. She was being very verbally aggressive to Resident #130. Three staff members had to remove Resident #129 from the bathroom. The incident report was electronically signed by Nurse #6. Review of a physician order dated [DATE] for Resident #129 read, Send to emergency room (ER) for evaluation. Resident #130 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #130's diagnoses included dementia. The quarterly MDS assessment dated [DATE] indicated that Resident #130 had long/short term memory problems, was moderately impaired for daily decision making, and no behaviors were noted during the assessment reference period. Further review of the MDS revealed that Resident #130 was always continent of bowel and bladder. Review of a Nurse's note written by Nurse #6 dated [DATE] read, staff heard yelling down the hallway. Nurse ran down hallway with NA and found Resident #130 sitting on toilet with injury. Right lower lip was bleeding, left nare was bleeding, left cheek bleeding, right wrist was swollen, bruised, and painful. Resident #129 was standing beside Resident #130 yelling and had a hold of Resident #130's right upper arm. The two residents were separated immediately, and aide was provided to Resident #130's injuries. Review of a physician order dated [DATE] for Resident #130 read, Send to ER for evaluation. Review of Discharge Documentation for Resident #130 from the local ER dated [DATE] read in part, no fractures were identified on scan, your right Xray shows old fractures, no new fracture. Keep area clean and dry, change dressing daily. Apply ice to the wrist 20 minutes on, 20 minutes off at least 5 times a day. Nurse #6 was interviewed via phone on [DATE] at 11:56 AM. Nurse #6 confirmed that she recalled the incident between Resident #129 and Resident #130 on [DATE] at approximately 9:30 PM. She stated, for starters we told management not to move them, they were on separate halls, and they moved them to the same hall to share a bathroom. Nurse #6 stated that both Resident #129 and Resident #130 were continent of bowel and bladder and went to the bathroom all the time. She stated she was working a double shift that day ([DATE]) and heard screaming down the hallway. Nurse #6 stated she ran down the hallway and opened the bathroom door and found Resident #130 sitting on the toilet with her lip, nose, and right nare bleeding and Resident #129 was standing in the other doorway screaming for Resident #130 to get out of the bathroom. Resident #130 stated she attacked me and Resident #129 stated I did not. Nurse #6 stated that she and the NA's removed Resident #129 from the bathroom and returned her to her private room while she stayed with Resident #130 and assessed her injuries. She stated she cleaned the blood off Resident #130's face and found a small cut under her eye and her lip was split but she was worried about her arm because it was bruised and swollen (could not recall for sure which arm). Nurse #6 stated that both Resident #129 and Resident #130 were sent to the ER that night and had not returned when she left her shift at 11:00 PM. Nurse #6 stated that when Resident #129 returned to the facility she was provided a one-on-one sitter until a private room with a private bathroom was available. NA #3 was interviewed via phone on [DATE] at 12:23 PM who confirmed that she recalled the incident with Resident #129 and Resident #130 that occurred on [DATE]. She stated that Resident #129 was always upset when someone was in her bathroom. NA #3 stated that on [DATE] Resident #130 had gone into the bathroom that the two residents shared and we heard Resident #130 yelling so we responded to her room. Resident #130 was sitting on the toilet and Resident #129 was standing in the doorway screaming at her to get out of the bathroom. She added that they immediately separated the two residents and Nurse #6 assessed Resident #130 lip, nose, and eye area that were bleeding. NA #3 stated that both residents went to the ER that night in separate ambulances and when they returned Resident #129 had one on one sitter until a private room with a private bathroom was available. The Administrator was interviewed on [DATE] at 5:02 PM who stated that on [DATE] Nurse #6 called her at home to report the incident. She stated that NA #7 separated the two residents and stayed with Resident #129 until Emergency Medical Services (EMS) arrived. Nurse #6 also told the Administrator of Resident #130's injuries to her face and her arm. The Administrator stated she was unaware of any issues with the shared bathroom but was aware that Resident 129 had verbal aggression but had not had any physical aggression. The Administrator stated that when Resident #129 returned from the ER she was placed on one on one and then moved to a private room with private bathroom. Nurse #7 was interviewed via phone on [DATE] at 6:01 PM. Nurse #7 stated that he knew of the incident that occurred on [DATE] between Resident #129 and Resident #130. He also confirmed that he was working when the two returned to the facility after being evaluated at the ER. He recalled that Resident #129 was placed on one on one until a new room was available. Nurse #7 stated if you ask me what I recall most about that incident was that we had told the Administration numerous times that it was not a good idea to put Resident #129 in a room with another resident or one that shared her bathroom because she was very territorial of her space. Unit Manager (UM) #1 was interviewed on [DATE] at 9:48 AM who confirmed she was aware of the incident between Resident #129 and Resident #130 on [DATE]. UM #1 stated for the longest time we avoided having a roommate with Resident #129 because we had tired a couple of other residents and it did not work out so well, so we knew we had to leave her alone in a room. UM #1 stated that when Resident #130 was moved into the room next to Resident #129 which shared a bathroom it was apparent rather quickly that it was not going to work but we decided to wait and see how the two residents would do. She confirmed that after the incident on [DATE], Resident #129 had one on one sitters until a private room with private bathroom was available. UM #1 stated that Resident #129 had history of behaviors in the facility, and she recalled one time that Resident #129 picked up a television and was going to throw it at her roommate until Nurse #6 intervened and removed the television from her hands. NA #7 was interviewed on [DATE] at 10:46 AM who confirmed that she was working on [DATE]. She stated she was down the hallway with another resident and she heard someone yelling. NA #7 stated she went down the hallway and found Resident #130 in her bathroom on the toilet and Resident #129 was laying on her bed screaming at her to get out of the bathroom. NA #7 stated she told Resident #129 to be patient that Resident #130 would be out in just a minute and to please not yell at her. NA #7 stated that she returned to the room she was in previously to finish what she was doing. About fifteen minutes later she heard screaming again and she again ran down the hallway. Resident #130 was sitting on the toilet and her face was bleeding and she stated, she hit me. Resident #129 was immediately removed from the bathroom and closed and locked the bathroom door and Nurse #6 assessed Resident #130. NA #7 stated she stayed with Resident #129 until EMS arrived to transport her to the ER, she was very calm and cooperative during that time. She added that when Resident #129 returned to the facility from the ER she was placed with one-on-one sitters until a private room with private bathroom was available. A follow up interview was conducted with the Administrator on [DATE] at 11:29 AM. She stated that after Resident #129 was moved to private room with a private bathroom she appeared to settle down and was only discussed in clinical meeting as needed. She did not feel like there was anything else the facility could have done to prevent the incident that occurred on [DATE]. The Administrator could not recall any staff members verbalizing hesitancy about moving the two residents on the same hallway to share a bathroom and was adamant she was not aware of any other physical behaviors Resident #129 had.

Based on observations, record reviews, and resident and staff interviews, the facility failing to clean oxygen filters for 2 of 3 residents (Resident #3 and Resident #13) reviewed for oxygen usage. 1. Resident #3 was readmitted to the facility on [DATE] with diagnoses that included asthma. A care plan dated 1/3/23 indicated Resident #3 requires oxygen usage with interventions to include may titrate oxygen rate to ensure oxygen saturations are greater than 92% and position for body alignment to facilitate optimal breathing patterns. A hospital discharge summary dated 2/24/23 indicated Resident #3 was to receive oxygen via nasal cannula at 2L (liters) continuously. Review of the Treatment Administration Record (TAR) dated February 2023 revealed the following: Change oxygen tubing when visibly soiled every Sunday night. The TAR further revealed that Nurse #4 initialed the oxygen tubing change on 02/26/23. Multiple attempts were made to contact Nurse #4 without success. An observation on 2/26/23 at 2:51 PM revealed Resident #3's oxygen concentrator contained a black filter which had a visible grayish-white fuzzy substance on the surface. An observation on 2/27/23 at 8:57 AM revealed Resident #3's oxygen concentrator contained a black filter which had a visible grayish white fuzzy substance on the surface. An interview with Nurse #3 on 3/1/23 at 2:24 PM revealed she is a night shift nurse (11 PM to 7 AM shift) and stated all residents who use concentrators should have their filter cleaned weekly on Sunday night when the nasal cannulas were replaced. An interview with the Director of Nursing and Administrator on 3/123 at 3:53 PM revealed the filters attached to the oxygen concentrator to be cleaned weekly on Sunday by the nursing staff on night shift. The DON indicated the nurses cleaned external filters and maintenance staff would clean internal filters. 35789 2. Resident #13 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and asthma. A physician order dated 10/27/22 read Oxygen at 2 liters per minute via nasal canula. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #13 was moderately impaired for daily decision making, had shortness of breath with exertion, and required the use of oxygen during the assessment reference period. Review of the Treatment Administration Record (TAR) dated February 2023 revealed the following: Change oxygen tubing when visibly soiled every Sunday night. The TAR further revealed that Nurse #3 initialed the oxygen tubing change on 02/05/23 and 02/19/23 and Nurse #4 initialed the oxygen tubing change on 02/12/23 and 02/26/23. An observation of Resident #13 was made on 02/26/23 at 4:13 PM. Resident #13 was sitting in her wheelchair at the foot of her bed. She was wearing oxygen via nasal canula that was connected to an oxygen concentrator sitting next to her. The concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. An observation of Resident #13 was made on 02/27/23 at 10:18 AM. Resident #13 was resting in bed. She was wearing oxygen via nasal canula that was connected to an oxygen concentrator sitting next to her bed. The concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. An observation of Resident #13 was made on 02/28/23 at 4:46 PM. Resident #13 was sitting in her wheelchair at the foot of her bed. She was wearing oxygen via nasal canula that was connected to an oxygen concentrator sitting next to her. The concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. An observation of Resident #13 was made on 03/01/23 at 10:08 AM. Resident #13 was being assisted to her recliner by the Physical Therapist (PT). The PT was observed to replace Resident #13's portable oxygen with the oxygen concentrator that sat next to her bed. The oxygen concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. Nurse #5 was interviewed on 03/01/23 at 10:21 AM who confirmed that she was caring for Resident #13. She stated that the third shift nurses were responsible for changing the oxygen tubing once a week. Nurse #5 was unsure of who was responsible for cleaning/replacing oxygen filters. She stated that in other facility's she had worked the maintenance department took care of them but could not say who was responsible in this facility. Nurse #5 stated she had not cleaned or checked the filter on Resident #13's oxygen concentrator because she did not know she needed to. The Maintenance Director was interviewed on 03/01/23 at 10:31 AM who stated that he cleaned/replaced the oxygen concentrator filers as needed. He was asked to observe Resident #13's oxygen concentrator and confirmed that there was no filter where it should be and that the dust needed to be removed from the empty space in the back of the concentrator. The Central Supply Clerk was interviewed on 03/01/23 at 10:44 AM who stated the third shift nursing staff were responsible for cleaning/replacing the oxygen filters. Multiple attempts to speak to Nurse #4 were made on 03/01/23. The Director of Nursing (DON) was interviewed on 03/01/23 at 12:02 PM who stated that on Sunday nights the nurses were responsible for changing oxygen tubing as well and checking/cleaning and/or replacing the oxygen concentrator filters. She stated that the nurses would do the external filters and the Maintenance department would do the internal filters. Nurse #3 was interviewed via phone on 03/01/23 at 2:24 PM who confirmed that she worked night shift at the facility on Sunday nights and was responsible for changing oxygen tubing and cleaning or replacing oxygen filters. Nurse #3 stated that she did not recall specifically checking or cleaning Resident #13's oxygen filter because she did so many. She further stated that it was her general practice to check and clean each oxygen filters for the residents on her unit on Sunday nights and if she documented that she did it then that would indicate it had been done.

Based on observations, record reviews, staff, and Resident interviews the facility failed to provide sufficient nursing staff resulting in residents not being treated in a dignified manner and missed showers for 2 of 6 sampled residents (Resident #22 and Resident #15). The findings include: This tag is crossed referenced to F 550: Based on record review, Resident, and Staff interview the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested (Resident #22) and for not providing showers as the resident preferred (Resident #15) for 2 of 3 residents reviewed for dignity. This tag is crossed referenced to F 561: Based on observations, record review, resident and staff interviews the facility failed to honor a resident's bathing preference for 1 of 6 residents reviewed for choices (Resident #15). This tag is crossed referenced to F 677: Based on record review, Resident and staff interviews the facility failed to provide incontinent care when requested by the resident for 1 of 6 residents reviewed for activities of daily living (Resident #22). An interview was conducted with the Weekend Supervisor via phone on 02/28/23 at 3:55 PM who explained that she worked every weekend from 7:00 AM to 11:00 PM on the medication cart, helping the Nurse Aides (NAs), and navigating whatever other issues came her way. She stated that nine times out of ten on the weekend the facility was short staffed, and residents had to wait longer than use for care. The Weekend Supervisor stated that showers were not being provided because they were too short staffed, these residents deserve better than what they get. She explained that on the weekends there were generally one NA on each floor then the Nurses were expected to help pass meal trays, answer call lights, and provide care as needed, no matter how much we asked for help we were just left to deal with it. The Scheduling Coordinator was interviewed via phone on 03/01/23 at 9:46 AM who confirmed that she had been at the facility since December 2022 and at that time staffing was terrible, they did not have a lot of staff, and the staff that they had were upset because they had to work every other weekend so a lot of employees quite or went as needed and then would not come in when we needed them. The Scheduling Coordinator stated that she asked and begged for the facility to allow agency staff to come in and help fill the staffing shortages and finally about two weeks they agreed. She stated that the agency staff has eased some of the burden but she still had openings on second shift and the weekends. She added she was very flexible with the facility staff that they had in regard to their hours, she stated some come in at 7, some come in at 8 but she remained flexible in attempt to retain the employees that they had. The Scheduling Coordinator stated that she liked to have 8 NA on first and second shift and 5 on the night shift and one nurse on each unit or 2 nurses and a medication aide this included the weekends. She stated with the help of agency they are able to do this more often then they were two weeks ago. The Director of Nursing (DON) was interviewed on 03/01/23 at 4:01 PM who stated that the last month she has been hanging on by a fingernail due to staffing shortages. She stated she was getting pulled to assist with the staffing shortages and everything that she needed to be monitoring was not getting monitored like it should because she was busy with other things.

Based on record review, facility activity calendar, resident and staff interviews, the facility failed to ensure group activities were planned in the evenings on weekdays and on weekends to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #65, Resident #14, Resident #22 and Resident #62). The findings included: A review of the February 2023 activity calendar revealed morning breakfast daily and dining with music Monday through Friday (lunch). An activity titled Social Time listed Monday through Friday at 4:30 PM, but was not listed on the weekends. There were no activities listed after 4:30 PM on the calendar on weekdays. On weekends, the following activities were listed: Saturday- 10:30 AM Snack social and 2:30 PM Bingo and Sunday- Spiritual in rooms (Channel 32) and at 2:30 Bible Chat. The calendar revealed there were no other activities available on the weekends. a. Resident #65 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #65 felt that it was very important to have activities that included music, books, newspaper, going outside, and doing things in a group setting. The assessment further indicated Resident #65 was cognitively intact. A review of the comprehensive careplan for Resident #65 revealed no care plan for activity interest or involvement. An observation and interview with Resident #65 was conducted on 2/26/23 at 3:24 PM. Resident #65 was in her room lying in bed and indicated staff did not ask her if she wanted to go to the few activities offered because they were short staffed. Resident #65 also stated life here is boring. Resident #65 had various art hangings in her room and she said she used to be able to participate in art activities, but the facility did not provide them anymore. b. Resident #14 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #14 felt that it was very important to do activities that included receiving the newspaper, listening to music, and doing things in a group setting. The assessment further indicated Resident #14 was cognitively intact. An observation and interview with Resident #14 was conducted on 2/26/23 at 5:09 PM. Resident #14 was in her room sitting in her wheelchair with the roommate's television on; however, Resident #14 was not watching it. She indicated she got bored often due to the lack of activities in the evening and on the weekends. A review of the comprehensive care plan for Resident #14 revealed no care plan for activity interest or involvement. c. Resident #22 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #22 felt that it was very important to do activities that included listening to music, pets, religious activities, and doing things in a group setting. The assessment further indicated Resident #22 was cognitively intact. An observation and interview with Resident #22 was conducted on 2/26/23 at 3:51 PM. Resident #22 indicated the facility did not have a lot to do for activities and she stated, we are so bored we cannot see straight. The activity calendar looks full, but it has our meals as three activities each day. Resident #22 was conversing with her roommate (Resident #62) during the interview, and Resident #22 stated the activity at 4:30 PM on weekdays titled Social Time was strictly where snacks were brought to each of their rooms and not an activity or a group activity to socialize. A review of the comprehensive care plan for Resident #22 revealed no care plan for activity interest or involvement. d. Resident #62 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #62 felt that it was important to do activities that included watching the news, listening to music, playing with pets, attending religious activities, and doing things in a group setting. The assessment further indicated Resident #62 was cognitively intact. An observation and interview with Resident #62 was conducted on 2/26/23 at 3:51 PM. Resident #62 indicated that the facility did not have many activities to do and indicated their activity calendar may look full, but it actually was very limited in structured activities and it included meals. Resident #62 explained we simply get bored because there's nothing to do. Resident #62 was conversing with her roommate (Resident #22) during the interview. Resident #62 agreed with Resident #22 (her roommate) that the activity at 4:30 PM on weekdays titled Social Time was strictly where snacks are brought to each of our rooms and not an activity or a group activity to socialize. A review of the comprehensive care plan for Resident #62 revealed no care plan for activity interest or involvement. An interview with the Activity Director was conducted on 2/27/23 at 11:45 AM which revealed she was in charge of developing the activity calendar each month. She acknowledged that the meals were included in the activity calendar and she had been trying to provide activities for the facility alone until an assistant was recently hired to help. She stated that an activity that was scheduled every Monday only benefited one resident in the facility, but remained on the calendar. She explained that this was a spiritual activity entitled Jehovah's Witness and this was not applicable to most resident's in the facility. The Activity Director explained that she added an extra day of bingo to the calendar but was not aware meals could not be counted as an activity and would try to modify the calendar beginning in April. The activity director acknowledged there were no activities in the evenings and on the weekends there was bingo on Saturday and on Sunday there was a worship service, but this activity was where residents were able to watch church on television and not a live in person service. During an interview with the Administrator on 03/01/23 at 3:24 PM she revealed she was aware that the residents had requested more bingo activities and that an extra day of bingo was added to the calendar in recent months. The Administrator stated that she was not aware of ongoing concerns with the lack of activities in the evenings and on the weekends.

Based on record reviews and staff interviews the facility failed to ensure code status information was available for use for Resident #68 and Resident #14 and failed to ensure the code status information was accurate throughout the medical record for Resident #35. This affected 3 of 3 residents (Resident #68, #35 and #14) reviewed for advanced directives. The findings include 1. Resident #68 was admitted to the facility on [DATE]. A review of Resident #68's electronic medical record revealed a physician order for a Full Code dated 11/06/22. A review of the Code Status notebook kept at the nursing station revealed there was no advanced directive in the notebook for Resident #68. An interview was conducted with the Admissions Director (AD) on 02/28/23 at 11:08 AM. The AD explained that she addressed the residents' advanced directive, do not resuscitate or full code while in the admission meeting with the resident and or responsible party and put the paperwork in the big red code status notebook at the nursing station. The AD continued to explain that she had only been responsible for doing it for about 2 weeks, so she did not know anything about why Resident #68's code status was not in the notebook. During an interview with the Unit Manager (UM) #1 on 02/28/23 at 12:20 PM the UM explained that the Admission Director (AD) informed her of the residents' code status, and she was responsible for writing the order for it and the AD was responsible for putting the proper paperwork in the code status notebook. The UM indicated she did not know why Resident #68 did not have a designated advanced directive in the notebook. An interview was conducted with the Director of Nursing (DON) on 02/28/23 at 11:28 AM who stated that it was her expectation that the residents' advanced directives be in the code status notebook at the nursing station, and they should match the residents' electronic medical record. 2. Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's electronic health record revealed a physician order dated 12/09/22 for Do Not Resuscitate (DNR). A review of Resident #35's care plan dated 12/21/22 revealed the Resident was a Full Code status with the goal to initiate all life sustaining technology as agreed upon. An interview was conducted with the Minimum Data Set (MDS) Nurse #1 on 02/28/23 at 11:19 AM who explained that she was responsible for care planning Resident #35's advanced directive and remembered the day of the care plan meeting with the Resident and her family. The Nurse continued to explain that when she reviewed her advanced directive with the Resident, she voiced that she did not want to be a DNR but that she wanted to be a Full Code, so she wrote the care plan for a Full Code status. She stated she sent a message to Unit Manager #2 about the change in the advanced directive. An interview was conducted with Unit Manager (UM) #2 on 02/28/23 at 12:20 PM. The UM explained that she was responsible for the residents on the hall that Resident #35 resided and stated she was not aware of being notified of the Resident's advanced directive needing to be changed. During an interview with the Director of Nursing (DON) on 02/28/23 at 11:28 AM she explained that the MDS Nurse should have care planned Resident #35's advanced directive for what it was at the time of the care plan meeting (DNR) and notified the UM about the Resident's wishes for the advanced directive to be changed to a Full Code. The DON stated when the order for the Full Code was obtained then the MDS Nurse should have updated the care plan to reflect a Full Code. 35789 3. Resident #14 was readmitted on [DATE]. Review of Resident #14's electronic medical record revealed a physician order dated 01/31/23 that read, Full Code. A review of the Code Status notebook kept at the nursing station where all residents in the faciltiy code status inforamtion was kept revealed there was no advanced directive in the notebook for Resident #14. An interview was conducted with the Admissions Director (AD) on 02/28/23 at 11:08 AM. The AD explained that she addressed the residents' advanced directive, do not resuscitate or full code while in the admission meeting with the resident and or responsible party and put the paperwork in the big red code status notebook at the nursing station. The AD continued to explain that she had only been responsible for doing it for about 2 weeks, so she did not know anything about why Resident #14's code status was not in the notebook. During an interview with the Unit Manager (UM) #1 on 02/28/23 at 12:20 PM the UM explained that the Admission Director (AD) informed her of the residents' code status, and she was responsible for writing the order for it and the AD was responsible for putting the proper paperwork in the code status notebook. The UM indicated she did not know why Resident #14 did not have a designated advanced directive in the notebook. An interview was conducted with the Director of Nursing (DON) on 02/28/23 at 11:28 AM who stated that it was her expectation that the residents' advanced directives be in the code status notebook at the nursing station. The DON stated that they implemented the notebook at the nursing station for the nursing staff to have a quick reference of code status during an emergency and a place to keep the original document so they could make copies if the resident was transferred to the hospital.

Based on record review, Resident, and Staff interview the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested (Resident #22) and for not providing showers as the resident preferred (Resident #15) for 2 of 3 residents reviewed for dignity. The Finding included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses of heart disease, diabetes, and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #22 was cognitively intact for daily decision making, required extensive assistance with toileting, and was frequently incontinent of bladder and occasionally incontinent of bowel. No refusal of care was noted during the assessment reference period. Resident #22 was interviewed in her room on 02/28/23 at 1:33 PM. Resident #22 stated that on 02/04/23 in the early evening hours she turned her call light on and when Nurse Aide (NA) #1 responded she made her aware she needed incontinent care and needed to be changed. NA #1 stated that she would be back, but she did not return to change her. Resident #22 stated that after the change of shift Medication Aide (MA) #1 came in and provided care to her, she stated she was saturated with urine, and MA #1 had to take her to the shower to get her cleaned up. Resident #22 further stated that on 02/05/23 at approximately 4:30 PM she began turning her call light on because the brief she had on was wet. Resident #22 stated that NA #1 kept coming in (at least twice) and turning her call light off and would say she would be back to change her, but she never returned to change her. Resident #22 stated that at change of shift another NA who she could not recall her name came into her room to provide care to her sometime after 7:00 PM. Resident #22 explained on 02/04/23 and 02/05/23 by the time the oncoming shift provided care to her she was saturated with urine that required an entire bed change. Resident #22 stated she did not like the fact that she sat soiled for so long, it doesn't make me feel good, but what else can I do? I have no choice but to sit and wait for the staff to come and help me. NA #2 was interviewed via phone on 02/28/23 at 2:43 PM and confirmed that she worked the weekend of 02/04/23 and 02/05/23. She stated that on 02/05/23 she reported to work at 7:00 PM. NA #2 stated that she responded to Resident #22's call bell at approximately 7:00 PM to 7:15 PM and was made aware that she was wet and needed to be changed. NA #2 stated that she told Resident #22 she had just arrived to work and was gathering supplies and she would be right back to get her cleaned up. NA #2 stated that she went and gathered her supplies and immediately returned to Resident #22's room at around 7:30 PM room to provide care to her. She stated Resident #22 was in the bed and was soaking wet with urine. She stated that she was so wet, Resident #22 required an entire bed linen change. NA #1 was interviewed via phone on 02/28/23 at 5:21 PM. NA #1 stated that she had just started working at the facility one month ago (01/25/23). NA #1 stated that she was familiar with Resident #22 and had provided care to her both days the weekend of 02/04/23 and 02/05/23. She stated that Resident #22 turned on her call light anytime she needed something including when she needed incontinent care. If Resident #22 was up in her wheelchair NA #1 stated that she would take her to the bathroom and provide care but if Resident #22 was in bed she would provide care to her in the bed. NA #1 did not recall the times that she provided care to Resident #22 on either 02/04/23 or 02/05/23 because she would just do so at the time Resident #22 turned her call light on and requested care. NA #1 denied that she had turned Resident #22's call light off and denied that she had not provided care when requested. MA #1 was interviewed via phone on 03/01/23 at 9:21 AM. MA #1 confirmed that she had worked the weekend of 02/04/23 and 02/05/23. She further explained that on 02/04/23 she took over Resident #22's unit at 11:00 PM. MA #1 recalled on 02/04/23 after shift change around 11:30 PM, she responded to Resident #22's call light. Resident #22 stated she was soiled and needed to be changed. MA #1 stated that when she pulled back the covers to provide care, she found that Resident #22 was soaking wet with a dried brown ring of urine on her bottom sheet. She stated that she told Resident #22 that she was going to get her up and take her to the shower so she could wipe down her mattress and let it air dry while they were in the shower. MA #1 stated she asked Resident #22 what happened and why she was so wet, she stated that NA #1 had left without providing care to her. MA #1 stated she assisted Resident #22 to her wheelchair stripped her bed of the soiled linens, wiped her mattress with Clorox wipes and let it air dry while she took Resident #22 to the shower. The Administrator and Director of Nursing (DON) were interview on 03/01/23 at 11:41 AM. The Administrator and DON confirmed that they were not aware of the incidents with Resident #22 that occurred on 02/04/23 and 02/05/23. She added that incontinent care should be completed when requested by Resident #22 before her call light was turned off. The DON added that she had a conversation with Resident #22 in the past about her wearing briefs when in the bed, she stated that Resident #22 toileted during the day while up and she did not think there was any reason why she could not toilet during the night to avoid wearing a brief. The DON stated she offered Resident #22 a bedside commode which she declined because she was afraid it would not get empty and would smell bad in her room. The DON stated she believed Resident #22 was being untruthful and exaggerating the time she was left soiled and about the staff turning her call light off. The DON further stated, I believe in treating everyone with the upmost respect and dignity and I have tired to promote her dignity and she refused. 43443 2. Resident # 15 was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #15 was cognitively intact. Review of Resident #15's Activities of Daily Living (ADL) sheet revealed the last documented bed bath was on 02/18/23. There was no documentation of Resident #15 receiving a shower. Resident #15 was scheduled to receive a shower on Tuesdays and Fridays on first shift. An interview and observation were conducted on 02/26/23 at 5:07 PM with Resident #15. She stated has not had a shower since she returned from the hospital on 01/09/23. She stated she had her face and hands washed a few times and a few bed baths but would like a shower so she could feel clean. Resident #15 stated she wanted a shower or at least a tub bath so she could just feel clean. She stated she just didn't know why the staff didn't want to clean her. Observations revealed Resident #15 did not look dirty, had no body odor, and her hair was pulled back and did not appear greasy. The highlighted sentences contradict each other. During a follow up interview on 03/01/23 at 8:31 AM with Resident #15, she stated she told the staff several times that she would like to have a shower but had still not received a shower or a tub bath since she was readmitted to the facility. Resident #15 stated she felt nasty and just wanted to feel clean. In an interview on 03/01/23 09:26 AM with Nurse Aide (NA) #3, she stated she cared for Resident #15 regularly on second shift and had not assisted Resident #15 with a shower because she was a 2-person assistance, and they did not have the staff to give Resident #15 a shower. In an interview on 03/01/23 at 3:10 PM with NA # 5, he stated he cared for Resident #15 regularly was not surprised that Resident #15 had not received a bath or shower since her re-admission because they did not have enough help to give showers. He stated he had not ever given her a shower. An interview was conducted on 03/01/23 at 3:12 PM with Nurse #1, she stated the reason that Resident #15 didn't get her showers was because there were not enough staff members to give showers. In an interview on 03/01/23 at 12:02 PM with NA #6 she stated she had never given Resident #15 a shower, only a bed bath. She stated Resident #15 was a 2-person assist and they didn't have enough staff to give her a shower. The Director of Nursing (DON) was interviewed on 03/01/23 at 11:41 AM and stated that she believed in treating everyone with the upmost respect and dignity and care should be provided as requested.

Based on observations, record review, resident and staff interviews the facility failed to honor a resident's bathing preference for 1 of 6 residents reviewed for choices (Resident #15). The findings included: Resident #15 was readmitted to the facility on [DATE] with diagnoses that included a heart failure, pneumonia, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively intact and displayed no rejection of care. The MDS further revealed Resident #15 required extensive assistance with activities of daily living and bathing was coded as did not occur. Further review of the MDS revealed it was very important to Resident #15 to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of the undated facility shower book revealed Resident #15 was to receive a shower on Tuesdays and Friday on first shift. Review of Resident #15's ADL sheet documented she last received a bed bath on 02/18/23. There was no documentation of Resident #15 receiving a shower. An observation of Resident #15 on 02/26/23 at 05:07 PM revealed she did not look dirty and had no body odor. Her hair was pulled back and did not appear greasy. In an interview on 02/26/23 at 5:07 PM with Resident #15, she stated has not had a shower since she returned from the hospital on 01/09/23. She stated she had her face and hands washed a few times and a few bed baths but would like a shower so she could feel clean. During a follow up interview on 03/01/23 at 8:31 AM with Resident #15, she stated she told the staff several times that she would like to have a shower but had not received a shower or a bath since she was readmitted to the facility. She stated she refused a bed bath one time because she did not feel comfortable with a male bathing her. In an interview on 03/01/23 09:26 AM with Nurse Aide (NA) #3, she stated she cared for Resident #15 regularly on second shift and had not assisted Resident #15 with a shower because she was a 2-person assistance, and they did not have the staff to give Resident #15 a shower. An interview on 03/01/23 at 11:37 AM with NA #4, revealed he attempted to give Resident #15 a bed bath on 01/25/23, but she refused because he was a male. He stated he was not aware of Resident #15's preference for a shower. In an interview on 03/01/23 at 3:10 PM with NA #5, he stated he cared for Resident #15 regularly was not surprised that Resident #15 had not received a bath or shower since her re-admission because they did not have enough help to give showers. He stated he had not ever given her a shower. He stated in the shower book, Resident #15 was scheduled for a shower on Tuesdays and Fridays during the day shift. An interview was conducted on 03/01/23 at 3:12 PM with Nurse #1, she stated the reason that Resident #15 didn't get her showers was because there were not enough staff members to give showers. She stated they had to prioritize resident safety and with limited staff, they couldn't send the NAs to the shower room and not have them on the floor caring for the residents and keeping them safe. She stated the NAs knew who was supposed to receive a shower by looking in the shower book. She further stated, if their name was in the shower book, that meant they were supposed to get a shower and not a bath. In an interview on 03/01/23 at 12:02 PM with NA #6 she stated she had never given Resident #15 a shower, only a bed bath. She stated Resident #15 was a 2-person assist and they didn't have enough staff to give her a shower. In an Interview on 03/01/23 at 3:53 with the Administrator, she stated if residents are scheduled and they want a shower then staff should give the shower as scheduled. If the resident does not to receive shower, then washing their face and hands would be appropriate. The lack of shower should be reported to the nurses to document.

Based on staff and physician interviews and record review, the facility staff failed to do a comprehensive assessment and provide emergency medical services for one (1) resident of nine (9) sampled residents following a significant change in her condition (Resident #1). Resident #1 was moved by staff after a fall and prior to being assessed by licensed nursing. Licensed nursing failed to complete a thorough assessment of the resident when notified of the fall and again when Resident #1 presented symptoms of difficulty breathing, diaphoresis, and impaired speech. Immediate jeopardy began on [DATE] when staff lowered Resident #1 to the floor during a transfer. Immediate jeopardy was removed on [DATE] when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee education. The findings are: Review of the facility's Changes in Resident Condition policy revised [DATE] revealed "for life threatening emergencies call 911 if initial assessment indicates that such action is necessary." Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 required the extensive assistance of two persons for transfers and was non ambulatory. The admission MDS coded the resident with short and long term memory problems with no behavior problems. The MDS assessment coded Resident #1 could make herself understood and understood others. The MDS marked no impairment in functional limitation of range of motion. Review of nursing notes dated [DATE] at 6:00 PM revealed Licensed Nurse (LN) #1 documented a skin tear was noted on Resident #1's inner left arm while staff lowered her to the floor during a transfer at 4:00 PM. LN #1 documented Resident #1 refused supper, was upset and "not communicating well." Review of a facsimile dated [DATE] sent at 6:20 PM revealed LN #1 requested [MEDICATION NAME] 1 milligram (for anxiety) because Resident #1 was "upset with staff who tried to give her a shower." This facsimile also notified the physician of the fall and resultant skin tear. Review of nursing notes dated [DATE] at 7:15 PM revealed LN #1 documented Resident #1 experienced garbled speech, a pulse of 114, vomiting and an O2 sat level of ,[DATE]%. The O2 sat level rose to 78% after an oxygen increase to 4 - 5 L/min and administration of a nebulizer treatment then returned to 73%. LN #1 documented two phone calls to the physician on call, family notification and Director of Nursing notification. Resident #1 was sent to the emergency room . Review of the Emergency Medical Services (EMS) Transport record revealed an emergency call placed from the facility at 7:44 PM on [DATE] for Resident #1. Review of the EMS Transport record dated [DATE] revealed an initial assessment of Resident #1 at 7:56 PM. Resident #1 was unresponsive and in respiratory distress. The report listed flaccidity of all extremities, weak pulse of 113, blood pressure of ,[DATE], shallow respirations of 22 with an O2 sat level of 73%. Review of Resident #1's hospital admission history and physical dated [DATE] revealed the admission [DIAGNOSES REDACTED]. Resident #1 expired on [DATE]. Interview with Licensed Nurse (LN) #1 on [DATE] at 3:45 PM revealed she heard Resident #1 crying on [DATE] during her afternoon medication pass "about 4:00 or 4:15 PM." LN #1 explained she administered medications to two other residents and entered Resident #1's room. LN #1 stated Resident #1 was sitting in a total lift sling and was positioned above the bed. LN #1 reported she asked Nursing Assistant (NA) #2 and NA #3 why Resident #1 was crying. She stated that Resident #1 did not usually cry. It was at this time, NA #2 reported the resident started to slide when they were manually transferring her. They lowered Resident #1 to the floor and saw a skin tear. LN #1 explained she informed NA #2 and NA #3 she would assess Resident #1 after they completed her care which included a bed bath after transfer. LN #1 reported she initially observed Resident #1 in the sling with a visual check of the legs. LN #1 reported she also visually assessed Resident #1's legs for swelling and broken areas after the bed bath. Interview with NA #2 on [DATE] at 4:20 PM revealed she did not notify LN #1 after lowering Resident #1 to the floor because this was not a fall. NA #2 explained LN #1 came into the room during the resident's transfer in the sling back to bed. NA #2 revealed she informed LN #1 of lowering the resident to the floor. NA #2 reported LN #1 said she would fully assess Resident #1 after the NAs transferred her to bed and completed the bed bath. Interview with NA #3 on [DATE] at 9:59 AM revealed she and NA #2 lowered Resident #1 to the floor during a transfer from bed to shower chair on [DATE]. NA #3 reported she did not immediately notify LN #1. NA #3 explained she decided it would be better to provide incontinence care before the nurse could assess her. NA #3 added she thought Resident #1 should be clean prior to the assessment. Interview with MDS Coordinator #1 on [DATE] at 10:38 AM revealed she was informed by LN #1 of Resident #1's change in condition and calls placed to the on call physician. MDS Coordinator #1 reported she assisted with the transfer papers to the hospital and did not assess Resident #1. Interview with the Director of Nursing (DON) on [DATE] at 2:00 PM revealed she expected nursing assistants to notify the charge nurse immediately after a fall. The DON explained an assessment should be made in order to determine the safety of moving a resident and to determine if emergency measures were required. An interview with LN #1 on [DATE] at 4:05 PM revealed she did not assess Resident #1's range of motion after the transfer back to bed because she observed Resident #1 "pull up" both legs. LN #1 reported Resident #1 was not coherent as normal. LN #1 revealed she applied a dressing on a skin tear of the left forearm but did not perform a full physical assessment because she thought the resident was upset about the transfer. Continued interview at this time with LN #1 revealed she saw Resident #1's uneaten supper tray in the room approximately "around 5:30 PM or so" and observed the resident who remained upset. LN #1 reported she faxed the physician a request for an [MEDICATION NAME] (a medication for anxiety). LN #1 explained Resident #1 became short of breath and vomited when she checked approximately "10 or 15 minutes later." In response, she increased the oxygen to 4 or 5 L/min because of an O2 sat in the low 70s, called LN #4 for a nebulizer machine, placed a call to the physician and notified the resident's family. LN #1 reported she placed a second call to the physician approximately 15 minutes after the first call when Resident #1's O2 sat remained in the low 70's after the nebulizer treatment. LN #1 explained she called 911 because the physician had not called back after two calls and Resident #1 continued to have trouble breathing. LN #1 (a Licensed Practical Nurse) explained she did not ask LN #4 (a Registered Nurse) or MDS Coordinator #1 (a Registered Nurse) because of her longevity as a nurse and own nursing skills. Interview with the Director of Nursing on [DATE] at 5:05 PM revealed she expected a full assessment to be conducted immediately after a fall including passive range of motion, vital signs and a pain assessment. The DON revealed 911 should be called when the physician could not be reached and a resident required immediate medical attention. Interview with the Administrator on [DATE] at 8:55 AM revealed she obtained confirmation of pages to the on call physician on [DATE] at 7:13 PM and 7:35 PM for Resident #1. Interview with LN #4 on [DATE] at 2:50 PM revealed she brought the nebulizer machine and mask into Resident #1's room "between 6:30PM and 6:45 PM." LN #4 reported she did not assess Resident #1 and described Resident #1 "having trouble breathing, pale and sweating and making noise like a chant." LN #4 reported Resident #1 vomited prior to nebulizer treatment. LN #4 reported she was at the nursing desk "about 10 minutes later" when LN #1 asked her to check the O2 sat after the nebulizer treatment. LN #4 stated Resident #1 "was still pale, sweating and having trouble breathing." LN #4 revealed she reported to LN #1 Resident #1's O2 sat was "in the low 70's" at which time LN #1 called 911. Interview with Resident #1's physician on [DATE] at 1:20 PM revealed she expected the facility nurse to conduct a full assessment after a resident fall. This assessment would include a pain assessment in addition to testing all extremities for joint movement. The physician explained 911 should be called in acute situations if the physician did not call back within 5 minutes. The Administrator was informed of Immediate Jeopardy on [DATE] at 4:22 PM for Resident #1. The facility presented a credible allegation of compliance which included: 1. Residents identified to be affected by the alleged deficient practice. Resident #1 transferred to (name) Hospital on [DATE] at 8:13 pm related to acute changes in her clinical status. This resident expired on [DATE]; therefore, no further corrective action could be accomplished. On [DATE] the facility's Director of Nursing began an investigation into the facts surrounding the resident's discharge on [DATE]. The investigation continued until [DATE] when the four employees involved were interviewed and pertinent documents were reviewed. This investigation included details regarding the discharge of Resident #1 on [DATE]. Director of Nursing provided one: one education in regards to utilizing assignment sheets, transfer techniques, communicating with supervisors regarding change in condition including incidents such as a resident being lowered to the floor and completion of change of condition forms, and counseling to three employees as appropriate. On [DATE]- [DATE], the Unit Coordinator educated all licensed nurses regarding assessment of a resident specifically related to falls, assessments in relation to change of condition and reporting. One exception was a PRN nurse who was educated on [DATE]. On [DATE], all available certified nursing assistants were educated on utilizing assignment sheets, transfer techniques, communicating with supervisors regarding change in condition including incidents such as a resident being lowered to the floor and completion of change of condition forms. There were three outlying Certified Nursing Assistants that were educated by [DATE]. Starting the week of [DATE] the facility Quality Assessment and Assurance Committee met weekly for three weeks to review actions associated with change in resident status. Going forward, the Quality Assessment and Assurance Committee will meet monthly or as needed. 2. Residents with the potential to be affected by the alleged deficient practice. Residents who exhibit acute changes in condition requiring intervention, such as hospitalization , have the potential to be affected by the alleged deficient practice. On [DATE], the Director of Nursing identified eight current residents who had an acute change in condition requiring hospitalization in the last 30 days. In addition, on [DATE], the Director of Nursing began a review of the current residents who have had an acute change in condition requiring intervention and residents who have expired in the last 30 days. On [DATE], the Director of Nursing audited the corresponding documentation in the medical records of these residents to determine that a nursing assessment was done and interventions were implemented. Items identified as a result of the audit were followed-up on as appropriate. 3. Systemic Measures On [DATE], facility initiated reinforcement of the facility's practice for the Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Unit Coordinator, Resident Care Management Director, and MDS Coordinator) reviews on a daily basis, Monday through Friday, those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms are documented, interventions were initiated, and the attending physician was contacted as appropriate. Adjustments to the plan of care and Care Assignment Sheets will be made based on these reviews and the input of medical professionals. On [DATE], the facility initiated provisions to account for weekend review of the 24-hour report, incidents and changes in condition by the manager on duty and/or charge nurse. The DON or Administrator will be called to discuss findings and initiate further action as appropriate. On [DATE], the Regional Clinical Director and the Director of Nursing conducted training with all scheduled licensed nurses regarding what constitutes a nursing assessment, post-change of condition assessment, use of Interact II tools as guidelines for assessment components, and timely intervention including calling 911 if initial assessment indicates a life threatening event and physician involvement for identified acute changes in resident condition. The Interact II tool is used for the identification of change in condition, communication of those changes and continuity of care. All licensed nursing staff will be provided this education via the Director of Nursing or Resident Care Management Director prior to being allowed to work. This education will be included in the facility's new hire orientation. Beginning [DATE], scheduled Certified nursing assistants were educated regarding notification of the nurse when a resident experiences a change in condition, including but not limited to respiratory difficulty, mental status changes and falls. Certified Nursing Assistants will be provided this education via the Director of Nursing or Resident Care Management Director prior to being allowed to work. In addition, on [DATE] the facility's grand rounds process, which includes Director of Nursing, Resident Care Management Director and/or Unit Coordinator, increased the frequency of the grand rounds to at least three times per week for the next four weeks to include observations, discussion with four randomly chosen licensed nurses regarding residents with the potential to have acute changes in condition, identified residents with acute changes in condition, physician involvement as appropriate, and interventions being implemented to address the resident ' s need. Grand Rounds were conducted on [DATE] by the Director of Nursing and Regional Clinical Director. Twelve residents were reviewed to assess for additional needs and interventions. The Director of Nursing and Regional Clinical Director also reviewed the documentation in the medical records of these residents to ensure identification of acute changes of condition and notification of physician. Necessary follow-up was completed and there are no outstanding concerns. 4. Quality Assessment and Assurance On [DATE], the Quality Assessment and Assurance Committee, including the facility administrator, Human Resources Coordinator, Director of Nursing, Resident Care Management Director, MDS coordinator, maintenance director, social worker, activities director, therapy program manager, medical records coordinator, medical records assistant, scheduler, unit coordinator, dietary manager to discuss the acute episode experienced by resident #1 on [DATE]. The Committee also has reviewed this acute episode with the facility ' s medical director. On [DATE], the Committee has reviewed the education materials provided to the licensed nursing staff regarding identification of change in condition, nursing assessment, and initiation of interventions based on assessment findings. Immediate jeopardy was removed on [DATE] at 6:50 PM with interviews of direct care and licensed nursing staff who confirmed they received in-service training on [DATE] prior to reporting on duty. Interviews with nursing staff revealed awareness of how to respond to a resident ' s change in condition. Nursing assistants interviewed reported direction to notify a licensed nurse immediately after a fall which included lowering to the floor. Licensed Nurses interviewed described the components of a nursing assessment and direction to call 911 when a resident required emergency medical attention. Record review of sampled residents revealed documentation of transfer assessments and documentation of nursing assessments. Observations revealed guidance tools for resident assessment available for staff use.

Based on record review and staff interviews the facility failed to safely transfer one (1) of four (4) sampled residents. (Resident #1) Staff transferred Resident #1 without using the maxi lift or wearing footwear to prevent sliding. The findings are: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] specified that she had short term and long term memory problems, moderately impaired cognitive skills for decision making, required extensive assistance with two (2) plus persons physical assist with transfers, was unsteady with surface to surface transfers, did not walk in room or in corridor could make herself understood and understood others. A review of the admission physician's orders [REDACTED].#1 was at high risk for falls. Interview with the facility's Physical Therapist (PT) on 05/26/11 at 12:00 p.m. revealed PT was not notified by nursing services that Resident #1 had a 03/31/11 physician's orders [REDACTED]. A review of a Resident Transfer Evaluation dated 04/05/11 and signed by a Licensed Nurse (LN) revealed Resident #1 required "caregiver performs 100 percent of the task with mechanical lift (total body/sling lift)." A review of Care Area Assessment (CAA) Summary dated 04/20/11 revealed Resident #1 was "triggered " for further review in the care area of "Falls." The resident's "Falls" CAA specified, "Resident is at risk for falls, is dependent for all transfers, unable to bear weight, is medicated routinely with a narcotic for pain, has dx (diagnosis) depression and is medicated daily for symptoms, requires extensive assist for most mobility, is O2 (oxygen) dependent with poor endurance." No referral for Physical Therapy was noted on the resident's Fall CAA. A review of the care plan updated on 04/12/11 contained a "problem" which identified Resident #1 as being at risk for falls. The care plan's goal specified she would be free of fall related injury through next review. Interventions on the care plan included; ensure resident has proper footwear as indicated and accepted. The resident's care plan did not address how staff was to specifically transfer the resident. A review of Resident #1's Nurse/NA Assignment/Care Plan Sheet dated 4/15/11 under the area of transfers specified two person assist and maxi lift. A review of a "SSC - Transfer Report" from 03/31/11 until 04/27/11 revealed Resident #1 was transferred by different methods including thirty-four (34) occurrences of two (2) plus person assist; eighteen (18) occurrences of stand/assist lift; thirteen (13) occurrences of full body/sling lift and two (2) occurrences with gait belt/sliding board. A review of nurse's notes of 04/27/11 revealed the following entries: 04/27/11 at 6:00 p.m. Resident #1 became upset when she was told by nursing assistants she would get a shower. During a transfer Resident #1 received a medium sized skin tear to inner left arm while " lowered to the floor " with two (2) staff members present. Resident #1 was asked if she was in pain or discomfort but her speech was unclear. A review of the emergency medical services transfer report dated 04/27/11 revealed Resident #1 was transferred to the hospital at 8:13 p.m. A review of the Hospital Admission History and Physical of 04/27/11 revealed admitting [DIAGNOSES REDACTED]. An interview on 05/10/11 at 2:10 p.m. with Resident #1's physician revealed Resident #1 had not walked in a couple years and she required two people to assist her with transfers. An interview on 05/10/11 at 3:00 p.m. with an orthopedic surgeon who had reviewed the x-ray of Resident #1's left leg revealed that the resident's fracture appeared to be a crunching type injury without a lot of soft tissue injury and when she went down into the floor a hyper-flexion of her leg was enough force to cause a fracture. The surgeon stated that the bruising could have been minimal since there was not a lot of soft tissue damage. An interview with Licensed Nurse (LN) #1 on 05/10/11 at 3:47 p.m. revealed that on 04/27/11 at approximately 4:15 p.m. she heard Resident #1 crying and she went into the resident's room. LN #1 explained that when she entered the room she observed Resident #1 sitting in a full body lift. LN #1 explained that she was first informed by NA #2 and NA #3 at this time Resident #1 had to be lowered to the floor when she began to slide downward as they attempted to manually transfer her from her bed to a shower chair and they were now transferring her back to bed. LN #1 confirmed she was aware that Resident #1 was supposed to always be transferred with a lift. An interview with Nursing Assistant (NA) #2 on 05/10/11 at 4:00 p.m. revealed on 04/27/11 at approximately 4:30 p.m. she and NA #3 attempted to manually transfer Resident #1 from her bed to a shower chair. NA #2 explained when performing this manual transfer she was holding under the resident's right arm and NA #3 was holding under the resident's left arm. As they assisted Resident #1 to stand up she began to slide off the bed and she had an episode of diarrhea. NA #2 stated as the resident began to slide downward, they were unable to hold Resident #1 up, so they lowered her to the floor. NA #2 stated that Resident #1 was sitting on the floor with her right leg and left leg bent next to the side of her body. NA #2 stated NA #3 straightened the resident's legs out, laid her down flat on the floor and put pillows under her head. NA #2 explained she observed a skin tear on the resident's left arm. Further interview with NA #2 on 05/25/11 at 4:35 p.m. revealed she did not use a lift when transferring Resident #2 from her bed to the shower chair on 04/27/11 because a lift was not available. NA #2 explained prior to performing this transfer Resident #1 was wearing either socks or slippers which had a hard rubber (non skid) material on the bottom. NA #2 stated Resident #1 said she wanted to keep her socks on while taking a shower, but she told the resident she could not wear them because they would get wet. NA #2 stated she took Resident #1's socks/slippers off prior to the manual transfer, so the resident did not have anything on her feet during the transfer and while being lowered to the floor. During an interview on 05/11/11 at 10:00 a.m. NA #3 stated Resident #1 was always a two (2) person transfer with one person under each arm to stand and pivot her. NA #3 stated that on 04/27/11 NA #2 asked her to help transfer Resident #1 from her bed to a shower chair. NA #3 explained they sat Resident #1 up on the side of the bed and as they started to assist her to stand up her knees bent; she had an episode of diarrhea and began to slide downward. They decided to lower her down onto the floor. NA #3 stated Resident #1 sat down on her buttocks but did not recall the position of her legs. NA #3 further stated they placed the resident on her side with one leg on top of the other, straightened her legs out and provided incontinence care. NA #3 stated she noted Resident #1 had a skin tear on her arm. Further interview with NA #3 on 05/25/11 at 2:10 p.m. revealed that on 04/27/11 Resident #1 had socks on her feet and requested for them to be left during her shower, but they were removed by NA #2 prior to transferring from her bed to the shower chair. NA #3 stated on 04/27/11 Resident #1 was in her bare feet when she was manually transferred and had to be lowered to the floor. NA #3 explained LN #1 was not informed of this incident until she entered Resident #1's room and saw her sitting in a maxi-lift. This was following the resident receiving incontinence care and before they transferred her back to bed. An interview on 05/11/11 at 10:46 a.m. with MDS Coordinator #2 she stated the Nurse Aide (NA) assignment sheets are based on an initial nursing evaluation and are updated at the interdisciplinary team meeting each morning. An interview on 05/11/11 at 2:00 p.m. with Director of Nurses (DON) revealed NA #2 and NA #3's decision to transfer Resident #1 without the lift was an option they had to transfer Resident #1 with two person assist or use the Maxi lift. During further interview with the DON on 05/25/11 at 5:00 p.m. it was revealed that Resident #1's 03/31/11 physician's orders [REDACTED].#1 needed to be evaluated. The DON also confirmed that on 04/27/11 staff should have ensured that Resident #1 was wearing proper foot ware, including non skid socks, as specified on her plan of care, before they attempted to transfer her from her bed to a shower chair and needed to be lowered to the floor.

Based on staff interviews and record review, the facility failed to honor one (1) of one (1) sampled resident's preference not to take a shower and wear her choice of clothing (Resident #1). The findings are: Review of Resident #1's record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed assessment of short term and long term memory problems and moderately impaired decision making abilities. The MDS assessment coded Resident #1 could make herself understood and understood others with no behavior problems. The MDS listed the resident required limited assistance with personal hygiene and dressing; extensive assistance was required with transfers. The MDS listed there was no bath given during the assessment period. Review of Resident #1's nursing care plan dated 4/12/11 revealed no concerns regarding crying episodes or resistance to care. Review of nursing notes dated 4/27/11 at 6:00 PM revealed Licensed Nurse (LN) #1 documented the "CNAs (Certified Nursing Assistants) present state pt. was told she would get a shower to which she refused and became upset." LN #1 documented "She remained upset for well over an hour and refused to eat dinner." Review of a facsimile dated 4/27/11 sent at 6:20 PM revealed LN #1 requested an anti-anxiety medication because Resident #1 "became very upset with staff who tried to give her a shower." Review of Resident #1's hospital admission history and physical dated 4/27/11 listed [DIAGNOSES REDACTED]. Review of the facility's five day investigation which included a statement by NA #2 dated 4/30/11 at 2:07 PM revealed a description of lowering Resident #1 to the floor and transfer back to bed. The statement continued: The resident refused to go to the shower prior to the incident. Staff decided that since the resident was so upset about going to the shower, they gave her a bed bath. Review of the facility's five day investigation which included a statement by LN #1 dated 5/3/11 revealed the following: "Around 4:15 PM I was at the end of the hall in front of (room number) and heard (Resident #1) crying. I medicated 2 other residents and still heard her crying. I then entered her room and asked (NA #2) what was wrong with (Resident #1) and she stated she was upset because she didn't want to take a shower and they had lowered her to the floor because she wouldn't stand." Interview with LN #1 on 5/10/11 at 3:45 PM revealed she heard Resident #1 crying on 4/27/11 during the afternoon medication pass. Upon entry into the room, LN #1 reported she observed Resident #1 crying while seated in a mechanical lift sling above the bed. LN #1 explained NA #2 and NA #3 informed her Resident #1 was upset because she did not want to take a shower. The staff attempted to pivot and transfer the resident but had to lower her to the floor. Interview with NA #2 on 5/10/11 at 4:20 PM revealed Resident #1 refused the transfer to the shower chair and did not want a shower without socks on her feet. When the resident made that statement, NA #2 explained she did not reply to Resident #1 and began the transfer her with NA #3's assistance. NA #2 reported Resident #1 began to cry. NA #2 explained Resident #1 made choices in her care but a shower was scheduled and Resident #1 usually refused showers. Interview with NA #3 on 5/11/11 at 9:59 AM revealed NA #2 requested her assistance with Resident #1's transfer on 4/27/11. NA #3 reported she was not aware of Resident #1's refusal of shower or transfer on 04/27/11. Interview with Minimum Data Set Coordinator #2 on 5/11/11 at 11:00 AM revealed Resident #1 did not resist care but did not always like to get out of bed. Interview with the Director of Nurses (DON) on 5/26/11 at 3:05 PM confirmed that after 05/11/11 she met with NA #2 and other staff involved in order to fully investigate Resident #1's shower refusal on 04/27/11. The DON explained that during the investigation NA #2 informed her that on 04/27/11 Resident #1 wanted to keep her socks on during the shower, but NA #2 told the resident that she had to remove her socks because they would get wet in the shower. NA #2 stated that she removed the resident's socks and then attempted to transfer the resident from her bed to a shower chair. The DON reported that she expected staff to accept a resident's refusal of a shower because it is their right to refuse care and treatment. The DON added that if a resident should refuse to take a shower staff should inform their charge nurse of the refusal, to approach the resident later to again ask them if they would like to receive a shower and if needed to offer the resident a bed bath as an alternative.

Based on staff interviews and record review the facility failed to develop a comprehensive care plan to include method of transfer and interdisciplinary referral for Physical Therapy for one (1) of four (4) sampled residents with falls. (Resident #1) The findings are: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the nursing admission assessment dated [DATE] revealed Resident #1 required extensive assistance with two plus persons physical assistance with transfers, was unsteady with surface to surface transfers and was non-ambulatory. The resident's 03/31/11 admission physician's orders [REDACTED]. A review of Resident #1's 04/05/11 "Fall Risk" assessment specified she was at high risk for falls. A review of Resident #1's "Transfer Evaluation," completed by nursing staff on 04/05/11, revealed she was non-ambulatory, none/no weight bearing, confused, followed simple directions, unable to sit on bedside without full back support and had [MEDICAL CONDITION]/arthritis. This evaluation specified that Resident #1 required "caregiver performs 100 percent of the task with mechanical lift (total body/sling lift)." The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had short term and long term memory problems, moderately impaired cognitive skills for decision making, required extensive assistance with two (2) plus persons physical assist with transfers, was unsteady with surface to surface transfers and did not walk in room or in corridor. A review of Resident #1's Plan of Care, which was initially developed on 04/12/11, contained a "problem" which identified her as being at risk for falls. The care plan's goal specified she would be free of fall related injury through next review. Interventions on the resident's care plan did not specify how she was to be transferred by staff, did not specify "appropriate footwear" as being non-skid shoes and/or non skid socks and there was no documentation in the section for Interdisciplinary referral for Physical Therapy services. A review of Resident #1's Nursing Assistant (NA) instruction sheet dated 4/15/11 under the heading for transfer and assist specified two plus person assist and maxi (full body) lift. A review of Resident #1's Care Area Assessment (CAA) Summary dated 04/20/11 revealed the resident "triggered" for further review in the care area of "Falls." The resident's "Falls" CAA specified, "Resident is at risk for falls, is dependent for all transfers, unable to bear weight, is medicated routinely with a narcotic for pain, has dx (diagnosis) depression and is medicated daily for symptoms, requires extensive assist for most mobility, is O2 (oxygen) dependent with poor endurance." No referral for Physical Therapy was noted on the resident's Care Area Assessments or on her plan of care. A review of the nurse's notes dated 04/27/11 revealed Resident #1 was "lowered to the floor" by NA #2 and NA #3 during a transfer. A review of the emergency medical services transfer report dated 04/27/11 revealed Resident #1 was transferred to a hospital at 8:13 p.m. A review of Resident #1's Hospital Admission History and Physical of 04/27/11 revealed admitting [DIAGNOSES REDACTED]. An interview on 05/11/11 at 10:40 a.m. with MDS Coordinator #2 revealed when completing Resident #1's Admission Comprehensive Assessment she was aware Resident #1 was extensive assist but she never observed Resident #1 while being transferred and was not sure if a lift was used. Further interview with MDS Coordinator #2 on 05/26/11 at 10:15 a.m. she stated if care areas are triggered on the MDS then a care plan would be developed if needed and if not needed would be documented on the CAA. She further explained she was unaware of Resident #1's physician's orders [REDACTED]. She stated she should have been aware of this order and should have noted a PT referral on Resident #1's Care Area Assessment (CAA). MDS Coordinator #2 confirmed the physical therapy component on Resident #1's care plan should have been checked for PT services, and standard practice in the facility was to use non-skid socks as proper footwear and should have been indicated on the care plan. During an interview on 05/26/11 at 10:37 a.m. the Director of Nursing (DON) demonstrated "gripper" socks used by the facility and stated she considered proper footwear was use of non-skid shoes or the non-skid "gripper" socks. She stated it was her expectation that proper footwear identified on Resident #1's care plan should have been specific to include non-skid shoes or gripper socks, and staff should have had some type of non-skid footwear on Resident #1 when transfer occurred. An interview with the facility's Physical Therapist (PT) on 05/26/11 at 12:00 p.m. revealed she was not informed of Resident #1's 03/31/11 admission order for a PT evaluation to be completed. The PT explained had she been made aware of this physician's orders [REDACTED].